dementia, parkinson's disease, Parkinson's Health, Parkinson's symptoms, Parkinson's treatment

Apathy: How to Combat: By Dr. De Leon

“Science may have found a cure for most evils; but it has found no remedy for the worst of them all- the apathy of human beings.” Helen Keller

It has been a few weeks since I have written. Why? Pure apathy or is it indifference! In our vocabulary we tend to use the words apathy, indifference, and impassivity interchangeably. However, are they really the same thing and if so what does it mean for us in our living with Parkinson’s disease? Why do we feel this way? Is it normal? And is there anything we can do to combat this feelings of inertia that seem to take over us from time to time. if not addressed and treated properly can lead to severe disruption of life as well as to isolation and depression.

Thus, I have chosen this particular topic for discussion now that my inertia has passed away. This is also a subject which has generated much interest in our community as per the choice award topics of interest gather by the former PDF ( Parkinson’s Disease Foundation). perhaps before we spend countless hours and research money on the subject we need to define exactly what we mean. As I said earlier, most of us equate apathy to indifference but they are not the same thing particularly when it is defined in terms of a neurological illness.

Apathy and indifference both denote a lack of responsiveness and interest to things that may normally stimulate, excite or cause great emotions. apathy comes from the Greek root word pathos meaning emotion ( a=pathos) without feelings or emotions. this is a deep rooted neurological problem that involves the frontal lobe of the brain which deal with personality, and executive functions. Not only do you not have much feelings or interest but you DON’T CARE! in neurology as I stated before when we use the word apathy we are saying there is a neurological problem in the wiring of the brain that has gone awry. Usually more common than not when we as neurologists see this behavior outside of structural injuries in brain (e.g. head injury,  stroke, etc.) is primarily related to dementia.

What most of us in PD experience commonly however, is not apathy but indifference. The difference between the two is the personal behavior attached to this feeling.  People with true apathy simply don’t give a hoot about anything and don’t know they are apathetic. As opposed to being indifferent or having inertia or decrease in concern or emotions; we are completely aware of the problem we want to change it and don’t want to feel this way but we lack the fortitude to do anything about it. This is the state where I have found myself recently and I am sure many of you as well.  I want to go out and socialize, get showered, write, exercise but don’t have enough stamina to make myself do these things because the energy involved to achieve these tasks supersedes our reward. Remember that the basal ganglia is also a center for reward and pleasure and if you don’t have enough dopamine to think and do necessary activities to stay alive then you wont have any surplus to go in search of feel good activities. the reason I experienced this has been due to a decrease in my dopaminergic intake due to cardiac issues being evaluated. however, once I took my regular doses of medications my concern for things that are pleasurable like socializing and writing have returned.

So what does this mean for you? evaluate your feelings? is it you feeling like you don’t care and rather not invest energy in things you normally would love to do like read or go to movies or is it your loved one saying what is wrong with you? you don’t seem to care? and it makes no difference to you, you are content in your lack of participation. You could careless if you never brush your hair or shower again in your life.

Independent of which feeling is plaguing you most, I want you to know that there are treatments available for both.

Apathy vs. indifference?

Both require evaluation by your physician/neurologist/MDS


  • evaluate for new brain abnormalities i.e. stroke ( just because you have PD does not mean you can have other diseases), rule out thyroid disease and other metabolic abnormalities.
  • Get new or follow up mini-mental status exam (MSE) or  CogTest
  • neurobehavioral evaluation (needed in some cases)
  • Treatments:
  1. medications for dementia if present -e.g. Exelon (Rivastigimine) – only drug approved for PD dementia, but can also use  Namenda (memantine), Aricept (Donepezil), and Razadyne (galantamine). in my experience combination of Namenda plus Exelon or one of the other works best in retarding dementia particularly if introduced early on. thus I suggest yearly screening for this especially if had had PD >10 years because dementia risk increases with age and disease process. 40-50% develop PD patients develop dementia eventually.
  2. anti-narcoleptics- Provigill, Nuvigil ( non-addictive- focus on alertness, no blood monitoring required, do not interfere with other PD meds.
  3.  stimulants- a whole host which are amphetamines and amphetamine derivatives like Adderall, Ritalin. These are controlled substances and usually require closer monitoring some may even require blood monitoring.
  4. increase dopamine – but if dementia present this may make cognition worst


  • evaluate for depression
  • adjust PD medications (usually go up)
  • rule out thyroid disease/other metabolic issues
  • get neuropsych/behavioral evaluation if not sure if depression vs. dementia
  • Treatments
  1. if depression treat with antidepressants ( e.g. Zoloft, Lexapro, Effexor, Remeron, etc.)
  2. fatigue may also be a cause- treat with amantadine, and evaluate sleep.
  3. may also need sleeping meds.
  4. participation in activities like art, singing, exercise, dancing, biking etc. can increase natural dopamine, serotonin, and endorphins among other. these will in turn allow you break that indifference. So don’t give in to it get a buddy who can help out to over come these challenges but don’t forget to talk to physician first.

Now that you are an expert on the subject, you and your family can discuss more accurately with your physicians as to the cause of your lack of interest and participation in previous activities which brought you joy. Soon you will be on your way to finding your passion once more. Find one thing that bring you joy and pursue it …..

Carpe Diem!

chronic illness, medications in Parkinson's, parkinson's awareness month, parkinson's disease, Parkinson's Health, Parkinson's symptoms

The perils of traveling when you have PD:by Dr. De Leon

As I have been traveling to promote my book and women in Parkinson’s issues, I am reminded of some of the perils of traveling which can make anyone a bit discombobulated but for those of us who suffer from a chronic illness like PD it can really throw us for a loop.

I absolutely love traveling and I am absolutely thrilled to be feeling so much better to be able to do this on my own after having to depend on someone for a while. However, I am reminded of my illness each time I leave my home by the number of medicines I have to pack in order to be able to enjoy my travels. It is sad that packing my medications takes me twice as long than actually packing my clothes.

