Freezing and Falling
Freezing is the sudden loss of the ability to walk forward. It may occur during a wearing-off episode (more commonly) or not, and may or may not be associated with a greater likelihood of falling. At such times, patients may recover if they either focus mental attention on walking, try marching in place or to either side, or get verbal or physical support to walk from someone else.
Falling is to be feared and avoided, if possible. Hips, arms, pelvises, necks, etc. can be broken and may not be repairable to restore adequate function. Heads can be injured, producing blood clots in or over the brain, requiring surgery.
Staying mobile, however, is essential. Whenever possible, patients should walk, within their own limitations. Others who can do more, physically, should.
Certainly, safe mobility must be maintained, whether that is achievable with some combination of medical, physical, occupational or surgical treatment. If these treatment modes alone cannot fully succeed, some form of physical support [i.e., cane, walker, scooter, or holding onto someone or some immovable object(s)] has to be used.
Speech and Swallowing
These issues are dealt with in detail elsewhere, but several general points are worth making. Communication with others is so important that it may be best to consult with a speech pathologist working with your doctor to optimize your individual function if you cannot be understood. Similarly, swallowing function needs to be evaluated in those patients who are choking on liquids or solids.
This important area of expertise is offered to patients who need special help to do activities of daily living, including standing, balancing, gait training, bathing and other bathroom activities, feeding, and others. Occupational therapists work well with others in the medical team to optimize function, offering individualized treatment programs.
This is very common, especially among those with moderate-advanced PD. It is because of an illness-related abnormality in the nerves supplying the bowel. It can be made worse by the use of anticholinergic drugs, and these may need to be discontinued if constipation poses a serious problem.
Patients often benefit from a high fiber diet, increased liquid intake, exercise, and the use of over-the-counter stool softeners. Frequent laxatives or enemas should be avoided, if possible, but these measures need to be discussed with a treating physician.
Patients will often notice an increased urgency to urinate, as well as an increased urinary frequency. In men, this may exaggerate ongoing symptoms of prostate enlargement, and such issues need to be clarified with urological consultation. Generally, it is useful to limit fluid intake after supper, and the use of either Ditropan® (oxybutynin) or Detrol® (tolterodine) may be considered.
Impotence (impaired erection) in men may occur in PD, as it does in nearly all cases of multiple system atrophy (MSA). One needs to consider the potential role of medications (e.g., beta-blockers, anti-anxiety drugs, anti-depressants, others), and of depression itself, when impotence occurs. Both men and women may experience a decrease in libido, independent of depression.
Depression is common among those with advancing PD, affecting as many as 30-50% over the course of the illness. There is often a loss of pleasure in usual activities, decreased desire to socialize, a loss of interest in sexual activity, insomnia, weight loss or gain, increased irritability, and, sometimes, a lesser ability to concentrate and perform other usual mental functions. Think about the possible presence of depression when these symptoms appear and go on for weeks or months. They rob people of the joy in life they otherwise might have and appear to make the motor portion of PD worse.
It is a common clinical experience that, unless depression is adequately treated with medication at least, and often also with some form of counseling, full responses of PD patients to their medications will not occur. So, not only should depression be treated on humanitarian grounds, but also to help the PD itself. Many experienced non-psychiatrists manage depression well, but some instances are best co-managed with a psychiatrist.
Some PD patients will have vivid dreams and/or insomnia because of one or more of their anti-PD medications. Such sleep disruptions may not only awaken the patient and his/her partner, but can also make it impossible to get all the rest that's needed to recuperate enough to do the next day's activities well or at all. In such circumstances, consider with your doctor reducing or eliminating late evening anti-PD medication dose(s).
We need to realize that some patients will require nighttime doses of anti-PD medication(s) to get out of bed to go to the bathroom, or simply to turn comfortably in bed to rest well. Obviously, this is another individual clinical decision to make, and one that may need revision over time.
Several years ago, it was reported that some patients may have "sleep attacks" (unheralded, sudden, irresistible sleep episodes) when taking agonist drugs. This remains an area of controversy since it isn't clear that such "attacks" haven't occurred because of another ongoing sleep disorder (e.g., due to excessive daytime sleepiness, depression, other medication effects, etc.). However, although there may be variable explanations for "attacks", the potential occurrence of dangerous sleep episodes (e.g., when driving a vehicle) makes it important to be aware of such a possibility. In my view, a physician should not hesitate to prescribe an otherwise potentially beneficial agonist or other anti-PD drug, and both doctor and patient should be vigilant about this uncommon, possible issue. As with many other therapeutic issues in PD, this needs thorough, individualized attention in a medical setting.
Dementia (loss of acquired cognitive function, including memory) can occur in about 30% of PD patients over the course of the illness. It is not inevitable.
When dementia occurs, it is important to try to identify the cause, as some 5-10% are potentially reversible, partly or fully. The list of potentially reversible causes includes hypothyroidism (low thyroid), vitamin B12 or folate deficiency, syphilis, subdural hematoma (blood clot over the brain), communicating hydrocephalus (impaired circulation of spinal fluid), and others. Studies to identify these disorders include blood tests (for thyroid [TSH and perhaps others], B12, folate, RPR or VDRL [syphilis], MRI or CT scan of the brain) and, perhaps, a spinal fluid examination for those whose dementia is rapidly advancing or otherwise atypical. Correcting the abnormalities, medically or surgically, will follow.
The same diagnostic studies, and perhaps others, may be needed to establish the cause of other forms of dementia. Some causes cannot be reversed, including: