Dizziness And Nausea Vomitting Induced By Ropinirole Therapy In An Elderly Patient With Parkinsons Disease : A Case Report
Emilia Sidharta, Hanny Cahyadi
Abstract
Background: Ropinirole is a non-ergoline dopamine agonist drug that is widely used in a therapy for patients diagnosed with Parkinsons disease. In long-term use, several published studies have mentioned the occurrence of side effects of ropinirole in the therapy of Parkinsons disease, but there has been no case report on the occurrence of side effects in the form of dizziness and nausea-vomiting, especially in Indonesia.
Analysis using Naranjo Scale shows a score of 6 which indicates a probable association between dizziness, nausea-vomiting and ropinirole in an elderly patient with Parkinsons Disease.
Keywords: ropinirole, Parkinson, case report, elderly, side-effects
Full Text:
Problems With Blood Pressure
Problems with blood pressure can affect people generally as they get older, but some Parkinsons medication can cause side effects, including problems with blood pressure. This can lead to dizziness and falls. If youve felt dizzy, or fallen because of dizziness, ask your GP or practice nurse to check your blood pressure both when youre sitting and standing, to see if its too low.
Drugs used to treat other medical conditions, such as high blood pressure, can potentially make dizziness worse, especially if you are losing weight or not eating and drinking as well as you used to.
Postural hypotension is a sudden drop in blood pressure when changing position, for example getting up out of a chair. It can make you feel very light-headed, which will affect your balance. You may experience postural hypotension as a symptom of Parkinsons. But it can also be caused by the drugs used to treat Parkinsons.
You can avoid some dizzy spells by taking your time. For example, before you get out of bed, sit with your feet touching the floor for a few minutes to get your blood flowing. Then stand up slowly, but try not to walk away immediately stand for a while until you feel steady.
What Are The Symptoms
The best-known symptoms of Parkinson’s disease involve loss of muscle control. However, experts now know that muscle control-related issues aren’t the only possible symptoms of Parkinson’s disease.
Motor-related symptoms
Motor symptoms which means movement-related symptoms of Parkinsons disease include the following:
Additional motor symptoms can include:
- Blinking less often than usual. This is also a symptom of reduced control of facial muscles.
- Cramped or small handwriting. Known as micrographia, this happens because of muscle control problems.
- Drooling. Another symptom that happens because of loss of facial muscle control.
- Mask-like facial expression. Known as hypomimia, this means facial expressions change very little or not at all.
- Trouble swallowing . This happens with reduced throat muscle control. It increases the risk of problems like pneumonia or choking.
- Unusually soft speaking voice . This happens because of reduced muscle control in the throat and chest.
Non-motor symptoms
Several symptoms are possible that aren’t connected to movement and muscle control. In years past, experts believed non-motor symptoms were risk factors for this disease when seen before motor symptoms. However, theres a growing amount of evidence that these symptoms can appear in the earliest stages of the disease. That means these symptoms might be warning signs that start years or even decades before motor symptoms.
Non-motor symptoms include:
Stages of Parkinsons disease
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Common Causes Of Dizziness And Vertigo In Parkinsons And How To Treat Them:
In people with early Parkinsons disease , the dizziness has in many cases linked to a lower Montreal Cognitive Assessment score raising the possibility that dizziness may be a non-movement symptom associated with cognitive decline .
Dizziness or vertigo can be tied to many causes and is not unique to Parkinsons. Symptoms can be caused by medications, low blood pressure, anxiety, cold, flu, dehydration, heart conditions and more. Tell your doctor immediately if you regularly experience dizziness or vertigo.
Page reviewed by Dr. Michael S. Okun, Parkinsons Foundation Medical Director, Professor and Chair, Department of Neurology, Executive Director of the Fixel Institute for Neurological Diseases a Parkinsons Foundation Center of Excellence.
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Whats Hot In Pd If You Are Dizzy Or Passing Out It Could Be Your Parkinsons Disease Or Parkinsons Disease Medications
This 3-page article, with references, is a personal statement by Dr. Okun describing the mis-diagnoses Parkinsons patients can be given when visiting the ER for symptoms of dizziness or syncope outlining what defines a proper diagnosis of orthostatic hypotension, its frequency in people with Parkinsons, medication and lifestyle changes that can help.
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What Are The Symptoms Of Parkinsons Disease
Symptoms of Parkinsons disease and the rate of decline vary widely from person to person. The most common symptoms include:
Other symptoms include:
- Speech/vocal changes: Speech may be quick, become slurred or be soft in tone. You may hesitate before speaking. The pitch of your voice may become unchanged .
- Handwriting changes: You handwriting may become smaller and more difficult to read.
- Depression and anxiety.
- Sleeping disturbances including disrupted sleep, acting out your dreams, and restless leg syndrome.
- Pain, lack of interest , fatigue, change in weight, vision changes.
- Low blood pressure.
Orthostatic Hypotension In Parkinsons Disease Multiple System Atrophy And Lewy Body Dementia
Movement disorder specialist, Dr. Veronica Santini spoke for a half hour on orthostatic hypotension, a common symptom of Parkinsons disease, Multiple System Atrophy and Lewy Body Dementia. Following her talk, moderator Candy Welch, Brain Support Networks MSA caregiver support group leader, presented Dr. Santini with questions from webinar participants for another half hour.
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What Can You Do If You Have Pd
- Work with your doctor to create a plan to stay healthy. This might include the following:
- A referral to a neurologist, a doctor who specializes in the brain
- Care from an occupational therapist, physical therapist or speech therapist
- Meeting with a medical social worker to talk about how Parkinsons will affect your life
For more information, visit our Treatment page.
Page reviewed by Dr. Chauncey Spears, Movement Disorders Fellow at the University of Florida, a Parkinsons Foundation Center of Excellence.