The first thing  we have to keep in mind when we travel, especially if going across various time zones, is the time changes when we are trying to keep up with our medication schedule. I find it a lot easier to go west than east. What I do is I continue to take my medicines as scheduled through out the trip and when I arrive I switch to that time zone and then proceed to take my medications on the same schedule (meaning every 6 hours and so on) – however, we must be aware of the time it has actually passed ..make sure you maintain the same hours between dosage so if you just took a medicine and arrived and now is time to take another medicine because it is noon for instance don’t double the dose wait til next dosing time ..but if you took medicine 5 hours ago and now new time zone indicates that you will have to wait another 3 hours but you know you take your meds every 6 hours take the medicine within the hour and adjust schedule… Do not suffer …and always keep medicines handy in your personal belongings and within your immediate reach like in a purse and carry water with you to facilitate intake of pills. I always keep my medications in my purse in a pill  box. Within this box, I also carry prn other words medications I don’t take on a daily basis but might need especially when traveling or sitting for a long period of time such as nausea medications, pain meds- like Tylenol & Motrin, migraine pills, and muscle relaxants.

Try to get seating with extra leg room and do stretch exercises  while sitting every hour…stretch your neck, legs, back, and feet. You can do small circular motions of neck and limbs including hands and feet for five minutes…walk about if you can. Also, if you tend to swell, like I, do when sitting you might consider wearing Ted hose or support stockings to avoid deep vein thrombosis (DVT’s) as well as improving circulation and decreasing edema.  Conversely, don’t wear tight socks that only go to your ankle- this will only worsen swelling rather use diabetic socks.

Since it is hard to take diuretics when traveling to decrease swelling, we must try to eat naturally diuretic foods like cucumber, lemons, tomatoes, and drink plenty of water especially if you are going to be out on the sun -need double amount of fluids. Drinking lots of water can actually help flush  all the toxins out and is the most effective diuretic. Another way to eliminate fluid build up in your body naturally is to drink cranberry juice, or add cucumber  or lemon wedges to your drinking water..of course any caffeinated drink will help to get rid of fluids but these will only dehydrate you in the end so not as healthy and do not recommend if traveling  for long distances. Another food which has lots of natural diuretic effect is oats. Go ahead and have an oatmeal bowel before traveling or in the mornings while your traveling, not only will this help get excess fluids but will promote better digestion.

Drinking plenty of fluids also helps to improve digestion and decrease constipation which also makes us feel bloated and causes swelling. Because we sit so long when traveling, the natural peristalsis of our bowels decreases even further. Now compound that with medication intake  side effects and PD itself and we are one miserable uncomfortable person with bloating, gas, increase nausea and poor absorption of our medications making them less reliable when we need them the most. I recommend taking ‘gas- X‘ or some equivalent..try to eat light like yogurts and take a probiotic capsule to stimulate  proper digestion since I have found it extremely hard to take laxatives when traveling especially if have a packed schedule.

In flight or on your trip you can also drink Sprite, ginger ale (this also aids with Gi upset and nausea, plus ginger is a good diuretic). Eat dry fruits  and crackers ..I like  to carry with me ‘thin addictives‘ they make a great snack, easy & convenient to carry plus they have dry  fruit and nuts to give you energy. If you are completely bloated and feeling constipated do a light liquid diet the first day  when you arrive at your destination. Although, you will certainly need a nap after you arrive, if possible you should continue your exercise routine there- sometimes hard to do if are speaking or are sight- seeing, good thing is that usually sight seeing entails a lot of walking so you will have plenty of exercise). but don’t neglect your sleep..of course the sleep may be a bit messed up. in order to avoid jet lag carry melatonin 6mg – 1-2 tabs a night.  when you are on vacation especially if at a tropical island you will be tempted as I have to do as the locals do and enjoy some nice alcoholic beverages with a little umbrella. however, we must be mindful of our alcohol intake for several reasons.

1)  initially it can make you sleepy after a few hours it becomes a stimulant disrupting your sleep wake cycle further and making you more lethargic and fatigue.

2) it is extremely dehydrating.

3) can worsen REM behavior

4) can interfere with your medications

5) increases swelling

When you get to destination and en route eat plenty of vegetables like carrots, asparagus, tomatoes, beets and celery which also are natural diuretics. ( I emphasize the diuretics because all of the Mao inhibitors,  along with the amantadine and dopamine agonist cause a lot of fluid retention especially in us women). The above foods are also healthy and can cause some slimming effect especially oat consumption. Did not our mothers tell us we are what we eat? Seems like there is a lot of truth behind this saying…Even before trip should avoid salty foods and no high fatty meals in transit especially if crossing several time zones.

I have learned these perils the hard way  making me look like a 9 month pregnant woman while traveling because I am unable to take my Linzess, & my diuretic pills because I am on the go and don’t want to have an accident or be detained every few minutes looking for a bathroom worst sometimes is hard to keep a eating schedule as I would at home  one thing we must always remember is that WHEN we eat is as important for us living with PD as WHAT we eat. so next time you are packing your suitcase getting ready for a travel adventure keep some of these points in mind to avoid the perils and focus on the FUN & Joy of it all!




dopamine and parkinsons, medications in Parkinson's, parkinson's awareness month, parkinson's disease, Parkinson's Health, Parkinson's symptoms

Breathing problems & PD: Dr. De Leon







Breathing ”

…because as long we are breathing we can start again!

a friend asked if I could talk about nocturnal breathing problems with PD. I will try to discuss the causes and treatments here.

As a trained Parkinson’s Doctor, I am still amazed by the enormity of symptoms related to PD which have a significant and possible deleterious effect on people’s qualities of life…many of which I was familiar with and many more which I have discovered as a consequence of living with PD myself.

One of the newly discovered symptoms is asthma…which I have developed since my diagnosis of Parkinson’s. We know from the literature that asthmatic patients have a higher risk of getting PD which could point and support theories of  PD being an autoimmune disease or having a viral trigger. However, the idea of PD or the medications used for its treatment triggering asthma remains to be proven. Yet, within the Parkinson’s support groups there has been many a talk about new onset of asthma after their diagnosis. First, I would not be surprised if this were true because some of the dopamine agonists have been linked to lung fibrosis and pleural thickening of the lungs- this syndrome was described as L-dopa respiratory dysfunction syndrome. This however was found to be more common in those with Parkinson’s plus diagnosis – with MSA ( multisystem atrophy) leading the list. Plus, Pergolide (Permax) an older dopamine agonist was removed from USA market in 2009 due to severe respiratory problems which resulted in fatalities.  The main cause of fatalities was valvular problems of the heart. A similar drug known as cabergolide ( Dis) also causes severe lung fibrosis, asthma and similarly causes heart problems by affecting the valves. However, since this is used only for  pituitary tumors and not PD remains available.

