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Parkinson's disease is a progressive disease that worsens over time and, as the disease progresses, so do the complications. The complications become more and more disruptive in the daily life of the patient and impact significantly on quality of life. It is important for the doctor to be aware of these complications by speaking with and observing the patient.

Complications of Parkinson's Disease may include:

• Depression
• Sleep disturbances
• Disturbances of the autonomic nervous system
• Dementia
• Sexual dysfunction
• Emotional disturbances
• Weight loss
• Shortness of breath
• Visual disturbances
• Progressive postural imbalance

Depression

Depression in Parkinson's disease is relatively common and may occur months or years before other Parkinson's disease symptoms are apparent. It is estimated that 25-40% of patients may be affected. The diagnosis can be elusive since symptoms of classic depression (not related to Parkinson's disease) may overlap with symptoms of Parkinson's disease (e.g., mask-face, fatigue, low energy levels). Many symptoms of depression also overlap with symptoms of hypothyroidism (e.g., akinesia, masked face, mood variations) which affects some Parkinson's disease patients. Depression can also appear as a side effect of some Parkinson's disease medications.

There is increasing evidence that depression is part of the disease process of Parkinson's disease. The reduced dopamine level found in Parkinson's disease patients affects the balance of several other neurotransmitters in the brain including serotonin which plays a role in depression.

The symptoms of depression in Parkinson's disease include:

• Depressed mood
• Fatigue
• Reduced energy levels
• Reduced appetite
• Sleep disturbances
• Memory disturbances

Doctors should be especially mindful to probe further into the possibility of depression if the patient complains of fatigue and reduced energy levels.

Sleep Disturbances

Sleep disturbances affect up to 70% of Parkinson's disease patients at varying stages of the disease and with varying intensity. There are several types of sleep related problems most of which arise either as part of Parkinson's disease or as side effects of medication used for treating Parkinson's disease. These include:

• Difficulty staying asleep at night - patients may have no trouble falling asleep but cannot fall back asleep if they wake up during the night. Patients who wake up very early in the morning experiencing tremors or feeling very stiff often have difficulty going back to sleep. This type of disturbance is usually related to the "wearing-off" effect of levodopa and may be helped by readjusting the dose of medication.

• Daytime sleepiness - this can be quite disruptive to quality of life since it affects many daily activities such as driving, reading, or sitting. The patient may take frequent naps during the day often leading to added difficulty sleeping at night. The daytime fatigue can be related either to lack of sleep at night or to side effects of medication.

• REM (rapid eye movement) sleep disorder - the patient physically acts out the dreams that occur during the REM stage of sleep. This can manifest itself in kicking, choking, trying to move as if running, or striking out, potentially injuring a spouse or caregiver sitting or sleeping nearby. Patients with this sleep disorder are at increased risk of developing dementia with Lewy bodies, which is distinct from Parkinsonian dementia that can occur late in the course of Parkinson's disease.

Disturbances of the Autonomic Nervous System