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Answers from Ask The Experts

Dr. Richard Cahill, a psychiatrist at St. Ita's, Dr. Tim Counihan, neurologist at UCHG, and Patrick Browne, PDNS at UCHG, form our panel of experts. It would be appreciated if your questions were as specific as possible to avoid any misinterpretation. Personal details such as names or addresses are not required and will not be included here, and your question will be answered as soon as possible.

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Questions & Answers

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Only your question will appear on this page; personal or identifying details will not. These questions, once published, along with the answers supplied by a member of our panel, may be used by either for patient education or information purposes. The answers will be based upon the information contained in your question, and will represent their professional opinion, given in good faith, on that basis. No action should be taken after your question is answered without consulting your own doctor or nurse specialist.

Question 1 Can depression in Parkinson's be avoided?

Answer 1 If the Parkinsonian symptoms are well controlled -especially if freezes and off periods are minimised, and pain is controlled, the risk of depression would be reduced. It is important however for carers and patients to be on the look out for signs of depression [low mood and irritability, inability to enjoy things, social withdrawal, reduced interest in life, sleep disturbance etc.] so it can be treated early; the presence of support structures and social contact will also help ...proper diet and exercise and using alcohol safely are also important. I don't think it is ever possible to state that by doing certain things you can prevent depression in every case but these are suggestions that may help to reduce the risk of onset.RC

Question 2 What makes depression in Parkinson's different from ordinary depression?

Answer 2 This is a difficult one. I guess it is different in that the person now has [at least] 2 disorders to cope with and that itself brings on frustration...there is some evidence that guilt feelings and suicidal ideas are less common in Parkinson's Depression; the big problem is that many of the symptoms of Parkinson's are similar to those of Depression so accurate diagnosis is not easy; in any event the principles of treatment are the same as in non-Parkinsonian Depression.RC

Question 3

Would it be a good idea to include a mild antidepressant with Parkinsons medication as a precautionery measure to keep depression at bay?

Answer 3 I would not recommend this as I am not aware that this approach has any scientific basis.RC

Question 4 Are there therapies or suggestions to improve memory and cognitive problems? What are the best things for the memory?

Answer 4 I do not know if there are specific treatment approaches to improve memory in PD; would suggest asking Dr Lynch. RC Ed. Dr. Lynch answers questions on the PALS YOPD branch website www.pdpals.com, not restricted to members.

Question 5 SSRIs seem to be prescribed for depression in Parkinson’s, but I read somewhere that these were contraindicated. If so, why are they being prescribed? Is it ignorance, indifference...

Answer 5 SSRIs are not contraindicated in PD depression; they are the treatment of choice, from my reading of the literature. please note that very little proper research has been done on which antidepressant is the best...all medications have side effects and sometimes SSRIs may worsen PD symptoms. Please note this doesn't happen to everyone and if it happens, the sensible thing is to try a different class of anti-depressant.RC

Question 6 My mother was diagnosed with Parkinson's in 2006 but last month she was told it is Parkinson's Plus. I read somewhere that there is only a life expectancy of no more than 10 years. Can you give me some more information on this as I don't know if she has been informed of this as she always thought you couldn't die from Parkinson's!

Answer 6 Before answering this question I would like readers to bear in mind that in unusual circumstances a diagnosis may have to be explained in a different way to the normal. This is especially the case when, or if, the knowledge of such a diagnosis might prove to be detrimental to the welfare of the patient concerned. Having said that, it must be remembered that this would be the exception rather than the rule. In many cases it can be a relief to the patient that a definitive diagnosis has been reached even in the event of its being one with a less than favourable prognosis. The human mind and body has a fantastic ability to deal with stress, but sometimes it must be delivered in measured amounts to prevent overload, i.e delivering the whole message over a period of time.. Your mother is right that "you can't die from Parkinson's." However the results of the symptoms can have serious consequences for one's health. Generally Parkinson's Plus diagnosed patients will have a more rapid onset of the problematic symptoms but the order of presentation can vary greatly depending on the type of Parkinson's Plus. In circumstances like this, it is often advisable to subtly find out exactly what your mother knows or expects from her state of health and the course of the condition. If you ask her would she like everything explained to her again in more detail, you may be surprised how much she knows already. However, one must bear in mind that, quite often, people being given information about their own health will hear what they want to hear. It is important that your mother liaises with her medical team regularly. She will more than likely be brought up to speed as to her diagnosis especially now that the prognosis has changed.PB

Question 7 My wife has PD and recently I have noticed slurring in her vocal sounds,also her signing does not make sense at times. Is this to be expected with deaf people? We use sign language a lot although I myself am not deaf. For the past three months I have noticed her signing is getting very confusing,she finds it hard to complete a sentence, and sometimes her signing is just gibberish. Communication between us is getting intolerable. please advise.

