Vision: More than Meets the EYE! Tricks to Aid PD Patients :By Dr. De Leon

” Vision is the art of seeing what is invisible to others.” ~ Jonathan Swift

The eyes have always held a great mystery for many since ancient times. Egyptians regarded them as one of the vital organs to be preserved for the after life to them see where they were going. Others claim the eyes are the window to the soul.

Whatever their mystical significance is one thing is for certain their function its even more complex yet! So important is vision that nearly 30% of  supratentorial (this is the area of the brain that lies above the cerebellum and supports the occipital lobe) region of the brain is dedicated to the activity of deciphering, decoding and understanding what we see around us.

As a neurologist part of our exam is to evaluate eye function as it pertains to the brain. That is to say to ascertain that what we (you & me) are seeing is being processed appropriately by our brains.

Like everything else pertaining to the brain there are a myriad of intricate connections and pathways which can be disrupted along the way from the eye to the vision center (occipital lobe. Our job, then, is to find out where the problem is and try to find a solution if at all possible.

I have discovered as a neurologist and PD patient that this is not always an easy task nor is there always an easy solution.

Yet, I will attempt to give some advice on ways to make PD visual symptoms more manageable however possible.

One of my first signs of PD was significant dysfunction involving my visual system which nearly cost me my life a couple of times as well as my drivers license. Although,  as a whole my vision problems are 110% improved from where they started from time to time they continue to challenge me in my activities of daily living.  Just  a couple of days ago I had an incident while driving through the bank teller which reminded me that all is not as it should. I bounced back and forth from side to side hitting the cement dividers like a ball in a Ping-Pong machine as I tried to exit onto the street with dignity intact avoiding eye contact with those around hoping that I had not taken out another chuck out of my tire which I had just replaced!

Obviously, my medication dose was no longer working as I would like it. Time to increase my dose but also time to see an eye doctor to make sure no new abnormalities had occurred causing this behavior.

  As I said before vision is a crucial sense upon which we heavily rely on and when not working well it can wreak havoc in our lives.

Common Eye Problems with PD: There are 6 tiny Muscles which move our eyes continuously even in sleep they are moving -like other muscles in our body these too get STIFF & SLOW.

  • decrease blinking
  • decreased visual acuity- usually normal or near normal in PD- problem lies with contrast
  • decreased color vision- colors become dull and less vibrant
  • decrease in ability to detect contrast – worst with night, rain, subtle shades, glare
  • double vision
  • dry eyes
  • visual hallucination
  • decreased visual field- result into bumping into things, walls, other cars etc. due to loss of peripheral vision (caused by eye muscles being stiff and not moving in all directions)
  • Impaired convergence- difficulty bringing eyes together in sync to view an object which is near by
  • smooth pursuit is choppy – may cause trouble with reading
  • saccades ( quick eye movements) in tracking or following objects quickly we undershoot- thus missing target.

UNCOMMON eye problems for PD but COMMON  of PARKINSON’s PLUS Syndromes:

  • Blepharospasm- abnormal blinking (increased) and sustained contraction of eye lids
  • Apraxia of eyelid -inability or difficulty opening eyes on command usually have to use touch stimuli -open manually
  • decrease vertical eye movements – sine qua non of PSP

****The retina has cells that produce levodopa.*****

As we begin to loose dopamine else where in our brains, guts, our eyes can become depleted as well especially if we are constantly using to read, watch TV, drive or perform any activity which requires visual precision and concentration.

So, I went to eye doctor yesterday and my color vision detection has decreased to my surprise while my ability to tell contrast has worsened. No wonder I am running over things can differentiate subtle things yet my convergence and visual fields have improved.

How do we address these troublesome visual issues and prevent our lives from losing quality and independence.

  1. Since our visual system is very much dependent on dopamine – the first line of treatment involves replacement! I have found personally that NEUPRO works best for this because it provides a continuous dose of dopamine agonist. Azilect works well too but does not last 24 hrs.
  2. Convergence insufficiency is a common problem- one way to help this is doing “Pencil push-ups” where you bring your pencil slowly towards your nose while you focus on it and then push arm away with eyes continuing to be fixed on pencil- repeat 10 times at least 2-3 times a day. Another thing is to add prisms to your reading glasses. Also, covering an eye with scotch tape or satin gift tape for a few hours then doing the other.
  3. decrease blinking/dry eyes- artificial tears- prefer preservative free- 3-4 times a day- more often if will be driving, reading or doing computer work because these activities cause a significant decline in tear secretion and distribution; decrease reading especially on kindle -e-books, get larger print with darker ink; decrease time on computer- take frequent breaks ( every hour 15 minutes) and do ‘push- pencil’ exercises. some medications may increase dry eyes like Artane or tricyclics  e.g. Elavil.
  4. contrast deficits – have eye doctor tint your glasses yellow or brown which will help with subtle shades, at night, and with rain. have anti glare on your glasses as well. At home make paths and walk ways with distinct visual patterns /lines to avoid falling and bumping into things.
  5. visual field deficits – dopamine replacement – but prisms may also help with this.
  6. double vision in my experience usually due to medication effect- adjust medications
  7. visual hallucinations-usually a sign of underlying dementia- if not causing problems to patient – no need to treat- otherwise treat with anti-psychotics e.g. Seroquel/ Clozaril.

