PD, levodopa, hallucinations and sleep

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Difficulty writing was the first symptom of his illness. Then his wife noted his walking was slower, and his face more fixed and rigid. Since diagnosis in 2001, he has taken a very light dose of medications: three doses of 25/100 daily and Mirapex. The doctor comments he has had a long honeymoon period; fortunate man. He sits without expression in the office chair, yet he asks questions. He wonders about the frequent hallucinations his is having. The doctor tells him that hallucinations are very common in PD patients. He relates a story of an older man who sees a young naked woman get into bed between him and his dozing wife. The physician asks the patient whether he reached out to see whether the woman was a hallucination, and he replied he didn’t dare move, for fear he would wake his sleeping spouse. That dream the patient comments, is one he would like to have. Instead, the dog hallucination visits him nightly.

When the honeymoon period runs out, patients begin to experience lapses in the effectiveness of medication. These periods, commonly known as “off” periods become more pronounced as illness progresses. The doctor notes the dopamine- rich cells in the brain lose their ability to store excess dopamine, their buffering capacity wanes and patients begin to vary in their levels of function according to the level of medication that reaches the brain. Here, the physician begins speaking about the importance of avoiding proteins, especially milk proteins in the morning meal. Milk proteins compete strongly with the morning levodopa (Sinemt) for passage into the brain; their presence in the diet inhibits the ability of levodopa to get through the blood- brain barrier. This is the reason for having a non-dairy creamer like Cremora instead of milk in coffee and cereal. Dopamine agonists, like Mirapex do not have this problem.

The physician dips into a discussion of sleep and PD, noting the disease ruins normal sleep architecture, causing sleep to fragment. Patients may doze during the day. Excessive daytime napping impedes sleeping ability during night hours, and works to further weaken normal sleep cycles. The body requires a certain amount of rapid eye movement sleep, when not acquired at night, the person with PD becomes susceptible to hallucinations, which are essentially waking dreams. In a study the physician conducted, he found 26% of patients with PD hallucinated; all 26% had fragmented sleep. Novel tranquilizers, such as Seroquel and Clozaril, when given in small doses in the evening counteract fragmented sleep patterns and encourage slumber. The physician prefers patients have a solid length of time given to sleep, as it is more likely they will acquire the needed amount of dreamtime. With a fixed sleep schedule, patients are less likely to hallucinate.

The practitioner- researcher informs the patient and family about a clinical research study he’s involved in, asking whether the patient would be willing to provide a sample of blood. The aim is to find out whether an agent or biomarker exists in the blood that changes with progression of illness. By identifying such an entity, it would be possible to gauge whether medications can truly inhibit the progression of disease.

Yenta

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Yenta, was the word she used to describe her brother in law. He has a lot wrong with him; the high blood pressure was discovered when he was in his thirties. Diabetes; he uses an insulin pump, and has a neuropathy in the left leg and foot, as a consequence of the illness. He underwent cardiac ablation, had a triple by pass surgery to his heart, and wears a pacemaker. The pacemaker for his heart makes an MRI of the brain impossible. He is sometimes incontinent, has difficulty rising from a chair, and has fallen and injured his right shoulder; doctors think he has a torn labrum and will need surgery. The toes of his left foot curl up in dystonic spasms he cannot control. Some time ago, he worked as an architect, and he retains the ability to draw well, though his handwriting has succumbed to illness.
They come for another opinion of what they can do for their family member. The patient has had speech and physical therapy. The specialist reads the notes from other physicians and the differential diagnosis; the list of possible diagnoses the patient may suffer from. Over the course of several months, the wife has seen her spouse decline in function. She contends he has lost a lot of drive. He was a Type- A personality and now lacks the motivation for common things. His personality has become more emotional, and he admits he cries easily. The physician listening comments to the medical student sitting next to him that it sounds as though the frontal lobes are affected, as the area on both sides of the brain, dampens emotional expression.
The specialist performs the physical examination and notes the patient’s eye movements are full. The women mention the patient usually has his eyes closed, and frequently walks into objects when using his walker. This makes some sense to the specialist, as other neurologists have noted he may suffer from Supranuclear Palsy, which usually results in the patient having difficulty looking downwards, though this is not his problem right now. Botox injections to the muscles of the foot helped relieve the uncontrollable spasms on the right. When given to the muscles around the orbit of the eyes, they have been less effective.
The specialist is concerned the patient may suffer from normal pressure hydrocephalus, which can mimic vascular, or lower body parkinsonism. He requests a CT of the brain, which will show whether the ventricles are enlarged. If so, a neurosurgeon can place a shunt in the brain, allowing the excess cerebral spinal fluid to drain out of the brain and into the body.
The doctor recommends the family have a consultation with a fellow neurologist trying to assemble a group of patients for a study on progressive supranuclear palsy. The colleague intends to do a drug study to discover whether a certain medication is useful in that population. At the very least, they will get another opinion from a movement disorder specialist, who will have the results of the CT of the brain to possibly to rule out normal pressure hydrocephalus.

