Autonomic Nervous System Dysfunction in Parkinson’s Disease
Often early signs of Parkinson’s Disease are non-motor signs. Autonomic dysfunction is an important non-motor phenotype of Parkinson’s Disease (PD) . Recently there has been more of an interest and a shift in the research looking at the role of the Autonomic Nervous System ( ANS ) in the prediction and early diagnosis of Parkinson’s Disease. In this blog post we will discuss common symptoms associated with ANS dysfunction and potential ways to manage symptoms.
So what is the autonomic nervous system and what does it do? In this post we will look at common symptoms associated with ANS dysfunction and ways to manage symptoms.
The ANS is in control of regulating a variety of body processes that occur without any conscious effort. It is responsible for regulating involuntary body function, such as heart rate, blood flow, breathing, and digestion.
The autonomic nervous system has two main divisions:
Sympathetic – Stimulates body processes and regulates flight or fight response.
Parasympathetic – Inhibits body processes and helps to maintain normal body function and conserve physical resources.
In individuals with Parkinson’s the parasympathetic and sympathetic components of the ANS can become out of sync causing people to experience an autonomic dysfunction called dysautonomia. Autonomic dysfunction in PD include: gastrointestinal malfunction, cardiovascular dysregulation, sexual dysfunction, urinary and sleep disturbances, and more. In the remainder of this post we will review common autonomic dysfunction symptoms and provide education on possible interventions to assist.
Gastrointestinal Dysfunction
The frequency of Gastrointestinal ( GI ) symptoms in individuals with PD is high. Roughly 88.9% of individuals with PD will develop GI symptoms prior to the onset of Parkinsonian motor symptoms.
Constipation
Constipation is one of the non-motor symptoms that often starts decades before an individual is diagnosed with Parkinson’s Disease. This is defined as fewer than three bowel movements a week. Just as Parkinson’s can slow down motor movements, it can also slow down the motility of the GI system. Normally the ANS tells your GI system to move food through, but there is now a dysfunction. Things are now moving slower through the intestines and spending more time here. This causes water to be extracted from the food within the intestine which leads to constipation. Some medication can worsen constipation so speak with your physician and take a look at possible medication side-effects.
Ways to combat constipation:
Stay hydrated! It is recommended to drink at least 6-8 oz glasses of water per day.
Fiber is important for continued motility. So, eat the rainbow! Fruits and veggies that are colorful are packed with fiber.
Exercise is critical to keep the gut moving! When you exercise and move your body, this stimulates the gut to move as well.
Prune juice or drinking something warm in the morning.
Over the counter remedies can be recommend, but speak to your Physician first.
Medications can be prescribed to help if other means are not helping. Speak to your Physician.
Bladder
One of the most common irritative symptoms in PD is nocturia, followed by frequency and urinary incontinence.
Nocturia is frequent urination that is occurring at night. The autonomic nervous system that controls the bladder and says when it is time to urinate is not working properly.
Ways to combat Urinary Frequency:
Drink fluids early and in the afternoon. Try to avoid fluids past 4pm.
Place commodes or urinals at the edge of your bed so you can more easily fall back asleep.
Medications can be prescribed, but tend to have a high number of side effects. Speak with your Physician.
SLEEP DYSFUNCTION
Sleep dysfunction is very common! There is a wide array of sleep disorders. One thing to remember is sleep is vital and especially important to those with Parkinson’s. If you are not sleeping, you are not resting your brain or your body which results in you waking up tired.
Insomnia – Insomnia is a difficulty falling asleep and more commonly in Parkinson’s, is a difficulty staying asleep. It can be common to wake up 2-3 hours later after going to bed. In Parkinson’s, low levels of melanin are being made in the brain. Speak with your Physician, oftentimes a low dose of over-the-counter melatonin can greatly improve sleep.
REM Sleep Behavior Disorder – Has someone ever told you that you talk in your sleep or even act out your dreams? When we go to sleep there is a “button” in the brain that sends a signal to our muscles to create a natural paralysis. While we all dream when asleep, everyone does not speak out or act out dreams. 40% of people with PD have REM Sleep Behavior Disorder. Acting out dreams can be dangerous at times, leading to falls out of the bed or accidently hitting your spouse in your sleep. This is a disorder that can be treated with prescription medication; speak with your physician.
Obstructive Sleep Apnea – Sleep apnea is very shallow breathing or at times complete cessation of breathing for seconds at a time. When breathing is stopped, there is a buildup of CO2 in your lungs which will eventually trigger your body to breath. This is something that needs to be addressed by your Primary Care Physician or Sleep Specialist.
Restless Leg Syndrome – This is an incredible urge to move your legs and tends to happen in the evening or when you lay down to go to sleep. This is something that can be treated medically so speak with your physician.
DAY TIME FATIGUE
In individuals with Parkinson’s the body is working overtime! You may not have an observable tremor, but due to the impaired signal from the brain, you are working harder throughout the day to execute tasks. Normal activities of daily living often require more effort. It's ok to take a power nap during the day, but ensure that it is for no more than 30 mins. Naps for longer periods of time will make it difficult to fall asleep at night and disturb your sleep cycle. 30 minutes will allow you to wake up and feel energized.
