Tardive dyskinesia’s: By Dr. De Leon

  • Today, I want to discuss a movement disorder on the rise due to increase use of neuroleptics and new indications for dopamine antagonists have increased over the years thus increasing the number of patients at risk. Also because some of the initial symptoms of this condition are acute extrapyramidal symptoms (EPS) like stiffness, slowness, and tremors; if not caught early can lead to full blown tardive dyskenesias (TD) or be inappropriately diagnosed as parkinsonism or Parkinson’s plus syndrome (e.g. multisystem atrophy) causing undue disability and frustration among patients and clinicians alike.

 

The most common symptoms of tardive dyskinesia are: occur after EPS

  • Grimacing
  • Tongue protrusion
  • Lip smacking
  • Puckering and pursing
  • Rapid eye blinking
  • Rapid movements of the arms
  • Rapid movements of the legs
  • Rapid movements of the trunk

First of all, tardive means late dyskinesia’s. These are abnormal involuntary undulating movement s often involving the face but can be seen in other parts of the body such as the extremities and trunk.

Why is it important to know about tardive dyskinesias? These are not to be confused with dyskinesias seen in Parkinson’s as I stated above but rather a secondary effect of long term dopamine replacement.

As the name implies these abnormal movements occur late after a prolonged exposure to dopamine antagonists ( blockers) such as anti -psychotics (particularly older)- e.g. Haldol; anti- nausea medicines- e.g. Reglan; anti-depressants- e.g. respideral. certain groups are already at higher risk like those with mental illnesses such as schizophrenia, cognitive or mood disorders  as well as those who are diabetic, have alcohol use or are immunodeficient, and/or  elderly. The risk goes up from ~13% to 50% with age and prolonged use of these medications.

of note: dyskinesias can appear after stopping medications which cause this and may even disappear weeks later. These are known as withdrawal dyskinesias.

 

Conditions resembling TD:

  • oral movements from ill fitting dentures
  • autism
  • chronic motor tics
  • Huntington’s chorea
  • restless leg syndrome
  • Tourette’s
  • Wilson disease – disorder of copper regulation
  • senile chorea (old age)
  • Meige’s syndrome ( face dystonia )
  • drug induced
  • Sydenham chorea ( associated with rheumatic fever)

 

Even in routine careful examination TD may be difficult to detect early by non specialists especially if a good history not taken. this is due to fact that agents causing problem can also mask the symptoms. doctors use a scale AIMS- abnormal involuntary movement scale

Usually is family that bring movements to attention of doctor!!!

Because in many cases people have been left with life long abnormal movements we must minimize the occurrence by minimizing drugs that are dopamine blockers and if needed using lower doses and shorter periods of time. Treat as quickly after it appears!

Treatments:

  • Tetrabenazine
  • reserpine
  • melatonin
  • donepezil ( Aricept)
  • vitaminB6
  • vitamin E
  • Valbenazine (should be available soon- better efficacy and tolerability than any to date)
  • AMANTADINE has no PLACE here…

Parkinson’s dyskinesias  on the other hand are due to prolonged use and exposure of dopamine agonists.  The best way to treat and diagnose these are keeping a diary of when abnormal involuntary undulating movements occur at peak dose, at onset, or at end of dose.

Time if they are predictable or random? as well as duration? are they painful?

Treatments for PD dyskinesia:

  1. prevent by using smaller doses and multiple mechanisms of action ( i.e. MAO inhibitor + dopamine agonist + levodopa)
  2. adjust medications i.e. shorten/ increase frequency of medications
  3. add amantadine ( shortly should have a new formulation of amantadine available to add to our armamentarium of drugs- Key treatment
  4. DBS  ( deep brain stimulation) is the gold standard treatment- discuss elsewhere in my blog.

When in doubt as to kind of movement disorder you have take a video and go see your MDS/neurologists ASAP many treatments are available.

 

As a side note: I would like to thank all of my readers and followers for making this blog one of your favorites as well as one of the top 50 blogs in topic of PD. could not do it without your love and support. Many blessings and Happy Valentine’s Day! ❤ ❤

 

 

Psychosis in PD (PDP): By Dr. De Leon

Image result for images of psychotic people

Since there are so many people that have this problem including myself in the past due to medications, I thought I would address some of the salient points which could help take care of our loved ones better as well as help those of us who live with the disease to manage our symptoms better if present because this is the highest cause of care-giver burden and stress. The presence of PDP also leads to significant disability and poor quality of life. The risk increases with disease duration.

