Category Archives: Parkinsons Disease

Learn about the disease, diagnosis, symptoms and changes over time

Impulsive behaviors and activities- What is the cause?


gamblingImpulsivity control problems are experienced in some individuals with Parkinson’s disease. This article will define these problems, discuss potential causes and provide information about the steps you can take if you are experiencing any of these problems.

What are impulse-control behaviors? Impulse-control behaviors include a reduced ability to resist impulses and an increase in behaviors that impair social or occupational functioning. Common behaviors include an increase in risk-taking activities, compulsive gambling, overeating, compulsive shopping or overspending, and hyper-sexuality.

Repetitive behaviors, such as compulsive manipulating or sorting of common objects, are referred to as “punding” when they are driven by a sense of desire or when the possibility of pleasure is associated with the activity. These behaviors are similar to ritualistic behaviors performed to reduce anxiety, as seen in obsessive-compulsive disorder.

If left untreated, these behaviors can result in such negative consequences as serious financial loss, legal difficulties, excessive weight gain, and social and relationship difficulties

Medication and impulse control.

Research supports a link between the use of dopaminergic medicines and problematic impulse-control behaviors in Parkinson’s disease. Dopaminergic medications are, of course, the primary treatment for Parkinson’s. Although all dopaminergic medicines have been linked to problems of impulse control, these problems are more frequent and more clearly associated with the use of dopaminergic agonists.

The most commonly prescribed dopaminergic agonists are ropinirole, rotigotine,  and pramipexole (Requip, Neupro and Mirapex).

It is not known how common impulse-control problems are in Parkinson’s patients because behaviors are difficult to measure and may not be reported.

These medications stimulate dopaminergic pathways in the brain that both regulate behavior and are a part of our reward and pleasure systems. This suggests a physiological link between dopamine and reward or novelty seeking activities and addictive and compulsive behaviors.

It is not known how common impulse-control problems are in Parkinson’s patients because these behaviors are difficult to measure and may not be reported by patients. One study found that the lifetime occurrence of pathologic compulsions (including shopping, hyper-sexuality and gambling) was about 6 percent in the normal population, a rate that increased to almost 14 percent in Parkinson’s patients taking dopamine agonists.

Who’s at risk? There is no clear way to predict who will experience impulse-control problems associated with medications; these side effects are quite rare for those taking agonists.

However, risk may be greater in patients who are just beginning therapy or in those taking higher doses.

In addition, younger patients, individuals with depression, those with novelty- or risk-seeking inclinations, those with a family history of alcohol abuse or bipolar disorder, and men may be at higher risk for medication induced impulsivity-control problems.

And individuals with prior gambling behaviors (even recreational) are more likely to develop pathologic gambling with dopamine agonists. The following chart was published in the Archives of Neurology Journal in 2010 and  illustrating the presence of these problems.

dominion study

 

What can you do? It can be difficult or embarrassing to admit to these types of behavioral changes.

Because of this, symptoms are likely underreported and may be more common than is realized.

  • Notice changes in behavior that are unusual, out of character for you, lead to a sense of loss of control or interfere with your normal daily activities.
  • Remember these symptoms are not your fault and do not reflect a personal flaw. They are related to an alteration in your brain chemistry and may be corrected with an adjustment to your medication.
  • You may be at greater risk if you have a history of these behaviors. It is important to tell your doctor if you’ve had these problems in the past.
  • Discuss any changes with your doctor. Do not stop taking your medication on your own without consulting your physician.
  • Get help from others. Discuss what you are experiencing with your loved ones. If you require additional support or want to confide in someone outside your circle, talk to a therapist. Behavioral strategies may also be explored and implemented.
  • Keep a list of your past and current medicine. Record the dose and any benefit or side effect experienced.

If you stopped a medicine, record the reasoning. This will help you and your doctor make the best medication choice for you in the years to come. Never change or stop your medicines without discussing this with your doctor or primary care provider.

 

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Top medicines that worsen Parkinson’s disease or cause secondary parkinsonism


Medication Assistance is availableMedications to avoid

Some medications can worsen movement symptoms of PD, including slowness, stiffness, tremor and dyskinesia. These drugs, listed below, are used to treat psychiatric problems such as hallucinations, confusion or gastrointestinal problems, such as nausea. The stress of your illness, hospital stay or new medicines can increase your risk of hallucinations while hospitalized. Common anti-hallucination medicines to be avoided are listed by generic or chemical name followed by the trade name.

