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Dr. Okun

Post of the Week: Neuropsychiatric Effects of Parkinson's Treatments

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Dr. Okun    409

Dear forum members,

 

It is important to always talk to your doctor about the benefits as well as the potential and important neuropsychiatric effects of PD treatments. Below is a recent review article on the topic.

 

Australas J Ageing. 2012 Sep;31(3):198-202. doi: 10.1111/j.1741-6612.2012.00632.x.

Neuropsychiatric effects of Parkinson's disease treatment.

Aarons S, Peisah C, Wijeratne C.

 

Source

Psychologist in private practice, Sydney, New South Wales, Australia.

 

Abstract

Advances in the treatment of Parkinson's disease have led to significant improvement in many of the disabling motor symptoms of the disease, but often at the cost of neuropsychiatric side-effects. These include psychosis, dopamine dysregulation syndrome, impulse control disorders, mood disorders and Parkinson's disease drug withdrawal syndromes. Such side-effects can be as disabling and have as much impact on activities of daily living, quality of life, relationships and caregiver burden as motor symptoms. Awareness of these potential side-effects is important both in terms of obtaining informed consent, and to aid early identification and intervention, as patients may not spontaneously report side-effects because of lack of insight, or deny them out of shame or embarrassment. The challenge of treatment can be a trade off between the emergence of such side-effects and the amelioration of parkinsonism, best mastered with an informed dialogue between clinician and patient.

© 2012 The Authors. Australasian Journal on Ageing © 2012 ACOTA.

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Dr. Okun    409

Can you be more specific? Also you can call our NPF helpline. Feel free to ask specific questions on this forum. Hope it gets better!

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Dr. Okun    409

I have actually written about this on my what's hot in PD blog on the main webpage.

 

In general I have not reacted to this in any way way with my patients. All of the agonists have the potential to cause the same group of side effects so we will need to watch them carefully.

 

Read the blog.....its pretty good.

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Edward10    0

Advances in the treatment of Parkinson's disease have led to significant improvement in many of the disabling motor symptoms of the disease, but often at the cost of neuropsychiatric side-effects. These include psychosis, dopamine dysregulation syndrome, impulse control disorders, mood disorders and Parkinson's disease drug withdrawal syndromes. Such side-effects can be as disabling and have as much impact on activities of daily living, quality of life, relationships and caregiver burden as motor symptoms. Awareness of these potential side-effects is important both in terms of obtaining informed consent, and to aid early identification and intervention, as patients may not spontaneously report side-effects because of lack of insight, or deny them out of shame or embarrassment. The challenge of treatment can be a trade off between the emergence of such side-effects and the amelioration of parkinsonism, best mastered with an informed dialogue between clinician and patient.

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jbranson    0

I am hoping to find information on this forum to help guide me in caring for my father, who is suffering from Parkinsons.

 

Over the past year my father has developed new onset behaviors that I believe are related to either parkinsons dementia or dopaminergic side effects. The symptoms include compulsive behavior and hypersexuality. To be more specific, he is making contact with strangers and arranging to meet with them. He meets them through online dating sites or through telephone services. Generally these people express a need for financial assistance.

 

It is of great concern to my family to keep him safe, however it has become extremely difficult to attempt to stop these behaviors without limiting his freedom. It is really tearing my family appart. We are afraid one day he will leave and not return.

 

The activity described above has been reported to his neurologist who stop prescribing Requip to him. This worked for a short time but he was simply unable to live with the tremors without having something. He currently takes the following meds:

 

Amantadine 100 mg Capsules 2 per day

Carbidopa-Levodopa 25-100 TAB 8 per day

Carbidopa/levo ER 25-100 TAB 8 per day (He takes two different Carbidopa Levo

Azilect 1 MG Tab 1 per day

Verapamil ER 240 MG TAB 1 per day

Carbamazepine 200 MG TAB 2 per day (This is the tegretol he took for Trigeminal Neuralgia, but still takes 2 per day.)

Valsartin-HCTZ 160-12.5 MG TAB 1 per day

Hydrocodon-Acetaminophen 5-500 only as needed. Doesn't take regularly

 

I feel that we can not continue the therapy as prescribed now and am hoping for any advice possible. He refuses to go through psychoanalysis. His neurologist now beleives he is suffering from Parkinsons dementia. The behaviors are becoming increasingly more dangerous. I need expert advice.

 

Dr. Okun, if you are reading my message I would like to mention that I also am involved in healthcare at Shands UF. Any help you can give me through the forum would be much appreciated. I would be more than happy to arrange to speak with you if you are ever available, however my father does not live here in town and he can not proceed with formal patient consultation at this time. Just looking for help.

 

Thank you.