mirapex ( pramipexole) and to a bigger extent the Extended release compound can cause symptoms of wheezing, coughing, chest pain, phlem, shortness of breath (sob) with minimal excertion and swelling. I myself when I was prescribed mirapex ER experienced severe dyspnea ( trouble breathing ) and a cough- which is when I was diagnosed with chronic bronchitis. However, even after I stopped the medication my sob persisted eventually being diagnosed with asthma. I first I attributed this problem ( sob) to my thyroid being off – which is important to rule out as cause of sob especially if fatigued and wheight changes. Then I thought it could be the fact that I had gotten radiation for my cancer but X-rays showed no scarring or abnormalities but my breathing test confined to be abnormal and consistent with asthma. I was treated with inhalers and I am well controlled; yet interestingly the last time I visited my pulmologist, he said my breathing test, which he does routinely, were normal except for the fact that my tests appeared as if I had not put normal effort and lungs were not fully extended. I had taken my medicines but had not fully kicked in. so no matter  how much I blew  air or tried to push air out, my lungs felt stiff and rigid. But once medicine kicked in – lungs were pliable (normally expanding). Which means that PD can cause sob simply by having disease and stiffness of the breathing muscles- hence as symptoms advance patients start feeling more anxious and short of bread when medications start to fluctuate especially if off’s are sudden and unpredictable.

Abnormal breathing function is important to address as soon as possible for several reasons:

  1. it increases risk of chest infection – if not able to cough and clear lungs
  2. can increase lung infections by creating stagnation and shallow breathing – a condition called atelectasis
  3. Voice is more raspy, husky and lower tone if have poor air way and decrease lung capacity making people feel even more isolated because they are not going to be heard well.

plus since stiffness and rigidity tends to increase with stress and cold thus we need to practice techniques of relaxation and practice staying warm.

At night, people may have breathing problems for a number of reasons:

  1.  Wearing off
  2. gastric reflux
  3. obstructive sleep apnea

The bottom line yes both medications and poorly controlled Parkinson’s can cause difficulty breathing. Therefore, it is imperative to talk to your doctor as soon as possible to rule out other medical problems like thyroid, heart disease, sleep apnea, gastric acid reflux and asthma a which may or may not be caused by PD meds.

discuss your concerns with your physician and practice breathing exercises and relaxation techniques.

one breathing exercise – repeat 4 times- start standing, sitting or lying down ( better if standing ) lift arms up and do below

i) take a deep breath through your nose, pushing your stomach down

ii) then release air out slowly as you bring your arms down to your side

conversely – you can just relax shoulders then do the other two.





chronic illness, medications in Parkinson's, parkinson's awareness month, Parkinson's Diagnosis, parkinson's disease, Parkinson's Health, Parkinson's symptoms, Parkinson's tratamientos, Parkinson's treatment

An Overview of Common Skin & Wound Challenges Encountered In Parkinson’s Disease:By Dr. De Leon

Parkinson’s affects our insides and outsides and although commonly labeled as a movement disorder it has many more non -motor manifestations which can wreak havoc in our daily life’s . Some are cumbersome and embarrassing while others can be downright difficult to bear and live with.

Since dopamine, the major neurotransmitter involved in PD abounds outside of the brain it is expected and of no big surprise to see problem areas arise outside of the nervous system, particularly when it comes to control of the autonomic nervous system which regulates temperature, pain, glandular secretions, and controls all involuntary functions of our bodies like bladder emptying, sexual function, and peristalsis (bowel movement).

Many people outside the neurological community may not be aware of the severity and impact of having an autonomic system which has gone haywire. Thus, presenting some of the greatest management problems to date due to lack of disease modifying treatments. The autonomic dysfunction in PD can be manifested in a number of ways presenting with various signs and symptoms involving the skin and appendages such as our hair and nails. For instance, when I first began to have symptoms of Parkinson I noticed a change both in my skin and nails which at first I assumed were due to my thyroid cancer. However, as my thyroid problems got treated and under control, I still experienced dry patches of Skin in the most unusual places- behind my ears, fortunately no one could see but I knew it was there.

Try as I might to moisturize, wash with shampoos containing Zinc and selenium, the patches remained stuck unable to be peeled away. To my amazement and surprise when I recently switched to Rytary I noticed that the patch of dry scaly skin had disappeared completely from one side and significantly diminished on the other. Such insignificant small victories that can make someone happy. But, much to my dismay about a week ago I began noticing a large scaly patch smack in the middle of my forehead – resembling a sunburn that is peeling away, I rather go back to the patches no one could see. Of course I have already discussed elsewhere the increase sweating, I like others have experienced. So I began thinking about all the changes that we experience with Parkinson’s some visible while others not so much and decided that a visit into skin changes( alterations) caused by PD, it’s medications, as well as those caused inadvertently by drug delivery methods and immobility merited my attention and a bit of discussion. Skin alterations are not commonly recognized by those outside of neurology field as I mentioned earlier yet; it appears that autonomic dysfunction affecting the eccrine sweat glands are involved early on in the disease process when compared to controls. There appears to be decrease innervation of blood vessels and to erector Pilli muscles (important in regulating temperature).

Common skin conditions:

  • Sialorrhea– increased drooling
  • Hyperhidrosis– increased sweating
  • Malignant skin lesions– most common is increased melanoma but other skin cancers can occur.
  • Seborrhea-greasy skin with limp oily hair

Seborrhea dermatitis – accumulation of sebum (oil) is the cause of seborrhea usually seen in hair, and in the forehead as well as in folds of the nose. When this becomes chronic it leads to dermatitis (inflammation of the skin- red, itchy, flaky). Skin and hair need to be washed routinely and use anti dandruff shampoos; however once dermatitis sets you may need to consult a dermatologist to treat with topical steroids. This dermatitis can affect the eyes as well causing small patches that get into the eyes and eyelashes. Inner parts of eyebrows eyelids and ears can be affected as well as chest area, under skin folds like in groin, breast and axilla. Solution to face and scalp seborrhea is to let the dandruff shampoo run over your eyes closed and wash away gently. Seborrhea is more pronounced when disease is most active.