 Sources: http://www.pdf.org- expert briefings-Gold, D. ” Vision more than meets the eye: Visons symptoms of PD”

@copyright 2016

all rights reserved by Maria De León MD

 

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.

Sources: http://www.pdf.org

http://www.dystonia-foundation.org

http://www.essentialtremor.org

10 Tips for a Divalicious Easily Accesible Kitchen for Every Parkinson’s Person: By Maria De Leon

10 Tips for a Divaclicious Easily Accesible Kitchen for Every Parkinson’s Person: By Maria De Leon.

InMotion to offer support for those with Parkinson’s disease – Health Beat – Cleveland Jewish News

InMotion to offer support for those with Parkinson’s disease – Health Beat – Cleveland Jewish News.

Tips to dealing with Apathy : by Dr. De Leon

Tips to dealing with Apathy : by Dr. De Leon.

Tips to dealing with Apathy : by Dr. De Leon

Scientists announced today that they have discovered a cure for apathy. However, they claim that no one has shown the slightest interest in it.” ~ George Carlin

I hear the word apathy tossed around all over the place from different places and people who use this term loosely to imply “lack of interest,” or ‘deep depression.’

However, as a neurologist the word apathy has not only a very special meaning but it also carries with it a specific diagnosis.

So, what does apathy really mean. Apathy as described by the Webster dictionary as  “a state of perfunctoriness.” I love that word.  It is a state of complete and total indifference in all realms of our being, emotional, spiritual, and social. People who suffer from apathy are completely and utterly devoid of concern, emotions, and feelings. Not because they don’t want to but because they are incapable of caring due to disconnect of fronto-cortical pathways.

Therefore, the term “apathy”  in neurology is always a harbinger of  brain illness particularly organic etiologies such as head injury, strokes, tumors, schizophrenia (although the latter usually considered a mental illness -I maintain it is an organic neurological disease because of involvement of dopamine- in this case too much) and of course the number one cause and almost synonymous with term of apathy is dementia – (e.g. Alzheimer’s, Parkinson’s, vascular, Lewy body, fronto temporal, etc.)

Therefore, giving someone a diagnosis of apathy in of itself is a poor prognosis which implies typically a rapid cognitive decline.

Having said this, one must always identify the cause and try to treat it as best as possible and prevent further cognitive decline.

Medications employed in the treatment of apathy:

1) [of course are] medications used to treat dementia – i.e the acetylcholinesterase inhibitors like Exelon (Rivastigmine), Aricept (Donezepil), Razadyne (Galantimine), and Namenda (Memantine) an NMDA inhibitor. Several of these compounds have extended release doses and come either in patch or liquid as well or both.

Other medications include:

2) Dopamine replacement– no better feel good drug than dopamine especially if deficiency is what is causing the apathy but it is not always as easy as that in dementia patients particularly those who have dementia of Parkinson’s disease or other dementias associated with parkinsonism because the addition of dopamine will increase visual hallucinations and other hallucinations and worsen confusion. therefore, this has to be measured in scale of risk and benefits but usually in the majority of cases in PD associated apathy combined with other medications like antichlolinerasterase and antipsychotics.

3) Stimulants like Provigil (Modafinil)/ Nuvigil – used in the treatment of Narcolepsy but also for hypersomnolance or increased sleepiness.  I prefer  this class as first line of treatment over amphetamines after dopamine replacement.  In my practice, I  had a moderate  to great success with them.  Other stimulants include amphetamine derivatives such as those employed in the treatment of attention deficit disorder (Methylphenidate-e.g. Concerta, Ritalin; Aderall; Straterra).

4) Antipsychotics are also a good source to combat apathy but best if use atypical drugs like Clozaril or Seroquel because of decrease potential for extrapyramidal side effects like tardive (late onset) dyskinesias and parkinsonism. This is especially crucial if already dealing with apathy related to Parkinson’s or Parkinson’s plus syndrome. We don’t want to make motor symptoms worse resulting in freezing and falls or increase dyskenesias.

