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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



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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


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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Signs that your body is in trouble – especially in midst of living with PD: By Dr. De Leon

There are many subtle ways that our bodies tell us that something is not right. The body is a perfect organism always in balance. Have you suddenly had a craving for something sweet, sour or salty? I have – and is not just pregnant women that have cravings. Funny thing when I was pregnant I had only cravings for fruits. Then when I began to have cramps and pain, oh boy was I craving sour and salty things. All my pickles were dry in the refrigerator and even margaritas sounded delicious because of the ice, salt and lemon. Once my cramps got treated I had no more need for dill pickles at the movie theater.
One must learn to listen to our bodies and take note of the subtleties because they can be screaming at the top of their lungs for us to take heed and correct what is gone amiss.

When one lives with Parkinson’s disease, not only are we not immune to other illness, as I mentioned before according to a study only about 22% of patients with Parkinson’s have that as their only illness, Plus, Parkinson’s is a systemic disease which affects almost every major organ system. Thus, we need to be Elle to recognize silent or subtle symptoms to avoid further heartache.

We know that the gi system is one of the most commonly involved in Parkinson’s disease. Common symptoms can vary from constipation, paralysis or parestesis of the gut including reflux caused by both medications and disease itself. One of the common signs of having reflux is frequent coughing, unexplained wheezing and sometimes chocking a few minutes after finishing a meal or eating snacks. Sometimes only symptom of gi symptoms and severe reflux is not heartburn or pain but foul mouth smell/taste (halitosis) or wearing out of enamel of back of mouth. Untreated reflux can not only lead to tooth decay, motor fluctuations of Parkinson’s as well as esophageal cancer. Remember of the causes is H. Pylori

As I said previously one of the most common causes of pain and cramping in people with Parkinson’s is due to electrolyte imbalance brought on by repeated laxative use to relieve chronic constipation. Signs that you have electrolyte imbalances  is what I mentioned earlier cravings for sour and salty things – a good fix is a spoonful of mustard and going to see doctor about electrolyte imbalance, potassium, magnesium and calcium.

Some of us who have LRRk2 gene as a cause of our Parkinson’s, are also at risk of developing another autoimmune or inflammatory diseases. One of the common autoimmune diseases who are a frequent comorbidity with PD is inflammatory bowel disease (both ulcerative colitis and Chron’s disease). One of the subtle ways a recurrence of Chron’s disease is the presence of pseudo -hemorrhoids. Of course you may think we’ll I have chronic constipation so it’s not surprising. You should always should check with your doctor and visit a gi specialists. Chron’s can affect the anal area in the form of fleshy growths which may mimic hemorrhoids. This type of Chron’s is extremely painful and Has a worse prognosis especially if left untreated causing bowel obstruction, anal fissures, and even cancer of the colon. So make sure that one of your team players in the fight against PD includes a gi doctor whom I recommend seeing at least twice a year or more frequently if having other problems. And especially if already have a history of inflammatory bowel disease.

Another frequent not so subtle problem that indicates something might be wrong is change in bladder habit. In men with Parkinson’s especially those who take or have taken Stalevo for while are at a higher risk of developing prostate cancer. So if your stream changes or are making more frequent trips to the ‘john’ don’t assume is just age or PD; get in checked out. Another common cause of increase frequency and urgency is Diabetes which  usually results in increase trips as well as increase amounts of urine (frothy) due to body’s attempt to rid of excess sugar. A big sign is increased thirst which sometimes can be confused by the fact that so many PD meds also cause dry mouth but we must look out for changes especially when no new meds are added into the mix. another sign could be increase frequency at night, although it could be that you need a booster dose at bedtime or even a sign that we are simply getting older- if you experience this as a new or worsening symptom consider talking to your doctor ASAP. The best way to check is to get a HgA1C which measures your  blood sugar levels over a period of 3 months. this is extremely important because there is some evidence as I posted before that excess dopamine can lead to insulin resistant condition and hence diabetes. Finally, I  can’t discard the increase risk of urinary infection triggered by both bladder malfunction and medication effect. Two good meds which help with symptoms of urgency and frequency are phenazopyridine and UTA. The former turns urine dark yellow and the latter turns it slightly bluish hue.

You are here... ...Run!!!
You are here… …Run!!!





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I have A Tremor: Does it mean I Have Parkinson’s Disease ? By Dr. De Leon

“Shaking is great. Shaking is one of the oldest practices known to man…connecting the earth and restoring energy through Out…” Jerome Flynn

Is my tremor a sign of PD? This is always the million dollar question on everyone’s mind when they go see a Movement disorder specialist for the first time. Although, this is the one tremor everyone ruminates on it is not the most common of the movement disorders nor the only tremor.

