Understanding ‘Off’ Times in Advanced Parkinson’s Disease
Neurological DisordersParkinson's Disease

Understanding ‘Off’ Times in Advanced Parkinson’s Disease

Understanding ‘Off’ Times in Advanced Parkinson’s Disease
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Published on January 8, 2026
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Parkinson’s disease, a progressive nervous system movement disorder, weakens and damages nerve cells in parts of the brain. This leads to declining production of brain chemicals, says Karen M. Thomas, DO, a neurologist and the director of the Comprehensive Parkinson's Disease & Movement Disorders Program at Sentara Health in Virginia Beach, Virginia. “The most significant chemical affected is dopamine, which is used by the nervous system and body for many functions, including movement (motor function),” says Dr. Thomas.

The reduction of dopamine production in the brain is what leads to Parkinson’s symptoms, which typically include tremor, repetitive movements, stiffness, and difficulty with balance. In advanced Parkinson’s, these symptoms can get worse and interfere with walking, communication, and everyday self-care tasks.

Medications that treat Parkinson’s disease increase dopamine levels in the brain, mimic dopamine’s effects, or address symptoms directly.

 But some people with Parkinson’s disease experience “off” times: worsened symptoms between doses, when a dose begins to wear off, or when the medication doesn’t work as well as it used to.

How to Reduce 'Off' Times in Advanced Parkinson's

Discover lifestyle tips that can help reduce Parkinson’s off times.
How to Reduce 'Off' Times in Advanced Parkinson's

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What Are Off Times?

Off times, sometimes called motor fluctuations, can happen when Parkinson’s medications don’t work for as long as they once did.

 “These off periods can occur prior to the patient taking their first dose of the day [or] between doses during the day, and can also be unpredictable at times,” says Vikram Shivkumar, MD, a neurologist and researcher at the Orlando Health Neuroscience Institute in Florida.
Over time, many people with Parkinson’s disease stop responding consistently to levodopa — the primary medication for motor symptoms, says Matthew Barrett, MD , a neurologist in the division of movement disorders at Virginia Commonwealth University Health in Richmond and a professor of neurology at VCU School of Medicine. "’On’ time is when medication response is good and motor symptoms are best treated. Off time is when there is loss of response to medication because the blood level of levodopa drops.”

Besides a change in response to the medication, other factors can also affect how well it works, says Thomas. “[These] include stomach and intestinal function, constipation, protein intake, hydration, stress, sleep level, and activity level.”

People experience off times differently, but many report symptoms like:

  • Stiffness
  • Foot cramping
  • Increased tremors
  • Problems with walking
  • Sudden episodes of increased difficulty moving

Some also report symptoms unrelated to movement, says Dr. Barrett. “These nonmotor off symptoms vary and can include anxiety, mood disturbances, pain, or autonomic symptoms like sweating or gastrointestinal discomfort.”

“Off time can become very bothersome and interfere with function when severe,” says Thomas. But you have options to manage it.

How to Talk to Your Doctor About Off Times

If you experience off times, sharing information with your healthcare team can help them create a plan to resolve your symptoms. “It is important that patients report off periods to their neurologist, since there are many options currently available to address these episodes,” says Dr. Shivkumar.

Keep a symptom diary every day, and note what you feel and when you feel it. Mark down the times you take your medicines alongside these observations, plus anything that may have triggered your symptoms, like a stressful event, physical activity, or constipation.

It can also help to bring a caregiver with you to your appointments — they can help you remember symptoms and their timing and offer a valuable outside perspective.

At your visit, your provider may ask these questions about your off times:

  • When do they happen?
  • Do they come on slowly or suddenly?
  • How long do they last?
  • How do they affect you, physically and emotionally?

Treatment for Parkinson’s Off Times

“We use various strategies to treat off time,” says Shivkumar. These may include medication regimen changes, rescue medications, diet adjustments, and deep brain stimulation.

