Movement Disorder Program
Kane Hall Barry Neurology
Bedford/Keller
Halim Fadil, MD: Movement Disorder
Neurologist
Susan Imke, FNP: Gerontological Nurse
Practitioner
In partenership with:
Abdolreza Siadati, MD,DBS Neurosurgeon
Fort Worth Brain and Spine Institute
• Neurology Residency: LSU Shreveport, LA
• Neurophysiology Fellowship: UC Davis
• Movement Disorders Fellowship: Cedars-Sinai
Medical Center, Los Angeles, CA
With Dr. Michele Tagliati
An Essay on The Shaking Palsy
“Involuntary tremulous
motion, with lessened
muscular power, in parts not
in action and even when
supported; With a
propensity to bend the trunk
forwards, and to pass from
a walking to a running pace:
the senses and intellects
being uninjured.”
James Parkinson, 1817.
Clinical Features of PD
Four cardinal signs
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Bradykinesia (Slowness)
Muscle rigidity (Stiffness)
Resting tremor
Postural instability
Characteristic traits
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Asymmetric onset
Masked face
Micrographia
Low volume speech
Flexed posture
Shuffling and festinating gait
Response to levodopa
Non-Motor Symptoms of PD
Psychiatric
• Dementia
• Hallucinations
• Delirium
• Mood Disturbance
• Depression
• Agitation
• Anxiety and Panic Attacks
Autonomic
Sleep Disorders
• Insomnia
• Sleep Fragmentation
• Parasomnias
• Restless Legs Syndrome
• PLMS
• Excessive daytime sleepiness
• Sleep attacks
Sensory
• Orthostatic Hypotension
• Loss of sense of smell
• Constipation
• Urinary problems
• Sexual problems
• Sweating and Thermoregulation
• Pain
• Paresthesias
• Altered sensation
• Restless legs
Constipation
What is this?
• Less than 3 bowel movements a week or excessive straining to pass stool
How frequent?
• 3 in 4 PD patients suffer from constipation
What can you do about it?
• Drink enough water
• Add fibers to your meals: whole wheat products, lentils and beans, prunes,
apricots
• Moderate exercise can help
• Bulking agents: Metamucil, Stool softeners (Docusate), Laxatives (Senokot)
Uncontrolled loss of stool
What is this?
• Refers to inability to control bowel movements with “accidents”
or leakages
How frequent?
• Less than 10% of patients
What can you do about it?
• Plan bathroom trips before times when you often have
accidents
• Meds used to treat PD symptoms may help
Nausea/Vomiting
What is this?
• Sense of unease in the stomach
Why does this happen?
• The most common cause of nausea is starting a new Parkinson’s drug
What can you do about it?
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If with drugs, symptoms usually go away by themselves
Taking medications with meals may help
Taking extra carbidopa (Lodosyn) with carbidopa/levodopa may help.
Anti-nausea meds such as Tigan may help
If nausea is causing you not to eat, you must speak with your doctor
Bladder dysfunction
What is this?
• Hyperactive bladder causing you to rush to the bathroom and urinate
frequently or underactive bladder causing difficulty starting urination
How frequent?
• 1/3 of people with PD
What can you do about it?
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If hyperactive bladder, schedule bathroom trips at regular intervals
Sometimes meds for motor symptoms may help
Meds: Anticholinergics (Oxybutynin or Trospium chloride) may help
Desmopressin, a nasal spray, is recommended for nighttime urination
Changes in taste and smell
What is this?
• Changes in taste and smell are often unnoticed because they are
gradual
How frequent?
• Smell is altered in all patients with PD. 1/3 have no sense of smell. Can
occur years before motor symptoms
What can you do about it?
• No treatment
• It’s important to continue eating a full balanced diet, even if appetite may
be poor
• Ensure that smoke detectors are installed and are working properly
Unexplained pain
What is this?
• May feel like stiffness, cramps, spasms, or muscle pain, usually in legs.
Thought to be related to rigidity. Often occurs when meds are wearing
off
How frequent?
• 1/3 of patients may experience it
What can you do about it?
• Stretching muscles, massage, warm baths
• OTC pain meds
• Treatment dosage may be increased to reduce off-time
Unexplained changes in weight
What is this?
• Weight loss is more common than weight gain. Exact reason not known
Why does this happen?
• Can be related to nausea from meds, or be caused by dyskinesia
• Excessive eating and weight gain may happen after starting DA
What can you do about it?
• Make sure you are eating enough
• Try meals during “on times”
• If weight loss continues, consider using milkshakes or calorie
supplements (Ensure..)
• Correct any underlined problem
Cognitive impairment and dementia
What is this?
• Common symptoms of cognitive impairment in PD pts are problems with
attention and planning. Solving complex problems can be a challenge.
Memory can also be impaired but not as much
Why does this happen?
• Spread of pathology. Dementia is very rare in patients less than 65.
What can you do about it?
• Keeping yourself cognitively active might help prevent dementia
• Exercise, good diet, control of BP, cholesterol, and prompt treatment of
diabetes
• Medications are available to help: rivastigmine and donepezil.
• Meds used to treat other features of PD may worsen cognitive function
Hallucinations
What is this?
• Hearing or seeing things that are not there. Usually visual. Affect 1/3 of
patients
Why does this happen?
• Partly related to medications, partly to the disease itself
What can you do about it?
• Not all hallucinations need to be treated
• You might be afraid to talk about your hallucinations. It is important to
discuss them with your doctor
• He may consider reducing doses of some meds
• Meds such as Quetiapine or Clozapine may help
Depression
What is this?
• Not able to experience joy, may stop hobbies that once enjoyed, No
interest in learning new things, fatigue. Can be an early sign of the
disease. 1/3 of pts may experience anxiety or depression
Why does this happen?
• Living with PD can cause stress and sadness.
• May be caused by changes in areas of the brain that affect mood
What can you do about it?
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Keep yourself active and engaged with family and friends
Regular exercise
May be useful to speak to a psychologist
Meds: Nortriptyline, Citalopram
Orthostatic hypotension
What is this?
• Drop in BP when standing leading to dizziness. 1/3 of patients
Why does this happen?
• Part of the disease process
• May be worsened by certain meds
What can you do about it?
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Stay well hydrated
Avoid Standing up quickly
Try elevating the head of the bed when you sleep
Slightly increase salt intake
Wearing compression stockings can help
Sexual dysfunction
What is this?
• Difficulty with erection (men), or orgasm (women), or decreased sex
drive (both men and women)
How often?
• Half of patients with PD
What can you do about it?
• Regular exercise helps developing stamina
• Meds: Sildenafil for men (Viagra), HRT (with caution) for women
Insomnia
What is this?
• Trouble falling asleep or staying asleep
Why does this happen?
• Part of the disease
• Occasionally can be caused by PD meds
What can you do about it?
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Bedtime and waking time should be as regular as possible
Do not spend over 8 hours in bed
Do not lie in bed more than ½ hour if you can not fall asleep
Bright light in the morning and regular exercise during day
Use your bed for sleep and sex only
REM sleep behavior disorder
What is this?
• Acting out your dreams. You may punch, kick, shout, fall. May lead to
injuries
How often?
• 1/3 of patients
What can you do about it?
• Safety in bed: bed rails, pillows beside the bed…
• If mild, no need for treatment
• If violent, meds: melatonin or clonazepam
Thank you