Article from October 2017 E-Newsletter

Non Motor Symptoms Part 2
Cognitive problems generally don’t present initially in Parkinson Disease (PD) but they do present in advances stages of PD. When it does occur, it tends to affect a patient’s ability to concentrate and pay attention along with following along with conversations. Complex things become difficult for a PD patient versus a patient with Alzheimer’s disease. The same medications to treat memory in Alzheimer’s are used in PD patients. Techniques such as doing word puzzles, Sudoku, and other complex tasks can help a patient’s memory without the use of medication.

Hallucinations also present in later stages of PD. These involve seeing shadows in one’s peripheral vision. PD patients tend to understand that these hallucinations are not real but they can get scary over time. When this happens it is time to treat the hallucinations. In some cases, levodopa, dopamine agonists and amantadine can lead to hallucinations. In that case, you either remove or lower the doses of medications. If hallucinations are not drug induced then the current treatment options are quetiapine (Seroquel), clozapine (Clozaril) and pimivanserin (Nuplazid). Other medications used to treat hallucinations associated with schizophrenia are contraindicated in PD because they block dopamine.

Depression and anxiety are very common in PD given the lack of dopamine production. If these symptoms don’t improve with the introduction of PD medications, then the use of SSRI’s, SNRI’s and other antidepressants or anti-anxiety medications should be initiated. This can be done by a movement disorders specialist but when more than one medication is required, the assistance of a psychiatrist is helpful.

Article written by Nisha Chhabria, MD from the Parkinson’s Disease and Movement Disorders Center of Boca Raton and Member of the APDA South Florida Chapter Medical Advisory Council

Article from September 2017 E-Newsletter

Sleep and PD
The average person spends about a third of a day from birth to death in sleep. Sleep allows rejuvenation of the mind and body. Disrupted sleep has an adverse impact on quality of life for all but is particularly harmful for persons with Parkinson’s disease (PD). A poor night’s sleep can mean a day of less well controlled PD symptoms and cause excessive drowsiness in the daytime.

Three circuits in the brain determine whether one is wakeful or asleep. The first wakefulness circuit involves dopamine. The second circuit involves a brain chemical called orexin that acts as a switch between wakefulness and sleep. The third circuit works through GABA that inhibits brain function and predisposes to deep sleep. A decline in body temperature at night activates the GABA neurons triggering a change in the sleep-wake switch leading to onset of sleep at night. The reverse mechanism leads to wakefulness in the morning. The function of these circuits can be altered by lifestyle, stimulants such as caffeine, medications and disease states including PD.

PD patients show a variety of sleep disorders including insomnia, excessive daytime drowsiness, REM sleep behavior disorder (RBD), and restless legs syndrome (RLS). Insomnia can include both difficulty falling asleep as well as staying asleep. Medications for PD, especially dopamine agonists can cause insomnia. Urinary frequency can also disrupt sleep. Anxiety is common in PD and can lead to insomnia. Excessive drowsiness in the daytime can come from the disease state or medications, especially dopamine agonists. This can lead to a reversal of the sleep-wake cycle where patients are sleepy during the daytime but have difficulty falling asleep at night.

Diagnosis and Treatment of Sleep Disorders in PD
Most sleep disorders can be diagnosed on a clinical basis. If there is suspicion of obstructive sleep apnea (OSA) an overnight sleep study is recommended. A sleep study can be helpful in patients who have periodic limb movements of sleep. Patients with excessive drowsiness in the daytime may benefit from a sleep study to rule out narcolepsy as a cause.

Good sleep hygiene is critical for adequate sleep. Avoid watching television or use of smart phones and iPads later in the evening or at night. These devices have a refresh rate on their screens that acts as a driver to wakefulness activation circuits preventing onset of sleep. Avoid caffeine in the late evening. Caffeine containing drinks also act as diuretics and can exacerbate urinary frequency at night which can disrupt sleep.

Melatonin released by the pineal gland is the natural pacemaker that controls the sleep drive. It can be taken as a supplement to help initiate sleep. Unlike benzodiazepines such as valium or prescription insomnia medications, it is not associated with dependence and less likely to cause side effects. Valerian root capsules have also been suggested as a sleep aid although the evidence for benefit is less clear than for melatonin.

When non-pharmacological measures fail then prescription medications can be used. Typically, benzodiazepines such as clonazepam or temazepam can be used. Certain antidepressants such as mirtazapine can be helpful. Sleep medications such as Ambien or Lunesta can also be used, but with caution, as side effects such as sleep walking may occur.

Article written by Arif Dalvi, MD, MBA, Palm Beach Neuroscience Institute and Medical Director for the APDA South Florida Chapter

Article from August 2017 E-Newsletter

Clinical Trials
Are you interested in participating in a Parkinson’s disease (PD) clinical trial, but not sure what to expect? Clinical research can seem intimidating, but the process is designed to protect people willing to help discover treatments. In fact for many people, the experience of participating in a clinical trial is very rewarding.

While each trial is different, every trial undergoes a rigorous process to design the study. Participants in early Phase I trials can typically expect to have a health assessment conducted before the trial, regular checkups with physicians and nurses and a careful assessment after the trial is completed.

Researchers actively work to accommodate the needs of their patients. At my clinic, we provide transportation to and from visits, and for many trials, participants are paid for their participation. During one clinical trial I worked on, the participants needed to stay at our clinic for a few weeks for observation, and we even made special arrangements for one participant’s dog to accompany him. The needs of our participants come first, and we work hard to make sure they feel comfortable and supported throughout the clinical trial process.

Volunteers experience great satisfaction knowing they play a key role in advancing medical science that may help people live longer, better lives. Despite this fact, less than 10 percent of Americans enroll in clinical trials. Volunteers like you are critical to help us continue to bring innovative treatments to PD patients around the world.

Article written by David Wyatt, MD, Vice President, Medical Affairs Miami Clinic | inVentiv Health

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