First of all, there are many causes of underlying neuropsychiatric disturbances which can present in the confines’ of Parkinson’s disease. These can be related to treatment(s) or disease itself.

  1. PD process- including visual processing e.g. contrast recognition, visual acuity, and color acuity reduction
  2. Abnormal activation of brainstem and cortical regions
  3. Sleep disturbances
  4. Brain abnormalities e.g. Lewy body
  5. Genetic factors – i.e./ APO E – particularly the E4 allele which increases risk of Alzheimer’s.
  6. Over activation of dopamine neurons by chronic use of dopamine replacement
  7. Decreased serotonin ( due to 6)
  8. Over activity of acetylcholine – same as above

Parkinson’s disease may be associated with a wide range of psychotic symptoms, including delusions, hallucinations in multiple sensory modalities –i.e. auditory, tactile, olfactory, visual, and gustatory). Psychotic symptoms may occur with retained insight, or may involve severe paranoid delusions and confusional states. In the early stage, PD-related hallucinations are primarily visual, with retained insight and a clear sensorium. (Meaning patients are fully aware and awake not confused!) With PD progression (late stages), patients may exhibit worsening hallucinations, with loss of insight. Visual hallucination are most common, (22% to 38% of patients with PD). Visual hallucinations are generally well formed, and may consist of people or animals (less commonly, inanimate objects), tend to persist over time, and typically involve recurring content. Up to 20% of patients experience auditory hallucinations, which usually accompany visual hallucinations and are less likely to occur in isolation. Olfactory and tactile hallucinations are less common, but can occur. These hallucinations tend to occur most often during periods of decreased stimulation (e.g., in the evening or when the lighting is low).

Delusions are also part of the neuropsychiatric disturbances in PD affecting approximately 5% of patients. The delusions tend to be of the paranoid either persecutory or jealous in nature. I myself suffered extreme jealousy directed towards my husband – un -common for me. The subject of mine and the majority of my patients has been an unshakable belief of spousal infidelity). I also have had on occasion independent of any other problems and not related to medication but mere factor of my PD some gustatory and olfactory hallucinations which last only but a few seconds.

Visual hallucinations tend to be non-invasive and non-frightening to the individual since they usually involve children or small animals. the family are the ones usually troubled by this. bit on occasion they can be violent and extremely frightening for patient and scary to watch for family members – these must be treated always.

Of Note, although auditory hallucinations can present themselves in PD, this is an extremely rare occurrence. Auditory hallucinations usually imply a underlying brain structural abnormality ( i.e., stroke), schizophrenia, or  substance abuse.

In PD patients, clinical rating scales like UPDRS, sleep scale, the Hamilton scale, and the PD psychosis questionnaire can help to identify psychotic symptoms and other common comorbid neuropsychiatric disorders, such as depression ( more common in early stage), anxiety( present in about 40% and associated with worsening motor function), impulse control disorders (ICDs) and disorders of sleep. Sleep disorders are an integral part of the disease and occur in as many as 90% of patients. Some of the problems commonly seen are insomnia (my major problem and many of ours – sleep wake cycle appears to be shifted), hypersomnia, sleep fragmentation, sleep terrors, nocturnal movements, restless legs syndrome, sleep apnea, and Rem Behavior disorder. However, to date there are no well validated scales and we depend on clinical diagnosis and exclusion of other things.

In the geriatric PD population common causes of psychosis:

  • Steroids are frequently a cause of psychosis
  • Dehydration
  • Infection (urine especially)
  • Lack of sleep
  • Medications – e.g. amantadine, artane, dopamine agonists

 

How do you treat PDP?

FIRST! Stop offending drugs or correct any of above deficits or infections

Antipsychotics-

  1. Seroquel (quetiapine)- biggest side effect is orthostatic hypotension (low bp) and sedation which is not always a bad thing we often want this to normalize sleep wake cycle. Oher side effects include dry mouth, hyperlipidemia, constipation, dyspepsia, dizziness, weight gain, increased appetite, fatigue, hyperglycemia, dysarthria, and nasal congestion. – I not had problem with these in past much.
  2. Clozaril (clozapine) not used much because of weekly blood draws needed due to possible agranulocytosis.
  3. New medication FDA approved is PRIMAVENSERIN (non-dopaminergic- actually serotonergic antipsychotic) 0nce daily – 2 tablets 17 mg each – the biggest side effect is peripheral edema and confusion. (should be first line of treatment)

Cholinesterase inhibitor:

Exelon (rivastigmine) only FDA medicine approved for PD dementia

So it is possible to have sensory hallucinations early on in the disease as part of illness itself which does not necessarily require intervention if patients are aware and not bothered or interfering with activities of daily living or social aspect. Usually these are olfactory or tactile and occasionally visual. However, as disease progresses visual hallucinations and delusions become more prominent and as PD advances there is a higher likelihood of being related to underlying dementia. Treat symptoms, remove offending causes and treat underlying dementia. But for all PD patients although no current treatment to prevent progression of disease or prevent dementia several things like staying mentally and physically active can help greatly as well as proper nutrition and adequate sleep. Seek immediate attention, if you or loved one experience any of these problems.