Answer 7 A colleague has recommended an assessment through the CRC in Dublin as an option. I agree that the issue is whether the difficulty with signing is due to bradykinesia or whether there is a true language or cognitive disorder present. I would suggest that this is a perfect situation for a multidisciplinery assessment with Neurologist, SLT and audiologist. Difficult situation but should be fixable. Should be set up promptly. TC Another suggestion from a reader was to see if assistive technology would be of any use - e.g. a Lightwriter - a machine into which you type and what you type displays to the reader. Obviously an assessment would be needed to determine its potential usefulness.

Question 8 Is it common to have moderate to severe dementia with mild to moderate Parkinson's? [Diag 2006]

Answer 8 It is definitely uncommon to have moderate or severe dementia with mild to moderate Parkinson's. While it is true that dementia can occur in a minority of patients with Parkinson's disease, so-called PD dementia typically emerges 15-20 years after PD symptoms begin. There is a condition called Lewy body dementia in which patients develop early dementia, along with some symptoms of parkinsonism. Patients often have marked visual hallucinations (seeing things that are not really there), as well as disturbances in sleep. Sometimes the Parkinson's symptoms in these patients are quite mild. In any patient who has a severe dementia with Parkinson's disease, the doctors need to be certain that they are not missing something that is easily treatable; even simple infections can cause severe confusion in some patients, and these must be sought for and treated. Some medications still used to treat PD symptoms (especially Artane, Kemadrin and Cogentin) can cause severe memory disturbance. The doctor looking after any patient with dementia must treat any ailments and stop any medications which might be making the patient confused.TC

Question 9 My mother has just been diagnosed with Parkinson's. She had been on Amytriptiline and is waiting to start medication for Parkinson's. She wants to know if she should come off the Amytriptiline while waiting. Thank you.

Answer 9

Question 10 My wife has has PD since 2002. She recently changed to a Neupro patch instead of Mirapexin. She has recently been feeling quite nauseous. Is there anywhere on the Internet you would recommend that I look to get an answer to this question.

Answer 10 Nausea is a very common problem in Parkinson's. Reasons:

  1. All dopaminergic drugs are nauseating. This is usually seen when commencing treatment or like in this case when changing from one treatment to another, even within the same class of drug.
  2. Constipation is a problem that everyone with PD will experience at some point or another, some will suffer all the time. A person will have a bloated uncomfortable feeling and will often have a reduced appetite also as a result.

Solutions:

  1. When commencing a new antiparkinson treatment it is often advisable to take this medication with food for the first few weeks as this will reduce the risk of nausea, and when the treatment is established and tolerated then revert to taking the medication half hour to 1 hour pre-meals.
  2. Domperidone (Motilium) is the most commonly used antiemetic in the treatment of nausea in Parkinson's. Although it is slightly dopamine antagonistic it doesn't cross the blood brain barrier and therefore doesn't cause the side effects that one may experience with prochlorperazine (Stemetil) metoclopramide (Maxolon). Domperidone acts by being prokinetic i.e. it increases peristalsis in the gastrointestinal tract. The best way to use domperidone in this case may be to take it about a half an hour before the anti-Parkinson's medication.
  3. To prevent constipation being a contributing factor then it is important to maintain a healthy balanced diet with lots of fruit and roughage. Fibre is the best method to prevent constipation as it expands to absorb water. This distension is the main stimulus for peristalis to increase in rate. Regular longer term laxatives can desensitise the the bowel and ultimately worsen constipation as they will damage the nerve endings in the gut wall. However, short courses of these medications can be used without any need for concern. Hot prune juice is an excellent remedy - studies have shown that prune juice is more efficacious than other natural substances as a stool softener and can be used as maintenance and treatment for constipation.

