Article from December 2017 E-Newsletter

How Can You Make the Holidays Senior Friendly
As we grow older, things change, including how much we can manage during the holidays. How might you adjust your family’s traditions to accommodate the elders in your clan? Take a look at these suggestions:

  • Re-think the time of day your family gets together. Seniors have more energy to enjoy festivities earlier in the day.
  • Enlist some help when preparing the meal. This will give mom an extra pair of hands in the kitchen, the ability to spend some quality time with her family, and she’ll have the opportunity to pass on some family recipes.
  • Play music that will stimulate pleasant memories for your senior. Music can be very good medicine for people of all ages!
  • Be aware of the temperature inside and outside. Keep a sweater or blanket handy to help keep your loved one comfortable.
  • Re-think the amount of time spent decorating. This could get over-tiring.
  • Help with your senior’s gift giving. Ask if they need help shopping or wrapping.
  • Be aware of possible physical limitations. With aging comes poor hearing and failing eyesight. Make sure your loved one is able to participate in the activities.
  • Help your senior stay in touch. Bring your phone or computer to help re-connect with family members and relatives.
  • Drive around the neighborhood and enjoy the outside decor. Enjoy the fresh air.
  • Take time to share your favorite holiday stories. Be sure to come prepared.
  • Be open to letting new memories replace old traditions. They may no longer be possible or appropriate.
  • Take lots of pictures. Your senior can proudly show off their family to other friends and care-givers

Article written by Senior Care Authorities

Article from November 2017 E-Newsletter

The Mechanism of Transfer of Pathologic Alpha-Synuclein
In 1817, James Parkinson first described the clinical condition with resting hand tremor, muscular rigidity, diminished bodily and facial movements, and a forward stooped posture with impaired balance. This disease description was further refined by the French neurologist Jean-Martin Charcot and given the name Parkinson Disease (PD) in 1877. In 1912 Frederic Lewy first described intracellular inclusion bodies in a number of degenerative brain disorders, and these inclusions were subsequently referred to as Lewy bodies. In the 1950s the pathology of PD revealed that darkly pigmented cells in the midbrain substantia nigra were dying off (60% loss by the first clinical symptoms) and the remaining cells had Lewy bodies (LB). By the late 1990s the principal component of the LB was found to be a mis-folded protein alpha synuclein. Over time it has become apparent that pathologic alpha synuclein fibrils mis-fold, causing clumps of a toxic protein that will lead to the brain cell death occurring in PD. It is similar to the extra cellular amyloid protein that plays a role in brain cell death in Alzheimer disease. Furthermore, the pathologic alpha synuclein seems to spread from one cell to a neighboring cell, and is felt to account for the gradual but inexorable progression in PD. Early in PD, when fewer cells are lost, the disease remains one sided and balance is not involved (Stage I PD). However, as more cells are involved, more function is lost and bilateral involvement with balance impairment occurs (Stage III PD). With progressive spread of pathologic alpha synuclein into higher brain structures in the cerebral cortex, cognitive problems may become apparent in the later stages of PD.

Researchers at Johns Hopkins University school of medicine, Dawson group, have discovered a mechanism by which the pathologic alpha synuclein fibrils are getting into neighboring cells. They have found that lymphocyte-activation gene 3 (LAG3) acts as a receptor which binds the alpha synuclein fibrils, thereby acting as a doorway for these pathologic fibrils to move into the next cell. The abnormal alpha synuclein binds to the LAG3 receptor then is brought into the new cell by endocytosis. Once inside the new brain cell, the mis-folded alpha synuclein starts to kill that cell. Strategies to block this doorway are being investigated. However, new discoveries often lead to new questions. For example, why is the LAG3 receptor on brain neurons? What is LAG3 normal function? Are there other receptors that open a doorway into brain cells for pathologic alpha synuclein? One therapeutic PD strategy being looked at is to administer antibodies against LAG3 to disable the receptor and shut the doorway. It is not clear that the LAG3 antibodies will cross the blood brain barrier and get into the brain tissue where they must act. This strategy is under active investigation. The approach of blocking cell membrane receptor sites that allow one cell to adversely affect a neighboring cell has had recent success in cancer therapy. Hopefully it will lead to slowing or halting disease progression in PD.

Article written by Thomas Hammond, MD from the Marcus Neuroscience Institute and Member of the APDA South Florida Chapter Medical Advisory Council

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


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