Ways to prevent & Treat Seborrhea Dermatitis:

  • Wash face and skin with warm water using a mild soap (e.g. unscented glycerin soap) and rinse with cold water
  • Avoid cosmetic products which contain alcohol
  • Increase hair washing especially using a dandruff shampoo containing selenium (selenium sulphide), zinc, or shampoos containing 5% tea tree oil, and olive oil shampoos
  • For males who made be bald- use mild soap or sorbolene cream in scalp
  • If you have severe crusts or scales in your scalp try rubbing a mineral or olive oil several hours prior to washing hair
  • Medicated eardrops to treat ear canal flakiness
  • May need a short term steroid based cream or ointment if itching and redness is severe. (a home remedy I often tried on my patients before steroids is application of Crisco lard on scaly patches- just don’t go sit out in sun or get near fire)

Drug Therapy & Skin Changes:

Melanoma – increased risk in PD population with all dopamine and dopamine agonist especially with levodopa. Constant vigilance is of the utmost importance. See elsewhere in my blogs as to risks and diagnosis of these.

Skin sensitivity– this is something that is important to note as well since all of us with PD appear to have hypersensitivity to the sun specially when taking Mao-inhibitors like Azilect. Make sure that you protect your skin, wear cool clothes and hats and stay in the shade if possible do not go out in extreme heat particularly if you are elderly because as we age we tend to have increased skin sensitivity and fragility.

Drug side effects

Amantadine– an oral anti flu medication used for Parkinson’s treatment particularly for tremors. However, this medication can cause skin changes known as Livedo reticularis (purple stria) in the lower extremities, it can affect the trunk as well as arms but less commonly seen. This rash is asymptomatic and usually comes up anywhere from a month to 4 years later on average. The good news is that this discoloration of skin resolves completely with cessation of drug intake.

Apomorphine– is a dopamine agonist used for treatment of acute and intermittent ‘off ‘episodes with long standing drug therapy treatment for PD. This medication can be given IV infusion or by subcutaneous injections these can lead to skin necrosis (dying out skin ulcers) at site of injection; also can occur years after use. Make sure always clean area before and after and have a nurse from pharmaceutical company train you on how to use properly to decrease potential for side effects.

Transdermal drug delivery– Neupro patch, Exelon patch, Selegeline patch. These reactions can range from mild irritation to severe inflammation, pain, whelping, itchiness, and burning. One way to decrease this sensitivity is washing area thoroughly before use and drying it well; also rotate sites recommending using same site no less frequent than every 3-4 days.

Steven Johnson reaction/syndrome– serious idiopathic life threatening skin rash which can be lethal fortunately extremely rare. It is usually to a medication or an infection- begins with flu-like symptoms followed by a painful red or purplish rash that spreads and blisters. Go to ER ASAP if have this…but in all honesty not seen this with PD.

Pressure sores- As, PD advances many of us become immobilized forced to sit in wheel chair or in bed 24 hours a day. This along with the already decreased mobility of disease and increased rigidity along with moisture of chronic sweating and of urine incontinence can lead to pressure ulcers particularly in the heels and buttock areas due to pressure, shear, moisture and friction of skin and blood vessels. Need air mattresses, heel booties, constant supervision and turning by a caregiver, changing sheets and clothing, dressing in cool garments, maintaining room temperature cool and if going to maintain in disposable undergarments need to change every 2 hours at the most and wipe are clean from sweat and dirt, bathe in bed frequently (daily). If urine incontinent consider placing a catheter less risk of infection. This is what I did for my grandmother and never developed any sores or ulcers because these can get supra-infected with ordinary common organisms easily like staph infections. At the first sign of skin break down begin treatment with medicated gauzes and talk to nurses and doctors caring for patient ASAP to avoid progression, hospitalization or death.

Fungal infections-Risk of fungal infections increase in patients with PD who are incontinent of urine. These infections look like rashes in the perineal area and groin. They are moist, itchy, red and looks like satellite as infection spreads outward, sometimes they are white like babies ‘cotton-mouth/thrush’ this risk may increase with diagnosis of diabetes ( which we as Pd patients are at higher risk). Treatment consists of anti-fungal medication topically like mycostatin ointment. One way to prevent is as I said above maintaining dry are but also apply 1-2 times a week some Desitin (or other baby rash ointment with zinc) to groin area to help with moisture and decrease this type of infection.

Addendum: Eltamd UV Clear SPF 46, 48-Gram 1.7 oz.

2 possible treatments are:

Elta MD sunblock- can find at amazon

Over the counter Cerave skin cleanser & lotion helps with eczema



Parkinson's awereness, Parkinson's Diagnosis, parkinson's disease, Parkinson's Health, Parkinson's symptoms, Parkinson's tratamientos, Parkinson's treatment, Parkinsons disease, parkinsons health and beauty tips

Camino al Mundial 2016 (Congreso del Parkinson -WPC 2016):Dra. De Leon

Estoy muy entusiasmada y agradecida de poder formar parte del comité encargado de los preparativos para un evento tan especial e importante como es el congreso mundial del Parkinson. Este evento se lleva acabo cada 3 años. El último se llevó acabo en Montreal. Este año se celebrará el cuarto Congreso Mundial en la ciudad de Portland, Oregón  en septiembre 20 al 23 de 2016. Los invito a todos ustedes a que consideren asistir a este gran evento.

¿Pero Porque asistir se preguntarán? Primero un poco de historia – en el 2002 el ex director del Instituto Nacional de la Salud (NIH) Dr. Elías Zerhouni hizo la pregunta ¿Porque no había una conferencia donde todos pudieran asistir al mismo tiempo en el área del párkinson? Esto creo la iniciativa del primer mundial del Parkinson e se llevó acabo en Washington del Distrito de Columbia en febrero del 2006. Esta fue una idea innovadora para juntar a la toda comunidad nacional e internacional del Parkinson  incluyendo pacientes, familiares, doctores y científicos.

Desde la primera conferencia a la cual asistieron 3 mil personas ha crecido enormemente. Este año, se espera que participen delgados de más de 60 países. Pero en los últimos congresos ha habido poca participación por la comunidad hispana. ¿Pueda que tal vez sean las barreras del idioma el que nos separe de tales eventos o tal vez el costo o la misma distancia? Pero aunque todas estas razones son muy legítimas especialmente acudir a algo que no vamos a entender puede ser problemático.  A la vez si no ponemos interés de ir y participar en algo de tan gran importancia que podría dejar grandes beneficios para nuestra comunidad damos la apariencia de que no nos interesa este tipo de evento. Es imperativo que las puertas se nos habrán a nosotros los latinos para tener voz en las fundaciones principales del país porque aquí en los Estados Unidos los Hispanos formamos la minoría más grande y también entre los hispanos tenemos dos veces más riesgos de ser afectados por esta enfermedad llamada Parkinson que afecta más de 7 millones mundialmente (con casi dos millones aquí en nuestro país). Pero a pesar de esto no somos representados igualmente en los estudios científicos ni recibimos los mismos tratamientos médicos ni quirúrgicos.

