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Review
. 2025 Jan 3;272(1):90.
doi: 10.1007/s00415-024-12730-5.

Diagnosis and treatment of autonomic failure, pain and sleep disturbances in Parkinson's disease: guideline "Parkinson's disease" of the German Society of Neurology

Alessandra Fanciulli  1 , Friederike Sixel-Döring  2   3 , Carsten Buhmann  4 , Florian Krismer  5 , Wiebke Hermann  6   7 , Christian Winkler  8 , Dirk Woitalla  9 , Wolfgang H Jost  10 ; German Parkinson’s Guideline Group; Claudia Trenkwalder  2   11 , Günter Höglinger  12   13   14
Collaborators, Affiliations
Review

Diagnosis and treatment of autonomic failure, pain and sleep disturbances in Parkinson's disease: guideline "Parkinson's disease" of the German Society of Neurology

Alessandra Fanciulli et al. J Neurol. .

Abstract

Background and objective: Non-motor symptoms frequently develop throughout the disease course of Parkinson's disease (PD), and pose affected individuals at risk of complications, more rapid disease progression and poorer quality of life. Addressing such symptom burden, the 2023 revised "Parkinson's disease" guideline of the German Society of Neurology aimed at providing evidence-based recommendations for managing PD non-motor symptoms, including autonomic failure, pain and sleep disturbances.

Methods: Key PICO (Patient, Intervention, Comparison, Outcome) questions were formulated by the steering committee and refined by the assigned authors. Recommendations were drafted based on relevant studies, systematic reviews, meta-analyses and high-quality guidelines identified by the literature search. They were subsequently reviewed, revised, and voted by the Guideline Group in online consensus conferences. Consensus was achieved in case of > 75% agreement among the group members. The consensus was considered strong, if agreement was > 95%.

Results: The guideline entails: (i) 10 PICOs and 23 recommendations on the diagnosis and treatment of urogenital, cardiovascular and gastrointestinal autonomic failure; (ii) four PICOs and four recommendations on the possible types of pain in PD individuals, their diagnosis and treatment; (iii) 11 PICOs and 11 recommendations on the screening, diagnosis and treatment of sleep disturbances and excessive daytime sleepiness in PD individuals, as well as on their prognostic implications. Thirty-one out of 38 recommendations achieved a strong consensus.

Conclusion: The current German PD guideline provides a practice-oriented and etiology-driven stepwise approach to the diagnosis and treatment of autonomic failure, pain and sleep disturbances in PD individuals.

Keywords: Constipation; Daytime sleepiness; Erectile dysfunction; Nocturia; Orthostatic hypotension; Pain; Parkinson’s disease; REM-sleep behavior disorder; Sleep; Supine hypertension; Urinary incontinence.

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Conflict of interest statement

Declarations. Conflicts of interest: A.F. reports royalties from Springer Verlag, speaker fees and honoraria from Bial, Theravance Biopharma, CNSystems, Medtronic, Sanofi, Broadview Ventures, Austrian Autonomic Society, Austrian Neurology Society, International Parkinson Disease and Movement Disorders Society, Elsevier and research grants from the FWF-Austrian Science Fund, Medical University of Innsbruck, Mission MSA and Dr Johannes and Hertha Tuba Foundation, outside of the present work. F.S.D. has nothing to disclose. C.B. reports fees for lectures and/or honor boards from AbbVie, Bial, Desitin, Kyowa Kirin, Merz, STADA Pharma, TAD Pharma, UCB, Zambon. He has received royalties from Thieme Press and Kohlhammer Press and reports funding from Hilde-Ulrichs-Stiftung für Parkinsonforschung.F.K. received personal fees from Institut de Recherches Internationales Servier, AbbVie, Takeda Pharmaceuticals, Sanofi, Teva, and Bial in the past 12 months, and he has ongoing grant support from the Austrian Science Fund (FWF) and the National Institutes of Health, outside of the submitted work. W.H. has nothing to disclose. C.W. has received honoraria for presentations or advisory boards from Abbvie, Bial, Licher MT, Stada, and UCB, outside of the present work. D.W. has received honoraria for presentations/advisory boards/consultations from Abbvie, UCB, STADA, Bial, Zambone, Esteve, outside of the present study. WHJ has received honoraria for presentations/advisory boards/consultations from Abbvie, Bial, Merz, Stada, Zambon, outside of the present study. C.T. has received funding from the DLR (German Research Association) by ERA-Net Project BRAVA (EU-Grant) outside the present study. She has received honoraria for presentations/advisory boards/consultations from Abbvie, UCB, STADA, Bial, Roche, Boehringer Ingelheim Pharma, Convatec, Esteve, Ono Pharmaceuticals outside the present study. She has received royalties from Thieme Publisher and licence fees for Parkinson Disease Sleep Scale-2. She has received travel stipends from the Movement Disorder Society. She serves as an editorial board member for Sleep Medicine. G.H. received research support from Abbvie, UCB; has ongoing research collaborations with Roche, UCB, Abbvie; serves as a consultant for Abbvie, Alzprotect, Amylyx, Aprinoia, Asceneuron, Bayer, Bial, Biogen, Biohaven, Epidarex, Ferrer, Kyowa Kirin, Lundbeck, Novartis, Retrotope, Roche, Sanofi, Servier, Takeda, Teva, UCB; received honoraria for scientific presentations from Abbvie, Bayer, Bial, Biogen, Bristol Myers Squibb, Kyowa Kirin, Pfizer, Roche, Teva, UCB, Zambon. He holds a patent (Höglinger GU, Höllerhage M, Rösler T. Treatment of Synucleinopathies. United States Patent No.: US 10,918,628 B2, Date of Patent: Feb. 16, 2021; and European Patent No.: EP 17 787 904.6–1109 / 3 525 788). He received publication royalties from Academic Press, Kohlhammer, and Thieme. He was funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) under Germany’s Excellence Strategy within the framework of the Munich Cluster for Systems Neurology (EXC 2145 SyNergy – ID 390857198); the German Federal Ministry of Education and Research (BMBF, CurePML EN2021-039, JPND consortium SynOD, 01ED2405A); European Joint Programme on Rare Diseases (Improve-PSP); Deutsche Forschungsgemeinschaft (DFG, HO2402/18-1 MSAomics); and participated in industry-sponsored research projects from Abbvie, Biogen, Biohaven, Novartis, Roche, Sanofi, UCB.

Figures

Fig. 1
Fig. 1
Algorithm for treating pain in PD. Reproduced with permission from Journal of Parkinson’s disease, vol. 10, no. s1, pp. S37–S48, 2020
Fig. 2
Fig. 2
Symptoms and causes of sleep disturbances in PD. RLS restless legs syndrome
Fig. 3
Fig. 3
Diagnostic algorithm for sleep problems and excessive daytime sleepiness in PD. ESS Epworth Sleepiness Scale, MSLT Multiple Sleep Latency Test, MWT Maintenance of Wakefulness Test, PDSS-2 Parkinson’s Disease Sleep Scale-2, vPSG video-supported polysomnography
See this image and copyright information in PMC

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