Nausea Vomiting And Gastroparesis
Nausea and vomiting are reported by many Parkinsons patients, and may be the result of dopamine-based treatments aimed at alleviating motor symptoms.32 These symptoms can occur as the enteric nervous system of the GI tract, like the central nervous system, makes use of dopamine as a means of communication between neurons.33 Identical receptors for dopamine can be found in the GI tract as in the brain, and these play an important role in the movement of material through the intestinal tract.34 Nausea and vomiting can result from dopamine receptors within the gut interacting with Parkinsons treatments, such as levodopa, that are intended to act upon dopamine receptors in the brain. These symptoms can alleviate over time however, in cases of severe reaction to levodopa therapy, adjustments to treatment made in conjunction with a physician may be necessary. Such adjustments can include changes to dosage, or simply how such medication is taken, for example, by taking medication with a meal.21
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The Gastrointestinal Effects Of Parkinsons Disease
Surveys show that between 20% and 40% of people with Parkinsons disease suffer from serious constipation . Larger numbers of people with PD have related gastrointestinal issues such as bloating, a feeling of fullness and nausea. As the disease progresses, all of these GI problems become more common. In rare cases, serious complicationssuch as megacolon and perforation or tearing of the colonmay arise from these GI problems.
The connection between the two may seem odd on the surface, but research shines some light on these unpleasant consequences of the disease.
A large survey of healthy people who were followed over several years revealed that men who reported having less than one bowel movement daily had a 2 to 7 times higher risk of developing PD than that of men who had daily bowel movements their risk was four times higher than that of men who had two or more bowel movements a day.
Vemp Recordings And Measurements
All VEMPs were recorded using disposable silver/silver-chloride surface electrodes abrasive gel was applied before attaching the electrodes to ensure that the impedance levels were below 2 kOhms, with a maximal side-to-side impedance difference of 1 kOhms. The ground electrode was place at Fpz.
For oVEMP recording, the active electrodes were placed symmetrically over the middle part of the lower eyelids, on top of the inferior orbital edges, and the reference electrodes were place 2 cm below these. During the measurements, subjects were asked to sit upright and to look upward at a fixed target . The peak latencies of the N1 and P1 were measured, as were the N1-P1 peak-to-peak amplitudes .
For cVEMP recording, the active electrodes were placed symmetrically over the upper middle part of the sternocleidomastoid muscle bellies with the reference electrode over the sternal manubrium. The patients were asked to lift their heads up from a headrest and turn their heads away from the ear that was being stimulated. The peak latencies of the P13 and N23 were measured, as well as the P13-N23 peak-to-peak amplitude .
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What Causes The Condition
Although there are several recognized risk factors for Parkinsons disease, such as exposure to pesticides, for now, the only confirmed causes of Parkinsons disease are genetic. When Parkinsons disease isnt genetic, experts classify it as idiopathic . That means they dont know exactly why it happens.
Many conditions look like Parkinson’s disease but are instead parkinsonism from a specific cause like some psychiatric medications.
Familial Parkinsons disease
Parkinsons disease can have a familial cause, which means you can inherit it from one or both of your parents. However, this only makes up about 10% of all cases.
Experts have linked at least seven different genes to Parkinson’s disease. They’ve linked three of those to early-onset of the condition . Some genetic mutations also cause unique, distinguishing features.
Idiopathic Parkinsons disease
Experts believe idiopathic Parkinsons disease happens because of problems with how your body uses a protein called -synuclein . Proteins are chemical molecules that have a very specific shape. When some proteins dont have the correct shape a problem known as protein misfolding your body cant use them and can’t break them down.
With nowhere to go, the proteins build up in various places or in certain cells . The buildup of these Lewy bodies causes toxic effects and cell damage.
Induced Parkinsonism
The possible causes are:
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.
Show Sources
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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.
Late Complications Of Parkinson’s 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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Living With Postural Hypotension
This 7-page fact sheet was developed for people affected by MSA, but is just as useful to those with Parkinsons disease, who are experiencing drops in blood pressure and postural hypotension. It covers symptoms, when they are likely to happen, what to do, exercise and other tips for daily living with OH, including medication options.
Dizziness Caused By Parkinsons Disease
Parkinsons disease is a neurological condition that affects a persons ability to move. Research has linked the dizziness associated with Parkinsons to cerebral hypoperfusion. In laymans terms, this means not enough blood is getting to the brain. What can cause a reduction in blood flow to the brain?
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What Are The Surgical Treatments For Parkinsons Disease
Most patients with Parkinsons disease can maintain a good quality of life with medications. However, as the disease worsens, medications may no longer be effective in some patients. In these patients, the effectiveness of medications becomes unpredictable reducing symptoms during on periods and no longer controlling symptoms during off periods, which usually occur when the medication is wearing off and just before the next dose is to be taken. Sometimes these variations can be managed with changes in medications. However, sometimes they cant. Based on the type and severity of your symptoms, the failure of adjustments in your medications, the decline in your quality of life and your overall health, your doctor may discuss some of the available surgical options.
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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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.
When Is Orthostatic Hypotension Treated
Not all forms of orthostatic hypotension require treatment. If you experience a drop in blood pressure when you stand up, but have no other symptoms you probably won’t need treatment. Sometimes all it takes is sitting on the edge of the bed for a minute or steadying yourself for a moment after you stand up. But, if you feel dizzy or lightheaded to the point where you might lose your balance or lose consciousness, you will need treatment.
Because some drugs can cause severe orthostatic hypotension, your doctor may first try reducing some of your medicine or may switch you to another type of medicine. If you have significant symptoms of orthostatic hypotension, and it is not possible to change your medications, then your doctor will likely treat the orthostatic hypotension itself.
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