caregivers and chronic illness, chronic illness, parkinson's disease, Parkinson's Health

The Top 10 SPOOKY Things Living with PD which Can Send a Frightful Scream! : By Dr. De Leon

1. Getting PD Diagnosis– this can suddenly make your heart stop beating – feels like you have flat lined until a helpful friend comes along.

2. Losing control of your mind. I get off the car to check the mail only to see my car rolling down the hill because I just step out without putting brakes or turning engine off!

3. Losing control of your body– food is flying in every direction except into your mouth as you try to remain calm and poise while attempting to look dignified.

4.Losing control of your bowels. no matter the age, circumstances, or location – this is enough to send one howling and expelling such frightful wailings that causes a chill to run down anyone within ear range!

5.Bladder urgency/loss– if you have to find a bathroom one more time after having gone 20 times in the last 30 minutes you must just flush yourself down the drain as well.

6.Pills,Pills, Pills- all colors, sizes and shapes- how can anyone person take so many medications and not pass out? where do they all go? you think they would fill ,up my stomach and I would not need to eat!

7.Visual disturbances: see playing children all around that no one else can see but the car in front of us that everyone else sees we cannot see well.

8.Doctors, doctors, doctors: I have my own collection of specialists for everybody part even when I look at the mirror I see one staring right at me!

9.PAIN!! EVERYWHERE PAIN!!– what a pain it is to be in constant pain- irritable and shout-y, I have become. Sometimes, I scream just to let out the frustration of being  me with this disease.

10. People Judging: I can’t smile much so must be depressed; can’t talk loud must not have much too say/contribute; constant shaking and shuffling must be mentally challenged.

This Halloween I ask to NOT let your PARKINSON”S DISEASE SPOOK you and others-After all, “the only thing we have to fear is fear itself and perhaps a spider or two.”

Put an end to the fear by self -advocating and raising awareness for others that can’t do for themselves! 

alzheimers, dementia, dopamine and parkinsons, parkinson's disease, Parkinson's Health, parkinsons treatments, parkinsons y tratamientos

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 -depressantsSsri’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.

Parkinson's Diagnosis, Parkinson's Health, Parkinson's treatment

What is Parkinson’s Disease? By Dr. De Leon

It has been nearly two centuries since the name of a famous English surgeon by the name of James Parkinson was assigned to a chronic neurological condition affecting nearly 10 million people worldwide known as Parkinson’s disease (PD).  For years Parkinson’s specialists have based their treatment of this progressive neurological disease on the clinical characteristics involving the 4 cardinal symptoms of PDtremors at rest, slowness of movement, stiffness in muscles, and gait abnormalities. However, as it turns out the movement abnormalities are just the tip of the iceberg. PD is a complex disorder in which there is no one typical face representing this malady since it can also affect mood causing depression and anxiety, impair memory, interfere with sleep, disrupt bowel and bladder function, as well as cause loss of smell.

Although, at present there is no blood test to make diagnosis a skilled movement disorder specialist (MDS) can make diagnosis confidentially 95 % of the time.

Parkinson’s disease can affect all walks of life’s and all socioeconomic status. There is no known cause for the disease in the majority of the patients hence the term idiopathic PD although about 10% do have a genetic abnormality. Some risk factors for disease development include age over 55, gender (slightly more men in older populations), race (Hispanics have twice as much risk as whites in developing PD), exposure to pesticides, early hysterectomy and family history of PD and tremors.

Therefore, anyone experiencing difficulty with several of these areas  such as trouble walking, balance problems, tremors, trouble writing particularly exhibiting small handwriting, having stiffness or slowness of muscle movement, drooling, trouble swallowing, constipation, muscle pain, muscle cramping, frequent urination, trouble seeing (depth perception problems especially at night), loss of smell, poor sleep could be experiencing Parkinson’s disease and should seek the advice of a neurologist/MDS.

Recognizing some of the early features of Parkinson’s disease is not only crucial but necessary to the overall improvement of quality of life by prolonging independence and productivity in society in those afflicted with this disease; but early treatment can also delay hospitalization and nursing home admittance.

With the advent of new treatment modalities which include new medications such as dopa agonists, surgical procedures like deep brain stimulation (DBS), as well as non-conventional therapies such as dance and art therapy quality of life in people with Parkinson’s disease has improved significantly in the past two decades.  In addition to these new modalities Sinemet (levodopa/carbidopa) still remains the gold standard of treatment of PD.

