Understanding Blood Pressure Fluctuations In Parkinson’s Disease
In this 1-hour webinar Anindita Deb, MD, Movement Disorder Specialist, provides an overview of the human nervous system, which controls blood pressure, before explaining what orthostatic hypotension is, how to monitor nOH, medications that can affect blood pressure, lifestyle changes to improve nOH, how nOH affects cognition and mobility. She then spends considerable time sharing physical maneuvers and medications to treat nOH before answering listener questions.
How Is Orthostatic Hypotension Treated
Droxidopa . fludrocortisone , or midodrine capsules are approved for the treatment of orthostatic hypotension. Common side effects include headache, dizziness, nausea, high blood pressure, and fatigue.
Another approach in treating orthostatic hypotension is to decrease the pooling of blood in the legs with the use of special stockings called compression stockings. These tight stockings compress the veins in the legs, helping to reduce swelling and increase blood flow. There are a number of companies that make these stockings in a wide variety of sizes, and they usually can be found at stores that sell medical supplies, as well as at some pharmacies.
You should wear these stockings when you are up and about. You do not need to wear them when you are in bed. Further, it is recommended that you put the stockings on first thing in the morning while in bed and before getting up for your daily activities. It is important that you do not let the stockings bunch, gather, or roll, since this can compress the veins too much and could harm circulation. You should always watch for signs of decreased circulation, which could include discoloration of the skin, as well as pain or cramping, and numbness of the lower legs and feet.
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Overview Of Conventional Treatment For Parkinson’s
Nearly all authors agree that treatment with carbidopa-levodopa ) is the single most helpful medication. Levodopa has enabled patients with Parkinsonism to live normal life spans, and greatly ameliorates symptoms in most patients .
There is presently considerable controversy as to the value of adjunctive agents to levodopa. As a summary, it seems prudent to recommend an approach which incorporates levodopa, direct dopamine agonists, and potential neuroprotective agents such as seligiline. Patients with significant deficits which cannot be adequately treated with drugs may be suitable candidates for surgical approaches. An algorithm for managing parkinsonism published by the American Academy of Neurology can be found here.
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Late Complications Of Parkinsons Disease
Patients with PD respond to levodopa almost immediately. However, 20 to 50% of patients will develop motor fluctuations or dyskinesias within 5 years of starting levodopa therapy. Response fluctuations consist of a mixture of wearing-off phenomenon, on dyskinesias , Diphasic dyskinesias , and off dystonia .
Wearing off can be managed by decreasing the dosing interval, switching to a longer acting product, or by adding or increasing the dose of dopamine agonist. On-off effects are harder to manage. The addition of a direct dopamine agonist or switching to a slow acting dopamine preparation may reduce the frequency of dyskinesias and on/off events. Pramipexole, as initial therapy compared to levodopa, reduces the risk of developing complications by about 55%, but it is not as effective as Levodopa and has some adverse affects . COMT inhibitors may smooth smooth out the peaks/troughs of dopamine and reduce fluctuation.
Psychiatric adverse effects include psychosis, confusion, agitation, hallucinations and delusions. These can be treated by decreasing dopamine medication, reducing or discontinuing anticholinergics, amantadine or selegiline, or by using clozipine at doses of 6.25 to 50 mg/d .
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When Should I See My Healthcare Provider Or When Should I Seek Care
You should see your healthcare provider as recommended, or if you notice changes in your symptoms or the effectiveness of your medication. Adjustments to medications and dosages can make a huge difference in how Parkinsons affects your life.
When should I go to ER?
Your healthcare provider can give you guidance and information on signs or symptoms that mean you should go to the hospital or seek medical care. In general, you should seek care if you fall, especially when you lose consciousness or might have an injury to your head, neck, chest, back or abdomen.
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Dizziness And Vertigo In Parkinsons
Dizziness and vertigo are not unique to Parkinsons disease .3 There can be multiple causes and determining an effective treatment depends on good reporting of the symptoms and the ability to identify a cause. Additionally, symptoms may be less notable in the early stages of Parkinsons.3 As with most aspects of Parkinsons, the experience of symptoms is unique you may not ever experience these.
How Do I Prevent Falls From Common Hazards
- Floors: Remove all loose wires, cords, and throw rugs. Minimize clutter. Make sure rugs are anchored and smooth. Keep furniture in its usual place.
- Bathroom: Install grab bars and non-skid tape in the tub or shower. Use non-skid bath mats on the floor or install wall-to-wall carpeting.
- Lighting: Make sure halls, stairways, and entrances are well-lit. Install a night light in your bathroom or hallway and staircase. Turn lights on if you get up in the middle of the night. Make sure lamps or light switches are within reach of the bed if you have to get up during the night.
- Kitchen: Install non-skid rubber mats near the sink and stove. Clean spills immediately.
- Stairs: Make sure treads, rails, and rugs are secure. Install a rail on both sides of the stairs. If stairs are a threat, it might be helpful to arrange most of your activities on the lower level to reduce the number of times you must climb the stairs.
