Table 5.

Treatment options for the NMS in atypical parkinsonian syndromes

Symptom	Treatment options
Constipation	1. Increase fibre in the diet and rehydration 2. Lactulose or Macrogol or Senna
Excessive day time sleepiness	1. Investigate for and treat any underlying cause first 2. Modafinil (avoid in pregnancy)
Orthostatic hypotension	1. Review and address pharmacological causes 2. Support stocking and increase salt/fluid intake 3. Fludrocortisone 4. Midodrine
Pain	1. Investigate for and treat any underlying cause first 2, Pregabalin or Gabapentin or Duloxetine
Urinary urgency or incontinence	1. Investigate for and treat any underlying cause first 2. Trospium or Solifenacin for overactive bladder 3. Intermittent self-catheterization if underactive bladder
Restless legs	1. Treat iron deficiency and look for secondary causes 2. Ropinirole or Pramipexole or Rotigotine
Anxiety	1. Cognitive behavioural therapy 2. Low dose anti-depressant (SSRI or TCA)
Depression	1. Cognitive behavioural therapy 2. Low dose anti-depressant (SSRI or TCA)
Hallucinations and delusions	1. Investigate for and treat any underlying cause first such as UTI causing delirium 2. Quetiapine if no cognitive impairment 3. Rivastigmine if coexistent dementia
Psychosis	1. Investigate for and treat any underlying cause first such as medication overdose 2. Quetiapine or Clozapine
Impulse control disorders	1. Withdrawal of any dopamine agonists (DA) (done gradually to avoid DA withdrawal syndrome)
REM sleep behavior disorder	1. Clonazepam 2. Melatonin
Dementia	1. Investigate for and treat any reversible cause first 2. Cholinesterase inhibitor (e.g. Rivastigmine)
Sialorrhoea	1. Using handkerchief to wipe excess saliva 2. Speech and language therapy 3. Glycopyrronium or Atropine drops 4. Botulinum toxin injections into salivary glands