Hoy más que nunca necesitamos unir nuestras voces para poder hacer cambios en el tratamiento en nuestras comunidades para poder lograr mejor calidad de vida. Solamente con asistiendo a programas como este podemos empezar a dejar nuestras voces resonar en aquellos que tienen la capacidad de hacer verdaderos cambios en la ciencia. Para poder encontrar cura es importante entender la cultura y la genética que nos separa. Y nosotros necesitamos encontrar apoyo en nuestra comunidad aquí dentro y fuera del país. Porque como dice la antigua canción de Roberto Carlos “yo quisiera tener un millón de amigos y así poder cantar mejor” porque en la unión esta la fuerza. Además también es importante como saber encontrar los recursos necesarios para nuestras familias y para nosotros para participar en estudios científicos y para obtener beneficios algo de lo que pueden aprender más allá en la conferencia. Allí conocerán a otras personas como ustedes de aquí y otros países que les servirán de guías y mentores en su jornada con esta enfermedad. O tal vez alguna de ustedes que ya tienen muchos más años viviendo con la misma pueden ser embajadores o partidarios de otros que apenas comienzan esta larga trayectoria.

Por ultimo allá podrán asistir a conferencias donde aprenderán cosas prácticas para el diario vivir como nuevos tratamientos al igual que los últimos avances en la ciencia que ustedes después pueden desimanar en sus comunidades médicas y con sus otros amigos que también padecen del párkinson. Si tienen bajos recursos pueden aplicar para becas de viaje y ayuntamiento. También si dirigen a médicos o científicos a esta conferencia se les garlaran premios y puntos para viajar. Entre más refieran más ganan (tienen que ser gente nueva que nunca ha ido). Y si usted tiene algo científico o clínico de interés que presentar a la comunidad por favor sometan un cartoncillo (poster) de presentación. Allí estaré yo, y Claudia directora del centro de  Parkinson de Mohammed  Ali (MACP) (que trabaja con la comunidad Hispana de Phoenix en  Julio uno de los bloggers del congreso, Israel embajador y partidario activo de la comunidad del párkinson al igual que Fulvio que es también embajador del congreso y  estuvó en Glasgow en 2010 cuando se presentó  la cobija  ( Quilt Project del PDF) representando a todos los del párkinson mundialmente (ahí tuve yo un pedazito también- en honor de mi abuela) y asistio al congreso en el 2013 en Montreal. También por medido de Julio, Claudia,  yo, y otro les mantendremos informados de los nuevos avances y temas de importancia que se presentaran por allá. Esperamos verlos en la ciudad de Portland en Septiembre a todos ustedes.

Para más información acerca de los temas:

O para inscribirse o seguir a Julio:

  Fulvio Capitanio (Spain) is an economist and ITC manager. He was diagnosed with Parkinson’s in 2007 and retired from his job in 2009. In January of 2008, with a group of PD friends he met over the Internet, he started an online organization called “Unidos contra el Parkinson” (together against Parkinson’s disease) at

Israel Robledo Claudia Martinez Claudia Martinez


chronic illness, parkinson's awareness month, parkinson's disease, Parkinson's Health, Parkinson's symptoms, parkinsons dementia, parkinsons health and beauty tips

Go Red: A must for women with PD: By Dr. De Leon

“Follow your heart but take your brain along.”


February is not only the month of love but is also more importantly the month in which we bring awareness to the 2 most important organs we have -our BRAIN & our HEART. Brain & heart health are extremely important for all but particularly for women with PD because the symptoms of a heart attack and a stroke are not similar to those of men in many cases. Thus, women may go un-diagnosed and are more likely to suffer long standing consequences. In fact in a study looking at women and stoke they found that most physicians still regard cardio/cerebrovascular disease as a man’s disease. Thus, women are not often offered the appropriate counseling. Only 22% of Primary care physicians and 42% of cardiologists felt equipped to deal with cardiovascular issues in women. These figures puts us at a significant disadvantage from a diagnosis and treatment standpoint.

A few years ago, I had an episode of severe sudden chest pain with exertion along with nausea, dizziness, and sweating. Of course being a physician I could not exclude a cardiac cause for my symptoms. However, when I went to the cardiologist his response was less than I would have expected given my condition because in his words ‘women simply don’t get heart attacks‘ especially at your age. Of course, no one wants a heart attack (and by the way I do have family history of young onset heart disease)  at any age but excluding an entire differential based on gender seemed a bit worrisome. My symptoms turned out to be caused by a combination of acute endocarditis along with malignant hypertension. Fortunately my blood pressure is now under control (at least for now) and my endocarditis has resolved.


However, you may be wondering why I am writing about strokes and heart attacks in a Parkinson’s blog?  Well, for several reasons. First, because those of us who suffer from Parkinson’s disease and other atypical Parkinson like Shy-dragger disease have autonomic dysfunction; with this problem comes severe alterations in blood pressure ranging from extremely low to extremely high as is my case. In my experience as a neurologist taking care of stroke patients i have found that it is the constant fluctuation from very high to very low that is most damaging along with the rate at which it changes (rapid change is more deleterious to vital organs like the brain and heart). Furthermore, high blood pressure is the single most important risk factor and leading cause for stroke. We often talk about low blood pressure in PD patients but rarely do we talk about high blood pressure. But even if our blood pressure did not rise the sudden drop can be equally detrimental to an organ that is critically dependent on blood flow and oxygen levels to function properly.

Second, patients with PD and other atypical Parkinson like MSA have tendency to have as part of disease sleep apnea. It is believed that half of those who have sleep apnea also have high blood pressure. Plus, the severity of the hypertension is directly related to the severity of sleep apnea. But, you don’t have to have severe sleep apnea to have problems. Even mild sleep apnea can alter your blood pressure putting you at risk for a stroke. This is crucial especially given the fact that most strokes occur in the early hours of the morning when we are at sleep.


Third, migraines with aura appear to be a risk factor of PD and who has more migraines other women? In fact recently, in a medical journal it was speculated that having an aura increases the risk of having atrial fibrillation yet another risk factor for developing stroke.

