Tips for Dealing with Sleep Disorders in Parkinson’s : by Dr. De Leon

As many of you know sleep problems can wreak havoc with our lives if f we don’t get enough rest we are liable to turn from a mild manner soft spoken individual to an irritable cranky creature!

Not only does poor sleep affect our mood but also causes poor concentration leading to memory loss, fatigue, increase weight, and poor judgment. All of these can mimic actual Parkinson’s symptoms either from disease or as side effect of medications.

Therefore, when we don’t get enough sleep we are doing ourselves a disservice and making our symptoms seem worse while making our doctors jobs more difficult as they try to sort out the source. One way to avoid this confusion is to tell your doctor immediately if you are having trouble with sleep and be specific. The more details you tell them the better they are able to help you get back on your feet.

Keep a record of your problem :

1) Is the problem staying asleep

2) Falling asleep

3) Pain at night

4) Restless legs

5) Trouble turning- getting stuck in one place or in the sheets

6) Going to bathroom to often (as you are falling as sleep or does it awake you from sleep)

7) Trouble breathing and snoring

8)  Acting out dreams at night and or talking during sleep

9) Vivid dreaming and or hallucinations

10) Disturbance in sleep wake cycle-sleepy during day and awake at night

Sleep is a way we humans encode all the information we have learned during the day and store for long term. If sleep becomes interrupted enough this will lead to short term memory loss making it seem like you might have cognitive problems when I fact may just be sleep deprived. However, for those that do have early cognitive problems can through them into full blown psychosis and hallucinations and for those that have advance dementia or memory loss it will make things much worst. Not only this but also increase high blood pressure and risk of having a stroke and early death particularly in the presence of sleep apnea. As we age, our bodies do often require less sleep and there is a slight shift in cycle going to bed earlier and awaking earlier. But most people according to studies still need a good 7-8 hours to function optimally.

Some of the sleep problems can be treated more easily than others. For instance, for shift in awake cycle …two ways to treat one is to treat with medications like Provigil to maintain alert during daytime and prevent falling asleep so can then fall asleep at night and / or maintain a routine sleep hygiene where no naps are allowed during the daytime.  You MUST also arise at same time and go to bed at same time daily. Plus only use bedroom to sleep or  for sexual activities. Keep bedroom dark at a comfortable temperature. Do not try to force sleep. If you cannot sleep get out of bed and move to a separate room to read or watch TV or listen to soothing music. Go back to bed, if still unable to sleep repeat cycle. Do not exercise at least 3 hours before bedtime. If you have to go to bathroom a lot at night avoid drinking fluids 3 hours prior to bed time. Ask physician for medications to help with falling asleep or staying  asleep if none of these things work…there are many options.

If you are snoring and having sleep apnea your doctor will recommend a sleep study test-called a sonogram. I believe every Parkinson’s patient should have this done at some point in their disease process. This will also help evaluate for restless leg and periodic leg movements as well as REM behavior ( acting out in sleep your dreams when your body is supposed to be paralyzed!) so that adequate treatments can then be given. One sign that you might have sleep apnea is early morning headache or awaking from sleep with headache. Tegretol or Klonopin are some of the medications used for REM sleep disorders.

Do not drink alcohol particularly after dinner since this tends to interfere with sleep pattern may help to fall asleep quickly but will often arouse you because it causes shallow sleep patterns plus it can severely worsen sleep apnea. If trouble falling asleep- Do Not drink caffeinated beverages after noon and limit amount to one a day as well as try taking decaf products. These still contain caffeine only 50% less so you won’t feel totally deprived. If you smoke consider cessation since this is a stimulant. Increase physical activity- being active helps to deepen sleep.

If pain is a factor- your doctor will have to evaluate the source and treat accordingly. As he or she will also have to adjust dosages of medications if experiencing wearing off or freezing in bed and getting stuck. Likewise if having hallucinations. Therefore, if you are having any sleep disturbances make sure you speak with your physician as soon as possible since there is usually a good and effective treatment for most of the problems of sleep. Make sure you do not make any changes to your medication regimen without first consulting your doctor.

