Category Archives: Parkinson’s Medical therapy

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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Filed under Medication Side Effects

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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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

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

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 do I best time doses of carbidopa/Ldopa?


Medication Assistance is availableThe following excerpt is from a question received by NWPF.

We were told by our neurologist that my husband should take carbidopa/Ldopa (Sinemet) every 5 hours and also told to take it with meals. What is the best way to time the dose of this medicine?
There is no standard way to take carbidopa/ldopa. Dosage truly depends on the person’s symptoms, stage of disease and side effects.  The following situations describe some of the different ways that carbidopa/ldoap can be given:
  • Without food. Protein does delay absorption of this medicine from the intestines.  For this reason you sometimes hear the recommendation to avoid this medicine with food so it can be absorbed faster.
  • With food. This is helpful if disease is mild, a person has no wearing off symptoms, or nausea is a problem. In this case, medicine is often taken with meals for convenience and to minimize side effect.
  • Spread dose out during waking hours. To keep things easy, your doctor can simply tell you to spread out doses during the day (in your case every 5 hours.) This is especially helpful early in disease or if there is no wearing off, dyskinesia or side effect.
  • Specific times given. Timing of doses is also tailored to the individual’s day and night.  If a person wears off at end of dose, has dyskinesia or side effects then medicine is given at more specific times based on these symptoms.
The best thing to do is to talk to your Neurologist about the conflicting guidance you have been given so that you can decide together which one is best for your husband.
See related article to learn more about protein and medicine.

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My mom has PD and almost every evening, any time between 4-8 pm she experiences hot flashes, she gets really red and hot from the neck up, while the rest of her body is cold. Is this a PD symptom? We have to put ice packs and iced towels all over her head and face to get it to calm down.


Autonomic nervous system influences blood vesselsThere are many causes of hot flashes including hormonal changes in women, anxiety, medicine side effects and certain medical conditions. Alterations in perception of temperature can be seen with advanced Parkinson’s disease. It is thought, in part that these symptoms can be caused by an alteration in the autonomic nervous system. This branch of the nervous system can control how our blood vessels constrict or dilate – altering blood pressure, blood flow and temperature. Drenching sweats and redness of skin can be associated with motor off periods when medication dosing and effect is low (often seen at end of dose) or the alternative situation when medicine is at its peak (often associated with dyskinesia or too much medicine.) Off related problems are often experience with sweating a condition called, off-related drenching sweats.

Continue to track the timing of the symptoms, along with the time medicine for Parkinson’s is taken and whether movement symptoms are well controlled. This will help your neurologist determine if there is a relationship between these variables especially if symptoms are noted after a dose is taken or just prior to the next dose. With this added information, your neurologist and primary care provider can help you determine the cause.

 

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Absorption of Sinemet requires optimal GI health. Is anyone working on a sublingual delivery of the medication?


Medication Assistance is available Carbidopa/Ldopa is one of the most commonly used medicines for Parkinson’s disease. Ldopa chemically resembles the amino acids or building blocks that make up protein. Because of this, Ldopa ‘competes’ with protein for absorption through the intestines and into the brain.

As the question suggests, optimal absorption of ldopa is important to avoid fluctuations in motor response. A dissolvable form of carbidopa/ldopa does exist but unfortunately it does not absorb through the mouth and still requires swallowing of medicine into the intestine for absorption. An infusion form of Ldopa gel was developed to deliver Ldopa directly to the intestine. This allows precise changes or titration of  the  amount delivered by using a pump to match the needs of the patient. This form of the medicine and pump delivery is still being studied in clinical research trials and requires that a feeding tube be placed by a surgical procedure into the stomach and advanced through to the small intestines where Ldopa is absorbed. Researchers are also studying different ways to deliver Ldopa using special techniques such as a patch formation. This mode of delivery is not currently available because Ldopa does not easily absorb through the skin requiring special technology to enhance its absorption.

The following tips can help:

  • Treat constipation and bloating
  • Be sure to get plenty of water, fiber and exercise to help transit of food through the GI tract
  • Separate timing of Ldopa dosing from meals
  • Eat the majority of your day’s protein when you are less active such as the endo of day
  • Eat plant sources (nuts, beans, soy) over animal sources of protein

Click here to read more on this topic is available

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Filed under Nutrition, Vitamins and Supplements, Parkinson's Medical therapy

How can I tell whether medications are wearing off or Parkinson’s disease is progressing?


How Parkinson’s motor symptoms respond to dopaminergic medication changes over time. Although everyone is different the following stages can help you understand the role of medicines and expectations for their benefit:

Early Stage: Early in the disease,  dopaminergic medications are effective and their effect on movement continues from one dose to the next. This results in a seamless control of motor symptoms and no clear fluctuation in response to each dose. In fact, many people do not notice that their next dose is due and must make the effort to take their medication on the schedule as directed by their healthcare provider. Of course people with Parkinson’s can still have ‘good’ and ‘bad’ days or find that their symptoms change in different situations such as stress, fatigue or illness.   

Mid Stage: Over time, movement control with dopaminergic medical treatment can become more difficult as time progresses. The effects of each medication dose does not last from one dose to the next. However, medication doses continue to improve movement symptoms such as tremor, rigidity and slowed movement. Yet this improvement does not last from one dose to the next requiring medication change – these problems first appear as motor fluctuations often referred to as on and off periods.

  • On – Off periods describe the change throughout the day in response to medication.
  • On is when the medicine improves symptoms
  • Off is when the medicine effect is worn off or is no longer working and symptoms worsen or return. It is first described prior to the next dose of medicine called end of dose wearing off.
  • Dyskinesia or involuntary (unintentional) movements or jerky motions is a side effect of dopaminergic medication and usually occurs after it “peaks” in your system.

Advanced Disease Progression:  Certain symptoms become less responsive to dopaminergic medicines and can increase in severity as the disease progresses. These motor symptoms include balance, freezing of gait, speech and swallowing.  These symptoms do improve with rehabilitation therapy even if they do not improve with medication. It is important to review these problems with your healthcare provider so they can refer you to these specialists.

Talk with your healthcare provider to better understand how your symptoms are responding to medicine.

Rehabilitation therapy includes any of the following
Physical therapy- especially effective for gait, balance and mobility
Occupational therapy- especially helpful for daily activities, chores and hobbies
Speech and Swallowing therapy- focuses on speech and swallowing.

See Take Charge! Build your Team and print a copy of the Comprehensive care worksheet posted on NWPF wellncess site for more information on how these therapies can help you

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Filed under Parkinson's Medical therapy, Symptoms, Diagnosis and Progression