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Dr. Okun    409

I think you are wise to closely examine this situation. The behavior could be the sign of a dopamine related side effect (punding, dopamine dysregulation, impulse control disorder), or could be something related to a dementing syndrome (though it is far more likely to be the former).

 

We would recommend him seeing a PD specialist and possibly coming off the amantadine. Then we would likely assess if he needs all of the sinemet or if it is driving the behavior. We may consider cutting it down or adding clozaril or depakote to control the behavior. Interesting that he is on carbamazepine; it may help to have the neurologist try higher dosages instead of the depakote.

 

There are a lot of directions to potentially take, but I definitely agree he should be treated and this is likely to get better if treated.

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I researched fifteen years of my psychiatric care and med regimen to see if my problem was possibly secondary from meningitis or some infection that could have occurred after I had an adverse reaction to Luvox that started as a blurring of vision and culminated three years into an immune system compromise (angular chelitis) or something similar because as soon as the Luvox was withdrawn, both conditions improved completely.  Also my white blood count a year after was normal, but during the three years of adverse reactions my Lithium level went to a level considered toxic that my doctor never alerted me about.  But I was having REM Sleep Disorder four years prior to the Luvox withdrawal and I know that is no litmus test to PD, but I am beginning to think the unmasking of subclinical levels makes more sense even though my genetic predisposition is slight, but the evidence of some type of aggressive Parkinsonism is impossible to ignore unless it is some peudo variety very exotic or overlooked.  I have requested a PET and denied, then a SPECT, but I doubt that too. The sinemet is sort of seeming like maybe it does something, but not much.  My short term memory is incredibly bad and the strength in my legs is about half what it was a year ago when I was diagnosed parkinsonism.  My extrapyramidal symptoms come for visits and leave without saying goodbye.  And I became subject to life threatening Migraine without auras last year which have turned into Migraines with auras this year.  During the period I was having the adverse reactions to Luvox, I was having auras that were unbelievably strange, but my opthamolagist tells me that is what it was and that despite the visual symptoms of macular degeneration  I started having earlier this year that makes five years since the Luvox reaction of blurry vision happened.  Some other auras that are very strange, but not hallucinations, drop in but no talking animals or anything like that.  Its a big mess of ANS dysfunction going along with it that has improved since last year.  I have been off neuroleptics for a year without improvements, only reoccurring symptoms.  I took Clonazepam for nine months and still have occasional REM Sleep Disorder.  None of this stuff is supposed to be possible, I guess.  I don't know. Vertigo, Parasthesia, Dysphagia, painful muscle spasms, symmetric cogwheels, the list goes on and on.  Any ideas of a book or an article or anything that might be recommended to think about.  Believe me, I have good days.  Productive days.  I write comic satire and publish stuff places.  I do not have to use my real name like some people do, but that is the beauty of creating something with language instead of living cells.  I recommend everyone read "Proof of Heaven."  There is one and that is an article of faith.  Faith has articles.  Read them.

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I did as you said and got the same person I talked to for the last three times.  The first time a year ago she recommended a neurologist at Vanderbilt called Heddera.  I researched his credentials and found them solid.  I tried to get my family doctor to get a referral and he said it would be eight months wait.  My family doctor also was too busy involved in a malpractice civil suit that was settled out of court so was too busy to bother with my referral which I had to take the initiative on my own to procure.  I had just suffered from a life-threatening migraine that had me in the emergency room and this family doctor let that pass without ordering an MRI and was too busy to advocate my cause or even notice that my neurologist at the time not only misdiagnosed me terribly, but gave me the wrong medication he had promised me (he ordered me a duplicate of the same medication he had written for me two days before, added together six refills at a dose less than even approaching the appropriate level) and never returned my numerous phone calls to his answering machine, but my family doctor took things seriously later when he had time to develop a backbone, putting that behind him and I mean at a very large personal cost because he was not what he seemed to the small town I then resided in.  I put my trust in him knowing that he was responsible for another patient's death and the suit was settled because the family of the deceased was poor. I am on good terms with the lawyer who was in on the negotiating in case you have that much curiosity I could have him fax the terms to you with the names marked out.  I can even send you the medication log from the pharmacy that proves how incompetent my neurologist was and how useless my family doctor was ignoring the issue.  Probably you do not want that kind of information either though, would be my best guess. It doesn't matter, I was homeless anyway and took months to secure public housing and find new doctors.  My life in crisis on a rollercoaster as doctors danced around their lack of time and ethical failings.  I put miles in a car given to me as an act of charity with migraines as my motivating factor and extrapyramidal symptoms as their backup.