5) Anti -depressants– Ssri’s/SNri’s -E.g. Zoloft, Lexapro, Effexor, Cymbalta, etc.

6) ECT– electro convulsive therapy when all else fails -it works tremendously well despite all of the bad the media has given it based on past history and  portrayal of patient abuse in movies like One Flew Over the Cuckoo’s Nest. Currently, there are several state of the art centers in the country which provide these much needed services which can help patients  have a higher quality of life than the would otherwise -one may be near you. The alternative is earlier institutionalization.

As always early recognition of apathy is Key to improved quality of life by securing proper diagnosis followed by prolonged watchful supervision and treatment by a team of experts which include Neurologist, Neuropsychologist, counselors, social workers, therapist and loved ones to help with financial issues of caring for a chronically ill patient as well as help prolong nursing home admittance for as long as possible.

10 Things Every PD Woman Should Have: By Maria De Leon

10 Things Every PD Woman Should Have: By Maria De Leon.

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

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

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

  “He stopped loving me in the thick of my loving him.

    He was finished but I was not.

 I felt like I had been stopped in the middle of an orgasm.” ~ Stopped by Carmen  R. Rutlen

When I was practicing I used to have an intellectual grasp of  the motor fluctuations ; yet never fully understood until I got PD as well. Cocaine being so similar in structure to dopamine, it binds at same receptor. Thus, I could imagine and understand how the euphoric initial response one gets with time would diminish therefore needing to escalate dose in order to achieve same response. In my training, I  was past the days where doctors as part of their learning of medicine experimented with compounds they were to use in order to better understand their effects so had to go on theory. Never did I dream that I would one day become a walking pharmacy and where my knowledge of pharmacotherapy would be put to the test repeatedly.

I often talked to my patients about the feeling of being ‘on’..and how long the effect of dopa lasted. However, I used to think perhaps due to my naïveté that patients could only feel the change as they advanced in disease. But, in actuality one of the tall tale signs that you do have a dopaminergic disorder is quick and exaggerated initial response to levodopa.  Several of my patients stated they could not tell any difference with levodopa or when it was in their system. This usually was a clear  sign we were dealing with atypical causes of Parkinsonism.

As I am sure those of you who have Parkinson’s disease can attest to the significant mental rush you achieved when you first started levodopa. I could tell exactly when it kicked in and when it wore off suddenly, the first time I took Sinemet (levodopa/carbidopa). I despised the sudden feeling of unable to focus and feeling spent. Some of you have agreed with me of experiencing same feeling independent of any motor changes. When we first took dopamine,  our minds felt “on,” more focused, alive- like you could conquer the world and felt a bit euphoric not unlike the sensation we all have felt when we were first in love. No wonder and not at all coincidentally, dopamine is the “feel good” chemical released when we are in love! Dopamine is released when we see our loved one looking back at us, or just think about the love of our lives makes our brains light up like a Christmas tree.

But, just as in life and relationships maintaining that constant state of  happiness, giddiness, and feeling high is impossible to do. Now, I truly understand why cocaine is so addictive. We all love the feeling of being in love. When dopamine wears ‘off’ suddenly is like experiencing an emotional and physical heart break over and over..

Some may say it feels like living you hanging in the midst of an orgasm. If we never give ourselves time to heal we will go down a dark path of depression building an emotional scab that bleeds at the slightest touch. When we lose our love, we feel hopeless, anxious,nervous, unable to sleep, or sleep too much, listless, tearful, aloof,  and experience physical and emotional aching. So are the feelings when we experience levodopa withdrawal.

In order to avoid these feelings what should you do?

One thing you don’t do is chase after that person or in this case keep adding more and more dopamine…only lead to more hurt, withdrawals and serious complications. We find support from others which may not provide as good of a feeling but will help to stabilize you and regain strength.

In order to avoid repeated break -ups with your medication and being a slave to it…a combination regimen is advised- you would never let one man/ woman rule your world right?  Neither should you do the same with PD meds.  to take a page from Mambo # 5 song  by Lou Bega, a little bit of  (dopa agonist) and a little bit of  (levodopa) is best way to go to keep you and happy and balanced …

In my  experience in years of dealing with PD from all aspects, a combination of the following drugs dopa agonists, with NMDA receptors medicines like amantadine, Mao – inhibitors, and compt inhibitors along with levo- dopa is the best way to keep PD stable  for the long run. Sprinkle of ssri’s ( Zoloft,lexapro), tricyclics ( eleavil, remeron), or SNri’s ( Effexor) on top is the icing to the cake.

With age comes wisdom, so they say! As our Parkinson’s  advances, it is ever so crucial to learn how to fall in love (using our dopamine) without losing ourselves in the process.