Anti-hallucination medicines to avoid

Note: the anti-hallucination medicines Quetiapine (Seroquel) or Clozapine (Clozaril) can be used. The following should be avoided:

  • aripiprazole (Abilify), chlorpromazine (Thorazine), flufenazine (Prolixin), haloperidol (Haldol), molindone (Moban), perphenazine (Trilafon), perphenazine and amitriptyline (Triavil), risperidone (Risperdol), thioridazine (Mellaril), thiothixene (Navane)

Anti-nausea medicines to avoid

  • metoclopramide (Reglan), phenothiazine (Compazine), promethazine (Phenergan)

Medicines to avoid if you are on Rasagiline (Azilect) or Selegiline (Eldepryl)

  • Pain medicines – Meperidine (Demerol), Tramadol (Ultram),Antispasmodic medicine Flexeril , Dextromthorphan and St Johns Wort.
  • This is not a complete list of medicines to avoid. If you have questions about other medications, ask your pharmacist or doctor.

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Is leg pain a symptom of Parkinson’s?


calfLeg pain can be significant and have many causes; some related to Parkinson’s disease, some that increase in frequency with age and others that are more common in both conditions. Here are just a few:

Pain associated with Parkinson’s

  • Off related pain – diffuse aching and/or throbbing pain that increases at end of dopaminergic medicine dosing or when medication levels are low. Unlike joint pain, this pain is often located in the muscle such as the thigh or calf but not the knee of ankle. PD medications can often improve this pain.
  • Restless leg syndrome – uncomfortable sensations most commonly felt in legs that is worse at night and while resting and relieved with movement. See related post on restless leg syndrome for more information.
  • Dystonia-involuntary contraction of muscle. This can be common as a symptom of PD, an off related symptom or as a form of dyskinesia from medication. An example is early morning foot dystonia described as painful cramping of the toes and feet. Botulinum toxin (Botox, Myobloc) therapy can help

Musculoskeletal

  • Arthritis of the knee, hip or ankle typically causes pain in the join and not muscle. Although this is unrelated to PD, arthritic pain can worsen when the natural biomechanics of the joint is altered with PD rigidity, loss of strength and loss of flexible. Physical therapy and anti-inflammatory agents are an important treatment for this and the condition described next.
  • Achilles tendonitis is pain located at the ankle and plantar faciitis is pain located under the sole of the foot. Both conditions can flare with a change in exercise routine, with improper stretching and secondary to the tightness of the ankle and foot often found in PD.

Neuropathic

  • Peripheral neuropathy is caused by nerve damage that begins in the feet. Associated symptoms are pain, burning, numbness and tingling. The most common causes are aging, diabetes, vitamin B12, deficiency, thyroid deficiency and blood protein disorders. this condition not only causes pain but also can worsen balance. Blood tests can help identify the cause of this problem.
  • Radiculopathy or sciatic nerve compression can cause pain in the thigh, calf in foot depending on the nerves affected. Causes could include arthritis and disk disease of the spin and compression of the sciatic nerve in the buttock region due to muscle tightness,
  • Spinal stenosis is a problem of narrowing of the spinal canal. Often associated with back pain and pain in both legs. this type of pain often improves when a person is bent forward.

General Pain

  • Leg swelling can occur with PD, medications and other medical conditions. Abrupt change in leg swelling associated with pain could be a sign of a blood clot requiring immediate medical attention. Lack of movement and dehydration can increase this risk in PD.

This information does not represent all types of pain that can occur. As always, be sure to talk with your healthcare provider if you are experiencing pain in your legs.

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Filed under Non-movement Symptoms, Self-Care, Symptoms, Diagnosis and Progression

Look beyond Parkinson’s when symptoms change quickly


Tremor is one the cardinal symptoms of ParkinsonsAn abrupt change in PD symptoms may be caused by a problem other than PD. Treatment therefore may require a different approach then simply changing Parkinson’s medicines.