- Entrances and doorways: Install metal handles on the walls adjacent to the doorknobs of all doors to make it more secure as you travel through the doorway.
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Falls And Parkinsons Disease
A loss of balance often resulting in falling affects many with Parkinsons. This is due in part to general motor dysfunction caused by the disorder. Falling can depend on each persons symptoms and how they respond to medication. This should be monitored for any pattern noted at the time of these changes or fluctuations.5 Syncope is one of the most commonly overlooked causes of dizziness in people with Parkinsons.2
Stress Anxiety And Depression
Depression and anxiety are often mistakenly thought of as purely psychological issues, where in fact they have real physical effects on the functioning of our body processes. A sudden flare up in this area , excessive exposure to stress , or prolonged, unmanaged anxiety and depression, can all lead to irregular nervous system activity which can produce various symptoms of dizziness.
These causes are commonly overlooked as both patients and medical providers can dismiss this as a legitimate source of dizziness. However, proper treatment can be highly effective in managing and eliminating your symptoms.
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Cognitive And Psychiatric Symptoms
- depression and anxiety
- mild cognitive impairment slight memory problems and problems with activities that require planning and organisation
- dementia a group of symptoms, including more severe memory problems, personality changes, seeing things that are not there and believing things that are not true
How Should This Medicine Be Used
The combination of levodopa and carbidopa comes as a regular tablet, an orally disintegrating tablet, an extended-release tablet, and an extended-release capsule to take by mouth. The combination of levodopa and carbidopa also comes as a suspension to be given into your stomach through a PEG-J tube or sometimes through a naso-jejunal tube using a special infusion pump. The regular and orally disintegrating tablets are usually taken three or four times a day. The extended-release tablet is usually taken two to four times a day. The extended-release capsule is usually taken three to five times a day. The suspension is usually given as a morning dose and then as a continuous dose , with extra doses given no more than once every 2 hours as needed to control your symptoms. Take levodopa and carbidopa at around the same times every day. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take levodopa and carbidopa exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor.
Swallow the extended-release tablets whole do not chew or crush them.
To take the orally disintegrating tablet, remove the tablet from the bottle using dry hands and immediately place it in your mouth. The tablet will quickly dissolve and can be swallowed with saliva. No water is needed to swallow disintegrating tablets.
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Preventing And Treating Orthostatic Hypotension: As Easy As A B C
Drug therapy alone is never adequate to treat orthostatic hypotension. A patient-oriented approach that emphasizes education and nonpharmacologic strategies is critical. This article provides easy-to-remember management recommendations, using a combination of drug and non-drug treatments that have proven effective.
Dizziness Vs Vertigo Vs Lightheadness Vs Imbalance
Dizziness is symptom that can be very specific or very hard to describe. For medical professionals, dizziness is the general term that refers to everything from a spinning sensation to a foggy head to losing your balance when you walk.
We can define dizziness more specifically in these following ways:
VertigoThis is the sensation of motion that should not be there. Its usually described as a feeling that youre spinning or that the room is spinning, or can be felt like youre being pulled in a specific direction.
Central instability at restThis is the sensation of rocking or swaying when youre still
LightheadednessThis is a vague sensation commonly described as having a floating head or feeling ungrounded. Its usually persistent, and can often comes with anxiety, being overheated or feeling as if youre about to faint.
ImbalanceThis is the loss of stability that occurs when you change position quickly or while you are walking.
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The Dizziness Connected To Parkinsons Linked To Cerebral Blood Flow
Dizziness is a common symptom of many conditions. Perhaps your doctor was able to identify the underlying cause of your dizziness. If so, youre actually in the minority. In most cases of dizziness, the cause is a mystery. As a result, a patient may remain to wonder if the symptom will return.
In other cases, the underlying cause of dizziness is identified, but there is no cure for the condition. One condition where this is the case is Parkinsons disease.
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Parkinsons diseasea chronic and progressive brain disorder that causes loss of muscle controlaffects nearly one million people in the U.S. This disease results in the death and malfunction of nerve cells in the brain, many of which produce dopamine, a chemical responsible for controlling movement and coordination.
While symptoms such as tremors, slowed movement and speech problems are among the most common symptoms of Parkinsons, they tend to present themselves only once the disease has progressed. To detect Parkinsons disease in the early stages of development, the following are 12 signs to keep an eye out for.
What Causes Parkinsons Disease
Parkinsons disease occurs when nerve cells in an area of the brain called the substantia nigra become impaired or die. These cells normally produce dopamine, a chemical that helps the cells of the brain communicate . When these nerve cells become impaired or die, they produce less dopamine. Dopamine is especially important for the operation of another area of the brain called the basal ganglia. This area of the brain is responsible for organizing the brains commands for body movement. The loss of dopamine causes the movement symptoms seen in people with Parkinsons disease.
People with Parkinsons disease also lose another neurotransmitter called norepinephrine. This chemical is needed for proper functioning of the sympathetic nervous system. This system controls some of the bodys autonomic functions such as digestion, heart rate, blood pressure and breathing. Loss of norepinephrine causes some of the non-movement-related symptoms of Parkinsons disease.