Chaotic House in the Prairie: By Maria De Leon

“There is no great loss without some small gain.” Laura Ingalls Wilder Ok so it’s not exactly the prairie but I do like to think of it in the middle of nowhere. I am after all sur…

Source: Chaotic House in the Prairie: By Maria De Leon

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

Apathy–

  • 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

Indifference–

  • 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!

Is numbness in my feet caused by my Parkinson’s disease/dystonia? : By Dr. De Leon

“I have become comfortably numb.” Unknown

On a weekly basis, I get the question can PD cause numbness? Well today, I thought I would tackle this sensitive topic from a different angle than before. hopefully this will help so many of you who like me are  plagued with this problem and are not sure where to turn. Image result for images of radiculopathy

First, let me explain a couple of things. we have learned in the last decade or so that Parkinson’s disease can cause pain and central sensory deficits. this means that the brain does not process sensation normally because these connections pass through the basal ganglia on their way to the thalamus (sensory control center in the brain). This usually manifest in abnormal sensations when touch is involved. Plus, this abnormal basal ganglia dysfunction is the source for what we call “central” pain in PD. This is a burning, searing, excruciating pain that is constant deep in the bone aggravated by touch and follows the normal pathways of the brain – usually unilateral but can become bilateral. But, this does not cause numbness or tingling typically. as you might recall one of my initial symptoms was pain- this central pain. I could not stand anyone to touch my limbs which started on my left side, showering was torture. I felt like the water touching me was pure acid.

However, peripheral sensory deficits like toe, feet, and hand numbness has not been shown to be caused by PD itself. The usual test we use to detect neuropathies  called  NCV (nerve conduction velocity) study are normal in PD. Yet, many of us have been down with severe numbness particularly in our lower extremities.

So, why is this?

Well you are neither alone nor crazy. Well, I think I have a logical explanation for these symptoms from my own experience, living with my Parkinson’s and also having treated many patients in the past who regularly complained of this problem.

The cause is a simple mechanical problem. I have had two herniated discs in the past and know full well the symptoms of radiculopathy – numbness and pain shooting down your leg along with accompanying weakness. Of course, the first time I had numbness in my feet and back pain I immediately thought I was having exacerbation of my injured back. however, I had no pain nor weakness only numbness. I discovered that the usual treatments for back spasm like Lidoderm patches, Nsaid’s (non-steroid anti-inflammatories), wearing a brace did not alleviate this problem completely. However, increasing dose of dopaminergic medication e.g. levodopa stopped symptoms instantaneously as soon as medicine kicked in.  Also, over the years I have noticed that when muscles get very tight i.e. dystonia especially in the neck and arms it can mimic cervical radiculopathy, carpal tunnel syndrome, and ulnar neuropathy. as a matter of fact when I was in residency because I was starting to get dystonia carrying my heavy doctors bag I was erroneously diagnosed and given a splint for carpal tunnel. since it was difficult to carry my bag with the brace the symptoms stopped abruptly.

As far as foot and toe numbness, I know too well the feeling. Although not painful it is extremely uncomfortable and if severe it can lead to falls due to loss of proprioception (not knowing where floor is). The main cause for this as I stated earlier is a mechanical one. as we stiffen rather our backs get rigid it decreases the normal curvature of the spine putting tension in our back muscles which then in turn pull on our spine to maintain posture this stretches the space between the vertebra and compresses the nerves as they exit the foramen. end result, the nerves get stretched and compressed decreasing their function acting as if they were being pinched  permanently. As I sit here writing my back is getting tighter and I begin to feel some discomfort in my feet telling me I have to move about. however, when someone is under-medicated you get the same effect severe rigidity of axial muscles ( neck and back) with loss of normal curvature and subsequently the entire nerve collection known as a plexus gets compressed and stretched causing numbness in feet because these are the biggest fibers- so get affected first. the key is that usually this occurs bilaterally simultaneously and without pain or weakness and gets better quickly after taking medication or realigning spine like laying down supine in a flat surface.