White-haired Sisters

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Tuesday morning hours are allocated for new Parkinson’s patients, but secretarial staff performs scheduling and their understanding of the illness is basic, tremors. For hints, the doctor peruses the patient’s history. Sometimes the nursing staff scans the paperwork the previous day; in this case, the history is online shortly before the patient enters the room. The physician has several moments to form an opinion about what he might see. He knows the patient’s history is atypical for someone with a diagnosis of Parkinson’s disease, and when he meets the patient and her sister, he has further doubts. The woman who has come for a second opinion speaks, emphasizing certain words with hand gestures. At times, she pulls her body to the front of her chair and speaks as she sits on the edge of her seat. Her face is animated and worried. She explains her sister is present because she frequently forgets things.

In efforts to find out what the true cause of her discomfort is, she has sought the help of an alternative type of doctor. He has told her that she suffers from Candida, a fungal infection. He has restricted her diet eliminating sugars, fruit and white bread. She has lost weight on the diet, and some strength.

At the moment, she feels fine though there may be hours in her day when her body aches. The doctor asks whether the pain she feels is worse on one side of her body. Some people with PD experience deep aching pain, akin to what one would experience after having performed a grueling workout on untrained muscles. The pain stems from having muscles in contraction for prolonged spans of time. The patient’s painful episodes engulf all of her body. She mentions the burning sensation she feels in her feet, her precarious sense of balance, double vision and that she has always been a nervous type of person. She has suffered with depression for years, and sees a psychiatrist regularly to adjust her medications.

The doctor scans the past blood test results and notes her rheumatoid factor was within normal limits. On physical examination of the patient, he notes her neck is supple, as is her right side. On the left side, she has the slightest hint of rigidity in the muscles surrounding her arm joint. Her eye movements to the left are difficult due to a weak lateral rectus in the left eye; the muscle pulls the left eye away from the nose and towards the temple, and accounts for her double vision and lack of depth perception. Brisk reflexes of her arms and legs hint her nerve roots may be compressed in her neck. Yet, having reflexes indicates she lacks a neuropathy, and having sensation to vibration and pinprick means her peripheral nerve fibers are also working adequately, so she should have position sense. The patient admits she has had problems with her neck, in the past.

She asks, what will account for her decreased sense of balance? Her troubles with vision? She knows the answer to her own question. Three things give us our location in space: the vestibular system, feedback from muscles, and our eyes. Summarizing his findings the doctor feels she might have some subtle signs of PD, but she lacks sufficient evidence to suggest she needs dopamine replacement. He feels she may suffer from a parkinsonian syndrome, such as lower body PD, caused by microvascular disease; a condition commonly caused by diabetes, high cholesterol and high blood pressure. An MRI of the brain will confirm whether there is evidence for this diagnosis. Meanwhile, he suggests she gradually discontinue taking the Stalevo, eat a balanced diet rich in vegetables and fruits to provide food-based antioxidants and fiber, exercise daily to increase circulation to the brain, and take 300mg of coenzyme Q10 to keep her mitochondria happy.