Scientists arent sure what causes the neurons that produce these neurotransmitter chemicals to die.
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What Medications Are Used To Treat Parkinsons Disease
Medications are the main treatment method for patients with Parkinsons disease. Your doctor will work closely with you to develop a treatment plan best suited for you based on the severity of your disease at the time of diagnosis, side effects of the drug class and success or failure of symptom control of the medications you try.
Medications combat Parkinsons disease by:
- Helping nerve cells in the brain make dopamine.
- Mimicking the effects of dopamine in the brain.
- Blocking an enzyme that breaks down dopamine in the brain.
- Reducing some specific symptoms of Parkinsons disease.
Levodopa: Levodopa is a main treatment for the slowness of movement, tremor, and stiffness symptoms of Parkinsons disease. Nerve cells use levodopa to make dopamine, which replenishes the low amount found in the brain of persons with Parkinsons disease. Levodopa is usually taken with carbidopa to allow more levodopa to reach the brain and to prevent or reduce the nausea and vomiting, low blood pressure and other side effects of levodopa. Sinemet® is available in an immediate release formula and a long-acting, controlled release formula. Rytary® is a newer version of levodopa/carbidopa that is a longer-acting capsule. The newest addition is Inbrija®, which is inhaled levodopa. It is used by people already taking regular carbidopa/levodopa for when they have off episodes .
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The Gastrointestinal Tract And Parkinsons
As promised in a previous blog, I now return to the topic of the gastrointestinal tract and Parkinsons disease . As most of you know, GI symptoms are very common in PD. We will discuss what those symptoms are, why they occur, and the current research that links what is happening in the gut to theories as to why PD occurs at all. Many of you have suggested gut-related topics for this blog including a discussion of symptoms such as bloating and constipation, and a discussion of the use of probiotics in PD. I will address these issues as well. Submit additional topics that you would like to read about here.
GI symptoms can be among the most bothersome of the non-motor symptoms of PD. Constipation is the most common of these symptoms, affecting 80-90% of people with PD. APDA has a helpful brochure with practical tips to prevent and treat constipation in PD.
GI pathology in Parkinsons disease however, can involve the entire GI tract and includes sialorrhea and dysphagia . In addition, delayed gastric emptying, in which the digestive contents are held up in the stomach and do not move normally into the small intestine, can cause sensations of nausea and bloating.
The gut has its own nervous system
The gut as a biomarker
Entry to the brain
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Understanding Blood Pressure Fluctuations In Parkinsons Disease
In this 1-hour webinar Anindita Deb, MD, Movement Disorder Specialist, provides an overview of the human nervous system, which controls blood pressure, before explaining what orthostatic hypotension is, how to monitor nOH, medications that can affect blood pressure, lifestyle changes to improve nOH, how nOH affects cognition and mobility. She then spends considerable time sharing physical maneuvers and medications to treat nOH before answering listener questions.
What Are The Primary Motor Symptoms Of Parkinsons Disease
There are four primary motor symptoms of Parkinsons disease: tremor, rigidity, bradykinesia and postural instability . Observing two or more of these symptoms is the main way that physicians diagnose Parkinsons.
It is important to know that not all of these symptoms must be present for a diagnosis of Parkinsons disease to be considered. In fact, younger people may only notice one or two of these motor symptoms, especially in the early stages of the disease. Not everyone with Parkinsons disease has a tremor, nor is a tremor proof of Parkinsons. If you suspect Parkinsons, see a neurologist or movement disorders specialist.
Tremors
Vocal Symptoms
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What Causes Parkinsons Movement Symptoms
Dopamine is a chemical messenger that is primarily responsible for controlling movement, emotional responses and the ability to feel pleasure and pain. In people with Parkinsons, the cells that make dopamine are impaired. As Parkinsons progresses, more dopamine-producing brain cells die. Your brain eventually reaches a point where it stops producing dopamine in any significant amount. This causes increasing problems with movement.
Benign Paroxysmal Positional Vertigo
This is a sudden onset of vertigo, lasting only a few seconds, typically after a sudden head movement such as turning in bed. Research reveals BPPV may occur in 11% of people with Parkinson’s who experience dizziness and becomes more common with age. It can be diagnosed using an in-office assessment called the Dix-Hallpike maneuver. Your doctor, or a physical therapist who is an expert in vestibular rehabilitation can offer treatment options or teach you the Semont maneuvers, a series of simple movements to self-administer at home.
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What Should I Do If I Forget A Dose
Take the missed dose of the regular tablet, orally disintegrating tablet, extended-release tablet, or extended-release capsule as soon as you remember it. However, if it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Do not take a double dose to make up for a missed one.
If you are using levodopa and carbidopa enteral infusion and will be disconnecting the infusion pump for a short time , other than the normal nightly disconnection, ask your doctor if you should use an extra dose before you disconnect the pump. If the infusion pump will be disconnected for longer than 2 hours, call your doctor you probably will be advised to take levodopa and carbidopa by mouth while you are not using the suspension.