Parkinson’s disease is a neuro-degenerative disorder with progressive loss of dopaminergic neurons in the substantia nigra, the region of the brain that deals with movement, muscle control and balance.
The classic motor symptoms include:
- Postural instability
Often patients with Parkinson’s disease are being monitored by their neurologists, perhaps 3-4 times a year. They may adjust their medications, perform some neurological exams to assess and determine the stage of progression as well as any motor complications such as freezing, wearing off, dyskinesia. But patients with Parkinson’s disease need more attention from their primary care providers. It is often assumed they are being followed by the neurologists and thus we have little to offer. But that’s not an accurate assumption.
In hope to increase awareness of the challenges faced by patients with Parkinson’s disease, here are few points that I wish to share:
1. Timing of medication is very important. Most Parkinson’s patients are prescribed either Sinemet (Levodopa/carbidopa) or Prolopa (Levodopa/beserazide) to help manage their day-to-day symptoms. It is often ordered to be given every few hours and sometimes at ungodly hours at 5- 6am. Respect the timing of the medication please. If a dose of Sinemet is scheduled at 6am, please make an effort to give the dose to the patient. If the patient “appears to be sleeping”, he or she may be frozen from the Parkinson’s disease and really need that morning dose to relieve the symptoms.
2. Don’t give Gravol (Dimenhydrinate) for Nausea. Sinemet and Prolopa can be very nauseous to take, especially for a new Parkinson’s patient. Please don’t turn to Gravol for help. I hate Gravol – it’s a heavy anti-cholinergic that can worsen cognition, increase risk of falls, contribute to constipation. I wish we can ban this drug altogether. Instead if nausea is unbearable even with non-drug measures, consider domperidone as it is a dopamine antagonist and can off set some of the side effects of these medications.
3. Treat the constipation. Patients with Parkinson’s disease will have challenging constipation, due to the disease and the medications that they have to take. Proactively manage it. Severe constipation can eventually affect absorption of medications, which means it can worsen Parkinson’s symptoms when medications are not well absorbed. Many effective treatment options include Senokot, Lactulose and PEG 3360. Avoid docusate sodium as it is not effective in chronic constipation.
4. Keep an eye for low blood pressure. Hypotension is common in Parkinson’s disease. It may be necessary to discontinuing any existing anti-hypertensives or medications that can lower blood pressure. Often, encouraging fluids and salt intake is needed to counteract the hypotension and to minimize the risk of fall. If necessary, midodrine and fludrocortisone may help to treat or manage the hypotension.
5. Parkinson’s patients will fall but let’s hope to minimize injuries. Patients with Parkinson’s disease will fall. Interventions should be implemented to minimize falls and to protect the residents from injuries. Encouraging Vitamin D intake as well as assessing if resident may qualify for devices such as a hip protector may be beneficial. If the resident has a diagnosis of osteoporosis or previous history of fractures, consider if the patient requires treatment of osteoporosis.
6. Monitor for mood lability or hallucination. Patients with Parkinson’s disease may develop mood symptoms or hallucination especially if taking high doses of Sinemet or Prolopa. Watch for odd behaviours. They may not be quick to offer to share their experiences such as “seeing a cat” or “hearing voices”. Be sensitive and screen for mood symptoms and hallucination. If need to manage the hallucination, keep in mind many anti-psychotics may worsen Parkinson’s symptoms. Agents that may be safer include quetiapine and clozapine.
7. Dementia is inevitable. In my opinion, many patients with Parkinson’s disease eventually develop dementia – some with quicker onset, others develop at much later stage in life. If there is doubt with cognitive impairment, consider screening with tools such as MMSE, MoCA. Of the three available cholinesterase inhibitors (donepezil, galantamine, rivastigmine), rivastigmine has been studied in Parkinson’s dementia but all three can be used if indicated.
8. Daytime drowsiness. Patients with Parkinson’s disease may also experience daytime drowsiness. It is important to review other medications that can cause sedation and adjust accordingly. If daytime drowsiness is affecting the quality of life, there is some experience in using modafinal to treat this condition.
Finally, medication is only part of the solution in Parkinson’s disease. Working with other healthcare professionals such as physiotherapist as well as the patient directly will help understand the challenging symptoms and to identify strategies to help improve the quality of life. Patients with Parkinson’s disease have so many challenges that they face daily and these challenges continue to evolve as the disease progresses. We all need to be more engaged to help them as best as we can.