For more information on the subject go to www.pdf.org or PDF Helpline – 1800-457-6676

parkinson's disease, parkinsons symptoms, parkinsons treatments, parkinsons y tratamientos

Dyskinesias- 8 Tips to prevent & manage DYSKENESIAs: By Dr. De Leon

The things I have learned about dyskenesias in a nut shell.

They are not a sign that you are having fun because you look like you are dancing even if they occur at the beat of   your favorite tune.

yes, although most of the time you prefer over being off or stiff, you can’t wait to go to sleep so the movements  can stop.

although, they are a great form of exercise you wish you did not have to exercise so much to look so great!

dyskenesias are great for doing the twist and Mixing fruit salad but not for putting on make up or reading a favorite book.

Is there a solution to dyskenesias?

yes…

mind you is not an easy feat….

The first thing to remember iS that is much easier to prevent than to stop once they occur.

Key points women are more likely to develop dyskenesias than men.

altough, We as patients know our bodies best and know a lot about Parkinson’s disease we should not manage our own symptoms without the guidance of a professional (MDS).

One, because it is very hard to be objective when it comes to our own disease state.

Second, most of the time what we intuitively think should be the right thing to do is not always the BEST treatment plan for the long run of the disease…this is where experts like myself and other movement disorder specialists come in handy.

Third, as I have mentioned many times before, anyone can treat Parkinson’s in the first stages because it will respond to any and all PD medicines; however as disease advances the expertise in the art of treatment provided by a seasoned specialist is indespensible. This is where knowing how to treat rather than what to treat with becomes crucial.

Fourth, when I was in practice it was common to see my first stage PD patients 2-3 x a years unless they needed something because they were pretty autonomous; but as Parkinson’s progressed the frequency of the office visits increased as should your visits to your physicians. It was usually every month to every 6 weeks  evaluation in my late stage disease patients and 4-6 times a yeAr for middle stages.  Even though, I understand as a patient we all get tired of visiting and going to the doctor, unfortunately this is the type of commitment that is required to keep DYSKENESIAs at bay and control before they become intrusive by adding medications like amantadine, Keppra, zonegran, comtan or Tasmar (or STALEVO which I love because it has so many doses ranging from 50 mg to 225mg) and adding long term release intermixed with short term and intermediate release.  Also things like DBS and other surgeries like pallidotomies; apomorphine and even Botox injections if have focal DYSKENESIAs or dystonias are great treatment options with proven benefit and low risk in the right hands of experienced physicians.

Fifth, although certain autonomy is allowed for patients it needs to be evaluated frequently because invariably most patients will overdose creating more side effects and DYSKENESIAs. More is not always better…we feel bad can’t walk, move, talk, swallow so we not only increase our doses but start increasing frequency sure way to develop DYSKENESIAs faster ! The key is to mix dopa agonists( especially NEUPRO because the continuous release will potentials the effect of levodopa giving it a more continous star in your body without having so many peaks and valleys), MAO inhibitors along with dopamine in various forms…don’t be afraid of taking several types of medications this is how you get the most benefit without having to take such large doses of levodopa and keep number of times you take medications down ( e.g. 4-5 x a day instead of every 2 hours).  We have so many new choices now.

Sixth, remember that dopamine agonists and amantadine effect usually work for several years in the range of 5-7 years after which their effect starts to wane but after a small period of rest ( 1-2 years off these medications) they can be again reintroduced having again a positive effect.

Seventh, It is recommended that around the time you enter the middle stages of disease (3-4th stages) every patient should start keeping a calendar of every medication taken. This needs to include time of intake of each medicine along with name, how long it takes to kick in ( what do you notice when it kicks in), how long each medication last,  can you tell when it wears off- what do you notice and the does medicine wear off suddenly. your doctors usually have copies of these calanders in their office, you can get from them or get from the website Or create your own. For instance, I can tell you that my azilect helps my pain & walking, my Neupro helps my vision and my STALEVO helps my brain feel “on.”

Eight, most important advice to prevent and stop these intrusive involuntary movements which make our lives miserable is early DBS before they start…if you Wait till after they start it will take longer to find right setting. when DBS setting is adjusted in brain It is imperative to adjust medications at the same time  for maximum result so need to find a doctor who can program in office and has extensive experience – this is one of those art things where experience truly dictate outcome. Patients with DYSKENESIAs by definition have already more advanced disease taking more medications therefore adjustments have to go even slower for maximum results which can be extremely frustrating. so find someone close by because will need a lot of visits; if not able to travel frequently to maximize benefit then should consider doing pallidotomies instead.