There are many other tremors associated with other neurological and medical conditions w hich can present challenges for daily living for those experiencing tremors independent of etiology.

Therefore, I want to spend a little bit of time talking about some of these and in particular the more common type of tremor also known as “essential tremor” since this seems to be one of the main reasons for which people are referred to a neurologist.   Many of these usually  have been misdiagnosed as having PD . It is estimated that about 20% of people with ET are labeled as having Parkinson’s according to a study by Henderson et al.(1995)

Essential tremor (ET) unlike Parkinson’s tremor is a postural, action tremor that progress slowly over many years. It is significantly more common than rest tremor of PD. In 60% of those with ET have an autosomal dominant trait. This disease can start early in life but it is much more common in older individuals due to increase in frequency due to age. There is an anticipatory mechanism with every generation making the tremors present sooner or at younger age than parents or grandparents. People with essential tremor can become severely disabled especially socially although diseases progresses very slow.  Individual’s with ET usually are hard of hearing and have bilateral tremors and can have great difficulty with activities of daily living. They are also at higher risk for developing Parkinson’s disease later in life. Sometimes they also have accompanying head tremors (mostly nodding -yes), voice tremors and at times orthostatic tremors –which I will discuss later.

The test you can do at home is to draw a spiral first with one hand then the other and watch for cauliflower like pattern. also draw a straight line between two other lines in a narrow space and if it looks like the line is an inching worm or squiggly line then you have action tremors. See picture: Also, even though handwriting is affected it is completely different than that of PD. It is shaky and messy. Furthermore, this type of tremor responds well to alcohol intake sometimes causing patients with severe tremors to become alcoholics. Subsequently, they too are misdiagnosed because physician’s erroneously assume they have tremors due to their drinking and not the other way around.  Besides alcohol which is not really recommended is treatment with Mysoline, Neurontin, Klonopin, Topamax, Beta-blockers -which I do not recommend in young people especially men due to tendency to cause severe depression besides lowering blood pressure.  Botox works well if focal, but DBS to thalamus is best treatment plan if symptoms are severe.

Parkinson’s (rest) tremor, the second most frequent type of tremor has a much slower amplitude as if sending a ‘Morse’ code. It is often described as -‘pill rolling’ tremor  present primarily at rest and starts unilaterally unlike ET.  PWP’s often feel like they have to hide their tremors by putting their hands in their pockets when walking or sitting on their hands if at rest as to not draw attention to themselves. Person’s with rest tremor can do normal action specific maneuvers such as  shaving or putting on mascara, without much if any interference. Occasionally, PD individuals can experience action tremors but these are different from above tremor in that the frequency is same as rest tremor. When asked to do above diagrams, PWP’s exhibit normal patterns- smooth and even! The handwriting is also affected as you know with PD but instead of messy is small and tight which usually gets smaller and tappers down as we write.Best treated with Anti-cholinergics – Artane & Amantadine and to a lesser extent dopamine replacement- Best results is DBS.

Another commonly seen tremor is Dystonic tremor. This tremor is said to be a forme fruste of ET. The best example of this is in patients who have cervical dystonia (i.e. spasmodic torticollis) who have a tendency to turn their head involuntarily in a particular direction say to the left and when they try to maintain their head and neck in a neutral position their head will shake involuntarily. One simple way to differentiate this tremor from essential tremors is a clear response and decline in tremor when a person uses antagonistic gestures. This means that the tremor improves through touch of the head or by lifting an arm etc. ET will not respond to antagonistic gestures!!Best treated with Klonopin and Botox.

Orthostatic tremors- Unique tremor syndrome more common in elderly and middle aged. This usually presents as a feeling of unsteadiness or dizziness while standing still. It typically does not interfere with gait unless is severe. the shaking or tremors are concentrated to the trunk and legs occasionally the arms. Best treated with Klonopin.

Cerebellar tremors- Unilateral Intention tremors but unlike essential tremors these patients have trouble with reaching target; not only do they shake as they get closer to target but when asked to do ‘finger to nose’ they overestimate or overshoot distance. Best treatment for this is Isoniazid, Tegretol, Mysoline.

Physiologic tremors. We all have very fine tremors of fingers especially pinky and can be visualized to naked eye. frequency is not as fast as those with ET- much more subtle and fine. yet they can increase under certain conditions such as stress, increased caffeine intake, abnormal metabolic disorders like diabetes and thyroid disease to name a few. Treatment finding root of problem. too much caffeine consumption is usually a big factor but these will present with other non- neurological medical problems.

