Non-Pharmacological Treatment of Autonomic Dysfunction in Parkinson's Disease and Other Synucleinopathies

Abstract

Symptoms of autonomic dysfunction are prevalent and can be very debilitating, reducing the quality of life in patients with Parkinson's disease (PD) and other synucleinopathies such as dementia with Lewy bodies and multiple system atrophy. Non-pharmacological therapies are key to effective management and are frequently used alone in patients with mild autonomic symptoms, or in combination with pharmacological therapies in patients with moderate and severe symptoms. This article focuses on non-pharmacological approaches. Our objective was to review the non-drug and non-surgical approaches to treating autonomic symptoms in patients with PD and other synucleinopathies, focusing on cardiovascular, gastrointestinal, and genitourinary autonomic dysfunction. Evidence supporting the effectiveness of non-pharmacological treatment for the management of neurogenic orthostatic hypotension, supine hypertension, constipation, and bladder and sexual dysfunction is available. High-quality prospective trials are scarce, yet some non-pharmacological interventions (e.g., physical counter maneuvers) can be evaluated relatively quickly on an individual basis and often seem effective. The emerging variety of clinical presentations advocates for a stepwise, individualized, and non-pharmacological approach for the management of autonomic symptoms. Often, the first step is to reduce or discontinue drugs that cause or aggravate autonomic symptoms followed by lifestyle measures. While non-pharmacological and non-surgical treatments are available and, in many cases, effective to improve symptoms of autonomic dysfunction in PD and other synucleinopathies, they are often overlooked. Large randomized trials testing and comparing non-pharmacological approaches are warranted.

Keywords: Parkinson’s disease; constipation; dysautonomia; non-motor symptoms; orthostatic hypotension; sexual dysfunction; supine hypertension; urinary dysfunction.

Fig. 1

Blood pressure variability and stock market volatility. The upper panel shows an ambulatory 24-hour blood pressure (BP) monitor recording of a patient with Parkinson’s disease with neurogenic orthostatic hypotension and supine hypertension. The monitor takes a BP measurement every 30 minutes during the daytime and every 60 minutes during nighttime. The red line denotes systolic BP, the blue line diastolic BP, and the grey line mean BP. The tracing depicts high BP variability with low (as low as 65/32 mmHg at around 6 PM) and high blood pressure readings (as high as 160/100 mmHg at around 2 AM, during bedtime). Note that for several hours during bedtime (i.e., supine position), multiple BP readings were in the hypertensive range. The lower panel shows a 6-month tracing (May-October 2022) of the London Financial Times Stock Exchange (FTSE) 100 Index, depicting high variability.