Parkinson's Disease Quality of Life Issues Barbara Fitzsimmons, RN, MS Lisette K. Bunting, RN, MScN NONMOTOR FEATURES Depression Depression in PD has been the focus of numerous studies. Research indicates that 20% to 90% of patients with PD will experience a major depressive episode as compared to 7% of the general population. Depression accounts for the majority of psychiatric referrals in patients with PD and can be the initial feature of PD. It has been hypothesized that the shared neurochemistry of these two disorders accounts for the high incidence of depression in PD.(2) Depression can be viewed in two ways. Some patients may become demora- lized with the diagnosis of PD and experience a "reactive depression." Reactive depressions are linked to external events and are short in duration. Typically the patient experiencing a reactive depression is able to resolve the issue and accept the diagnosis. Individuals experiencing a reactive depression may benefit from sup- portive psychotherapy, however.(2) The most typical depression experienced by the patient with PD is endogenous depression. Endogenous depression is caused by a biochemical imbalance in the brain and can be life-threatening if not treated. The difficulty in diagnosing depres- sion in patients with PD lies in the shared clinical features of the two disorders (Table 2). Dementia Sleep Disturbances Sleep disorders are a frequent complaint in patients with PD. Disorders of sleep initiation, sleep fragmentation, early morning awakening, excessive daytime somnolence, and parasomnias represent the disorders of sleep seen in PD. A detailed history of the sleep complaint, validated by a bedpartner, is the best method of establishing the cause of sleep disturbances.(11) Patients may complain of initiation insomnia as, "I can't get to sleep." C)nce asleep they are able to sleep soundly through the night, however. Researchers have concluded that sleep initiation insomnia in PD is related to anxiety, agitated de- pression, or levodopa therapy. The more typical sleep disorders seen in PD are sleep fragmentation and early morning awakening." Sleep fragmentation can be related to the inability to turn over in bed. Rigidity compounded by the wearing off of medication reduces pa- tients' ability to reposition themselves in bed. Patients state that they must wake up to change sleeping positions and then are unable to return to sleep. One solution to this problem is the use of satin sheets to decrease friction and facilitate turning. Early morning awakening typically represents onset of a depressive episode, and the nurse should evaluate the patient for other vegetative symptoms such as decreased appetite, psychomotor retardation, and constipation. Early morning awakening may be related to focal dystonic cramping in the calf and feet, however. Focal dystonia is related to diminished levels of levodopa.(11) Excessive daytime somnolence is the most frequent sleep complaint made by family members of PD patients. In some individuals, daytime somnolence is related to a disturbance in the circadian control of sleep. These patients are up at night and take multiple naps throughout the day. Families report that daytime sonuiolence is disruptive to normal family life. Families should discourage day time napping in an attempt to correct the circadian clock. Patients who are described as sleeping all day, however, should be screened for metabolic abnormalities that may cause disturbances in the sleep-wake cycle. Parasomnias are the most debilitating and difficult of the sleep disorders to manage. Sleep talking, sleep walking, vivid dreams, and nightmares are the most frequently reported parasomnias experienced by patients with PD. Most typically, these occur as a side effect of levodopa therapy. Unfortunately, treatment for parasomnias is limited.(11) Sexual Dysfunction Sexual functioning in patients with PD has received inadequate attention. The paucity of literature can be attributed to the assumption that patients with PD are elderly and therefore have a diminished interest in sex. Research indicates that frequency of sexual intercourse decreases with age; however, sexuality continues to play a role in the lives of the elderly. Sexual dysfunction has a significant impact on patients who are diagnosed with PD in their midadult years when an active sex life is the norm.(1) Dysfunction of the autonomic nervous system, depression, medications, and interpersonal issues all play a role in sexual dysfunction in PD. Autonomic dys- function in the urogenital system resulting in impotence is the primary reason for sexual dysfunction in male patients with PD. Secondary issues affecting sexual function include motor fluctuations, fatigue, medications, sleep disorders, depres- sion, and interpersonal issues.(1) The motor fluctuations and fatigue can be related to antiparkinsonian drugs, primarily levodopa. Patients with PD find that they are better able to function in the morning, after their initial dose of medication, and become more fatigued with greater motor fluctuations as the day progresses. Numerous reports document hypersexuality with the use of levodopa. This may result in a problem when one partner has heightened sexual interest that is not shared by the other partner. To adapt to these changes in their sexual life, couples may need to change their daily routine to accommodate morning sexual activity and take advantage of optimum energy levels and motor functioning. Unfortunately, sleep disorders experienced in patients with PD may result in bedpartners sleeping in separate beds, which diminishes opportunity for spontaneous sexual activity.(1) Depression can also have a significant impact on sexual activity in patients with PD. As discussed earlier, depression is common in patients with PD and can produce a markedly decreased libido. Sexual partners may also experience depres- sion and fatigue as they struggle with the caregiving role in the relationship; thus, they also may not have the energy or interest to engage in sexual activity. In addition, autonon-dc dysfunctions that result in droohn& diaphoresis, and excessive facial oiliness may interfere with perceived attractiveness of the patient by the sexual partner.(1) The issues surrounding sexuality in PD are complex. Patients should be rou- tinely questioned regarding satisfaction of their sexual life. A referral to a urologist or sex therapist can assist in identifying issues affecting sexuality. Open conununi- cafion regarding sexual issues can be limited by the patient's reduced facial expres- sion and altered speech pattern. The ability of the couple to communicate their sexual needs within the liniitafions of the disease state can have a significant impact on the couple's marriage and sexual life.(1)