Why Parkinsonian Symptoms Can Worsen During the Day

Parkinsonian symptoms can get worse at certain times, and many people have good days and bad days with Parkinson's disease. While symptoms can fluctuate naturally, patients can also experience periods where their medication doesn't work as effectively as usual, typically when they've been taking it for a long time. Some people with Parkinson's disease find that their symptoms are worse due to the decreased effects of levodopa medication (known as OFF periods) that occur over time. Let’s look at why this happens and explore ways to treat daytime Parkinsonian symptoms.

Why Are Parkinsonian Symptoms Worse in the Morning?

Most patients with advanced Parkinson’s disease experience fluctuating symptoms, known as ON and OFF episodes, when they take medications such as carbidopa/levodopa. When you first take a dose, you may experience an ON episode where you are energetic and able to move around freely. OFF episodes can occur when you're waiting for your next dose of medication, resulting in a marked decline in physical ability and a returning of symptoms.

Some people find that Parkinsonian symptoms are worse in the morning. The medical term for the daytime worsening of Parkinsonian symptoms is “morning akinesia," affecting around 60% of Parkinson’s patients. OFF episodes occur when levodopa medications become less effective over time, resulting in motor fluctuations. These periods usually start first thing in the morning after a treatment-free night.

Why Do “OFF” Episodes Happen During the Day?

There are various reasons why you might experience OFF episodes in the morning or during the day. A period is termed an OFF episode when levodopa plasma concentration decreases, causing the medication to wear off temporarily and symptoms to return. According to a 2011 study, daytime OFF episodes reflect the “natural dopaminergic decline with insufficient nighttime storage of the dopaminergic system during sleep.”

In other words, your body naturally struggles to produce dopamine at night, which leads to inadequate stores of dopamine during the day. As we know, it is primarily the loss of dopamine cells in the brain that causes PD motor symptoms, and this is what levodopa/carbidopa intends to treat. Unfortunately, the medication stops being as effective over time (usually three to five years), causing patients to experience more OFF than ON episodes. Daytime worsening of Parkinsonian symptoms can also be caused by nighttime stress or sleep disturbances in Parkinson's patients.

Tips for Dealing with Morning Akinesia

Depending on the severity of your Parkinsonian symptoms, morning akinesia can make it difficult to dress, bathe, use the toilet and prepare breakfast for yourself. Here are some tips to help you deal with morning akinesia and the worsening of PD symptoms:

• Talk to your doctor about shortening the time between doses. You should never make changes to your medication schedule without advice from a professional, but your doctor may suggest reducing your interval between doses by 30 to 60 minutes, especially if you have advanced Parkinson’s.
• Ask to change your levodopa medication. Some people with Parkinson’s disease respond well to different forms of levodopa medication, such as controlled-release L-dopa. Your doctor may also recommend adding a medication such as dopamine agonists or MAO-B inhibitors, to reduce your OFF episodes.
• Make things as easy as possible. You have an advantage if you know when your OFF episodes occur, so take this as an opportunity to make things easier on yourself. Lay out clothes to wear the night before (ideally comfortable items with no fiddly buttons or laces) and prepare your breakfast items for the next morning. It may be helpful to avoid cooking hot meals during your OFF periods if you experience tremors or frozen gait as this can lead to accidents.
• Take your medication as soon as you wake up. Store your medicine next to your bed so you can take it last thing at night and first thing in the morning. If you take multiple pills, make sure you discuss the best way to space your doses with your doctor.
• Ask for help. Depending on the stage of your Parkinsonian symptoms, you may need help looking after yourself when your OFF periods occur. If you live with a partner or family member, be sure to ask for additional support during these episodes, and don't be afraid to ask for what you need. If you live alone and are struggling with day-to-day life, talk to your doctor about your care options.

Most patients who experience morning akinesia are in the advanced stages of Parkinson's disease, meaning their Parkinson's symptoms are more pronounced. At this point, your doctor may suggest a different combination of medicines or see if you are eligible for surgery. If you know your Parkinsonian symptoms are worse in the morning, it's important to seek the help you need to take care of yourself and stay safe.

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