Of  course this is not to say that Parkinson’s patients do not get neuropathies ( progressive nerve ending atrophy) from other common causes like B12 deficiency, diabetes, or vitamin deficiencies, or presenting symptom of cancer.

My recommendation to evaluating this problem and feeling better soon is to maintain diary.

  • When it happens?
  • How long it lasts?
  • Does it follow a pattern close to your medications wearing off?
  • Other symptoms associated with it? like changes in bowel/bladder function, weakness, pain, one sided?
  • Does it improve? or is it constant?
  • Have you had dyskinesia’s/ dystonia involving more commonly neck to cause cervical radiculopathy and myelopathy but will have other symptoms.  (the constant gyration of neck can lead to herniated discs, as well as torticollis – abnormal posture of neck due to involuntary sustained contractions).

Talk to your physician and discuss problem. as they check for metabolic problems ask them to adjust your dose of medication ( up usually) before proceeding with any more invasive or expensive tests because in my experience this will remedy problem if caused by Parkinson’s-indirectly.

Finally, staying active and keeping muscles limber by doing exercises routinely- does not necessarily mean daily but at least couple of times a week, can reduce this problem dramatically. As an aside never start any vigorous exercise program like boxing, or other physical regimen before discussing with your physician especially if having numbness or other symptoms because you can seriously injure yourself.

So next time you have problems with feet being numb do not fret and follow these recommendations as you call your doctor to discuss further. However, if symptoms come on suddenly on one side of the body go to ER asap. This could be a stroke!

@copyrights 2015
all rights reserved by Maria De Leon

Musings of a Parkinson’s Night Owl: By Maria De Leon

“Every Renaissance comes to the world with a cry, the cry of the human spirit to be free…” Anne Sullivan Macy   The other day as I stayed up half the night like most of us with PD…

Source: Musings of a Parkinson’s Night Owl: By Maria De Leon

New Year Resolutions! By Maria De Leon

First, let me take a moment to wish everyone a very happy and prosperous new year! I am sure that many of you as is customary made a list of New Year’s Resolutions which you wholeheartedly intended…

Source: New Year Resolutions! By Maria De Leon

Happy New Year-2017! By Dr. De Leon

With this in mind, I am aiming for the stars. But, first I want to thank all (you) my readers for almost 6 years of wonderful communication, interaction and allowing me to come into your homes. I think this will be our best year yet. I hope that you will continue to share with me in this journey of life with Parkinson’s disease as the year unfolds.

Surely, we will face challenges as we traverse the hills and valleys of our lives with PD just as certain I am that there will also be many triumphs to rejoice over. No matter what lies ahead for you, I want you to know that you are not alone. God loves you as do I, remember this as you reach for endurance as you begin to climb mountains of despair, pain, misunderstandings, or self-pity  to reach the summit of acceptance, self-love, and inner strength, showing PD who’s boss. When you do, the view will be breath taking, as some of my closest friends who have climbed Kilimanjaro will attest and every bit worth the fight to the top.

There will also be valleys of green grass and flowing water where you can rest and feel at peace helping others who come behind to remain steadfast in the battle; to stay silent when there is nothing to say, laugh as much as you can whenever possible for it is the best medicine there is, lend a helping hand, or simply sit by someone’s side in the midst of adversity. Because those of us who have lived with chronic illnesses in our lives have learned that the race goes to those of us who remain always vigilant, humble, with steady nerves and habits with a keen eye never turning our back to a monster that can destroy us if we lose interest and let our guards down.

So don’t make lofty goals and resolutions you are likely to break rather invest in yourself, prioritizing your time, your energy and your gifts. Make short, intermediate, and long term goals. As I said before, one shuffling step at a time!

Happy New Year!

Topics to be covered this year per the choice award interests survey of PDF ( Parkinson’s disease foundation)-

dystonia, dyskinesia, fatigue, constipation, cognition-ways to maintain, sleep /rem behaviors

Please let me know if there is a special topic you are interested in learning about/ or if you want to be a guest blogger-

send me information to deleonenterprises3@yahoo.com

 

Advocates for Parkinson’s Disease Join Women’s March — Parkinson’s Women Support

Please join us in San Francisco on Saturday, January 21 for the Women’s March. We’ll march to advocate for Parkinson’s research, health care, support services, and affordable meds for people with Parkinson’s disease.

via Advocates for Parkinson’s Disease Join Women’s March — Parkinson’s Women Support