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Excess Saliva, Hypotension and Dry Eyes

Excess Saliva Glycopyrrolate Hypotension Dry eyes

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#1 daddysgirl

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Posted 12 August 2013 - 10:44 PM

Question for online doctor:

Hi, my dad is 89 yrs. old, and he has advanced Parkinson's with dementia, but he is lucid most of the time. Recently, he has been salivating and drooling excessively. I have tried a variety of non-medical treatments (ex. ice, sugarless candy, tea w/ lemon), but it has gotten so bad now that we had to buy a suction machine. Unfortunately, we live on a small island with only one ENT who has never used Botox for drooling, so this is not an option for my dad. His neurologist prescribed glycopyrrolate, but I am afraid of using it, because he is prone to hallucinations already, which we have been treating with a 1/2 dose of clonazepam at night. He also takes 25/100 Sinemet 3x a day and Aricept (10 mg.) once a day. Do you have any suggestions of what we can do to help alleviate his swallowing problem? I heard that pineapple juice and ginger tea may help with the excess saliva, have you ever heard of this? We also just started using a tablespoon of coconut oil in his cereal to see if that will help with any of his symptoms.

My other two major concerns now are his blood pressure and his vision. He has been experiencing sharp drops in his pressure upon rising from a lying position and after meals. We are giving him Pedialyte for this on an as needed basis. One of his doctors suggested giving him the Pedialyte every day, but since my dad has a history of hypertension (which is controlled by the Sinemet), I am reluctant to do that. I will definitely double check this with his neurologist. I also noticed that he has been keeping his eyes closed a lot. I thought he was doing this because he has dry eyes, but now I’m thinking this is an involuntary action due to apraxia. (He has the masked face appearance.) We give him Systane eye drops every two hours daily and Trobodex when his eyes look inflamed (he's only used it once for a 10 day period at bedtime). I would appreciate any advice you can give me. Oh, he had surgery on July 10 for a hernia, aside from a hematoma, his recovery is going well. (His pressure was dropping prior to his surgery.)

#2 Dr. Okun

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Posted 13 August 2013 - 02:31 PM

Thanks for the question.

Parkinson's disease orthostasis can be addressed by hydration, stockings on the legs, diet, and in some cases adding midodrine or florinef. We generally do not treat unless symptomatic (dizzy when he stands up may be a symptom).

If he cannot take botox for drooling ask your doc about atropine drops under the tongue.

Hope that helps.
Michael S. Okun, M.D.
Author of the Amazon Bestseller Parkinson's Treatment: 10 Secrets to a Happier Life
National Medical Director | NPF
UF Center for Movement Disorders & Neurorestoration
Read More about Dr. Okun at: http://movementdisor...hael-s-okun-md/
or Visit Parkinson's Disease treatment and research blogs at:
NPF's What's Hot in Parkinson's disease
or his parkinsonsecrets.com blog for treatment tips

#3 daddysgirl

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Posted 15 August 2013 - 03:53 PM

My dad saw his neurologist yesterday, but I didn't ask him about atropine drops, because it is my understanding that this medication also causes confusion in the elderly. I did, however, ask his eye doctor about the atropine drops several months ago, but he did not think it would help. His neurologist prescribed Marinol. I haven't had a chance to do any research on this medication yet, but can you tell me what your thoughts are on this drug? Also, what do you think about the use of THC and CBC, medical marijuana, for treating Parkinson's symptoms, and is Marinol the same thing as THC? As always, your advice is appreciated.

#4 Dr. Okun

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Posted 16 August 2013 - 07:06 AM

Atropine drops in the mouth for drooling has been effective in our clinic and others in the NPF network. Something to consider.

