She fell between two cars three years ago and just recently finished the final treatment to her jaw and teeth. The accident resulted in a fractured jaw and arm; not simple fractures but compound, and they didn’t heal well. The jawbone had to be rebroken, aligned and held in place with a titanium plate. Three years later, she noticed the tremors in her mouth and hands. At night, she felt her entire body twitching.
The first neurologist the patient saw diagnosed the tremors as Parkinson’s disease and prescribed Mirapex. The medication can increase patient compulsivity, and receives blame for instigating gambling habits in people ordinarily not prone to wagers. The husband of the patient vouches that the personality of his spouse changed when she began the drug. Now, when she gets an idea in her mind she must follow it to the end. Delaying or minimizing the chore is insufficient, the patient feels compelled to carry out whatever it is her mind has settled on.
Generally, the rule with prescribing levodopa containing medications is, not to begin treatment with Sinemet in patients younger than 60 years of age, because half all patients treated with levodopa medications develop dyskinesia in three to five years. Dyskinesia is uncontrollable, often fluid movements of the limbs. The patient in her early seventies might have received the drug and been more completely relieved of her symptoms. In the physician’s opinion, tremor is really a cosmetic issue, embarrassing to the patient but usually not disabling. The patient admits that when she becomes aware of her tremor there are things she does to subdue it.
The movement disorder specialist would like the patient to begin taking amantadine twice a day for symptoms, because it may slow progression of the disease. He relates he would like to taper to only one Mirapex, right before retiring for the night. He also states that if the patient feels symptoms are worse, she might try a course of Sinemet. Now confused by how many drugs the physician is recommending, the doctor clarifies; always take the amantadine twice a day, take the Mirapex before bed and if worse begin weaning onto Sinemet. Sinemet is one of the drugs best to begin gradually. He writes out a schedule, the first several days the patient takes a single pill at breakfast. After that, the patient steps up to taking a total of two pills, once at breakfast and again at lunch, this continues for several more days. The second step takes the patient up to three pills total, at breakfast, lunch and dinner.
The specialist notes the patient has mild symptoms of PD. She has rigidity in both arms and makes small excursions when performing repetitive fine hand gestures. Strolling in the hallway, the doctor notes her gate is solid and her arm swing full. Perhaps the course of illness will remain mild. He requests the couple return in three months, so he can check the status of the patient and make any changes in medications. Encouraged that she walks for an hour on the treadmill, the doctor emphasizes the role physical activity has in enhancing physical function.