Category Archives: Medication Side Effects

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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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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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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Manage nausea from medicines


I get nausea in the morning. Could this be caused by my medicines?

All dopaminergic medicines can cause nausea.  Nausea is worse when you first start a medicine and can increase as you increase dose.  Nausea usually gets better but many people find the following tips helpful:

 

 

 

  • Take medicine with food (exception may be carbidopa/levodopa- see protein article.)
  • Eat smaller more frequent meals throughout the day
  • Drink plenty of water or ginger ale with medicines
  • Try eating ginger- dried ginger, fresh ginger, candied ginger or ginger candies
  • Camomille tea, peppermint and peppermint tea soothes gastric upset
  • Ask your doctor about carbidopa (Lodosyn) if you are taking carbidopa/levodopa (Sinemet)
  • Always see your doctor for nausea that is severe or does not improve
  • Vitamins and supplements can also cause nausea.  Switch these to  night time dosing

Learn more about medicines and their side effects

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Is gambling a side effect of medicine?


  • I have heard that gambling is a symptom of Parkinson’s disease?

Impulsivity control problems can be a side effect of dopaminergic medicines used to treat Parkinson’s.  These behaviors are an exaggerated an often uncontrollable form of a particular behavior (these behaviors are often associated with a feeling of  reward or similar pleasurable.) The dopaminergic agonists, ropinirole and pramipexole are most commonly associated with this problem.  Reducing the dose or avoiding certain medicines can help. Examples of impulse control are

  • Increased risk taking
  • Pathologic Gambling
  • Binge Eating
  • Excessive Spending
  • Hypersexual behavior

Learn more

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