Speaking specifically about Neupro the dopamine agonist patch: For a person on Neupro the medication managment of nausea will be a little different to those on oral medications. If the person is prone to nausea there would be no problem with starting a person on domperidone 30mg three times per day (i.e 3 tablets, three times per day). This should help reduce belching and stomach pain. When established on the medication and the doses have been titrated upwards then it would be time to reduce down the domperidone again and stop it if possible. PB

Question 11 I am tired of this disease; no way out. Please tell me how I can look normal- I hate this zombie look.

Answer 11 [Ed.:All three experts have answered this question in detail] One can only imagine the frustration and pain that Parkinson's disease can inflict upon the sufferer. As treating doctors and specialists, we are probably guilty of ignoring certain important yet debilitating aspects of the condition, not least the poverty of facial expression which can occur. However I think for many patients, this appearance should improve considerably with appropriate medical treatment. Patients' spouses or partners will often notice that the PD medication is "kicking in", even before the patient themselves do, simply by observing the return of animation and emotion to the face of their partner. Therefore I would be concerned that the questioner might be somewhat undertreated, and would hope that with careful medication adjustment, the "zombie" look would vanish. In addition to medical treatments, patients have found it beneficial to practice contorting their face in the mirror. Although this may sound strange, it should be viewed as physiotherapy for the face. It serves to strengthen facial muscles, and reduce facial muscle tension and stiffness. Remember Michael J Fox managed to continue his Hollywood acting career for over a decade after his PD was diagnosed, and as an actor, his job depended on him being able to use multiple facial expressions. Occupational therapists and speech thrapists will also help with training to exaggerate facial expression in order to overcome facial impassivity.Regular facial massage is also excellent, either by a trained physiotherapist or even beautician. This is an opportunity to treat yourself for medicinal purposes! I strongly feel that a combination of the above treatments will at least improve your confidence and appearance.TC It is important for this lady to realise that hypomimia (or a mask like face) is part of Parkinson's disease, acceptance may be an issue. Many people have issues with altered body image and being more self-conscious of their body when it changes slightly. This is very apparent with many different types of conditions and surgeries, PD is no different in that regard. However, on the other hand by being more aware of this should in fact help a person who is striving to return to their pre-PD look. This is because they will be more enthusiastic towards exercises which will help facial tone etc. It may however be treatable. Often times when a person is undertreated their lack of facial expression is exaggerated, therfore it would be important to determine if the person is undertreated or not.PB Please do not despair - I think you should discuss your situation with your neurologist as soon as possible; it may be pssible to adjust your anti-parkinsonian medication; if you feel depressed, lacking in motivation, with reduced appetite or reduced interest in life, with persistent feelings of despair and hopelessness, you may be suffering from depression which is very treatable; your neurologist or your GP will help you to obtain treatment for depression if it is indicated; please do not give up hope; seek support from the Parkinson's Association. Richard Cahill

Question 12 My mother was diagnosed with "mild" Parkinson's today. She has symptoms for 3 yrs (tremor, stiff, weak left shoulder). She has been prescribed Sinemet 110 4 times a day. Is this too strong a medication as an initial treatment for Parkinson's?

Answer 12 The dose of Sinemet 110 is not as much as many people think, as this includes levodopa 100 mg and carbidopa 10mg. It is not uncommon to start treatment on L-dopa when a person is older as it will improve their quality of life quickly, and increase their safety by reducing the risk of falls. PB

Question 13 All medicines have failed for me. I am to be fitted with an APO pump next week.I was offered DBS but I fear it.I am in contact with X Cell Centre in Germany,they claim good success with stem cells. Is there any proof of this or what else can I do.THANK YOU

Answer 13 I would strongly advise caution here. I would not rush into the stem cell treatment in Germany. I have looked at the website before and found it amazingly uninformative. I have no evidence to suggest that it is safe. There is none of the necessary detail given as to how the stem cells are harvested and processed before reinjection. At least we know that apomorphine and DBS are tried and tested methods. PB This person should proceed with caution. TC

Question 14 How does a kidney infection affect a Parkinsons patient. Father has lost use of limbs due to kidney infection, slow to respond to medication (7days)