So far the use of medical marijuana or Marinol in PD has not been shown effective in published careful studies, however there are many patients who say they benefit from its use.
Michael S. Okun, M.D.
Author of the Amazon Bestseller Parkinson's Treatment: 10 Secrets to a Happier Life
National Medical Director | NPF
UF Center for Movement Disorders & Neurorestoration
Read More about Dr. Okun at: http://movementdisor...hael-s-okun-md/
or Visit Parkinson's Disease treatment and research blogs at:
NPF's What's Hot in Parkinson's disease
or his parkinsonsecrets.com blog for treatment tips

#5 daddysgirl

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Posted 07 September 2013 - 04:24 AM

Hi, I took my 89-year-old father to his neurologist yesterday to discuss the frequent fluctuations in his pressure. He suggested that we take him off of his Sinemet for 24 hrs. and if his pressure does not drop, then he wants to put him on Mirapex instead. His pressure has been dropping almost every day, and we have been giving him Pedialyte to try to keep it up. (Gatorade has too much sugar.) We have also tried to keep him hydrated and put on compression socks, but only for about an hour and half during his mid-day nap. We were told that keeping the socks on overnight would not be good because of his age. Despite all of these measures, his pressure and pulse keep dropping. Currently, he is on Sinemet 25/100, 3X a day; Aricept 10mg. 1X a day; and 1/2 dose of Clonazepam. I am concerned about the side effects of Mirapex, because he is already prone to hallucinations (that's why he is on the clonazepam), and he is very drowsy during the day. Do you think giving him a lower dose of the Sinemet would be better? I would appreciate any suggestions you may have. The doctor now suspects that he may have Shy-Drager syndrome. Also, I talked to the doctor about my concerns about the glycopyrrolate, and he said we should try it first on an as needed basis, and if that doesn't work then try the atropine drops. We just started thickening his liquids with Thick-It, but I read a recent NIH study that said that thickening solutions may interfere with the absorbency of certain medications. Can you tell me if it will interfere with any of his medication? Here is a link to the study: http://www.ncbi.nlm....les/PMC3660277/ Thank you.

#6 Dr. Okun

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Posted 07 September 2013 - 06:44 AM

It depends on how you thicken the foods whether it will affect medication absorption or not...

Since he is on a low dose of sinemet and there is a suspicion of MSA (Shy-Drager) you should be very careful with Mirapex or other dopamine agonists which could make this situation worse. We tend to halve the sinemet tablets, hydrate, use compression stockings and then add midodrine or florinef. One important issue is whether the sinemet is helping him; if the answer is yes, then you should try to use dose reduction strategies, and adding medications before stopping it. Also remember if you ever decide to stop sinemet always wean it off very slowly as it can lead to a very bad syndrome called neuroleptic malignant syndrome.
Michael S. Okun, M.D.
Author of the Amazon Bestseller Parkinson's Treatment: 10 Secrets to a Happier Life
National Medical Director | NPF
UF Center for Movement Disorders & Neurorestoration
Read More about Dr. Okun at: http://movementdisor...hael-s-okun-md/
or Visit Parkinson's Disease treatment and research blogs at:
NPF's What's Hot in Parkinson's disease
or his parkinsonsecrets.com blog for treatment tips

#7 daddysgirl

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Posted 08 September 2013 - 12:06 AM

Hi, thank you so much for your prompt response to my inquiry. I am really concerned about the condition you mentioned, neuroleptic malignant syndrome. Per my dad's doctor's orders, we stopped giving him the Sinemet for 24 hrs, beginning at 5pm. on Friday, Sept. 6. (He usually take it 3X a day at 7a.m., 12noon and 5p.m.) His doctor wanted to see if the Sinemet was the source of the drastic drops in his pressure and pulse. So far, he has been fine. For most of the day Saturday, Sept. 7, he was mobile, alert, lucid, and he didn't shake. He still drooled a lot thought. Even though his pressure fluctuated, the lowest it dropped was 109/60. It was mostly in the 130s to 140s range. For the past couple of months, his pressure has been dropping below 90/60 and the top number has dropped as low as 76, and his pulse has dropped as low as 45. However, around 7:30 p.m. on Saturday his hands started shaking and his pulse went up to 101, but it came back down. When I informed his doctor on Saturday afternoon how good he was doing, he told me to keep him off of the Sinemet for another day, but now after reading your response I am really nervous. His doctor did say he may have to put him on midodrine and/or Mirapex if the Sinemet is the source of the problem, but after reading about the Mirapex I don't think that is a good idea either. I don't know what to do? I don't want to take any chances. How do I wean him off the Sinemet? Will two days off the Sinemet cause the condition you mentioned? He is currently on 25/100 Sinemet, should I ask his doctor about 10/100 Sinemet? His doctor is pretty good about working with me so that's a good thing. (He doesn't take offense.) Help please.

