Dysautonomia - Symptoms and Approaches to Care
On Monday, October 7, 2024, Parkinson Wellness Projects (PWP) partnered with Dr. Pamela Hutchison, ND, to host Dysautonomia - Symptoms and Approaches to Care. Approximately 80% of people with Parkinson’s disease (PD) experience some form of dysautonomia, often without realizing it. Below are some highlights from her session:
What is dysautonomia?
Also known as autonomic dysfunction or autonomic failure, this is a condition where the autonomic nervous system is improperly performing.
The autonomic nervous system is the part of the nervous system that controls our unconscious bodily processes. It regulates many things including blood pressure, heart rate, digestive and bowel function, blood sugar control, and more.
The autonomic nervous system contains two distinct arms: sympathetic and parasympathetic. The sympathetic nervous system (SNS) is responsible for the body’s fight or flight response. The parasympathetic nervous system (PSNS) is responsible for the “rest-and-digest” body processes.
When in balance, these two systems coordinate their functions. The SNS activates body processes, while the PSNS deactivates or lowers them. That balance is important to the body's well-being and ongoing survival. It is often referred to as the body’s autopilot.
How does dysautonomia present in people with Parkinson’s disease (PD)?
80% of people with PD have dysautonomic symptoms, which are typically under-recognized and under-treated.
Highly variable presentation between patients.
Subject to vacillation with ON and OFF states aka “non-motor fluctuations”.
What are some common presentations?
Constipation
Affects 80% of people with PD.
Diagnosed using Rome IV Criteria (if any two symptoms persist for 6+ months):
Fewer than 3 bowel movements per week.
Straining for over 25% of bowel movements.
Lumpy/hard stools 25% or more of the time.
Incomplete bowel movements, feeling the need to go again.
Need to manually disimpact stool 25% of the time.
Consequences of Constipation
Abdominal discomfort and bloating.
Poor absorption of PD medications like levodopa (causing delayed or missed responses).
Increased risk of Small Intestine Bacterial Overgrowth (SIBO).
Early alpha-synuclein involvement in the gut is an indicator of autonomic pathology in PD.
Constipation may precede motor symptoms by decades, showing PD is a whole-body condition.
Treatment
Lifestyle Modifications
Hydration:
Drink 2 - 2.5 liters of water daily (use 1-liter bottles to track intake).
Add variety with bubbly water, juice, or herbal teas.
People with PD often experience reduced thirst signals, leading to dehydration.
Fiber-rich Foods:
For example: bran fiber, whole wheat products, lentils, beans, brown rice, prunes, prune juice, dried apricots, chia seeds.
Exercise:
Regular (ideally daily) exercise supports bowel function.
Dr. Hutchison recommends you aim for 1 complete bowel movement per day.
Supplements/Medications
Start with fiber supplements (e.g., psyllium husk, Metamucil).
If needed, add emollients (e.g., docusate sodium) or osmotic agents (e.g., magnesium citrate/hydroxide, PEG).
Use bowel stimulants (e.g., senna) as a last resort if no movement in 3+ days.
Probiotics
Medication Review
Work with your ND, NP, MD, or neurologist to identify and adjust medications contributing to constipation.
Common medications that worsen constipation:
Opioids
SSRIs (e.g., fluoxetine, sertraline, citalopram)
Tricyclic antidepressants (e.g., amitriptyline)
Mirtazapine (for sleep/depression)
Alternative agents may be needed.
Gastroparesis
Common in all Lewy body disorders, including PD.
Also called delayed gastric emptying, it slows or stops the movement of food from the stomach to the small intestine.
Symptoms
Nausea, early satiety, gastric retention, abdominal distension.
Consequences
Reduced quality of life (due to nausea, discomfort, and decreased food enjoyment).
Weight loss.
Increased missed or delayed levodopa doses, worsening PD symptoms.
Treatment
Dietary Modifications
Consult a dietitian.
Avoid high-fat, high-fiber, and high-protein meals, as well as large meals (these worsen symptoms).
Dietary goals:
Ensure adequate nutrition.
Make digestion easier.
Liquids are normally emptied faster than solids.
Use smoothies, soups, and blenderized foods to aid digestion.
Focus on low-fat foods and reduce insoluble fiber (e.g., fresh fruits, vegetables).
Soluble fiber or well-cooked, finely blended foods are easier to digest.
Medications
Domperidone (Dopamine 2 antagonist that does not cross the blood-brain barrier).
Taper when discontinuing to avoid emergent depression.
Other options: Prucalopride (may also help with constipation).
Orthostatic hypotension (OH)
Affects 30-50% of people with PD.
Less than 1/3 of those affected are symptomatic (around 16%).
Prevalence increases with age and disease duration:
14% in early stages.