Answer 14 A number of possibilities come to mind: 1. The infection has contributed to a transient worsening of PD. It would not be uncommon for patients to have sudden, transient deterioration in the setting of infection. Toxins produced by the offending bug can disrupt a variety of neurologic functions, which can be slow to recover, even when the infection has been adequately treated. a delay in recovery may be due to a resistant bug. Antibiotics may interfere with the normal absorption of medication. 2. The infection is a red herring and not the cause of the deterioration. 3. The loss of use of his limbs is not due to worsening but has some other cause. Numbers 2 and 3 are less likely, but your patient's doctor needs to keep all possibilities in mind, especialy if the expected recovery is not happening. Number 1 I think is most likely. Again I would emphasise an EARLY return to the doctor if improvement is not reasonably prompt. TC

Question 15 My wife was hospitalised with very bad Cellulites in one leg below Knee and all the way to her toes with open flesh to front and rear of leg on Christmas Eve 2008 and was released home on 16 Jan 2009. She was also diagnosed having a Hiatus Hernia and a Duodenal Ulcer and having further tests soon for these same items. I suffer sometimes quite severely from carpal Tunnel in both hands and my wife had lost the use of the ability to walk prior to entering into hospital and she could only shuffle very slowly with her hands on my shoulders as she barely moved forward and I moved backwards and often I had to take the full weight of her body and found it very difficult to do so as I took her to the toilet and back to her bedroom again The room she sleeps in is in very close proximity to the toilet but both rooms are very small and the bedroom with a single bed and chair and two small wardrobes is quite full and again the toilet is quite very small indeed and I have used a variety of bath chairs to not much avail. A swivel chair for bath times and one at a lower point in the bath. I wrote and explained to the Surgeon a detailed and concise letter with pictures and measurements for these rooms and requested for all the help and assistance possible. When the Occupational Therapist that is eventually sent to access all of these situations, what should he be assessing and what should he be recommending be undertaken on both of our behalfs. Should there be an assessment of my wife trying to have a bath and use the facilities in real time along with everything else in our home she might feel capable of doing and my abilities to help and assist her. Should the Occupational Therapist have good knowledge of her symptoms and Clinical diseases and medication?

Answer 15 Your Occupational Therapist should be able to help find solutions. If you feel there is an undue delay in seeing an Occupational Therapist, ask your GP to see if anything can be done to speed things up.

Question 16 My father has been slowing down over the last few years - he is 74, and if I'm honest the doctor has never really said he has Parkinson's. He was sent to the hospial and there were tests done - they may have said it was a very mild stage of Parkinson's, but i bought a book a few months ago and it was only then i realised that the symptoms in the book were a mirror image of what he was doing like finding it hard to get out of a chair, tying or opening his shoe laces, dribbling from the mouth especially when asleep, stopping when he went under door openings, slow swallow, shuffling, balance, turning around i also noticed lately when he was sleeping he was scratching himself so we had to cut his finger nails short. He was getting up a lot in the night, he would say to me he felt useless, he has of yet no physical signs of shaking in his hands so i dont really know how much it may have progressed. I did speak to my GP but i really only got well he is getting old and he is very healthy - this was when i asked him about tablets for him. I got the impression he wanted him to get worse before he wanted to do anything. I am new at this so any advice u might have I would recommend.

Answer 16 The first thing to determine is whether your father has Parkinson’s or not. Not everyone who is “slowing up” or who has difficulty arising from a chair has Parkinson’s, although the symptoms you describe are suggestive of Parkinson’s. It is essential that an accurate diagnosis is made as soon as possible. If he has not been assessed by a neurologist/geriatrician, I think this should be the first step. Many disorders that cause older people to “slow up” (such as Parkinsons, arthritis, depression, polymyalgia and others) are treatable, and might improve his quality of life immeasurably. Sometimes, making a definite diagnosis of Parkinson’s is not that easy, especially if there is no shaking. In these cases, some doctors will suggest a trial of medication to see if it improves things. There is no longer any justification to withhold treatment because he is not “bad enough”. If he has Parkinson’s, early treatment will improve his quality of life and perhaps, slow the rate of progression of his condition. TC

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