Second Opinion

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The dark glasses he wears lie on the physician’s desk in front of him; he had cataracts removed from both eyes, but he still suffers from macular degeneration- a condition where retina gradually thins and results in blindness. He carries a large magnificying glass which he holds close to his nose as he peers at his list of medications. The purpose of the visit is to seek another opinion regarding the tentative diagnosis of Parkinsonism. He has already seen several physicians who have conflicting opinions about his tremor.

Losing his hearing, the patient asks the doctor to speak up, interrupting him, as he speaks. The doctor repeats himself, with abbreviated thoughts. The patient holds his palm up towards the doctor, interrupting, telling him to let him speak. His hands are big, his finger long. Several of the fingernails on his left hand are cropped off, midway through the nail. He is 88 years old and states with a serious expression that he expects to live to 120. An American chess champion in the over 75-year division, he visits Florida once a year to compete. He claims in his youth he could play ten games blindfolded, now he can play only one game this way; his short term memory is not what it was. But it is the tremor in his hands that bothers him, especially when eating soup. Three years ago, he noticed his handwriting became larger and shakier. He comments also he has lost the bounce in his step; he no longer rises up onto his forefoot when he walks. Balancing is tricky.

The doctor stands and takes the man’s hand, and folds it inward towards his shoulder and out. He tells the patient his upper body is supple, without rigidity. The patient concedes he was a magician, and takes a packet of cards from a small leather case in his trouser pocket. He describes a trick he was able to do with one hand, holding the deck of cards divided into two bundles, he was able to shuffle them with one hand. Standing, he positions the cards in his left hand, and then nothing happens. The doctor follows his actions, and nods, understanding dexterity is gone from his hands. With a tuning fork, the doctor assesses the patient’s reflexes and notes whether the patient can sense the vibration of the fork, when applied to the bony prominences of his feet and legs. Noteworthy, the patient fails to feel vibration applied to the right leg. The physician explains it is a cheap way of assessing the integrity of the long nerves in the body, and states the lack of sensation explains some of the change in his walking style, as he appears to have a mild sensory neuropathy. The cause, the physician guesses is from compression of the nerve roots in the spine. The doctor explains we rely on three mechanisms to keep us upright in space; position sense derived from the sensory nerves in our limbs that pick up vibration, fine touch and temperature; our vestibular system and our vision.

When the physician summarizes his findings, he notes the patient has a mild action tremor, and a mild sensory abnormality in the right leg and foot. He would like an MRI to look at the blood vessels of the brain. However, the patient leaves on Thursday to his home state, he’d prefer to have the testing performed there. The doctor agrees to send notes to the physicians involved in his care and the conversation shifts to what sort of cutting edge therapies exist in the field of Parkinson’s and Alzheimer’s disease. Sitting behind the desk, the physician explains a study in which people with Alzheimer’s are getting GCSF(granulocyte- colony stimulating factor) to remove the amyloid plaques from the brain and improve cognition. The patient voices some interest in undergoing the same treatment, and the doctor wonders whether that would be ethical, or even practical, as the patient lacks the symptoms of those with the illness. He also notes when the amyloid is removed it can get stuck in small blood vessels, and result in micro-hemorrhages. He is unsure of the consequences of such trauma in the brain of a healthy, yet older individual. The man, wearing a woolen red sweater over a collared shirt, reaches into a file and withdraws the list of therapies he receives regularly from a physician whose specialty is aging. In the second or third line is a product called Neupogen, the same substance used in the research study for patients with Alzheimer’s.