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Dr. M. De Leon is a movement disorder specialist on sabbatical, PPAC member and research advocate for PDF (Parkinson’s Disease Foundation); Texas State Assistant Director for PAN (Parkinson’s Action Network). You can learn more about her work at http://www.facebook.com/defeatparkinsons101 you can also learn more about Parkinson’s disease at www.pdf.org or at www.wemove.org; http://www.aan.org, http://www.defeatparkinsons.blogspot.com All materials here forth are property of Defeatparkinsons. without express written consent, these materials only may be used for viewers personal & non-commercial uses which do not harm the reputation of Defeatparkinsons organization or Dr. M. De Leon provided you do not remove any copyrights. To request permission to reproduce release of any part or whole of content, please contact me at defeatparkinsons101@yahoo.com contributor http://www.assisted-living-directory.com

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Parkinson’s & Fall Prevention : By Dr. De Leon

Parkinson’s & Fall Prevention : By Dr. De Leon.

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Parkinson’s & Fall Prevention : By Dr. De Leon

 

 

We all know that one of the biggest problems in Parkinson’s is the risk of falls especially as we age and the disease advances the risk seems to increase exponentially.  Recently, there was a new consensus released by the Academy of neurology offering tips on fall prevention since according to the AAN 50% of all Parkinson’s patients have a fall within their last visit to a physician- this is not only astounding but also points to a greater problem that either we as physicians are not spending enough time evaluating for risks and that we as patients are also minimizing our problems with gait.

In an effort to prevent further injury, I will try to recapitulate some of the recommendations and provide some of my own personal expertise from my own experience.  I heard it say in one talk presented by PDF expert that we as PD patients begin to experience abnormal strides in gait even from early stage even before we are completely aware that we have a problem, we are already taking smaller steps and unsteady. If we wait to fall or have a loved one fall to take preventive measures, we have missed the mark. We are not only increasing the risk of serious harm (like broken bones –hip replacements are particularly troublesome for Parkinson’s patients to overcome being hospitalized longer and having greater decline in activities of daily living within first year requiring usually skill nursing), increase need for medications, as well as increase in disability and decrease quality of life due to decrease mobility along with an increase financial burden. This is too high a price to pay when we can prevent most falls with some strategies to reduce fall risk.

First, and foremost keeping active starting a physical therapy program, or an exercise program that will help strengthen core muscles (neck, back, legs).

Second, especially if getting up in age make sure you get routine eye and hearing exam. Poor hearing and vision added to stiff muscles with already have poor coordination make for disaster waiting to happen. 

Third, avoid interaction between medications especially sedatives like benzodiazepines (e.g. klonopin, xanax), anti histamines ( e.g Benadryl), pain medications. Sometimes levels of levodopa have to be adjusted for those that fall during dyskenesias or if blood pressure is dropping especially if taking a blood pressure medication as well.

Fourth, have your doctor check your B12 levels which are commonly low in Parkinson’s patients –low levels of this can alter your sense of perception increasing your sense of lack of coordination if your feet are sending wrong signals to the brain about the terrain underneath them. 

Fifth, walking with a stooped posture can also be problematic- although it can protect against backwards falls it makes it more likely to fall forward especially when rising or transferring from chair or bed.

Sixth, if reason for falls is decrease motility or movement then need to talk to your physician or provider about increasing your medication unless contraindicated like having hallucinations or severe dyskenesias in which case strength training and teaching cueing strategies are helpful. For those that have cognitive impairments, they need to be supervised at all time while transferring from seating and from bed as well as when walking and assistive walking devices are highly recommended.

At all times a team approach works best to ensure safety of all those involved.

Always keep a list of all medications even over the counter and discuss all falls even when no injury occurred to your physician. Even if you are just getting off balance but no falls have occurred mention it to start preventive treatment before a fall occurs.

Some of the exercises that will help keep and maintain balance are yoga, tai-chi, and aerobics in deep water.

