1. 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 Movement Disorder Program Kane Hall Barry Neurology Bedford/Keller

3. Neurology Residency: LSU Shreveport, LA Neurophysiology Fellowship: UC Davis Movement Disorders Fellowship: Cedars-Sinai Medical Center, Los Angeles, CA With Dr. Michele Tagliati

4. “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. An Essay on The Shaking Palsy

5. Clinical Features of PD Four cardinal signs Bradykinesia (Slowness) Muscle rigidity (Stiffness) Resting tremor Postural instability Characteristic traits Asymmetric onset Masked face Micrographia Low volume speech Flexed posture Shuffling and festinating gait Response to levodopa

6. Non-Motor Symptoms of PD Sleep Disorders Insomnia Sleep Fragmentation Parasomnias Restless Legs Syndrome PLMS Excessive daytime sleepiness Sleep attacks Sensory Loss of sense of smell Pain Paresthesias Altered sensation Restless legs Psychiatric Dementia Hallucinations Delirium Mood Disturbance Depression Agitation Anxiety and Panic Attacks Autonomic Orthostatic Hypotension Constipation Urinary problems Sexual problems Sweating and Thermoregulation

7. 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) Constipation

8. 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 Uncontrolled loss of stool

9. 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? 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 Nausea/Vomiting

10. 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? 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 Bladder dysfunction

11. 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 Changes in taste and smell

12. 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 pain

13. 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 Unexplained changes in weight

14. 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 Cognitive impairment and dementia

15. 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 Hallucinations

16. 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? Keep yourself active and engaged with family and friends Regular exercise May be useful to speak to a psychologist Meds: Nortriptyline, Citalopram What can you do about it? Living with PD can cause stress and sadness. May be caused by changes in areas of the brain that affect mood Depression

17. 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? 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 Orthostatic hypotension

18. 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 Sexual dysfunction

19. 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? 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 Insomnia

20. 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 REM sleep behavior disorder

21. Thank you