Although, there are many other less frequent tremors these are the most common type. All tremors should be investigated and evaluated by a neurologist or MDS; so that the correct diagnosis and treatment can be initiated on a timely basis before there is interruption of function.


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Wearing off it’s hard to do! By Dr. De Leon

Wearing off it’s hard to do! By Dr. De Leon.

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Tips for Treating Swallowing Difficulties in Parkinson’s: By Dr. De Leon

Most of us know that one of the hallmarks of PD is muscle rigidity. Since the muscles of mastication and deglutition (swallowing) which include tongue, palate, pharynx and esophagus can also become affected and stiff as the disease advances swallowing can become not just a challenge but a matter of life and death as time goes by.

There are 4 Phases of Swallowing:

If there are problems in any of the main 3 phases (oral, pharyngeal or esophageal) this can lead patients to feel like they are chocking, feel like something is stuck in their throw, or like a child who can’t seem to coordinate the swallowing maneuvers (i.e. their tongue to push pill back at same time as they swallow) no matter how much fluid they drink.

Dysphagia (or difficulty swallowing) affects not just intake of pills but solids, liquids, and eventually even one’s own saliva resulting in increased drooling. This sensation can cause anxiety, feeling of panic. If dysphagia goes untreated it can lead to a person becoming malnourished because the energy required to consume a small amount of food can become extremely tiring to the point that many people with this disorder simply give up. Further, the more weakened and malnourished someone becomes the less energy they have to toil creating a potentially hazardous vicious cycle unless there is proper medical intervention.

So what can you do to avoid feeling this frustration? To avoid poor nutrition? And most importantly to avoid hospitalization due to aspiration?

Silent (not even being aware) aspiration resulting in pneumonia is one of the most common reasons for hospitalizations in those with PD. Although, it is preventable, this remains one of the top reasons of morbidity and mortality in PD patients.

First, like everything else prevention is the key to improved quality of life. However, before prevention one must learn to recognize the symptoms of dysphagia. This means frequent follow up with your MDS/neurologist to adjust medications especially if you feel like saliva is pooling, this is caused by the muscles of throat becoming stiff and not working properly. If you are having to cut things up into smaller pieces or drink water (fluids) more frequently or taking a longer time to eat this is a sign things are not going so well. You should have frequent evaluation by a speech therapist (ST) throughout the course of disease especially as disease advances. They will not only evaluate quality of speech but also evaluate for risks of aspiration and teach proper swallowing techniques. Your neurologist may order a Swallowing test to be done by the speech therapist to further evaluate.

The speech therapist will teach how to:

  • Close lips and make tight seal
  • Move tongue and cheeks to prep for the swallow.
  • Instruct on types of food should be eating (liquids, semi-solids, thickened).
  • Sit upright when drinking & eating (this includes pills)
  • Take small sips and bites- alternating between the two. Do not gulp.
  • Avoid straws if possible because can pull too much liquid very quickly into pharynx (before airway has had time to seal). Straws are best kept for those with severe tremors or dyskenesias but actually now there are many other tools for this like Sippy cups and cups especially designed for PD patients. (see my book on Parkinson’s Diva: A woman’s Guide to Parkinson’s disease for other tools).
  • Keep your chin tilted down when eating and as your mother said please don’t talk with your mouth full (turns out she knew what she was talking about after all)

Second, once swallowing difficulty sets in, in my experience this does not mean is the end; in the majority of cases with medication adjustment and the aid of a peg tube ( feeding tube) symptoms are only transitory. I highly recommend for patients and families in the advanced stages who are experiencing dysphagia to consider a feeding tube usually in most of cases this is a temporary measure of assistance which serves to protect the airway.

Having a feeding tube allows patients to still taste food but not rely on it for nutrition and also if only having trouble while off then can use to get medications down until they kick in. Plus, with the advent of new treatment options becoming available the time patients have to endure feeding tubes is getting shorter. In my practice, I often used feeding tubes successfully to maintain quality of life while we adjusted medications and allowed for new medicines to come to market. I had a few patients who were end-stage and had been on everything to date and now were bedbound on feeding tubes in a nursing home but when Neupro patch came to market these patients were able to leave the nursing home and ditch the peg tube. So, I don’t ever like to look at feeding tubes as the final step necessarily but a means to an end. this allows patients also to stay hydrated because as dehydration sets in so does confusion, psychosis, agitation and worsening PD symptoms.

