He’s tan, robust and loves to spend time fishing off a bridge. Dyskinesia draws his jaw sideways and his hands make extraneous movements that the doctor notices. It’s past the time for his pill and the physician encourages him to stay on schedule, take the pill. His wife sits in the chair at his side. She is much more fair, her dark hair hangs past her shoulders and she carries a water bottle.
The doctor asks how things are and reads the note from the prior visit. He had recommended Seroquel to help the patient sleep at night. He tried it. The prescription was too costly for the sleep it provided and when the bottle was empty, he did not refill it. The doctor comments the company provides the drug at reduced to no cost, to those who are unable to afford the monthly bill. The patient relies on a disability check to live. He supports himself, his child and his wife. Meanwhile he recommends Mirtazipine, an anti-depressant that causes drowsiness and in the long run may improve sleep. It is also a less costly drug.
An assistant coach to his son’s soccer team, he froze for the first time, coming across the grass at the park. He felt his legs weaken and he couldn’t move. The children weren’t sure what was happening. He worried what they were thinking. His wife gazes at him and tells him not to be concerned what others think. He admits worrying gets him nowhere. It is all energy directed inward, and it brings him nothing. At home he worries about the bills. The doctor nods and comments the birds and the bees don’t worry about where they will sleep, what they will eat. The wife comments sometimes she wishes she was the dog. The dog eats and sleeps, not preoccupied with daily concerns. It’s a simple life.
The doctor goes to watch the patient’s gait in the hall and I ask how long ago her husband was diagnosed. He was thirty-five, and now he’s fifty-two. He looks forty. The doctor comments he had young-onset illness and the illness appears to be advancing very slowly. The patient worries about his memory. He speaks with his wife and can’t remember the details. The doctor, with a deadpan expression belying the humor, comments that’s because they’re married. Explaining the difference between dementia and Alzheimer’s, he tells the patient those with PD tend to suffer from failing “executive” function or the ability to plan ahead and to multi-task. He animates the meaning by answering the phone, checking the computer, sending a text, conferring with a nurse and making a call. Asking the patient to follow his movements, he conducts a Luria test and the patient has trouble learning the sequence of three hand movements. The confusion he experiences is evidence of a decline in executive function, in earlier days he would be able to knock, chop and slap with no hesitation, and he demonstrates the motions rapidly with his hand.