Internal Tremors—-felt by the patient but not seen by others

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Fifty years of age, with a multitude of health problems, he appears at the clinic to rule out parkinsonism as the cause of his tremor. Since he began using the CPAP machine to sleep, he has noticed feeling tremulous in the morning. Sometimes the symptom lasts only an hour, but occasionally the feeling stretches out to encompass the entire day. The movement disorder specialist asks what part of the body is affected. With his hand to his chest, the patient indicates he feels the vibrations occurring in his torso, and the movements feel similar to the heart palpitations he’s experienced, though he has asked his wife to touch his shoulder and see whether she can detect the quivering motion, and she feels nothing.
The doctor considers this then gazes at the patient’s medical history. Various practitioners have diagnosed the patient with lupus, myasthenia gravis, and multiple sclerosis- all neurological conditions. The doctor states that lupus can produce a wide range of neurological conditions, and possibly tremor. Diabetics may also experience tremor in an episode of low blood sugar or hypoglycemia, occurring due to an imbalance between insulin or diabetic medication, food consumption and level of exercise and activity. The patient is unable to exercise due to failed spinal surgery. He recounts he has put on eighty pounds because of his immobility. Diabetes as a cause of the trembling doesn’t seem to fit the patient’s description of the action continuing throughout the day.
The specialist relates in a study he is familiar with, people with Parkinson’s disease were asked whether they experienced an internal tremor. Those that reported such a sensation all had depression in common. For people diagnosed with PD, there appears to be a correlation of that symptom and clinical depression. Though the patient lacks slowness, rigidity, and a resting tremor, a course of an antidepressant may alleviate his symptom. The medication the physician has in mind is an old-fashioned antidepressant, Doxepine. However, the medication can’t be given to people with cardiac arrhythmias, which he experiences. Inderal or the generic propanalol is helpful in blocking tremor, though the medication also veils the symptoms that come as a consequence of hypoglycemia; dangerous for a diabetic who may pass out or experience a seizure when blood sugars drop too fast. Depending upon how uncomfortable the tremor is, the physician concedes the whole class of SSRI’s that include Zoloft, Paxil and Prozac are possibilities, if he would like to see whether they calm the symptom. The physician concedes the good news is the patient does not have evidence to suggest he suffers from parkinsonism.

He is young

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He’s young, wearing blue jeans, a polo shirt and sporty shoes. Told that he has the symptoms of Parkinson’s disease, he wants another opinion, before he can stare the future in the face. Online, he’s read about the drugs given regularly to control the symptoms and learned they eventually lose their efficacy. The movement disorder specialist interrupts him, and clarifies the facts about the disease, and the changes that proceed as illness evolves. He explains levodopa does not lose its usefulness; rather that other neurotransmitter systems (like noradrenaline) become involved, and dopamine replacement cannot affect those systems. For example, sudden freezing episodes and loss of balance which gradually appear as the disease advances typically don’t respond well to dopamine replacement and we do not have medicatons that will directly improve those symptoms. Attempts to replace noradrenaline with a precursor have not been helpful in ameliorating freezing episodes. In addition, repeated dosing with levodopa/carbidopa affects the neurons downstream of the dopamine system resulting in development of what appears to be an excessive and/or erratic response to levodopa. Whether this is a function of the way the drug is given- intermittently, so the body contends with repeated wave- like influxes, or if the change is due to the neurotransmitter itself, is still unclear. Note that levodopa gets converted into dopamine in the brain. The neurons which are originally able to store an excess of dopamine in neurotransmitter terminals are lost and so the response to medicine parallels the circulating blood levels of levodopa. The combination of loss of dopamine terminals and the development of supersentivity of the dopamine receptors in the striatum becomes evident when people with PD begin experiencing motor fluctuations, wearing off, freezing and excessive involuntary movements known as dyskinesias. The doctor reassures the young patient this is one of the reasons why people under the age of sixty rarely get initial treatment with Sinemet and are started with dopamine agonists (“synthetic” medications which act like dopamine), which are less likely to produce dyskinesias than levodopa/carbidopa.
Physical examination includes determining the level of rigidity in his left side, the dexterity of his movements, the attributes of his gait and the fullness of his eye movements and other subtle symptoms. The doctor agrees with the previous diagnosis, the patient has the signs of a parkinson syndrome, only when he takes levodopa, will they be able to determine whether he suffers from a deficiency of dopamine; a positive response to the drug, as in easing of symptoms means he suffers from Parkinson’s disease. At the moment he recommends Azilect or the generic rasagiline, an MAO inhibitor, which has been shown to slow the progression of illness as well as ropinirole, a dopamine agonist that acts directly on dopamine receptors. The doctor scans the MRI of the brain, looking for evidence of a stroke, which might also account for some of the weakness on the left side of the body, but finds nothing.
When the patient has the two prescriptions in hand, he confides he has had a hard time falling asleep and received a small prescription for Xanax from his general physician. He asks whether the physician has an opinion on the medication. The specialist responds he dislikes the medication for treatment of depression, if that is the cause of the sleeplessness. Xanax is a depressant, and habit forming. It can be used in the short term, but he adds he would like to see the patient in six months, to see how he is faring on the two medications. At that time, they can speak again about whether there might be a need for a medication for depression. He adds the vast majority of patients with PD have need of an antidepressant, and it can be a helpful tool in maintaining a positive outlook and a high quality of life.