Parkinson’s disease is an extremely complex disease encompassing multiple body systems outside of the brain thus in order to have the best quality of life is to have disease managed by a movement disorder specialist who serves as the conductor in a well orchestrated performance involving many other subspecialties (including Gi, neurosurgeons, dermatologists. Urologist,internist, anesthesiologist, ENT, and ST, PT, and OT).  Together they can allow you to dance in whatever fashion you desire without the presence of DYSKENESIAs.

chronic illness, disability in PD, parkinson's disease, parkinsons dementia, parkinsons health and beauty tips, research

How To Make The Most Out of Your Neurology/MDS Visit: by Dr. De Leon

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I know many of you have expressed the concern that some of the issues don’t get addressed or addressed in a timely manner when visiting your neurologist or MDS. This especially difficult to deal with since many do not live close to a neurologist and have to travel a way to go see them. So of course you are tired and frustrated of  having to wait both to see a neurologist or movement disorder specialist as well as in pain and discomfort if asked by your doctor to be off your medications for evaluation.

We all have experience the feeling of disgust at ourselves when after leaving the doctor’s office after being there several hours we realized that we forgot to ask or discuss an issue that was utterly important.

A few tips to minimize frustration and maximize our time and neurologists focus on our issues are the following recommendations based on my extensive experience as a Parkinson’s specialist and as a patient.

First, I am sure many of you have experienced the phenomena I like to call the ‘doctor syndrome.’ For some reason, it happens to me all the time and I am certain it happens to you because many of my patients told me that they were worst before coming to see me. I am not sure why that is but my Parkinson’s symptoms are always better when I see my doctor!

Second, especially if it’s the first visit make sure if possible to bring someone with you that can be your ears. Because unless you are savvy in the medical field and medical jargon, after the first few sentences where your doctor tells you the diagnosis I guarantee you will not remember anything else said or explained.

As physicians we usually concentrate on what’s visually in front of us and have to pay close attention to non visible symptoms and rely on you unfortunately too much to let us know how your life is being affected by these invisible otherwise known as non-motor symptoms.

Parkinson’s disease is extremely complex illness and increasingly getting more as we speak even though most neurologists and movement disorder specialist like me typically spend an hour or more per patient it is impossible to cover ALL possible symptoms in detail.

Therefore it is imperative that you prioritize your problems:

  1. Are you there as a new patient and looking for diagnosis and new treatment?
  2.  New patient for second opinion and alter treatment?
  3.  Established patient for management of symptoms?
  4.  Established or new looking for disability?
  5.  Interested in participating in studies or research and what are you willing to do?-e.g. participate in studies with new unknown meds vs. known medications already approved, invasive vs. non-invasive?

All of these will require different focus from your doctor.

I recommend that you limit your discussion to main reason (chief complaint-e.g. new patient looking for diagnosis) you are there and two other symptoms that need immediate addressing!

If you have more pressing issues make an appointment sooner than what they will suggest don’t settle for appointment in 3-6 months if NOT doing well!

Also if need a family intervention to discuss prognosis and long-term treatment plan and care, make appointment with you, family and doctor exclusively to discuss these issues. Let the doctor know ahead of time that this is purpose for visit so doctor and staff can be prepared for meeting as far as time so you won’t be rushed and also and most importantly so doctor can formulate plan ahead of time and bring ancillary services if needed such as social services or names of assisted living, nursing home, or rehabilitation places etc.

Third, know your insurance coverage of medications. This will expedite treatment and allow doctors to know which prescriptions to write. Unfortunately, due to recent changes in healthcare and medication coverage (at least in this country) it is becoming increasingly more common for doctors particularly specialists to prescribe medications base on a patient’s formulary rather than what they think should be first choice! Ask for samples, ask for assistant programs, and let them know if meds will require pre-authorization or paper work filled out. If you are new patient or established patient who will be on new drug- it is best to not have that medication sent to mail order pharmacies until required dose achieved and / or know if can tolerate otherwise will get stuck with a bunch of medicine can’t use.

Fourth, always bring a list of your medications better yet the medications themselves which should ALWAYS include name of over the counter medicines even if they are as needed because could possibly interact with new prescription.