52% in advanced stages or older patients.
Symptoms
Postural lightheadedness or dizziness.
Falls and fainting.
Visual disturbances (e.g., blurred vision).
Fatigue.
Generalized weakness.
Cognitive dysfunction.
Neck pain/discomfort (coat hanger pattern).
Orthostatic shortness of breath (difficulty breathing when standing).
Consequences
Strong independent predictor of falls in PD.
Falls are associated with transient cerebral hypoperfusion due to blood pooling in the lower limbs.
Increased fall risk is present even in asymptomatic patients.
Treatment
Address Aggravating Factors:
Anemia/Iron Deficiency:
Identify and treat low red blood cell count or low hemoglobin.
Ferritin levels should be above 30.
Dehydration:
Ensure regular fluid intake (2-2.5 liters of water daily), spaced out in 250 ml servings.
If OH is worse in the morning, rapidly drinking 500 ml of water can quickly reduce symptoms.
Lifestyle Modifications:
Limit carbohydrate-heavy meals and avoid sugary drinks.
Avoid excessive heat exposure.
Avoid straining during urination or bowel movements.
Increase Salt Intake:
Consume 1-2 tsp salt daily or take 0.5 to 1 g salt tablets.
Use products like:
LMNT (1,000 mg sodium per packet).
Pedialyte (high sodium content).
TriOral rehydration salts.
Dietary Modifications:
Eat smaller, more frequent meals.
Reduce carbohydrate intake.
Limit caffeine, as it acts as a diuretic.
Decrease Nighttime Urination:
Sleep with head elevated (8-12 inches, using a sleep wedge).
Wear Compression Garments:
Abdominal binder (20-40 mmHg), or even Spanx:
Wear before rising in the morning and keep on throughout the day.
Remove at bedtime.
Compression stockings (15-20 mmHg) to improve blood circulation.
Perform Counter Maneuvers:
Contract muscles below the waist for a count of 30 seconds.
Repeat every 10-15 minutes or as needed.
Engage in Physical Activity:
Helps prevent downward spiral and deconditioning.
Consider activities in a pool, on a reclined stationary bike, or using a rowing machine.
Medications
Fludrocortisone:
Expands intravascular volume.
Midodrine, Droxidopa, or Norepinephrine Transporter (NET) Inhibitors:
Increase peripheral vascular resistance.
Consult with your GP, NP, or Neurologist for appropriate medication management.
Urinary Dysfunction
30-40% of people with PD urinary difficulties.
Urinary incontinence is relatively uncommon, with troublesome incontinence developing in only about 15% of individuals.
Symptoms
Frequent urination (overactive bladder).
Urinary urgency (trouble delaying urination once the need is felt).
Treatment
Pelvic Physiotherapy:
Work with a pelvic physiotherapist for resources and management strategies.
Scheduled Urination:
Go to the bathroom every 2-3 hours.
Fluid Management:
Limit fluid intake 2-4 hours before bedtime.
Sleep Positioning:
Use a sleep wedge to improve comfort and reduce urinary urgency at night.
Medications/Additional Treatments:
Flomax/Tamsulosin:
Side effects may include orthostatic hypotension (OH) and dizziness.
Mirabegron (Myrbetriq):
Side effects may include potential hypertension and dyskinesias.
Botox Injection:
Used to weaken bladder muscles.
Risk associated with dysautonomia
In early PD, the rate of dysautonomia is 3 times higher than in healthy age-matched controls, leading to an 8-fold increase in the progression of cognitive deficits.
Orthostatic Hypotension (OH) significantly impacts survival:
10-year survival rate:
PD with OH: 74%
PD without OH: 93%
Represents a 20% difference.
The prevalence of under-recognized dysautonomia in PD is close to 50%.
Dysautonomia is a key driver of:
Healthcare-related quality of life.
Mobility and cognition in PD.
The ability to have a rewarding day.
Cardiovascular autonomic neuropathy, including OH, can contribute to:
Disability and mortality in PD through chronic hypoperfusion and complications from falls and fractures.
OH leads to inadequate blood flow to the brain, increasing the risk of falls by 15-fold.
Dr. Hutchison’s seminar was an opportunity for our participants and their care partners to connect and learn about the latest in Parkinson’s research. Stay up to date with the latest information from PWP events by subscribing to our blog on our website: parkinsonwellness.ca/blog.
As founder of Acacia Health Ltd., Dr. Hutchison focuses her practice on supporting people with neurological disorders, mental health concerns, and complex chronic disorders. She is especially passionate about providing care for people living with Parkinson’s disease. Dr. Hutchison also hosts the podcast, The Well Nurtured Brain, which covers everything from nutrition and exercise to sleep and stress management.