Latin and Handsome

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He’s Latin, the kind of patient that when I learn he is sixty- one, I am surprised, he could be forty- seven. His hair is still mostly dark and his daughter- in- law accompanies him, when he comes in for a second opinion on his diagnosis. Shuffling gait and increased muscle stiffness are the two symptoms that initially warranted a physician’s visit. When the first neurologist gave him a scant ten minutes of his time, he sought a second opinion.
The disease is apparent in the lack of expression in his face. An attractive man with dark features, his face lacks the spontaneous motion typical of healthy people; even the fixed way he holds his head indicates some level of rigidity. He has had three surgeries on his back and neck due to collapsed and herniated disks and his brisk and spreading reflexes indicate the long cortico-spinal tracts running through the spinal cord were injured at a previous time. His gait also is peculiarly parkinsonian. Though he lifts his feet adequately, his torso and in particular his arms, fail to oscillate with the motion of his legs and feet. When he gets to the wall and needs to turn around, he takes several steps, rather than turning on his heel and swiveling his trunk.
The previous neurologist gave him a prescription for Stalevo. The dose was either too low to see any improvement in symptoms, or the proteins in his diet blocked the conversion of levodopa to dopamine in the brain. The specialist in movement disorders cautions the patient, telling him dietary proteins; especially those in milk interfere with the way medicine gets transported to the brain. If he is unable or unwilling to reduce the morning and lunchtime proteins, he will need to take a larger dose of the medication to see its effect upon his muscles. With this in mind, the physician writes out a chart of how to increase the dosage of medication. Every three days the patient is to increase the dose by half a tablet, at one meal. When he sees the medication is enabling him to move more freely throughout entire day, he is to cease increasing the dose, and stay at that level of medication. The doctor indicates, this is a stairway in which you can go forward and go backward, to attain the appropriate dose.
In addition to regular medications, the physician recommends the patient also use an over the counter supplement, enzyme CoQ10. Laboratory studies indicated the antioxidant at doses of 1200 mg/per day, were capable of slowing the process of disease. Though few patients can afford to buy such high levels of the supplement, they may receive some health benefits from a lower dose; the doctor indicates 300mg/day.
Other issues concern the patient. He worries about his constipation. The physician recommends changing the diet to include a large amount of fiber and copious water, as well as a stool softener. A previous MRI indicated the patient has decreased blood flow to the brain. For this, he received a prescription for persantine, which decreases the stickiness of platelets, thereby increasing blood flow. The specialist also notes that with time Parkinson’s disease affects the autonomic nervous system, which includes bowel, bladder and sexual function. He states many of his patients ask for a prescription for Viagra, and he has no problem prescribing it, as it doesn’t interfere with any of the medications and he is not taking medications to prevent angina. The specialist asks the patient to make another appointment in four months, so he can see how he is faring.