Ways to combat daytime fatigue:
One of the best things to do to combat daytime fatigue is to EXERICSE! Exercise creates energy! Even if you are tired make sure that you do it!
Have a regular schedule and stick with it!
Review your medication list with your physician and determine if any medications could be causing fatigue
Neurogenic Orthostatic Hypotension ( OH )
OH is prevalent in early stage PD.
This is when your blood pressure is not regulated appropriately. When you change position from sitting to standing or laying down to sitting up, a drop in blood pressure can occur. This often leaves you feeling off balance or feeling faint. It is also not uncommon for blood pressure to swing from low to high. Normally, when changing positions from lying down to standing up, there is a signal to the blood vessel, to constrict; especially around the neck. This occurs to keep the blood and oxygen in our head/brain so gravity doesn’t bring it to our feet causing the symptoms of dizziness and feeling faint.
Ways to combat OH:
Speak with your physician, medication can lead to low blood pressure. Sinemet has a side effect of lowering blood pressure. Sometimes individuals who take medication for high blood pressure may be able to stop due to Sinemet lowering blood pressure.
Drink more water!
Before going from sitting to standing, move your legs by marching or performing ankle pumps.
Wear compression stockings.
It can be recommended to add salt to your food. Prior to changing your diet, speak with your physician.
Speech and Swallowing
Just as PD can affect the movement in other parts of the body, it can affect the muscles of the mouth and throat as well. This can produce loud speech and affect one’s ability to swallow.
Dysphagia is difficulty with swallowing. More than 80% of individuals with Parkinson’s develop dysphagia and symptoms tend to increase as PD progresses. It is important to address dysarthria because it can lead to malnutrition, dehydration, and aspiration. Aspiration is when food or liquid “goes down the wrong pipe” which can lead to aspiration pneumonia the leading cause of death in individuals with PD. It is important that individuals with Parkinson’s can eat safely.
Sialorrhea is drooling or excessive salivation. This occurs in over 50% of early PD individuals. Oftentimes, drooling occurs due to the loss of automaticity to swallow or forgetting to swallow.
Have you noticed recent weight change, a sensation of food getting stuck in your through, coughing while drinking/eating, or drooling?
What about family asking you to speak up? Is the clarity of your speech variable or do you have to strain to produce voice?
Ways to combat speech and swallowing deficits:
If you are noticing difficulties with any of the above, it is important to speak with your neurologist. They will likely refer you to have an evaluation performed by a Speech and Language Pathologist. If difficulties with swallowing are noted there are often exercises prescribed to swallow hard, train expiratory muscles, and possibly a recommendation to change diet. If speech problems are noted, exercise to produce more purposeful and loud speech.
Quick tips to decrease drooling can be to suck on candy or chew gum. There are medications that can cause dry mouth by decreasing saliva production in addition to Botox to the appropriate submandibular glands.
Weight Loss
There are many reasons why individuals with Parkinson’s can lose weight. One of the common reasons is linked to one of the initial non-motor symptoms which is loss of smell. With the impaired sense of smell, it becomes difficult to taste food, leading things to taste like cardboard and without any flavor. Soon food in general becomes less appealing. Other causes of weight loss can be related to medications causing nausea which suppresses appetite, causes swallowing difficulties, and interferes with eating. Taking PD specific medication near mealtimes while avoiding protein can lead to malnutrition. Parkinson’s does not cause ongoing unexplained weight loss, so speak to your physician if you experience this symptom.
Ways to combat weight loss
It is often recommended by your physician to increase calorie intake. Sometimes it is as simple as adding. Ensure to your diet, but speak with your Physician about possible diet changes.
Eat small, frequent meals, every two to three hours or eat a nutritious snack between meals.
Eat foods you enjoy.
Increase consumption of whole grains (whole grain rice, breads, etc.)
Thermoregulatory dysfunction
Individuals with Parkinson’s experience changes in their skin. This can range from the development of oily or flaky skin due to excessive sweating. Hyperhidrosis, especially nocturnal sweating, is a common feature of ANS and thermoregulatory dysfunction in those with PD. This can occur at times when you're not even hot or participating in exercise. It has been shown that increased sweating can more often occur during off phases on carbidopa-levodopa.
Ways to combat sweating
Speak with you Physician and possible medication adjustments can be made
Take lukewarm showers
Wear lightweight cotton clothes in warm weather
Drink a lot of water and other liquids to ensure that you stay hydrated
In severe cases, for drenching sweats, your doctor may prescribe a medication such as propranolol. For sweating on the palms and the feet, your doctor can prescribe various topical medications.
*Disclaimer: this article is not intended to take the place of advice from a medical professional. For medical advice, please speak with your physician.
Sources:
Metzger JM, Emborg ME. Autonomic dysfunction in Parkinson disease and animal models. Clin Auton Res. 2019 Aug;29(4):397-414. doi: 10.1007/s10286-018-00584-7. Epub 2019 Jan 2. PMID: 30604165; PMCID: PMC6606399.
Zhichun Chen, Guanglu Li, Jun Liu, Autonomic dysfunction in Parkinson’s disease: Implications for pathophysiology, diagnosis, and treatment, Neurobiology of Disease, Volume 134, 2020,104700, ISSN 0969-996.