Compliance with National and International Guidelines in the Treatment of Nonmotor Symptoms in Late-Stage Parkinson’s Disease

Table 3

Pharmacological treatment of nonmotor symptoms in late-stage PD in relation to the recommendations of the priority rating in the Swedish National Board of Health and Welfare’s guidelines and in the Swedish Movement Disorder Society’s guidelines (n = 107).

	Total cohort	Symptom present^a(n, %)	Symptomatic individuals^b(n, %)
Depressive symptoms^c
No antidepressant medication, n (%)	56 (52%)	23 of 37 (62%)	26 of 63 (41%)
Antidepressant medication, n (%)	51 (48%)	14 of 37 (38%)	37 of 63 (59%)
SNRI (venlafaxine)	6 of 51 (12%)	1 of 37 (3%)	5 of 63 (8%)
TCA	1 of 51 (2%)	1 of 37 (3%)	0 of 63 (0%)
NaSSA^No prio (mirtazapine)	23 of 51 (45%)	7 of 37 (19%)	16 of 63 (25%)
SSRI	21 of 51 (41%)	5 of 37 (14%)	16 of 63 (25%)
Anxiety^d
Anxiolytics	15 (14%)	5 of 34 (15%)	1 of 17 (6%)
Psychotic symptoms^e
Antipsychotics	29 (27%)
Clozapine	9 of 29 (31%)
Quetiapine	20 of 29 (69%)
Hallucinations
Antipsychotics		16 of 49 (33%)	9 of 18 (50%)
Clozapine		6 of 49 (12%)	2 of 18 (11%)
Quetiapine		10 of 49 (20%)	7 of 18 (39%)
Delusions
Antipsychotics		12 of 27 (44%)	5 of 13 (38%)
Clozapine		6 of 27 (22%)	3 of 13 (23%)
Quetiapine		6 of 27 (22%)	2 of 13 (15%)
Cognitive impairment
Dementia^f; (MMSE ≤ 23, n = 60/≤18, n = 27)
Acetylcholinesterase inhibitors
Rivastigmine, n (%)	15 (14%)	14 of 60 (23%)	9 of 27 (33%)
Donepezil, n (%)	4 (4%)	3 of 60 (5%)	1 of 27 (4%)
Memantine, n (%)	23 (22%)	22 of 60 (37%)	10 of 27 (37%)
Autonomic dysfunction
Orthostatic hypotension^g
Antihypotensives	27 (25%)
Midodrine	16 (15%)
Fludrocortison	6 (6%)
Others	12 (11%)
Droxidopa	1 (1%)
Etilefrin	7 (7%)
Lightheadedness
Antihypotensives		20 of 54 (37%)	11 of 19 (58%)
Midodrine		10 of 54 (19%)	7 of 19 (37%)
Fludrocortison		4 of 54 (7%)	3 of 19 (16%)
Others		9 of 54 (17%)	4 of 19 (21%)
Droxidopa		0	0
Etilefrin		6 of 54 (11%)	2 of 19 (11%)
Fainting
Antihypotensives		12 of 21 (57%)	7 of 8 (88%)
Midodrine		7 of 21 (33%)	5 of 8 (63%)
Fludrocortison		3 of 21 (14%)	0
Others		4 of 21 (19%)	2 of 8 (25%)
Droxidopa		0	0
Etilefrin		3 of 21 (14%)	2 of 8 (25%)
Sialorrhea^h
Botulinum toxin, n (%)	4 (4%)	2 of 65 (3%)	2 of 42 (5%)
Constipation^i
Laxatives, n (%)	54 (50%)	33 of 58 (57%)	19 of 35 (54%)
Urinary urgency/frequency/nocturia^j
Peripheral anticholinergics
Detrusitol	0	0	0
Emselex	0	0	0
Vesicare	1 (1%)	1 of 91 (1%)	1 of 71 (1%)
Betmiga	3 (3%)	2 of 91 (2%)	2 of 71 (3%)
Botulinum toxin injection bladder	NAv	NAv	NAv
Sleep disturbances/disorders
Insomnia^k
Hypnotics/sedative/insomnia drugs, n (%)	28 (26%)	7 of 31 (23%)	4 of 16 (25%)
Daytime sleepiness^l
Psychostimulant drugs, n (%)	1 (1%)	1 of 63 (2%)	1 of 29 (3%)
Behavioral disorders
Dopaminergic dysregulation syndrome
Impulse control disorder
Naltrexone	NAv	NAv	NAv

PD, Parkinson’s disease; q1–q3, first and third quartiles; NMSS, Nonmotor Symptoms Scale (0–360, higher = worse); D, domain (severity × frequency of each item of the domain are added together; each item is scored 0–12 (higher = worse), 2 missing. MMSE, Mini-Mental State Examination (0–30, higher = better), 4 missing; GDS-30, geriatric depression scale (0–30, higher = worse), 7 missing; SSRI, selective serotonin reuptake inhibitor; NaSSA, noradrenergic and specific serotonergic antidepressants; SNRI, serotonin-norepinephrine reuptake inhibitors; TCA, tricyclic antidepressants. NAv, information nonavailable. ^aSymptom present, individuals with score ≥1 on item of the NMSS scored 0–12 (higher = worse), if nothing else is stated. ^bSymptomatic individuals include those who score above the cutoff of ≥6 (moderate–severe) on item of the NMSS, if nothing else is stated. ^cDepressive symptoms based on GDS-30 cutoff for depression (≥10 points): symptom present 1–9 points, symptomatic individuals ≥10 points. ^dAnxiety score refer to (NMSS item 9) feel nervous, as no other specific data for anxiety was collected. ^ePsychotic symptoms scores refer to item 13 (hallucinations) and item 14 (delusions) of the NMSS. ^fDementia as assessed by the MMSE, cutoffs cognitive impairment ≤23/dementia ≤18 MMSE. ^gOrthostatic hypotension based on item 1 (lightheadedness) and item 2 (fainting) of the NMSS. ^hSiallorhea based on item 18 of the NMSS. ⁱConstipation based on item 21 of the NMSS. ^jUrinary urgency/nocturia based on domain 7 of the NMSS. ^kInsomnia based on item 5 of the NMSS. ^lDaytime sleepiness based on item 3 of the NMSS. Priority according to the Swedish national guidelines (the Swedish National Board of Health and Welfare’s guidelines and the Swedish movement disorder society’s guidelines on diagnosis and treatment of PD): Priority 1–4 (recommended/should be used), Priority 5–7 (can be used), Priority 8–10 (can be used as an exception), research and education (Swedish FoU): should be used only in the frame of clinical studies, non-do: should not be used.