In general, Parkinson’s disease is a slowly changing condition, yet you may find that your symptoms change dramatically overnight. If your movement, thinking or cognitive function change dramatically and quickly it may be due to something other than a change in your Parkinson’s disease. The following information helps you and your health care provider find other causes for your recent change:

• A recent addition of Parkinson’s medicine or dose increase can cause confusion.
• Fall with head injury can worsen neurological function.
• Other medicines such as some medicines for Parkinson’s, sleep, emotions, bladder control, pain or muscle spasm can cause confusion.
• Stress. This can include may types of stress- emotional stress, physical stress (including physical pain), medical stress (such as a recent operation and recovery) and even lack of sleep.
• Medical problem. The added stress of another medical condition can significantly worsen Parkinson’s symptoms. Examples include:

  • Bladder infection
  • Dehydration
  • Heart or breathing problems
  • Sleep apnea
  • Pneumonia
  • Other infection

These problems can be treatable and symptom change reversible. Talk to your provider to determine if more testing is needed if you have experienced a rapid change in symptoms.

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Filed under Caregiving, Parkinson's Medical therapy, Parkinsons Disease, Self-Care, Symptoms, Diagnosis and Progression

What is atypical parkinsonism and how does it differ from PD?


NPHAtypical parkinson’s, parkinsonism, and parkinson’s plus are all terms used to describe syndromes that share features similar to Parkinson’s disease but are different conditions. These conditions are described below.

Just like Parkinson’s disease, the diagnosis is often a clinical one relying on an examination by a neurologist knowledgeable in these conditions. Because of this, the diagnosis may not be obvious at your first doctor’s visit and an accurate diagnosis may take time.

Common features of atypical parkinsonism that differentiate it from Parkinson’s disease are:
  • Symptoms present on both sides of the body at onset.
  • Early cognitive problems.
  • Early problems with balance, falls and/or freezing of gait.
  • Early problems with autonomic function such as orthostatic hypotension (lightheadedness when standing from low blood pressure.)
  • Earlier speech and swallowing problems.
  • Faster progression
  • Limited improvement with medicine.
  • Significant visual problems such as double vision, trouble focusing while reading.

Specific conditions include (note:  this list does not include all disorders)

Neurodegenerative Conditions. These conditions are associated with degeneration or nerve cell loss over time.

  • Lewy Body Disease. Cognitive problems, hallucinations and fluctuations in levels of alertness are present within the first year of movement problems. Motor symptoms can otherwise mimic Parkinsons disease.
  • Multiple System Atrophy (MSA): Slowness, walking problems, imbalance, and early autonomic nervous system problems (Orthostatic hypotension, constipation, bladder control) predominant in this disorder. [Click here for more information on the MSA foundation.]
  • Progressive Supernuclear Palsy  (PSP): Slowness, walking problems, imbalance, eye movement problems, speech and thinking problems predominate in this disorder. [Click here for information on the PSP Society.]
  • Normal Pressure Hydrocephalus (NPH): Early walking, thinking and bladder control problems predominate in this disorder. Brain MRI reveals enlarged ventricles and therefore is helpful in detecting this condition.
  • Wilson’s disease: A genetic condition with personality changes, thinking problems, dystonia and other movement problems.  Brain imaging, blood and urine copper testing can aid in making this diagnosis especially in young people.

Secondary Parkinsonism. These conditions are caused by other problems.

  • Drug induced parkinsonism.  Many antipsychotic medicines and anti-nausea medicines can cause symptoms of parkinsonism or even worsen movement problems when given to people with Parkinson’s disease.
  • Vascular parkinsonism. Can cause problems with slowness, shuffling gait and thinking problems.  Head CT or MRI may be helpful in determining this.  Treatment includes careful control and treatment of cardiovascular and stroke risk factors such as smoking, high blood pressure, high cholesterol, diabetes, depression and sedentary lifestyle.  Strokes
  • Brain injury. Repeated brain trauma with concussion (ie. Boxing) and injury from lack of oxygen such as after cardiac arrest.
  • Toxin exposure such as carbon monoxide poisoning, heavy metal exposure (industrial exposure to manganese, lead, cobalt or mercury), agent orange.

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Does glutathione help Parkinson’s disease


Glutathione (GTH) is a molecule and potent antioxidant found inglutathione our cells. Glutathione is produced by our bodies and levels decrease with aging, many diseases and Parkinson’s disease.  The role of glutathione is to eliminate these free radicals; in essence, putting out a fire. It is unclear whether the low glutathione content in the PD substantia nigra is due to impaired production, or because the burden of free-radicals is excessive.

