Medications 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.
Leg 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
- 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.
- 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.
- 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.
An 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
- Heart or breathing problems
- Sleep apnea
- 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.
Atypical 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.
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.
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.
Chances 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
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.
Hallucinations 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.
- 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.
There 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.
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
DBS treats movement symptoms of Parkinson’s specifically tremor, dystonia motor offs and dyskinesia. DBS does not typically improve speech and in some cases can be associated with worsening speech. The following information may help you understand the complex association between speech changes with Parkinson’s and DBS:
- DBS typically helps motor symptoms that also respond to medicine. Although difficult to predict, DBS may improve speech if levodopa also significantly improves speech. However, in most cases, speech is not helped by medicines suggesting DBS will also not help.
- If speech is still responsive to levodopa, under-medication can also worsen speech. Medicines are often reduced after surgery.
- Subthalamic (STN) DBS surgery can affect ‘verbal fluency’. This can be noticed as a difficulty ‘finding or getting the right word out’.
- DBS programming can worsen speech as a noted side effect to over-stimulation. This is probably the most common cause of significant speech change after surgery.
- Speech can worsen as Parkinson’s progresses over time even with DBS. This is usually a gradual decline.
- Immediate change in speech after surgery can occur as a result of brain bleeding or other problem during surgery. This can improve over time.
- A speech therapist can help you understand the potential impact of DBS on speech and help improve communication at any stage of your disease.
This information serves as a guide only. Only your healthcare provider can answer the questions about how DBS will impact speech for you.
Movement symptoms such as tremor, rigidity and slowness are the hallmark symptoms of Parkinson’s disease. Yet research confirms that these movement problems are not the main contributors to decline in life quality with disease progression. Trouble with balance and falls are a primary motor problem that occurs later in disease and correlates with a change in life quality. Fortunately early and aggressive Physical therapy and balance exercises can make a difference- whether started early before there is a problem or later after falls occur. The Wellness Center highlights additional information about the role of PT and exercise to improve balance and reduce falls.
Follow these helpful hints:
- See a physical therapy early before you have balance problems to improve your balance and before starting any exercise routine.
- Advocate for yourself and ask your doctor for a referral if you think you would benefit from PT.
- Occupational therapy can help reduce fall risk, offer tips and suggestions to improve your home and community safety by reducing risk of falls
- Remember fatigue and reduced stamina will also increase your chance of falling. Aerobic (cardio) exercise will improve stamina. Get professional advice from your doctor or PT before starting a program.
- Stay hydrated. Low blood pressure from dehydration can lead to dizziness, unsteadiness, fatigue, weakness and confusion- all potential problems that can affect walking.
- The best exercise is often the one that mimics what you want to do- walking and balance. If you can, walk, run, dance, play standing computer games such as the Wii, play tennis or other balance supports.
- Music and a metronome can help you time your gait to a beat.
- Freezing of gait can improve with queing strategies.
- Walking, trekking or hiking poles help with balance.
- Sometimes a walker or cane is needed for balance. This is a positive change not a negative one if this keeps you walking and keeps you safe.
- Multitasking or doing two things at once can worsen balance problems. Try to avoid distractions when possible and focus on the task at hand.
- Yoga and Tai chi can help balance and posture.
Learn more about walking and balance at the Wellness Center.