Fifth, ask for side effects of new meds, what to expect, how fast will notice improvement, do they need to be titrated and how often? In this should also inquire if meds will affect women issues such as safe if planning to conceive or are breastfeeding, ask especially if risk of melanoma, breast cancer and prostate cancer in family to be referred to specialist for follow-up given that some medicines will increase these risk and others like melanoma simply by having PD make you at higher risk.

Finally, at least in this country know that if you require paperwork filled out there most likely be a fee and a few days to get paper back so plan ahead.

Ask for literature, support groups, as well as ancillary services such as speech therapy if needed.

If you follow these simple rules, I guarantee that you will have a much happier and successful journey with PD as you and your doctor work as a team.

*******

Dr. M. De Leon is a movement disorder specialist on sabbatical, PPAC member and research advocate for PDF (Parkinson’s Disease Foundation); Texas State Assistant Director for PAN (Parkinson’s Action Network). You can learn more about her work at http://www.facebook.com/defeatparkinsons101 you can also learn more about Parkinson’s disease at www.pdf.org or at www.wemove.org; http://www.aan.org, http://www.defeatparkinsons.blogspot.com All materials here forth are property of Defeatparkinsons. without express written consent, these materials only may be used for viewers personal & non-commercial uses which do not harm the reputation of Defeatparkinsons organization or Dr. M. De Leon provided you do not remove any copyrights. To request permission to reproduce release of any part or whole of content, please contact me at deleonenterprises3@@yahoo.com contributor http://www.assisted-living-directory.com Contributor http://www.lavozbrazoriacounty.com

chronic illness, parkinson's disease, parkinsons health and beauty tips, tips for safe and happy teavel with PD

Tips to side step most common travel- related headaches in PD patients: By Dr. De Leon

As the country has been hit by numerous winter blizzard storms keeping a large portion of the population in the north indoors going stir crazy while the northwest is affected by the pineapple express, here in the south well is anybody’s guess what the weather is going to be like from one minute to the next.  One minute we are wearing our best summer dresses mean while the next thing I know we are gearing up for a wintery mix pulling out my scarves, gloves and parka jackets. As you all know, extreme temperature and PD do not mix, particularly cold weather. It appears, at least in my experience that my Parkinson’s symptoms worsen dramatically. I have it on good authority that it does the same for many of you. So, I have started dreaming of an escape to a nice temperate climate to soak in the rays and get a chance to stretch my muscles outdoors without fear of falling, slipping in the ice, catching pneumonia or the flu. Perhaps you too are planning your romantic escape to whisk your loved one away for a couple of days to celebrate Valentine’s Day?  Maybe we are just plain dreaming of leaving all the cold behind.

How do we manage our PD when we are away from home? How do we stay healthy and happy?

First before you travel or go anywhere you should always have a traveler’s medical kit ready.

Be sure to bring your Aware in Care Parkinson’s ID bracelet or wallet card with you. If you don’t have an Aware in Care kit, contact NPF’s free Helpline at 1-800-473-4636 while in the planning stages of your vacation.

  • Carry with you at all times all your medication including prescribing physician, should also carry snacks and water/juices
  • Make sure you continue to take medication at regular intervals despite time zone changes.
  • Pain medication – such as Tylenol or ibuprofen. I find that a Tylenol and a Motrin go a long way to cure most types of pain.
  • A mild laxative
  • An antacid
  • Medications for nausea
  • Medications for motion sickness
  • Hand sanitizer

Once you got your meds in place before considering your destination think about the logistics of getting there. Is it easy to do unassisted? Will you need help on the way? As most of us get past stage 1 of PD sitting for a long period of time can be problematic. Even early on RLS can be an early symptom and cause difficulty if sitting for a prolonged period of time. You know you can do it but still want to have a backup plan. Make sure there will be assistance at the airport, train station, bus station or cruise ship.

Finally you bypass all those hurdles and you are on your way to your dream vacation. However, this means being away from home, your doctors, your routine, your comfort foods so how do you manage to stay calm and enjoy your time away from home?

Well, first if you have a DBS you never have to go through the airport security machines again! This is a big plus. Have your doctor write letter and carry with you and inform them when you make reservations so they don’t give you hard time. Don’t forget your magnet at home. But since some of us PD patients may have a higher risk of certain cancers like breast or skin cancer do not worry that going through airport security will increase these risks by exposure to x-rays. Now they use millimeter wave scanners which use radio waves and are not believed to be a cancer risk!