IV glutathione is a popular complementary and alternative medicine (CAM) therapy for Parkinson’s yet the benefits are not clear, it is costly and side effects do exist.

In 2009, researchers in Florida conducted a study to determine whether IVGTH showed benefit compared to placebo. Over the four weeks of the study, individuals receiving IV glutathione had a mild improvement in symptoms, while those receiving the placebo did not. This benefit was lost when glutathione was stopped. (Hauser RA, et al. 2009). It is important to note that the differences between these two groups were not significant. While the study is small and only provides preliminary data, it is promising non-the-less.

Mechanism of Action

Continued interest in glutathione  explores this molecules anti-oxidant properties.   The loss of glutathione in the substantia nigra precedes PD symptoms by more than a decade, and occurs prior to the formation of Lewy bodies, considered a PD precursor. Just because low glutathione levels correlate with PD severity, doesn’t mean that the loss of glutathione causes the disease. This is highlighted by the fact that glutathione is decreased in many diseases including cancer, vascular disease and other diseases of aging. We have no idea whether glutathione has the potential to retard disease progression, as the study has not yet been done.

Future Research

More information is needed to determine if glutathione is helpful in Parkinson’s disease. Although studies to date showed no statistically significant difference between placebo treatments and  glutathione many questions are still unanswered such as the optimal dose, timing of treatment in relation to disease severity, and duration of treatment. Studies are on going and investigating other ways of delivery such as intra-nasal spray.

Caution about pills

Since GTH is made up of amino acid precursors (similar to proteins),it is broken down in the gut prior to absorption and therefore little is available for use. It is for this reason that treatments focus on intravenous or IV (administered directly into the bloodstream through the vein.

Safety and ADverse Events

  • Expense of treatment
  • Bruising and Infection at IV site
  • Rare cause of liver damage

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Filed under Complementary Therapy, Nutrition, Vitamins and Supplements, Vitamins and Supplements

When do I need to see a physical therapist?


Physical Therapist Working with PatientChances are you will benefit from a physical therapy (PT) evaluation and treatment if you have movement symptoms associated with Parkinson’s disease or other brain condition. However PT does more than simply treat movement symptoms. The objectives of PT vary with individual needs but do include these general goals:

  • Evaluate movement problems and recommend therapy early in disease before problems and bad habits occur
  • Reduce symptoms of disease associated with imbalance, rigidity, slowness, involuntary movements
  • Reduce or delay symptoms of disease progression through targeted exercise such as balance and falls
  • Optimize independence
  • Optimize your home exercise program with a focus on general health, stamina, disease symptoms and long-term compliance
  • Evaluate and recommend specific braces, orthotics, and ambulatory assist devices such as canes and walkers
  • Improve safety, enhance confidence and reduce fear of activity such as fear of falling
  • Neuro re-education designed to combat the abnormal movement associated with physiologic brain changes of disease, programs such as ‘Big and Loud’
  • Promote neuroplasticity or enhanced brain activity through movement
  • Promote healthy lifestyle changes to improve activity levels, quality of life and well-being both now and long-term

Don’t wait.

What is most important is that you advocate for yourself and take a proactive stance by seeking out a therapist even before you have problems. Most people wait until symptoms are significant or cause serious problems such as falls, pain or joint disease.
Advocate for your care.
Ask your doctor of healthcare provider if you can have a referral to a rehabilitation specialist.
Use this checklist to see how rehabilitation and other specialists can be of help to you and as a guide for discussion with your doctor or therapist.
Download and complete your Comprehensive-Care-Worksheet.

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Filed under Exercise, Self-Care, Symptoms, Diagnosis and Progression

Can you give any additional information about Othello Syndrome in the context of PD?


Othello syndrome describes a form of psychosis in which one has delusional thoughts about their partner having an affair or similar relationship that does not exist. They may misinterpret ‘clues’ to support this delusion.