Finally, just because we have one medical problem i.e. Parkinson’s does not mean we are immune to developing other neurological disease or medical problems that come with age such as high blood pressure.
The good news is that high blood pressure is a modifiable risk factor. We might not be able to do anything about our gender, our age, or our Parkinson’s diagnosis but we can be proactive in making sure, we eat right, we exercise, and we talk to our physicians about any weight issues we might have which directly impact our risk for both apnea and high blood pressure. Also, it is important to monitor your blood pressure and discuss treatments if needed as well as stroke prevention treatments. The other good news is that although stoke studies have not shown aspirin to prevent strokes in a sub-study of women it proved to be extremely effective. ( I take my aspirin daily!) Lastly, I firmly believe that because we have a higher likelihood of developing apnea we should be frequently screened. Thus, speak to your physician about these issues especially if you have family history of cerebrovascular disease or if you are a young woman with PD and have migraines with auras, or are on birth control pills.


Zedde m. Women and stroke: A matter of education?. Neurology. Published 2019. Accessed February 3, 2019.

Chang BP e. Neurology Concepts: Young Women and Ischemic Stroke-Evaluation and Management in the Emergency Department. – PubMed – NCBI. Published 2019. Accessed February 3, 2019.

High Blood Pressure Symptoms | Sleep Apnea Guide. Sleep Apnea Guide. Published 2019. Accessed February 3, 2019.

Aspirin May Lower Stroke Risk in Women with History of Preeclampsia – Published 2019. Accessed February 3, 2019.

Nogrady B. Increased risk of atrial fibrillation with migraine aura. Published 2019. Accessed February 3, 2019.

@copyright 2019

all rights reserved by Maria L. De Leon MD

fall prevention in parkinsons, falls in parkinsons, medications in Parkinson's, parkinson's disease, Parkinson's Health, Parkinson's symptoms, Parkinson's tratamientos, Parkinson's treatment

Common Causes & Treatments of Dizziness in PD: By Dr. De Leon


Parkinson’s disease (PD) is a progressive neurological illness affecting the basal ganglia causing neuronal cell death of the dopamine producing cells within the substancia nigra as well as neuronal death in other parts of the brain including the brainstem. Rest tremors, rigidity, gait impediments, and marked slowness of movements (commonly referred as motor symptoms) are the hallmark of this disease. However, there are also many other non-motor symptoms involving sleep, cognition, behavioral problems, and autonomic dysfunction. Among these dizziness is a common complaint among people living with PD making up to 30% of those over the age of 65.

So what is dizziness?

Because the term dizziness is so imprecise due to the fact that it can refer to vertigo, syncope, disequilibrium, general weakness, or a non- specific feeling such as giddiness; It is often dismissed by healthcare providers as trivial if one complains of ‘dizziness’ purely as a non-specific symptom. First, we have to understand what we mean by feeling dizzy- some people think of this as the room spinning or a sense of self spinning- this is actually known as vertigo and implies a different cause (etiology). While a feeling of unsteady in your feet when walking and actually veering or falling to one side as opposed to just falling all over the place implies more than loss of balance but rather a structural abnormality within the brain or ear canal. Some people feel lightheaded instead- feeling faint, and may complain of feeling a sensation of swimmy headed/ water inside the head.

So as you can see there are a multitude of causes of ‘dizziness’ and in order to get the right treatment you must learn to be specific with your problem.

The Medical definition of dizziness is- either someone who is mentally confused or is having a feeling of whirling in the head with a tendency to fall.

In order for someone to walk normally without unsteadiness or loss of balance, one must have intact sensory input (eyes, ears, nerves in feet referred to proprioception as well as intact cerebellum; extrapyramidal system-one involved in PD; and cerebral cortex). As you can see there are a lot of places where we can have a deficit causing us to feel ‘unsteady’ and ‘dizzy’ making us prone to fall or become confused.

Causes of Dizziness in PD:

  • Neuro-otological- meaning inner ear problems
  • Cardiovascular disease
  • Drugs
  • Multisensory dizziness syndrome- meaning poor input from various sources i.e. eyes, ears, nerves, etc.
  • Cervical vertigo
  • Postural hypotension
  • Postural instability due to tremors/dyskenisias
  • Pisa syndrome- antero-flexion of the trunk leading to loss of balance by shifting gravity forward- treat with brace, botox and medication adjustment.
  • Migraines- occipital (basilar migraines) may present only as dizziness and nausea without headache- common change in people who had migraines all of their lives. Stalevo and levodopa compounds are more likely to trigger. treatmnent migraine medications – e.g. maxalt, imitrex & preventive meds such as Topamax or keppra
  • BPPV-Benign Positional Vertigo- treated with vestibular therapy

Treatments of dizziness:

The most important thing to discovering and treating the cause of your problem is a good detail history. This includes:

