Talking About OFF Episodes: A Guide to Help Your Patients Uncover Their OFF Symptoms

OFF episodes may limit people with Parkinson's disease in varying ways

Patients with Parkinson’s disease (PD) may experience re-emergence or worsening of their PD symptoms associated with OFF episodes at any point in the course of their disease.1 Diagnosis of OFF episodes may be complicated by the heterogeneity of OFF symptoms, which can vary both within individual patients and among patients.2

HCP and Parkinson's Disease (PD) patient discussing OFF symptoms

Identifying symptoms of OFF episodes

Openly discussing specific OFF symptoms and frequently asking direct, proactive questions may help identify patients who are experiencing OFF episodes.3-5 Patients should be routinely asked about OFF episodes in the outpatient, inpatient, and skilled nursing settings.6

Make non-motor symptoms part of the conversation

Non-motor symptoms7:

  • Are common in patients experiencing OFF episodes
  • May be more problematic than motor symptoms

Non-motor symptoms can include a wide range of autonomic, sensory, and cognitive symptoms; however, recognition of non-motor complications can be difficult.3-5 Questioning patients directly about non-motor symptoms can help identify OFF episodes.3-5

Asking about OFF episodes

Here are some examples of open-ended, probing questions you might ask to help elicit a more complete clinical picture of your patients’ OFF episodes.

Ask...

    • What does your best “ON” feel like?
    • During which periods of the day do you feel your best “ON?”
    • Do you typically plan your activities around the times you feel "ON"?
    • Before your next dose is due, do your symptoms come back?
    • First thing in the morning, are you stiff and slow?
    • Is your response to your PD medication the same throughout the day?
    • Are you taking your medication because the clock says it is time? Or do your symptoms prompt you to take your medication?
  • Ask questions about cognitive and behavioral non-motor symptoms, such as:

    • Do you feel tired, anxious or depressed?
    • Do you experience mood swings or sudden/intermittent confusion?

References

  1. Stocchi F, Antonini A, Barone P, et al; DEEP study group. Early DEtection of wEaring off in Parkinson disease: the DEEP study. Parkinsonism Relat Disord. 2014;20:204-211.
  2. Stacy M, Bowron A, Guttman M, et al. Identification of motor and nonmotor wearing-off in Parkinson’s disease: comparison of a patient questionnaire versus a clinician assessment. Mov Disord. 2005;20:726-733.
  3. Hillen ME, Sage JI. Nonmotor fluctuations in patients with Parkinson's disease. Neurology. 1996;47:1180-1183.
  4. Raudino F. Non motor off in Parkinson’s disease. Acta Neurol Scand. 2001;104:312-315.
  5. Witjas T, Kaphan E, Azulay JP, et al. Nonmotor fluctuations in Parkinson’s disease: frequent and disabling. Neurology. 2002;59:408-413.
  6. Parkinson’s Disease Quality Measurement Set Update. American Academy of Neurology Web site. November 2015. https://www.aan.com/siteassets/home-page/policy-and-guidelines/quality/quality-measures/16pdmeasureset_pg.pdf. Accessed February 20, 2018.
  7. Jankovic J. Motor fluctuations and dyskinesias in Parkinson’s disease: clinical manifestations. Mov Disord. 2005:20(suppl 11):S11–S16.
  8. Obering CD, Chen JJ, Swope DM. Update on apomorphine for the rapid treatment of hypomobility (“off”) episodes in Parkinson's disease. Pharmacotherapy. 2006;26:840-852.