Medication Adjustments

If your Parkinson’s medication doesn’t work as well as it used to, you have a few options. “Medication adjustment is needed throughout the course of Parkinson’s, and some changes can help with off times,” says Thomas, whose treatment goal is to smooth out medication effects over the course of the day.

“[We can add] another medication to help the levodopa last longer or to work in a different way to help smooth out symptoms,” says Thomas. “Examples of these include entacapone (Comtan) or opicapone (Ongentys), rasagiline (Azilect), istradefylline (Nourianz), or amantadine (Symmetrel, Gocovri, Osmolex ER), among others.”

Instead of adding medications, your provider may recommend a change to a combination type of levodopa, like using immediate release and the extended release forms together, says Thomas.

“We can also switch to the recently approved subcutaneous infusions, which are similar to insulin pumps used in diabetes,” says Shivkumar. These pumps deliver medications at a continuous rate to minimize off periods.

Rescue Medications

Parkinson’s rescue medications can help bridge the gap until the next dose, says Shivkumar. For example, you can take Inbrija (an orally inhaled form of levodopa) up to five times a day for off episodes.

 This inhaled levodopa works especially well if your off episodes are unpredictable, says Barrett.

Diet Changes

As part of your treatment, your provider may recommend changes in diet or meal timing. “Some patients might experience reduced efficacy of medication if taken along with meals, as proteins can affect the absorption,” says Shivkumar, who recommends that patients take their dose one hour before or two hours after meals.

Some supplements or multivitamins, especially those high in iron or calcium, can also affect levodopa absorption, so it’s important to let your care team know if you are taking these supplements.

Surgery

If medication adjustments or dietary changes don’t resolve your off times, your provider may recommend surgery to place a tube in part of your intestine.

 Through this tube, you can take levodopa-carbidopa intestinal gel continually to keep your levels stable and reduce off times.

Another surgical option is deep brain stimulation, which can reduce off time in individuals whose motor fluctuations are difficult to manage with medications alone, says Barrett. Deep brain stimulation involves the placement of an electrode into the brain attached to a battery pack placed under the skin of your chest. When the electrode is on, it painlessly blocks signals that cause Parkinson’s symptoms.

Lifestyle Measures to Reduce Off Times

Treating Parkinson’s always includes nonmedication strategies, because no medication is completely effective, says Thomas. “These [approaches] involve some adjustments in lifestyle for many patients but can provide significant benefit overall.”

  • Manage stress. In one study of more than 2,000 people, most reported that coping strategies like exercise, meditation, and removing themselves from stressful situations improved this off time trigger.

  • Stay hydrated. When you drink enough fluid, your body absorbs pills more effectively. Try to drink between 9 and 13 cups of fluids per day, and watch for signs of dehydration like dark urine and dry mouth or skin.

  • Prevent constipation. Hydration, along with a fiber-rich diet, prevents constipation, a bowel symptom that can make Parkinson’s medications less effective.

     You can get fiber from foods like whole grains, beans, leafy green vegetables, and berries.

  • Get good sleep. “Poor sleep can worsen motor symptoms and response to medication during the day,” says Thomas. It can be hard to get a solid night’s sleep with Parkinson’s, so be sure to let your provider know if you need help getting enough rest.

  • Time your protein intake. For some, protein can interact with levodopa, limiting how well you absorb it, says Barrett.

     “[But] it's important not to avoid or reduce protein intake,” Barrett adds. “Timing of protein intake can usually effectively deal with this interaction.”
  • Stay active. Adding exercise to your routine, like yoga, walking, cycling, or swimming, can improve flexibility, balance, and strength when you have Parkinson’s.

     “While aerobic exercise may not directly reduce off times, it almost certainly could blunt their impact by improving motor symptoms overall,” says Barrett.