  • What do you mean by dizziness? Is it vertigo or light-headedness or swimming sensation in head or a feeling of confusion, etc.?
  • Are you falling? Or simply unsteady?
  • When does it occur? (After medication, before medication?)
  • How long does it last?
  • What makes it better? What makes it worse?
  • Other symptoms? Ringing in ears? Hearing loss? Numbness in feet? Weakness? Headaches?
  • Chest pain?
  • Only when you stand still? Or walking?
  1. Neuro-otological– it is important to have yearly check- ups of hearing and sight especially as we age. This is the number one cause of falls and unsteadiness in older people because the sensory input from these areas are no longer functioning as well as we would like. Especially in PD we already have vision problems including loss of contrast and difficulty moving eyes more so if you have PSP – vision is extremely limited in the vertical plane resulting in frequent falls because people are not able to see changes in sidewalks, like small steps. The other group who might have had essential tremor initially and then developed PD may suffer from significant hearing loss which is one of the hall marks of ET- which may then contribute to poor equilibrium.
    1. Get hearing aids and/ or prisms to help with these types of problems that lead to disequilibrium. This means seeing an ENT doctor and possibly getting an MRI brain, an electronystagmogram (ENG)- this test helps distinguishes between abnormalities in the vestibular system, brainstem, and cerebellum, and having a hearing test done. Also may need to see a specialist called neuro-opthalmologist if your regular eye doctor is not able to detect any eye abnormalities but have trouble seeing resulting in falls.
  2. Cardiovascular-of as we age we also have tendency to develop heart disease, women are not excluded from this- after menopause we have same risk as men. Furthermore, although it is still controversial and not well publicized most of the dopamine agonists do increase the risk for arrhythmias (this risk increases with age in my opinion and needs to be monitored especially if already have risks for heart disease or family history of such). I myself have developed a secondary heart degree block since I have been on my medications. This type of problem usually presents in the middle of the night but can occur anytime a person goes to the bathroom to void, they may experience near fainting or actual fainting- this is extremely serious and need to seek medical attention ASAP from cardiologist!
  3. Drugs-most of the drugs used for PD because they work on the neurochemicals can potentially alter cognitive status especially if have underlying dementia or a Parkinson’s plus syndrome. But in PD patients these medicines can often cause sleepiness making one feel somewhat unsteady and dizzy particularly when in a moving vehicle it may trigger actual spinning sensation even when the vehicle comes to a sudden stop. This feeling is more common with benzodiazepines (e.g. klonopin, valium, etc.) The dopamine agonists are more likely to cause sedation, the one least likely is Neupro patch. One way of counteracting is taking medications like Provigil & Nuvigil (narcolepsy drugs often used in PD to help maintain alertness). However, one simple solution is when you feel this way lay down and take a small nap- problem solved. If unable to function because feeling unsteady, and spinning talk to your doctor about adjusting your medication especially if you are actually experiencing outright confusion and disorientation.
  4. Multisensory dizziness syndrome– the biggest thing here is loss of proprioception- feeling or sensory input from the ground due to peripheral neuropathies. This is common from B12 deficiency, a common problem in PD easily corrected by checking blood work- levels should be in the 1000’s replaced only via IM B12 injections or nasal spray. Other common causes is diabetes – this is a risk that increases as we age plus as I mentioned in other blogs PD patients may be at higher risk of developing Diabetes due to insulin resistance cause by dopamine intake since it shuts down the pancreas. I suggest close monitoring of your sugars especially if had PD for a long period of time and/or have family history. * see how to tell if you are at risk of diabetes. Take B1- thiamine 100mg a day to protect against neuropathies. Another reason people may have sensory loss in their limbs is due to stenosis/herniated discs in neck and lumbar spine – frequent problems in PD. In order to avoid this from becoming chronic irreversible problem seek immediate medical attention if have pain, weakness or numbness shooting down a limb.
  5. Cervical vertigo- as I said above cervical stenosis can cause problems of proprioception- since head and neck move together any compromise of the neck disrupts the input into the brain- this may be one of the biggest problems in PD since so many of us as we advance in our disease experience problems in our neck due to dystonia/ dyskenisias/ and increased rigidity. Not only will this affect sensory input coming in as well as going out but may also disrupt blood flow into the brain by compromising the vertebral arteries if there is abnormal positioning of the neck. Hence it is extremely important that if you are experiencing neck issues especially in light of dizziness, vertigo or unsteadiness- seek immediate medical attention to adjust medications, get Botox, DBS or neck surgery and even take a blood thinner in form of aspirin to maintain blood flow if not contraindicated. The advantage is that an aspirin a day may also be beneficial (possibly neuro- protective) in PD.
  6. Postural hypotension –the #1 cause of dizziness and falls in PD patients. Most medications can cause low blood pressure upon arising quickly leading to loss of balance or falls as you first get up from sitting or lying down. Sometimes can be severe that it lasts several hours making gait difficult. When hypotension is medication related you will notice this symptom an hour -2 after medication intake and will improve as medication wears off. Usually most severe within first hour. Some patients if they have Parkinson’s plus syndromes like Shy dragger, LBD, or PSP may have symptoms from the beginning even before medication intake. These patients need to be on hypotension precautions like wearing support hose (ted hose, compression hose that go to their thighs), sleep with head of bed elevated at 45 degree angle (can get a bed tempurpedic mattress, or put a few bricks at head of bed), do not shower with hot water- only warm, drink cold water during an episode, and take medications like salt tablets, Northera, Midrodine, Fludrocortisone, and others like Remeron (because of increased BP potential). If you have advanced PD, you also may have this problem and may need to resort to similar symptoms. However, if you have early onset PD and are experiencing this type of side effects- one try adjusting medications or switching to another type. Sometimes taking meds on a full stomach helps decrease this side effects or taking meds early in am and going back to bed and sleeping symptoms off are some of the possible strategies to dealing with this issue. Talk to your doctor as soon as possible if you are experiencing light-headedness, dizziness, and disequilibrium and faint feeling upon arising. Also remember to get up slowly from sitting or lying down.


@copyright 2015 all rights reserved Maria De Leon

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Meningioma’s & Parkinson’s – Taking a Closer Look at Their Connection: By Dr. De Leon

Since both my mother and grandmother have been found to have brain meningiomas, I have begun to take a very serious look at this matter. My search has lead me to find a few cases of meningioma – benign brain tumor arising from the lining covering of the brain (the meninges) presenting as reversible Parkinsonism. However, my concern is the relationship between PD and an increase risk for occurrence of meningioma’s of the brain after PD diagnosis.

My grandmother as you might remember had Parkinson’s disease which began in her late 60’s. She had good response to PD meds for many years but then began having uncontrolled bladder issues first believed to be due to PD but the symptoms were out of proportion to disease state. It was then thought that the problem was due to Diabetes. Then came the increase falling and worsening vision. This continued until one day she suddenly developed hemiparesis and seizures which led to the discovery of an extremely aggressive meningioma of which she died of.

My search has lead me to a possible link of an increased incidence of ‘benign tumors’ (non- aggressive and normally do not spread to surrounding tissues; although they can be serious and life threating) with PD, this according to a large Taiwanese PD study. The incidence appeared to be an increase of 2.2. Furthermore, the incidence of benign tumors was higher in women with PD compared to women without PD especially in those over 50 years of age. However, the problem is that they never mentioned which ‘benign’ brain tumors?

The most common ‘benign’ brain tumor in adults are pituitary adenomas after gliomas, meningiomas, and schwannomas. So it would stand to reason that some of these benign tumors are indeed meningiomas.

What does this all mean for us?

3 things:

  1. Meningioma’s could be a possible treatable cause of Parkinson’s disease (parkinsonism)- these can present anywhere in the brain. Hence, the importance of obtaining an MRI of the Brain when first diagnosed. These occur more commonly in women ages 30-70; so YOPD women should always look, as any other PD patient, look at other treatable causes.