Hope

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The patient arrives early, a guy in uniform pushing his wheelchair. His head looks like it is attached directly to his torso; it’s called a kypho- scoliosis. He is only sixty- six, but his body says much older. In 1995, a physician diagnosed him with Parkinson’s disease. He recalls a tremor in his right hand that improved with the Sinemet he received a prescription for. The specialist in movement disorders is skeptical he truly suffers from Parkinson’s disease. He asks the patient to recall the sequence of events that brought him to a diagnosis with the neurological condition.
He’s a bit hazing. His speech is whispery, and the three in the room bend inwards to understand what he says. Some things he is sure of. He broke his neck when he was about fifty years of age, which coincides with the time of diagnosis with PD. The physician wonders whether the weakness and subsequent atrophy of the right arm was due to the cervical myelopathy, a stroke or cardiovascular disease. However the insult occurred, his right arm is fixed in a rigid position, bent at the side of his body, with the right hand tightly caught in a fist. When the doctor asks him to straighten his arms out in front of his body, his left arm cooperates. The right arm maintains its flexed position inward, and he is unable to tap his index finger and thumb together. He reports he used to be right handed.
Some things he is clearer about. The last time the hospital admitted him, he suffered from a urinary tract infection, fecal impaction, hypertension, chronic hepatitis C, an ulcer on his buttocks, and pneumonia. It was then that the staff recognized the prior diagnosis of Parkinson’s disease. This seems to be the reason for his visit this morning, to confirm whether the diagnosis has merit and resolve whether he should be taking Sinemet, and if so, what dose.
The doctor peruses the patient’s records that appear on the computer monitor. He informs the medical student and myself the patient has undergone multiple surgeries on his spinal column, to fuse and in some places to cut the bony growths that pressed upon his spinal cord. Areas fused on the spinal cord were bound with metal anteriorly, so he will never be able to undergo an MRI.
The physician begins the physical exam noting first the patient has no cogging of his muscles. The type of stiffness he feels is spastic, unlike that seen in PD. The patient has no reflexes in either the lower or upper extremities. Wondering aloud, the doctor asks the patient whether he feels the vibration of the tuning fork, and the patient reports his left leg scarcely feels the sensation. This fact seems to confirm the patient also suffers from a neuropathy. Hopeful, the patient states he is able to walk still, with a walker. The cause of the neuropathy may have been his low- functioning thyroid, or uremia. It bothers the physician that the patient has been using Sinemet for the last fifteen years and he suffers from no dyskinesia. It indicates he does not suffer from depletion of dopamine, meaning he does not have Parkinsonism. The doctor prescribes physical therapy and the patient wonders whether he will ever be allowed out of the assisted living facility. The doctor gazes at him directly and declares he is severely compromised, has but one useful hand and is at risk of falling.

Pretty Woman

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I notice the beauty in her face right away. She has an expansive aura and emanates a positive sense. Though as she sits, dyskinesia makes her turn in her chair, twisting her arms and legs and then turning her head to one side. The involuntary movements are what trouble her the most, and have been for some years. She wears a cotton blouse with cutwork, and her hair is tastefully brown so she appears much younger than the seventy- some years. She has come for her six- month evaluation.
The physician states the patient was diagnosed approximately fifteen years ago, with dyskinesia beginning during her eighth year of the illness. The patient enlightens the doctor with her regimen of medication. She takes Sinemet around the clock, waking throughout the evening roughly every two hours. The feeling of wearing- off causes her to panic, and she feels like she cannot breathe. Medication throughout the night results in poor sleep quality. The specialist feels she is over- medicated, and recommends she begin taking Seroquel at night. With several hours of sleep, the world appears a saner place. The patient also suffers from fibromyalgia, rheumatoid arthritis, and depression three other reasons the patient requires time in total body relaxation.
The physician recommends deep brain stimulation surgery in very specific situations and in this patient’s case, he thinks the intervention might bring considerable relief from the complex motor fluctuations with dyskinesias. His second recommendation is using the Neupro patch. The patch is placed on areas of the body not prone to sweating, and the area is changed daily to avoid skin reactions. Rotigitine (the generic name for Neupro), is a drug that mimics the actions of dopamine in the brain and does not require transformation into dopamine like levodopa (Sinemet). It is absorbed slowly through the skin, rather than through the intestines. It has a much longer effect and may be effective in people who suffer from motor fluctuations, or variability in their response to medication.
In addition to the patch the specialist also recommends the patient begin using a “liquid Sinemet” formula mixing her Sinemet in the morning with some vitamin C to stabilize and maintain freshness of the solution and sufficient water. The recipe is available on line. She is to sip the concoction every few hours during the day to maintain the level of dopamine at a nearly steady- state, thereby reducing the times when she may be wearing- off.
The doctor is pleased the patient has appeared with a caregiver, though she is only present four hours daily. When he spoke with the patient’s daughter, she conveyed some interest in having her mother placed in an adult – living facility, where she would get more attention. The patient reports she is quite fine, and independent on her own. The doctor recommends she return in six months time, when she can describe how well she sleeps.

