In PD, severe EDS needs treatment, and first concurrent medications that may be sedating should be eliminated or reduced (Table 5). Modafinil (100-400 mg/day), a nonaddictive sleep-wake cycle activator, is nonstimulating and the only drug that has shown efficacy in improving EDS in double-blind, placebo-controlled trials (87,88). A seven-week, double-blind, placebo-crossover study of modafinil (200 mg) followed by a four-week open-label extension (200 and 400 mg) study by Adler et al. (88) showed significant improvement in ESS with modafinil and improvement in clinical global impression scores for wakefulness in the open-label arm. Those with high ESS scores and a history of sudden onset of sleep should be advised not to drive alone or long distances. Dopamine agonists when initiated should be titrated up slowly, especially in older patients.
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