Parkinson’s disease symptoms can vary in intensity over the course of a person’s life and, for some, throughout the day. Often, worsening symptoms are linked to medications wearing off, though other potential causes exist.

Parkinson’s disease is a brain disorder characterized by uncontrollable muscle movements, including stiffness, balance and coordination issues, and shaking. Symptoms typically start out mild and worsen over time.

Some people may notice that their symptoms worsen or improve throughout the day. This may be due to a few different factors, but it is often the result of medication wearing off.

This article reviews when Parkinson’s symptoms may worsen, what “off” episodes are, ways to manage them, and more.

An older male sitting at a table in the evening. Parkinson's disease symptoms may worsen at different times of the day.Share on Pinterest
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Some people with Parkinson’s disease may notice that their symptoms worsen in the morning, while others may not notice any changes at all. Often, symptoms worsen over the course of a day due to what are known as “off” episodes.

“Off” episodes are when the motor or non-motor symptoms of Parkinson’s occur between medication doses. They can start suddenly or start gradually.

The primary medication for Parkinson’s disease is levodopa, which is available under the brand name Sinemet when mixed with the drug carbidopa. It works to decrease Parkinson’s symptoms by increasing dopamine in the brain.

When levodopa wears off, a person can experience a return of their motor or non-motor symptoms.

A person may experience morning akinesia (a loss of ability to move muscles voluntarily) because their previous dose of Parkinson’s medication has worn off or started to wear off. It is also common for people to experience morning bradykinesia (slowness of movement) due to levodopa wearing off.

Learn more about the signs and symptoms of Parkinson’s disease.

It is possible for a person to experience an “off” episode in the evening if their medication starts to wear off.

Parkinson’s is also associated with sleep issues. For some, sleep disturbances can develop before the start of movement or other symptoms associated with Parkinson’s and may be an early warning sign.

Several sleep disorders are associated with Parkinson’s. They include:

  • REM sleep behavior disorder (RBD): This occurs when a person’s muscles act out the movements in their dreams. It can be the earliest symptom for some people with Parkinson’s.
  • Insomnia: This is the inability to fall asleep or stay asleep.
  • Sleep apnea: This condition causes a person to temporarily stop breathing while sleeping. Obstructive sleep apnea is the most common type, where part of the airway collapses and obstructs breathing at night.

“Off” episodes may occur during the day due to Parkinson’s medication wearing off. They may also occur if a person misses a dose or takes a dose incorrectly during the day.

Symptoms may come on suddenly or gradually. A person may find that keeping a record of when their symptoms come on and how quickly they arise may help when speaking with a doctor about their treatment progress.

A person may also experience worsening symptoms due to anxiety. Anxiety can cause a person’s symptoms to worsen by decreasing the efficacy of Parkinson’s medication.

Learn more about treatment options for Parkinson’s disease.

Levodopa is the primary treatment for Parkinson’s disease, but long-term use may cause involuntary movements in some people. This is known as levodopa-induced dyskinesia (LID).

Symptoms may appear during the peak of a levodopa dosing cycle, known as peak-dose dyskinesia. They can also occur immediately before or after a person takes a dose.

Dyskinesia may present as:

  • Chorea: These are brief, irregular muscle contractions or twisting and writhing movements.
  • Ballism: A severe form of chorea with an involuntary flinging of the limbs.
  • Stereotypy: Random and repetitive movements and sounds.

Risk factors for developing LID include:

  • higher levodopa dose
  • younger age at the onset of Parkinson’s disease symptoms
  • worse disease severity

“Off” episodes can appear differently for everyone. A person may only experience a minor, slow onset of symptoms that indicates they are nearing their next dose, or they may experience a sudden onset of severe symptoms.

A person can take steps to help alleviate their symptoms or prevent them from occurring.

Morning bradykinesia and akinesia

Morning bradykinesia and akinesia occur when a person’s motor or non-motor symptoms worsen before the first dose of levodopa in the morning.

Around 60% of people with Parkinson’s disease experience morning bradykinesia. People with a long history of motor issues or at advanced stages of Parkinson’s have the highest risk of morning akinesia.

A person may be able to manage morning bradykinesia and akinesia by:

  • taking extended-release levodopa
  • tweaking the timing and dose of levodopa
  • eating smaller meals with lower fat and lower protein

Levodopa-induced dyskinesia

There are several treatment options that healthcare professionals may use to help prevent or manage involuntary movements brought on by levodopa use. These include:

  • delaying the introduction of levodopa in early disease onset until symptoms cannot be managed by other therapies or medications
  • taking amantadine, a medication used to treat dyskinesia
  • shortening the interval between levodopa doses
  • taking extended-release levodopa

Learn more about the stages of Parkinson’s.

Sleep problems

Treatment for sleep issues will vary based on the exact cause of a person’s sleep disturbance. Some possible treatments and management strategies include:

‘Off’ episodes

Similar to morning akinesia, a person who experiences “off” episodes during the day may benefit from:

  • eating smaller, more frequent meals throughout the day
  • making changes to their medication dosing and timing
  • eating less protein and high fat foods

A person who experiences worsening Parkinson’s symptoms throughout the day or at different points in the day may find it helpful to keep a record of the events. A person can record the following:

  • when symptoms occur
  • the severity of symptoms
  • how quickly symptoms come on

This information may help a doctor determine the best way to address the issues. It could involve changing medication doses or timings to help keep the medication from wearing off.

People may also want to speak with a healthcare professional if they experience sleep issues, such as insomnia or excessive movements at night. They can help determine the cause and provide suggestions on treatment.

It is also best to speak with a healthcare professional about stress levels, since these can affect a person’s symptoms.

Learn more about the early signs and symptoms of Parkinson’s.

Parkinson’s symptoms can worsen during the day. Often, this is due to medication wearing off, but stress can also contribute to worsening symptoms.

A person may address the issue by making changes to their medications and diet, such as eating less protein and fat and eating smaller, more frequent meals throughout the day.