Risks are:

  • Head injury (controversial)           
  •  Increase in progesterone (post- menopause
  •  Neurofibromatosis type 2 (genetic disorder)
  •  Exposure to radiation

2. Meningioma’s are a possible increased benign brain tumor in PD patients especially in women. Therefore, it is important to keep in the back of your mind and discuss with your physician if new symptoms arise especially if not responding to PD medications or occurring out suddenly or out of frame with expected PD course. This is a time to have a repeated MRI/CT of the Brain. MRI is recommended because they usually begin to have calcifications or changes in the bone and arise in areas where there are a lot of bony structures making it easier to overlook. Because these grow very slowly over time usually they present with gradually developing symptoms.

Symptoms: the hard part is that some of these symptoms are part of PD – thus we have to remain hypervigilant especially when not obtaining the desired affect from medication. (Not responding well)

  • Blurred vision/loss of vision/
  • Weakness in arms or legs
  • Numbness
  • Speech problems
  • Headaches
  • Seizures
  • (increased bladder/bowel function due to swelling when there is swelling of the brain)

3. Because benign brain tumors incidence has been reported to be increased in PD patients – until we have more defining studies even when all seems well maybe worthwhile to discuss with your physicians about an updated brain imaging to make sure some of the slow growing treatable tumors don’t sneak up on us. Furthermore, those of us who like me are LRRK2 carriers might be also at higher risk of another benign brain tumor a glioma.

Now, for a woman that was once proud of her brain it has been a big blow to watch my brain shrink since this disease took over me along with the realization that I may be at higher risk of having a brain tumor due to my genetics and family history. But, I will persevere and continue to fight and educate others in hope of a better tomorrow for all of us.



increased risk of brain tumors with PD :

meningioma brain tumors:

large intracranial meningioma masquerading as PD:







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When Is a Tremor a Sign of Parkinson’s Disease?: By Dr. De Leon

Are you often asked by others, if you are nervous or cold?

Do you frequently hide your hands in your pockets when you walk to avoid stares from onlookers ? When you are out in public  do feel all eyes are on you and makes you shake more? So you stick your hand(s) in your pocket as fast as you can? Sometimes do you feel the urge to just sit on top of your hands until they go numb just to stop them from shaking for a minute or two?

If you do any of these things- it maybe your brain telling you something is not quite right! The problem can be something as simple as drinking too much caffeine (but usually will also feel tired and  have a fast heart rate) to as difficult as having a neurological disease affecting the cerebellum caused by alcoholism or poor nutrition.

The first step in finding out the problem is getting to a neurologist preferably a movement disorder specialist.  He or she can tell if the tremor is metabolic due to thyroid problems or neurological in origin. May sometimes require a few blood test and even an MRI of the Brain when other symptoms are present to confirm there are no other underlying causes.

The key in diagnosis is in the characteristic of the tremor at hand. Typically neurodegenerative  diseases like stroke, MS, PD tend to start on one side and remain unilateral for a time. While tremors due to metabolic issues and benign essential tremors (ET) are usually bilateral (present on both sides). Although, in ET these can have a more severe dominant side.

However, when at the tremors are at rest, this could be a sign or one of the initial symptoms of Parkinson’s disease (PD), a chronic progressive neurologic disorder caused by the deficiency of a chemical called dopamine. PD tremors present typically in the hands. Usually it manifests itself while at rest in the thumbs; but any of the fingers can shake resembling a rapid tap as if sending a Morse code message. This tremor is often more noticeable to others when sitting or walking.  It can sometimes less frequently present in the feet with an involuntary rhythmic toe movement, most frequently noticed at night while trying to fall asleep. Unlike the more common tremor known as essential tremor (ET) which occur primarily with action; by definition, a rest tremor disappears as soon as a deliberate movement or motion is made such as reaching for a cup. The rest tremor is also usually accompanied by decrease in arm swing in the  opposite arm- opposite arm usually stiffer/ tighter. sometimes only way some patients have noticed a decrease in arm swing is by  decrease ability to keep time in a Rolex watch – since they are self winding with gait and arm movement.

Another important characteristic to look at is penmanship. Handwriting is significantly affected with both types of tremors which can be equally frustrating for different reasons and can lead to illegible handwriting in individuals suffering from both types of tremor. As you know, the characteristic features of those with PD are small, tight and progressively diminutive hand writing (micrographia) rather than shaky. Both types of tremors can worsen with stress, lack of sleep, and caffeine intake. According to Dr. Okun, National Medical director for the National Parkinson’s  Foundation, evaluating a sample handwriting helped identify early PD in over 97% of the cases. 

Along with tremors patients with PD are stiff, thus have trouble performing normal activities (i.e. bathing and dressing) due to lack of mobility. They often complain of shoulder pain caused by stiffness in the joint. Another important finding is an inherent slowness when performing any type of movement (e.g. walking, eating, and opening doors and jars). Further, Parkinson’s patients have difficulty with gait and balance leading to frequent falls. Other symptoms accompanying tremors include loss of smell, visual deficits, fatigue, pain, sleep and mood disorders along with bowel and bladder difficulties. Sometimes the latter findings may precede the tremor itself by up to 10 years.

People with ET typically have problems with shaving, putting on make up, drinking out of a cup etc. These individuals usually present in their later years unless there is a family history which tends to be anticipatory in nature. Some of them may be heavy drinkers due to self medication confounding etiology of tremor. (Alcohol alleviates these types of tremors; however I do not recommended as the treatment of choice). This means that if grandma had ET at 80, children will have at least 10 years earlier and so on. Eventually gene will die out with each generation. Interestingly persons with essential tremors especially those who are older at presentation tend to have increased hearing loss. On the upside of things these individuals have great longevity. They too may experience tremors of voice, and trunk as well as legs making them unsteady to walk and in cases where tremors start young there is an increased risk of developing PD in later years.

If you or a loved one have any of these characteristic features especially if there is a family history of tremors or Parkinson’s disease, then you maybe one of the nearly 10 or  1.5 million people living with essential tremors or  PD respectably in the USA. Although at present there is no known cure for either disease and we arte not certain of the cause, there are many efficacious therapies for both including medications such as levodopa- the Gold standard of treatment for PD. Also surgeries like deep brain stimulation (DBS) can be of great benefit to either disease and thus far is the only treatment available able to stop tremors 100%.

So, if you or a loved one got some tremors after a well shaken chocolate martini (preferably), seek immediate care from a movement disorder specialist. Early treatment is associated with an increased quality of life and decreased disability particularly for PD.

Go ahead & shake it like there is no tomorrow!

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