Plank of Wood

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He is as stiff as a plank of wood in the chair he sits in, and his voice is whispery ethereal. The wife responds when the doctor asks whether they are present to confirm a previous diagnosis. She nods enthusiastically and takes off on an explanation of their experience with a previous neurologist who put the patient on ropinirole. The physician nods and comments what he would really like to know is what the patient experienced as the first symptom that worried him and thought he should seek a doctor. The patient responds in a breathy whisper, he noticed weakness in his left side and felt he was dragging his left foot. His idea was confirmed when he detected the heel of his left sneaker had worn considerably more than the right. Then his voice changed. People on the phone have a hard time comprehending his words. The specialist admits he can see from the lack of adventitious movements, the patient suffers from a parkinsonian syndrome. He comments most people typically move about spontaneously, adjusting their legs, moving their hands and face, blinking and moving their glasses or repositioning themselves in the chair. People with Parkinson’s disease lose all these extraneous actions.
The doctor explains Parkinson’s disease may be divided into those that suffer predominantly from a rigid- akinetic form, and those whose illness is tremor- dominant. Those who partition the illness into such categories have found the rigid- akinetic form of disease typically carries a worse prognosis than the tremor dominant form, with a more aggressive course of disability and more dementia. Although the disease affects the dopamine- rich cells of the basal ganglia, causing them to die off in great numbers, the illness also affects other neurotransmitters. Noradrenalin, involved in the function of bowel, bladder and temperature regulation, also becomes depleted and patients usually are beset with problems of urinary frequency, constipation and episodes of feeling intensely hot and cold. Such problems however, are usually not part of the scenario so early in the course of illness.
When the patient has become comfortable on the examination table, the physician begins the physical exam beginning with an assessment of the patient’s eye movements. Though range of motion is full, the muscles that move the eyes show ratchet- like jerky motion, when the patient follows the pen in the physician’s hand. The good news is he is able to gaze fully upwards and downwards. There is marked cogging in the muscles of the left arm, with the left side showing more impairment than the right, and the physician comments this is what one might expect in Parkinson’s disease. The dexterity and the amplitude of movements of the left hand are also more affected than the right, though when resting his hands in his lap, there is only the finest of tremors in the left hand. The physician finds the reflexes in the patient’s legs are brisk, and spread to the other side of the body. He checks the reflexes of the arm; they are brisk as well. He comments brisk reflexes indicate the long, cortical spinal tracks, which course down the spinal cord, have lost their inhibition, in the cortex. He checks the reflex of the jaw, which is intact and normal, and speculates the patient may have some osteo- degenerative changes that are impinging on the long nerves in his spine, at the level of his neck.
The doctor draws out a chart, which illustrates the manner in which he is to add a half- tablet, every three days to the daily dosage of Sinemet. He notes the chart is a stairway in which the patient will go up, until he eventually arrives upon a dose where he feels good, and his movements are full. If he feels light- headed on a dose, he may elect to hold at that level, or even back off a stair, to a lower dose. He gives the patient and wife the chart, prescriptions for Sinemet, Seroquel for sleep and physical therapy and remarks he would like to see them back again in six months, to see how things have developed.

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