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For further reading on the subject go to Journal Parkinsonism & Related Disorders April 2014  

“How to prevent falls in Parkinson’s Patient’s? A new Consensus Document Offers Tips” Neurology Today, Vol. 14, issue 12, June 19 2014

Ellis, Terry PT, PhD, NCS “Gait, Balance & falls in Parkinson’s disease,” Expert briefs Parkinson’s Disease Foundation, January 15, 2013

www.ncbi.nlm.nih.gov/pubmed16130353

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Dr. M. De Leon is a movement disorder specialist on sabbatical, PPAC member and research advocate for PDF (Parkinson’s Disease Foundation); Texas State Assistant Director for PAN (Parkinson’s Action Network). You can learn more about her work at http://www.facebook.com/defeatparkinsons101 you can also learn more about Parkinson’s disease at www.pdf.org or at www.wemove.org; http://www.aan.org, http://www.defeatparkinsons.blogspot.com All materials here forth are property of Defeatparkinsons. without express written consent, these materials only may be used for viewers personal & non-commercial uses which do not harm the reputation of Defeatparkinsons organization or Dr. M. De Leon provided you do not remove any copyrights. To request permission to reproduce release of any part or whole of content, please contact me at defeatparkinsons101@yahoo.com contributor http://www.assisted-living-directory.com

 

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Working for a Cure: What Should Our Role Be to Become More Effective Partners in Research? : By Dr. De Leon

Everyone wonders and dreams about the next big study, the next big drug, the next big discovery that will set the course towards a cure and unleash all the pain and suffering from the nearly 10 million people suffering from Parkinson’s worldwide. But, I ask myself how do we do this? How can we convince others and ourselves that the way to ensure that we all have a better quality of life is participation and “stick -to it -ness?” More importantly, we must change the current thinking to bring forth not just new treatments but a cure?

In order to accomplish this goal, we need a genuine commitment from each and every one of us. Because although we as a whole like to talk about the need for research and need for participation, only a very small percentage of all PD patients ever volunteer. I set out to discover a couple of things. First, I tried to do small epidemiological studies involving various facets of Pd. Second, I was interested in finding out what kind of response I would get given a predetermined population size. Much to my chagrin, in three separate instances for three separate studies I found that the commitment rate was 10-12% even when all that was required was 15 minutes of a patient’s time – one time only. There were no risks, no side effects, no contraindications, yet although many showed interest the follow through was markedly disappointing.

So, I wondered if this was the case for other research studies in PD especially when clinical trials by nature are time consuming, have inherent potential risk, as well as potential side effects. Interestingly enough my observations were not dissimilar to those found by a study in 2012 on the trends of Parkinson’s research presented by the UF Parkinson’s symposium. They actually concluded as I did that only about 10% of PD patients participate in trials. They also observed that 30% of all trials never complete due to inability to fill or have recruitment problems and 85% finish late for same reason. With such lack of participation, cooperation and non adherence to doctor’s plans and recommendations which is an increasingly growing epidemic at least in this country is not difficult to conceptualize why trials take so long, why they are so costly and why a cure has yet alluded us.

One would presume that as medical advances have flourished patients would be more inclined to participate in research studies but it does not appear to be so.

Patients still take their cues not from their physicians but from other eternal sources mainly one another. So, if someone had a bad interaction or experience with a drug under study or a clinical trial this may tend to color the opinion of peers more than the medical experts opinion. This is particularly of interest since most of us are now on social media sites looking for advice and exchanging information 24/7.

In one study looking at medication noncompliance, it was discovered that “68% of patients turned to other sources to validate information provided by their physician needless to say these sources were not other physicians.” I believe same holds true for information regarding clinical trials but if we are going to trust our peers we need to have some way of ensuring that the correct information gets disseminated because physicians do not have enough time and resources to validate all information available out there in the social networks.

I believe that we as patients might be better served two ways 1) increasing our participation in all areas of research from peer reviews to advisory boards but keeping in mind that without you the patient participation in actual studies more than 10% our chances of finding are cure are very limited! 2) Concentrate our efforts in asking not for research money at this time but rather to INCREASE public awareness and teaching of what things to look for and expect from trials and how become involved with individual pharmaceutical companies to ensure that our needs are being met and our voices heard. Only then, do I think will we start seeing the pendulum swing in the right direction!

