Fact Sheets

Managing "Off" Time in Parkinson's

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Medications play a key role in managing Parkinson’s disease (PD) symptoms. Over time, the effects of each dose may not last as long. This can lead to "off" periods, when symptoms return between doses. There are steps you and your doctor can take to help reduce "off" time.

Quick Facts

In Parkinson’s, dopamine‑producing brain cells are gradually lost.
Dopamine helps control movement, mood and other functions.
Many PD medications replace, boost or work like dopamine.

What is "off" time?

"Off" time refers to periods when Parkinson’s symptoms return or worsen between doses. Symptoms may come back gradually or feel like a switch turning off as medication levels drop.

Signs of "Off" Time:

Moving more slowly than usual
Feeling stiff or tight
Tremor returning or getting worse
Shuffling or shorter steps
Feet feeling "stuck" to the floor (freezing)
Muscle cramps or twisting
Feeling anxious or uneasy
Restlessness
Low mood or irritability
Feeling very tired
Trouble thinking clearly ("brain fog")
Pain or discomfort
Sweating

What causes "off" time?

"Off" time can happen for several reasons:

Less dopamine available
As Parkinson’s progresses, the brain has less dopamine. Because of this, the same medication amount and schedule may not last as long, and symptoms can return between doses.
Shorter, less steady medication effects
Over time, the brain becomes less able to store and release dopamine steadily. This means each dose may not provide the same smooth, long‑lasting symptom relief it once did.
Food and digestion
High-protein or large meals, along with constipation or slow digestion, can make medication work more slowly or less effectively.
Daily factors can play a role
Stress, poor sleep, infection or changes in routine can affect symptoms and how medicine works. This may lead to "off" periods.

When do "off" periods occur?

"Off" periods are not the same for everyone. Most happen at the end of a dose, when medicine wears off, but others may happen suddenly or at unpredictable times.

How is "off" time managed?

There are several ways to help reduce "off" periods:

Track Symptoms
Keep a record of your symptoms and any factors that may affect them, like stress, activity or digestion. This can help you, your care partner and your doctor spot patterns and talk about possible treatment changes.

Manage Meals and Digestion
If food affects how your medication works, talk with your doctor about timing. Taking levodopa 30–60 minutes before meals or about an hour after eating may help. You may also need to manage constipation or slow digestion.

Adjust Medications
Your doctor may suggest changes to help reduce "off" time. This may include adjusting the timing or amount of your Parkinson's medications, using longer-acting options, adding other medications that help levodopa last longer or boost dopamine or using a quick-acting medicine for sudden "off" periods.

Finding the right balance between symptom relief and side effects can take time. For example, increasing levodopa may help reduce "off" time but can also lead to side effects, such as dyskinesia (extra, involuntary movements), dizziness (often due to drops in blood pressure) or nausea. Work closely with your doctor or a movement disorder specialist (a neurologist with extra training in Parkinson’s) to find options that work for you.

Explore Advanced Treatments
If standard medications aren’t enough, your doctor may discuss advanced options, such as continuous pump medications, deep brain stimulation or focused ultrasound.

Tips for Managing "Off" Time

Take medications on time. Staying on schedule helps reduce unpredictable "off" periods. Timers or phone alarms can help.
Manage stress. Techniques like deep breathing, yoga or meditation can help reduce symptom fluctuations.
Plan activities around your medication. Save outings or bigger tasks for when your medication is working well.

Books

Medications: A Treatment Guide to Parkinson’s Disease

The information included here will explain the types of medications available to manage motor and non-motor symptoms in the hopes that it will help you to work with your Parkinson’s specialist to find the right balance of medications to help you live well with Parkinson’s.

This book is only available digitally to view, download or print. It is also available in a Kindle format.

Books

Managing PD Mid-Stride: A Treatment Guide to Parkinson's Disease

If managing your Parkinson’s has become more challenging than it used to be, the book Managing Parkinson’s Mid-Stride: A Treatment Guide to Parkinson’s is for you. This book explains why symptoms may get better and worse throughout the day and how to treat and cope with them. Find answers and read tips and stories that can help.

This book is only available digitally to view, download or print. It is also available in Kindle and audiobook formats.

Podcasts

Episode 5: How to Manage Parkinson’s “Off” Time

Parkinson’s can be unpredictable – symptoms can come and go or get better and worse throughout the day. These so-called “on-off” fluctuations (also called motor fluctuations) and dyskinesias can be troubling, but movement disorder specialists can help with the choice of medication, dosages, and timing. Dr. Irene Malaty explains more about what causes these changes and how you can work with your doctor to manage them.

Dr. Malaty is a fellowship-trained movement disorder specialist at the University of Florida in Gainesville, FL. She is the director of the Parkinson’s Foundation Center of Excellence at UF and is site primary investigator of the Parkinson’s Outcomes Project. Additionally, Dr. Malaty is co-director of the Tourette Association of America Southeast Regional Center of Excellence and runs the interdisciplinary Tourette and tic disorders clinic for children and adults. In all these initiatives, Dr. Malaty cares for patients, coordinates team-based care, and promotes clinical research. Dr. Malaty is the director of industry-sponsored trials at UF movement disorders.

Dr. Malaty serves on the executive board of the Florida Society of Neurology, on the executive committee of the American Academy of Neurology Neuroendocrinology Section, as the Movement Disorder Subsection Chair, and on the Tourette Association of America Medical Advisory Board. She has specific interests in the non-motor aspects of Parkinson’s disease and Tourette’s syndrome and in using botulinum toxin to treat neurological conditions. She has written many peer-reviewed articles, is involved in numerous clinical trials in movement disorders, and enjoys lecturing on Parkinson’s disease, Tourette, botulinum toxin administration, dystonia, and other movement disorders.

She studied microbiology and psychology at Indiana University in Bloomington, IN, and attended Indiana University School of Medicine. After completing a transitional year of medicine at St. Vincent’s hospital in Indianapolis, she moved to Gainesville for neurology residency and served as chief resident. She completed a fellowship in movement disorders at the University of Florida and joined the faculty thereafter.

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For all of our Substantial Matters podcast episodes, visit Parkinson.org/Podcast.

Podcasts

Episode 148: How to Prevent Sudden “Off” Episodes

“Off” episodes can become a troubling aspect of Parkinson’s disease (PD), especially as the disease progresses. These are periods in the day when the effect of levodopa medication wears off, either suddenly or gradually, with a return of motor or non-motor symptoms.

The good news is that there are several ways to try to minimize “off” episodes, including medication timing, medication adjustments, and add-on medications. In this podcast episode, Dr. George Kannarkat, a movement disorders fellow at the University of Pennsylvania in Philadelphia, a Parkinson’s Foundation Center of Excellence, discusses “off” episodes, their causes, strategies that people can use today to minimize them, and what new technologies are here or coming along to help lessen them.

Released: April 4, 2023

Dr. George Kannarkat is an MD-PhD trained physician-scientist who is currently finishing his Movement Disorders fellowship at the University of Pennsylvania. After fellowship, he will be staying at the University of Pennsylvania as an Instructor to continue seeing individuals with Parkinson's disease while concurrently working in the lab of Dr. Alice Chen-Plotkin. His research interests are understanding the molecular mechanisms, particularly those outside the brain, that contribute to initiating pathology seen in Parkinson's disease. His ultimate goal is to help develop technologies that identify and treat disease in early or prodromal stages. He completed medical school and his graduate training at the Emory University School of Medicine where he worked in the lab of Dr. Malu Tansey to work on peripheral immune mechanisms of neurodegeneration. He completed his neurology residency at Johns Hopkins Hospital.