#8 Dr. Okun

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Posted 08 September 2013 - 09:02 AM

Its a pretty low dose of sinemet so you will likely be ok and get away with it; but in a perfect world you would cut to 1/2 tab three times a day for several days, and then maybe a 1/2 tab twice a day for a few days...then once a day and then off.
Michael S. Okun, M.D.
Author of the Amazon Bestseller Parkinson's Treatment: 10 Secrets to a Happier Life
National Medical Director | NPF
UF Center for Movement Disorders & Neurorestoration
Read More about Dr. Okun at: http://movementdisor...hael-s-okun-md/
or Visit Parkinson's Disease treatment and research blogs at:
NPF's What's Hot in Parkinson's disease
or his parkinsonsecrets.com blog for treatment tips

#9 daddysgirl

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Posted 08 September 2013 - 06:32 PM

Hi, I talked to my dad's doctor today and expressed my concern about the condition you mentioned. He said it is very rare, but I told him I didn't want to take any chances, so we agreed to wean him off even though he didn't have the Sinemet for 48 hrs. and he was doing good. I like your suggestion, so I will do the half pills starting tomorrow. I will give half of a pill 3x a day for one week, then half of a pill 2X a day for a week, and a 1/2 dose of one pill for one week. That will give him three weeks to wean off the Sinemet. I put him back on the Sinemet at 12pm. today (he usually takes it at 7a.m, 12pm and 5p.m.), but I decided not to give him the 5p.m. pill, because his pressure dropped below 90. His doctor also suggested that he starts taking midodrine, so we will do that too. However, I still do not know what to do when he gets off the Sinemet. His doctor still wants to put him on Mirapex too, but I told him I am really uncomfortable giving him that pill especially since he is prone to hallucinations. He said the side effects are not much different than the Sinemet, but I am very reluctant. Do you have any suggestions? Am I being overly cautious? As usual, your advice is GREATLY appreciated.

#10 Dr. Okun

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Posted 11 September 2013 - 01:24 PM

I personally do not use sinemet in cases where MSA is suspected and the blood pressure is already very low. I symptomatically treat only with what is tolerated. I would focus on the blood pressure, depression or other symptoms. Hope that is helpful.
Michael S. Okun, M.D.
Author of the Amazon Bestseller Parkinson's Treatment: 10 Secrets to a Happier Life
National Medical Director | NPF
UF Center for Movement Disorders & Neurorestoration
Read More about Dr. Okun at: http://movementdisor...hael-s-okun-md/
or Visit Parkinson's Disease treatment and research blogs at:
NPF's What's Hot in Parkinson's disease
or his parkinsonsecrets.com blog for treatment tips

#11 daddysgirl

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Posted 12 September 2013 - 03:17 AM

My dad's pressure actually has been ranging in 140-160 range today. We are currently in the ER, and they are keeping him overnight for observation because his pulse has been fluctuating. Yesterday his pulse was in the low 40, but tonight it shoot up to 184. When I called his doctor, he told me to bring him to the ER even though his pressure went back down. We have not given him the midodrine yet, because we were waiting until he was completely weaned off the Sinemet. So, I know that's not the problem.

#12 daddysgirl

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Posted 13 October 2013 - 12:12 AM

Hi, I just wanted to give you an update on my 89-year-old father's condition.  As I told you before, due to frequent drops in his pressure his doctor decided to wean him off the Sinemet, which he began using in 2005. His doctor also suspects that he may have Shy-Drager syndrome.  He has been completely off the Sinemet now for two weeks.  I have also been giving him coconut oil three times a day. So far, he has been more alert, lucid and his head has not been drooping as much. His pressure has also stabilized.  It still drops, but only occasionally after a meal.  I am actually worried about his pressure being too high, because prior to taking the Sinemet, he had hypertension. His pulse has also been a lot better, but it has gone up really high a few times.  However, the shaking in his hands is more pronounced, but not much.  Other than the fact that he is still drooling profusely, my main concern right now is that he is having more difficulty walking, so I don't know what to do. His doctor and I agreed that we would monitor him to see how he functions before putting him on Mirapex, but I am still very concerned about the Mirapex, especially since he has been having frequent spikes in his pulse. Per his doctors advice, I am taking him to see a lung specialist this week, and I am hoping he can help me figure out how to proceed. Do you have any additional advice for me?



#13 Dr. Okun

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Posted 13 October 2013 - 06:45 AM

Usually the Mirapex has more side effects than the sinemet in these cases.  Some of my patients have pursued mucuna pruriens which is an over the counter and often weaker formulation (natural formulation) of dopamine.  


Michael S. Okun, M.D.
Author of the Amazon Bestseller Parkinson's Treatment: 10 Secrets to a Happier Life
National Medical Director | NPF
UF Center for Movement Disorders & Neurorestoration
Read More about Dr. Okun at: http://movementdisor...hael-s-okun-md/
or Visit Parkinson's Disease treatment and research blogs at:
NPF's What's Hot in Parkinson's disease
or his parkinsonsecrets.com blog for treatment tips

#14 aab

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Posted 22 October 2013 - 01:19 PM

Dear Dr. Okun,
 

What is the recommended daily dosage of Atropine drops for the treatment of excessive drooling for Parkinson's Disease patients.

 

Thank you 



#15 Dr. Okun

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Posted 25 October 2013 - 08:15 AM

Generally you should speak to your doc as there is danger in atropine.  We generally start with a single drop and titrate very slowly against symptoms.


Michael S. Okun, M.D.
Author of the Amazon Bestseller Parkinson's Treatment: 10 Secrets to a Happier Life
National Medical Director | NPF
UF Center for Movement Disorders & Neurorestoration
Read More about Dr. Okun at: http://movementdisor...hael-s-okun-md/
or Visit Parkinson's Disease treatment and research blogs at:
NPF's What's Hot in Parkinson's disease
or his parkinsonsecrets.com blog for treatment tips

#16 daddysgirl

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Posted 25 October 2013 - 05:40 PM

Hi, I spoke to my dad's doc briefly about the mucuna pruriens you recommended, and he thinks we should try it.  I have an appt. with him on Monday, so we will discuss it in more detail then.  It is very difficult to find though. I ordered something called mucuna dopa, I hope that is not a synthetic form of this supplement.  Do you have a recommended dosage for this supplement, and can you tell me, since it contains levodopa, will protein affect the absorbency of this herb like it did with the Sinemet?  So far, my dad has been off the Sinemet for a month. He continues to function although he appears to have more difficulty walking, but he was not exactly walking well with the Sinemet, and his main problem continues to be excessive salivation, mucus in his throat and drooling which is affected his voice and ability to swallow allows he still eats (he's on a pureed diet).  I took him to a lung specialist who recommended that we give him atrovent with a nebulizer to help with the secretions in his throat (reminder: no one administers Botox here).  He said there will be side effects but not as much as with the atropine or glycopyrrolate (that's what his neurologist prescribed).  And, my poor dad, who is 89, only has about eight teeth left, all of which are infected.  We have been extracting them gradually to reduce trauma, but the lung specialist concurs with his dentist that we need to take all of them out, because he is swallowing bacteria which can lead to a form of pneumonia that is very difficult to treat.  (This is freaking my mom and siblings out.) Of course, I have concerns about extracting all one time too, especially given his swallowing issues, and although he does not have any side effects from the local anesthesia that was used in the past, we have never taken out so many teeth one time.  He also said that the infected teeth could be making his salivation worse. Do you have any thoughts about this? I will discuss all of this with his neurologist on Monday, but if you have anything to add I would appreciate it.  I really, really appreciate your insightful advice, as we do not have a movement disorder specialist here. His doc is pretty good with working with me, and I think he  appreciates the info I give him from you guys as well. Thanks again to you and your team for all that you do and for your thoughtful responses to my inquiries.



#17 Dr. Okun

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Posted 26 October 2013 - 07:05 AM

Botox is a great and safe treatment for the saliva and something to ask about.

 

Mucuna is not FDA regulated, so it varies greatly between manufacturers, so you may have to play with dose and different companies.  It is in my experience a little softer on the system, but i would still take it and wait 45 minutes before eating.


Michael S. Okun, M.D.
Author of the Amazon Bestseller Parkinson's Treatment: 10 Secrets to a Happier Life
National Medical Director | NPF
UF Center for Movement Disorders & Neurorestoration
Read More about Dr. Okun at: http://movementdisor...hael-s-okun-md/
or Visit Parkinson's Disease treatment and research blogs at:
NPF's What's Hot in Parkinson's disease
or his parkinsonsecrets.com blog for treatment tips

#18 daddysgirl

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Posted 29 October 2013 - 04:47 PM

Hi, I just wanted to update you on my 89-year-old father's condition.  I took him to his neurologist Monday.  Due to the fact that his blood pressure and pulse have stabilized since we took him off of the Sinemet, he says he doesn't think my dad has Shy-Drager after all, which is good news. However, he believes he may have Lewy Body Disease.  I don't know if this changes your position with regard to the Mirapex.  I ordered the Mucuna Pruriens you suggested after discussing it with his doctor of course, but I'm wondering how effective it will be without the carbidopa.  His doctor wanted to put him back on at least one Sinemet a day, but I declined, because it's clear to me that the Sinemet was not really helping him anymore. As I told you in my last post, he has been off the Sinemet now for a month (he started it in 2005), and his overall condition has actually improved except for the profuse salivation and drooling, thick phlegm in his throat (Botox is not available where I live), and he appears to have more difficulty walking.  Also, as I told you, he has only eight teeth remaining all of which are infected and the dentist wants to take everything out one time.  We have been extracting his teeth gradually over the past 2-3 years to reduce trauma, but now the dentist and the lung specialist concur that all of his teeth need to come out now.  They said it would be easier on his immune system. His neurologist said he is medically fit to undergo the procedure, but I'm concerned since he's anemic.  His WBC is good, but his RBC is a little low & his reticuloctyte absolute level is really low (we are doing more testing).  My chief concerns are excessive bleeding and the additional anesthesia he would have to have to extract so many teeth one time.  He usually does well with the local anesthesia, but we never extracted so many teeth one time.  Are there any special concerns that I should address with his dentist given his age and diagnosis? Do you have any literature that you can share with me that I can give to my family so they can understand the consequences of him keeping his teeth?  Per his doctors recommendation, I plan to start him on Atrovent via a nebulizer soon, because the thick phlegm in his throat is affecting his voice, mood, swallowing and it appears his breathing, because he told me that he has problems breathing at night.



#19 daddysgirl

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Posted 29 October 2013 - 05:13 PM

I forgot to mention that now I'm concerned about my dad's pressure getting too high, because prior to going on the Sinemet he was hypertensive.  His pressure still fluctuates often, but it is not dropping often like before, maybe once or twice a day after a meal, but not every day.  However, I have been keeping a chart, and I noticed that in the morning his pressure is elevated, so his doc wants to put him on some blood pressure medication at night. I am going to monitor him a little bit more before I do that though.  I have learned that sometimes it's better to wait and monitor him, because we were given Midodrine to control his low blood pressure, but I decided to hold off on giving it to him until we weaned him off the Sinemet and as it turns out, he didn't need it after all. By the way, do you have any idea how long the Sinemet will stay in his system? As I said, he began using it in 2005 and stopped completed on Sept. 29, 2013.



#20 daddysgirl

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Posted 29 October 2013 - 05:15 PM

The medication his doc recommended is Clonidine. (Please refer to my two previous posts.)






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