The Takeaway

  • Parkinson's disease off times happen when medications work for shorter periods, causing increased symptoms between doses.
  • To treat off times in Parkinson’s, your provider may recommend medication changes, medication add-ons, dietary adjustments, or surgical options.
  • To maximize your medication effectiveness and lessen Parkinson’s symptoms, try to manage stress, get enough sleep, prevent constipation, drink plenty of fluids, and stay active.

Resources We Trust

EDITORIAL SOURCES
Everyday Health follows strict sourcing guidelines to ensure the accuracy of its content, outlined in our editorial policy. We use only trustworthy sources, including peer-reviewed studies, board-certified medical experts, patients with lived experience, and information from top institutions.
Resources
  1. Parkinson's Disease. National Institute of Neurological Disorders and Stroke. March 5, 2025.
  2. ''Off'' Time in Parkinson’s Disease. The Michael J. Fox Foundation for Parkinson’s Research.
  3. Motor Fluctuations or "OFF" Times in Parkinson's Disease. Stanford Parkinson's Community Outreach. October 2025.
  4. Mantri S et al. The Experience of OFF Periods in Parkinson’s Disease: Descriptions, Triggers, and Alleviating Factors. Journal of Patient-Centered Research and Reviews. July 2021.
  5. Managing "Off" Time in Parkinson's. Parkinson's Foundation.
  6. You Don’t Have to Have “Off” Times with Parkinson’s. Davis Phinney Foundation. June 11, 2021.
  7. Fabbri M et al. Off-time Treatment Options for Parkinson’s Disease. Neurology and Therapy. January 2023.
  8. Inbrija: Prescribing Information. U.S. Food and Drug Administration. December 2018.
  9. Levodopa. Parkinson’s Foundation.
  10. Levodopa. Global Library of Women’s Medicine.
  11. Katzenschlager R et al. Continuous Subcutaneous Infusion Therapies in Parkinson’s Disease: Evidence of Efficacy and Safety. Parkinsonism & Related Disorders. September 2025.
  12. Hydrating for Health. U.S. Department of Health and Human Services. May 2023.
  13. Constipation. The Michael J. Fox Foundation for Parkinson’s Research.
  14. Food Sources of Dietary Fiber. U.S. Department of Agriculture. 2019.
  15. Stefani A et al. Sleep in Parkinson’s Disease. Neuropsychopharmacology. January 2020.
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Sneha Mantri

Sneha Mantri, MD, MS

Medical Reviewer

As the Parkinson’s Foundation first-ever chief medical officer, Sneha Mantri, MD, MS, leads medical and clinical care efforts, guiding the Foundation’s care portfolio and strategy to ensure impactful, sustainable initiatives.

Dr. Mantri is a practicing movement disorders specialist with extensive training and experience. She completed her medical education at Columbia University, residency at the University of Virginia, and a movement disorders fellowship at the University of Pennsylvania and Philadelphia VA Medical Center.

She brings her patient-centered philosophy to the Parkinson's Foundation, emphasizing that people come before their diagnosis and that Parkinson’s care must be personalized.

Throughout her career, Mantri has focused on building collaborations and expanding outreach to rural communities while raising Parkinson’s awareness in the medical field.

She developed collaboration with the Margolis Institute for Health Policy through the Duke Clinical Leadership Program in 2024 and participates in a PBS-NC panel discussion for her integrated, interprofessional care model.

She serves as a Macy Faculty Scholar, currently working to expand humanistic and community-engaged practice nursing, and physical and occupational therapy. She has also been leading THRIVE-PD since 2019, an early-intervention team-based care model for people with Parkinson's across the Carolinas.

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Abby McCoy, RN

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Abby McCoy is an experienced registered nurse who has worked with adults and pediatric patients encompassing trauma, orthopedics, home care, transplant, and case management. She is a married mother of four and loves the circus — that is her home! She has family all over the world, and loves to travel as much as possible.

McCoy has written for publications like Remedy Health Media, Sleepopolis, and Expectful. She is passionate about health education and loves using her experience and knowledge in her writing.

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