Exercise to avoid rigidity and blood clots:

  1. If you’re going to be on a plane or whatever mode of transportation of your choosing for a long time sitting make sure that you move around 1) to avoid blood clots and 2) to keep from freezing. One interesting fact: the risk of blood clots increases 2-4 fold by long distance air travel- same is true by other modes of transportation such as car etc. and if you choose the window seat as I often like to do, the risk doubles – this is presumably because people move less. So if you sit in a window seat make sure you still move around! Make sure that while you are sitting every hour or so do 5 minute of stretching. Flex and extend your feet like pressing on gas pedal and stretch arms and rotate neck. This will keep you limber, decrease pain and decrease blood clots and if possible walk down the aisle.
  • Constipation: 
    1. Constipation is the universal symptom that unites all of us Parkinson’s patients. We all know how uncomfortable it feels to be constipated. Now imagine that you are seating immobile for hours the body naturally goes into maintaining homeostasis which means every non essential organ shuts down. Constipation is both caused by our illness as well as aggravated by the medication and lack of activity can take it up a notch. In order to avoid this problem, I recommend that you drink at least four 8-ounce glasses of water daily. Take stool softeners before departing and on vacation. Carry some laxatives with you just in case. Try to maintain normal meal hours and carry high fiber snacks like nuts and fruits. I like carrying Nonni’s THIN Addictives which come individually wrapped; fruit and nut cracker snacks. They come in various flavors pistachio, cranberry are my favorite
  • Motion Sickness/Nausea/Vomiting: 
    1. We all know that Parkinson’s patients have our fair share of gi problems including a predisposition to nausea, vomiting and upset stomach particularly when we are traveling due to increase stress, decrease gut motility, poor nutrition during travel, and increased constipation subsequently. Prevention goes a long way to making your life and travel a lot happier. Best to take a nausea medication before departing (if possible carry sublingual nausea pills) it beats trying to find water, bags and air to cool off in the midst of your traveling. Of course along with these symptoms motion sickness can kick again particularly if blood pressure low, constipated, sleep deprived, or if you are prone to migraines. The condition usually occurs as a result of brain getting mixed messages from your eyes, ears and body. Motion sickness is a lot easier to prevent that to stop once in motion. If you know that you have migraines- take a migraine medicine before departing also the nausea medicine should keep this in check but just in case carry something like scopolamine patch to be placed behind the ear . it usually takes a few hours to work but can offer relief up to three days without the drowsiness that antihistamines would cause ( which also work).
  • Pain:
  1. Traveling can exacerbate pain of all sorts because we don’t move as we should and we are cramped in small spaces for a long time, medicines may not be absorbed as well if we get constipated or we miss a dose because of schedule and we might even unwillingly injure ourselves carrying our belongings. Again, prevention is the best approach. Take your migraine medicine and muscle relaxants before departing. Consider getting a deep tissue massage before and after the trip it will go a long way to keeping muscles limber and by all means do not forgo your exercise routine just because you are on vacation. If need be consider carrying parcopa (sublingual levodopa/carbidopa) which will kick in fast if need it without having to find water or worry about the status of your gi tract.

If you follow these simple steps as I do you can travel to your destination with greater ease and comfort and be ready to enjoy your vacation upon arrival.

Happy Valentine’s Day every One!

***this advice is not intended to take place of your physician counsel and recommend discussing any and all changes to medications and above with them before instituting!

Sources: “7 ways to stay healthy on vacation.” Consumer Reports on Health June 2014

www.parkinson.org

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Dr. M. De Leon is a movement disorder specialist on sabbatical, PPAC member and research advocate for PDF (Parkinson’s Disease Foundation); Texas State Assistant Director for PAN (Parkinson’s Action Network). You can learn more about her work at http://www.facebook.com/defeatparkinsons101 you can also learn more about Parkinson’s disease at www.pdf.org or at www.wemove.org; http://www.aan.org, http://www.defeatparkinsons.blogspot.com All materials here forth are property of Defeatparkinsons. without express written consent, these materials only may be used for viewers personal & non-commercial uses which do not harm the reputation of Defeatparkinsons organization or Dr. M. De Leon provided you do not remove any copyrights. To request permission to reproduce release of any part or whole of content, please contact me at deleonenterprises3@@yahoo.com contributor http://www.assisted-living-directory.com Contributor http://www.lavozbrazoriacounty.com