Delusions and hallucinations can be seen with certain psychiatric disorders and in the setting of Parkinson’s disease with the following conditions:
-High dose dopamine medicines especially dopamine agonists, amantadine and selegiline
-Other medicines that can cause confusion such as anticholinergics, muscle relaxants and pain medicines (narcotics)
-Illicit (street) drugs)Cognitive problems suggestive of dementia
-Coexisting medical conditions such as thyroid disease, vitamin deficiency (B12),infection or dehydration

Treatment includes:
-Reducing medicines when possible
-Occupational therapy evaluation to analyze how someone is taking medicines and help family administer medicines in the event the person with PD is taking more than prescribed
-Antipsychotic medicines- namely clozaril or quetiapine
-Cognitive enhancing medicines such as rivastigmine
-Counseling and psychiatric evaluation to evaluate for other conditions
-There is little evidence to date about the effect of a new antipsychotic.
-A combined neurology and psychiatry evaluation may be needed for this difficult problem.

See related article on hallucinations

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Filed under Caregiving, Cognitive Health, Emotional Health, Medication Side Effects

What causes hallucinations?


Van GoghHallucinations are a side effect associated with dopaminergic medicines used to treat Parkinson’s disease motor symptoms. Hallucinations are an altered perception of how our brain interprets information it receives about our environment, surroundings, senses and/or body sensations. Hallucinations can be visual, auditory or tactile. The most common type of hallucinations in PD are visual in nature. They may range from the experience of a simple illusion such as ‘seeing’ a spot on the wall turn into a well formed object such as a spider or they me be more complex and actual visions that do not exist. Sights of people and animals are common hallucinations. A person can have insight into and reason through the fact that a hallucination is not indeed real. In more advance cases, insight is lost and hallucinations are interpreted as real without the ability to reason that they are not grounded in reality.

The risk of experiencing hallucinations if you have Parkinson’s disease  increases with the following:

  • High levels of dopaminergic medicines. Specific medicines such as dopaminergic agonists, anticholinergic medicines and amantadine are associated with a higher risk of this problem.
  • Additive effect of other brain active medicines such as sedatives, sleeping aids, muscle relaxants, narcotic pain medicines and some bladder medicines.
  • Cognitive problems, confusion and dementia increases risk of hallucinations associated with Parkinson’s medicines.
  • Visual problems such as cataracts, glaucoma and reduced night vision can increase the risk of developing hallucinations especially at night. (Hallucinations are not directly caused by eye problems but reflect how the brain interprets sensory information. However, poor vision does exacerbate this problem in susceptible individuals.)
  • Stress can increase the risk – whether emotional, physical or the stress on your body from a medical condition or surgery.

Treatment includes:

  • Change or reduction in Parkinson’s medicines and other brain active medicines described above.
  • Antipsychotic medicines. Only two antipsychotic medicines are recommended for PD-clozapine and quetiapine. Other antipsychotics can worsen movement problems due their dopamine blocking activity.
  • Cognitive enhancing medicines such as Aricept or Exelon if dementia is a problem
  • Medical evaluation to insure other medical conditions are not contributing to the problem. Examples include cardiopulmonary disease, thyroid problems, vitamin B12 deficiency, infection, dehydration and kidney disease.
  • Lifestyle changes with a focus on stress management and improved sleep.

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Filed under Cognitive Health, Emotional Health, Medication Side Effects, Non-movement Symptoms, Symptoms, Diagnosis and Progression

How can I alert medical providers that I have DBS in an emergency? Can mammogram be done?


Deep brain stimulation viewed by skull Xray.It is important that your medical provider be aware that you have DBS since there are some procedures that can not be performed if you have DBS.  Examples of procedures that are not safe to be performed with DBS are body MRI, certain types of cautery and diathermy (a form of ultrasound used in specific situations to speed tissue healing.) It is recommended that your doctor call Medtronic Inc. (current DBS manufacturer) clinician support services (800) 707-0933 before any procedure to review if there are any concerns or interactions with your device.

One way to alert clinicians that you have DBS in an emergency situation is to wear a medic alert bracelet. This bracelet can be inscribed with important information such as allergies and a statement that you have DBS.  You can include the emergency clinician support phone number and warnings such as “MRI and diathermy contraindicated.”

Mammograms are often a concern because they are done close to the battery site. Mammograms can be performed as long as the technician avoids compression of the battery which is usually located just below the clavicle in the chest. It is important not to compress the battery or extension wires. Breast MRI can not be performed. Diagnostic ultrasound of suspicious breast lesions can usually be performed if needed; but once again the ultrasound probe should not be used over or directly adjacent to the battery. Your technician should call the Medtronic customer support number listed above for more specific guidance.

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