Many of my patients opted to leave their tube in place even after they were able to swallow as long as they maintained proper care just in case they had trouble in future. this worked very well. Only once in 15 years of practice did I have to remove a feeding tube due to infection.

Third, many Parkinson’s patients experience swallowing difficulty or choking sensation after the food has passed the pharynx on the way to the esophagus. Remember, the muscles of the esophagus not only do they get rigid and stiff but they become extremely slow as well not being able to properly move food along. It is important to have a good GI doctor that understand PD well and works well in conjunction with your Neurologists/MDS. He or she will help guide therapy plus be on the look out for reflux which often occurs as PD advances due to back pooling of food and acid that is not able to go down. the acid then burns the esophagus and even the vocal cords and pharynx muscles causing a sensation of chocking or difficulty swallowing. Another common problem is the presence of bacteria known as H.pylori that can also prevent motility and cause not just reflux but poor absorption of medications thus causing dysphagia. He/she may order an upper endoscopy to further evaluate.

As you can see, trouble can occur at any of the 4 stages of swallowing but with proper care, recognition, and prevention you may continue to lead a fruitful and productive life.

For suggestions on various dysphagic diets look at my previous post:Brunette Guide to Managing a Parkinson’s Dysphagic Diet 

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Tips for Treating Restless Legs Syndrome (RLS): By Dr. De Leon


Restless Legs Syndrome (RLS) also known as Willis- Ekbom syndrome is described as a discomfort, creepy- crawly sensation, or an irresistible urge to move the legs arising from a profound feeling of ‘restlessness.’ These sensations only occur at rest and primarily at night. They are relieved by moving the legs and walking up and about. As the name implies they occur predominantly in the legs, however once treatment begins these abnormal sensations can spread to involve the arms due to augmentation. RLS occurs 2.5% to 15% in general population.

RLS can be familial (1/2 of the time, some have abnormality in chromosome 12) or secondary to another neurological or medical illness such as PD or pregnancy. RLS can occur for the first time in pregnancy and more common in the second and third trimester. The symptoms undergo spontaneous remission after delivery. It can occur at any age and slightly more common in women than men.

As we know RLS is often seen in advance PD as a result of ‘wearing off’ and low dopamine doses (but who is too say is not due to low levels of Vitamin D in these patients?); however there is still much debate whether the two are linked or simply coexist. The debate comes down to the fact that RLS is a disorder of relative iron deficiency while iron levels are found to be high in the substancia nigra from oxidative stress. So even though they share similar treatment they do not appear to share a common brain defect.

Despite the fact that many neurologists and sleep specialists have believe that RLS is more common in PD, there is no data to support this claim to date. Three studies conducted outside of the US have shown controversial findings thus far; two studies stating increase RLS in PD compared to controls while a third one showed the opposite.  Thus, uncertainty of risk of RLS in PD remains. Yet, if you suspect you have this go see an MDS because sleepless nights triggered by pacing the floor to relief symptoms is no life!


Chronic diseases – Parkinson’s disease, diabetes, kidney failure, iron deficiency, vitamin D deficiency, folate deficiency (which happens to be one of the risk factors for PD).

Medications: some types such as nausea pills, anti-psychotics, some antidepressants, allergy medicines containing antihistamines can trigger these symptoms.

Pregnancy: In pregnancy the prevalence shoots up dramatically from 10% to 26%. This increase maybe due to an inherent iron and folate deficiency which are known risk factors for this condition.



  • Reduce alcohol
  • Exercise (especially yoga, tai- chi) 30- 60 minutes brisk walk or other type of exercise stretching and moving legs will improve symptoms and reduces night time fatigue, pain, restlessness, and help sleep better –this works best if followed by relaxation techniques like meditation.
  • Massage your lower legs or ask someone to rub /massage for you on a daily basis ( some of my patients would put soap in their socks or underneath the sheets so each time they moved essentially getting a massage- I think there are better ways) you can also get some massage boots at Wal- mart or other retail stores.
  • GET a Good night sleep – (sleep deprivation is a trigger)
  • Avoid sitting in one position for too long (same thing that makes us stiff with PD)
  • Medications- dopamine agonists – but I prefer as most movement disorder specialists a combined therapy plan to avoid augmentation and escalation of symptoms and increase drug dosage. Other medicines include Klonopin, Neurontin, Lyrica, Sinemet ( this is preferred treatment in pregnancy if symptoms are severe and iron and folate normal). Elderly patients with RLS should be ware of dopamine agonists especially advanced PD patients who may already be predisposed or have beginning of dementia.


Willis-EKbom Foundation

@copy right 2015 all right reserved Maria De Leon