Symptom	Agents for management	Considerations for use
Constipation	Probiotics Polyethylene glycol (Miralax) Lubiprostone (Amitiza)	Lifestyle modifications are first-line choice with diet, adequate fluid intake, and activity or exercise; most patients will need drug therapy in addition to lifestyle modifications Polyethylene glycol is a good first-line agent Administer lubiprostone for patients who do not respond to lifestyle modifications, polyethylene glycol, or probiotics Most patients with Parkinson disease need multiple agents to manage constipation as disease progresses
Daytime somnolence and sleep attacks	Modafinil (Provigil)	Review annually for effectiveness and adverse effects Should review dose of dopamine agonists because they can contribute to sleep attacks
Dementia	Acetylcholinesterase inhibitors	Rivastigmine (Exelon) has the most data on use in later stages of Parkinson disease No data support the effectiveness of memantine (Namenda) in Lewy body–associated dementia
Depression	Serotonin-norepinephrine reuptake inhibitors Selective serotonin reuptake inhibitors Tricyclic antidepressants	Use drug therapy in combination with cognitive behavior therapy Serotonin-norepinephrine reuptake inhibitors are preferred based on current data May have antidepressant effects from use of agents to manage motor symptoms (monoamine oxidase-B inhibitors, dopamine agonists)
Drooling	OnabotulinumtoxinA (Botox) injections, glycopyrrolate	Nonpharmacologic interventions (e.g., speech therapy) should be tried first
Erectile dysfunction	Sildenafil (Viagra)	—
Insomnia	Melatonin, ramelteon (Rozerem)	—
Orthostasis	Midodrine, fludrocortisone	Adjust hypertension medications and try nonpharmacologic lifestyle interventions first Adjust motor therapies for Parkinson disease when possible (e.g., dopamine agonists, anticholinergics) May consider adding drug therapy specifically for orthostasis if other options are ineffective
Psychosis	Quetiapine (Seroquel), clozapine (Clozaril), pimavanserin (Nuplazid)	Start with lower doses and titrate slowly because the patient may be more sensitive to effects (effectiveness and safety) Clozapine is reserved for patients who are intolerant or who have a poor response to other options because of the safety profile
Rapid eye movement sleep disorder	Clonazepam (Klonopin), melatonin	Start low and titrate slowly because the patient may be more sensitive to clonazepam effects (safety) Melatonin may be safer and better tolerated than clonazepam
Urinary incontinence	Solifenacin (Vesicare), mirabegron (Myrbetriq)	Start with lower doses and titrate slowly; monitor for urinary retention, dry mouth, and worsening of constipation with solifenacin Mirabegron takes 8 weeks to reach full effect; monitor for increases in blood pressure with mirabegron