He is subdued, well- groomed and has no objection to observers in the room. The doctor summarizes his last note, written six months earlier when the symptoms were confined to the left side of the patient’s body. Driving, hands on the steering wheel, his right hand moves along with the tremor in his left hand. That’s the only time he’s noticed tremor on the right. Bilateral symptoms indicate stage two illness. Six months ago the doctor documented, he was stage one, still the honeymoon period.
The general practitioner recently decreased the hypertensive medication he takes. Since then, he’s noticed his symptoms seem worse. He gave up his profession of forty-two years, when he felt it wise to arrive an hour early and review the charts of the previous day, to see whether he had made errors. He had trouble speaking with his patients. His voice became very soft, somewhat slurred, and people found it hard to understand him. Questioning his ability to perform as he had earlier, he sold the practice to a younger man. It’s been several months since he gave up his work and he’s been searching for ways to occupy himself during the day. He’s discovered a yoga class, attending three times a week. He exercises. The activity is not enough. A void exists where his work used to be.
The doctor notes most people with PD, the vast majority, begin taking antidepressants. Some experts even posit depression may be an integral part of the illness. The patient comments he took the antidepressant, nortryptiline several times and noticed it seemed to make him more constipated. The physician comments the medicine is an “old- fashioned” tricyclic anti-depressant with mild anti-cholinergic effects, which would benefit him. For its affects to be felt, the medication has to be taken regularly for more than a month. The patient laughs at this.
The doctor asks about sleep and the patient reveals he has occasional nightmares. In the last one, someone chases him. He turns in the dream, and in bed, and punches the guy. His fist hits the headboard. The skin of his knuckles split. His wife has chosen to sleep in another bedroom. The doctor nods, and notes that this sleep problem is called rapid eye-movement sleep behavior disorder. Most people with PD have unusual sleep architecture; most people when dreaming are incapable of moving their body. Those with the disorder are able to move and perform, acting out the scenarios of their dreams. Sleep walking and talking are other examples. To increase the patient’s sleep quality and quantity, the physician recommends Seroquel at very low doses, to be increased in dose until he can sleep at least six hours without waking up. The patient agrees he would like to sleep more. Seroquel, the Dr. explains, is considered a novel tranquilizer developed to treat psychosis, but is very effective in treating PD patients who have vivid nightmares and even visual hallucinations. Addressing his voice problem, the doctor comments a speech therapist would be able to work with him to increase volume and the clarity of his words. The man nods, he will add this to the vast span of time he has open in his afternoons.