 

The second time the lady whose number you gave me above was not so nice and in so many words, and I mean near enough to verbatim as verbatim gets, and said I was wasting the foundation's time, but she seemingly does not have much of a background in neurological pathologies other than Parkinson's Disease, or know the relevance when I say the lines of demarcation are blurry sometimes and the ranges of how an illness manifests itself are subjective and arbitrary.  Like when an autopsy sometimes informs our surety the whole thing was misinterpreted.   And I was homeless calling from the house that was letting me use it the time she was not being so nice and I was afraid to embarrass her with what trials we all have and is an NPO really worth the trouble of having in the first place. Seeing a doctor four hours drive away and a serious illness driving into a city.  Medicare did not drive me four hours away or tell me to wait eight months.  I had to deal with Vanderbilt Hospital on my own, the very place my sister died at the age of eight. 

 

But  I called a third time when I was occupying public property and spoke with her about creating my own NPO, because I have worked for three of them and thought it would be nice of you to perchance spare a resource as a token gesture of the influence yours has, compared to the benefit of any potential mine could demonstrate later. Quid pro quo in the annals of the layman's Latin.  I love to sound smart and pretentious and be one of the gang. That time I was told by her that the NPF does not do that sort of thing for publishers or writers and that my idea was noble to allow PD patients to get professional services if they are fit to write or have written in a condition that once allowed them.  And that I envisioned many escrow accounts to compensate that tiny allowance a disability check cannot make a world living in practical without --  the little starving artists like myself who I occasionally see in the chatter of cyberspace looking for a way to contend in the unfair advantages that other writers compete with them and always will as long as we let that happen.  So I accepted the words she spoke as truth when she challenged my conceit, but later found as I perused the shelves of another NPO's charity service outlet (Habitat For Humanity), a book that was reprinted by the NPO years ago that proved her words meant little and the book in my hand was worth two in an imagined world that dreams are worth having or sharing.

 

This last time I spoke with her, she was more professional and worked on a strategy that my neurologist ignored. She really impressed me. I am ready for Heddera, but not if it is going to be the failure that cost me so much time and effort when I nearly lost everything last year.  This pain is ridiculous and I am just about at my wits end with everything, except that my current neurologist is very tenacious and independent.  Sometimes that works for me, but sometimes it works against me.  And I want to know what is wrong with me.  Wouldn't you feel that way too, if you were in these clumsy shoes?  This condition is closing in on target to close all doors of hope that many seek, and few may find.  Consider the lilies of the field.   

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MusicMan    769

Advances in the treatment of Parkinson's disease have led to significant improvement in many of the disabling motor symptoms of the disease, but often at the cost of neuropsychiatric side-effects. These include psychosis, dopamine dysregulation syndrome, impulse control disorders, mood disorders and Parkinson's disease drug withdrawal syndromes. Such side-effects can be as disabling and have as much impact on activities of daily living, quality of life, relationships and caregiver burden as motor symptoms. Awareness of these potential side-effects is important both in terms of obtaining informed consent, and to aid early identification and intervention, as patients may not spontaneously report side-effects because of lack of insight, or deny them out of shame or embarrassment. The challenge of treatment can be a trade off between the emergence of such side-effects and the amelioration of parkinsonism, best mastered with an informed dialogue between clinician and patient.

This would lead a person to believe that it would be a wise choice to hold off taking meds as long as practical in order to stave off these "side effects"?

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Dr. Okun    409

We actually would disagree.  It is best to take medications to treat symptoms and improve quality of life and have them adjusted if any of these side effects emerge.  They are usually quite manageable.  Avoiding meds altogether can turn into a disaster scenario.  Our nurses are available at 18004PDINFO if you need em.

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Hi sir I contact you from Afghanistan cause of my father he has Parkinson's disease from 15 or more then 15 years doctors says that he is in 4th level he use sinemet tablets from 15 years his Parkinson have treatment by operation thanks

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Dr. Okun    409

There are many places in the United States and around the world that offer deep brain stimulation if this is the operation you are referring to.  Our NPF helpline 18004PDINFO may be able to help.

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Yokam    0

My mom is taking reuip and cardadopa levadopa and serequel, in very low doses because she's in a wheel chair .She is having trouble with auditory and visual hallucinations,she heard the tv saying things about the family and she sees people cats and rats a lot. She has depression,irratablity,and extreme paranoia. she thinks food is poison and that her pills are kiling her,that we are going to loose our house or that someone robbed us.It is very hard to get her to take her meds and most of the time she lets them dissolve in her mouth instead of swallowing them. I'm not sure what's going on but about a m9nth ago she started taking celexa for her deppression and she really lost touch with reality so we slowly got her off of it but I don't know if it triggered something but she seems like she's in a psychosis . we are going to take her to a psychiatrist but i was wondering how cbd and medical marijuana helps with or...I really think the pills are causing this she used to be on 4 times the pills when she was walking but it was impossible to hav3 a relationship with her. What do you think doctor?

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Dr. Okun    409

We usually do not keep our patients on requip (we use just sinemet plus either clozapine or seroquel).  The medications could indeed be contributing.

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