 Furthermore, we need to start taking matters into our hands by becoming proactive and begin raising public awareness so that treatment becomes about us, about what we need now not 10 years down the road. This can only be achieved by working in conjunction with your physicians, the pharmaceutical companies, the NIH, and other publicly funded health and social care research.

Fortunately for us, the tide is changing and big Pharma companies like UCB are taking notice of the need and importance for direct patient involvement in research to make it more relevant, meaningful and useful to our current needs, as well as more patient friendly in hopes of increasing overall participation and attract a wider array of patients. Others like UK clinical collaboration –Involve have also led development of people in research in the hopes of decreasing trial attrition and trying to get trials to finish not only on time but fill up.

WE MUST Remember: Doctors and patients are partners in your long term care and as such both should be equally vested in your overall well being. Like any partnership, the success or failure will depend on the participants. You can only get out what you put into it. So, if we only put in 10% participation we are ONLY going to YIELD 10 % results!

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Dr. M. De Leon is a movement disorder specialist on sabbatical, PPAC member and research advocate for PDF (Parkinson’s Disease Foundation); Texas State Assistant Director for PAN (Parkinson’s Action Network). You can learn more about her work at http://www.facebook.com/defeatparkinsons101 you can also learn more about Parkinson’s disease at www.pdf.org or at www.wemove.org; http://www.aan.org, http://www.defeatparkinsons.blogspot.com All materials here forth are property of Defeatparkinsons. without express written consent, these materials only may be used for viewers personal & non-commercial uses which do not harm the reputation of Defeatparkinsons organization or Dr. M. De Leon provided you do not remove any copyrights. To request permission to reproduce release of any part or whole of content, please contact me at defeatparkinsons101@yahoo.com contributor http://www.assisted-living-directory.com

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Real Life Zombies: A History of Cotard’s Delusion

defeatparkinsons:

Partial complex Seizures? Especially since episodic in ones the cases?.

Originally posted on The Chirurgeon's Apprentice:

In 1880, a middle-aged woman paid a visit to the French neurologist, Jules Cotard, complaining of an unusual predicament. She believed she had ‘no brain, no nerves, no chest, no stomach, no intestines’. Mademoiselle X, as Cotard dubbed her in his notes, told the physician she was ‘nothing more than a decomposing body’. She believed neither God nor Satan existed, and that she had no soul. As she could not die a natural death, she had ‘no need to eat’.

Mademoiselle X later died of starvation. [1]

Although this peculiar condition eventually became known as ‘Cotard’s Delusion’ the French neurologist was not the first to describe it. In 1788—nearly 100 years earlier—Charles Bonnet reported the case of an elderly woman who was preparing a meal in her kitchen when a draught ‘struck her forcefully on the neck’ paralyzing her one side ‘as if hit by a stroke’. When she regained…

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Dealing with Emotional Heartbreak & Depression in Parkinson’s Disease : by Dr. De Leon

Being defeated is often a temporary condition, giving up is what makes it permanent.” Marilyn vos Savant

The brain feels pain the same whether is from a broken heart or a broken leg. This is because the main sensory relay for the brain for both lies within the thalamus which is intricately and extensively connected to both the cerebral cortex and to the basal ganglia. So, it’s no wonder that so many of us battling with Parkinson’s have a hard time dealing with pain particularly emotional pain which can unfortunately lead to isolation and worst suicide as it occurred yet once again recently in our close knit PD community. This unexpected act of hopelessness especially among someone that seemed so upbeat left not only a huge void but also left us pondering the question, “what can we do to prevent these senseless tragedies from repeating themselves?”

Speaking as someone that not only has treated many patients in similar situations but has during my personal battle with this illness felt at times the isolation, devastation and once stood at the precipice starring into the big abyss. Feeling completely exhausted mentally, physically and emotionally in pain and tired of fighting what seemed at that time an uphill battle. The heartache I felt was so severe, I wondered if I had much more strength or reason to keep fighting. The things that kept me from giving up and losing hope and ending it all is what I discuss here with you.

First accept that, the pain is real as spilling hot coffee on yourself. So, don’t try to deny it or sweep it under the rug…just like dealing with physical pain you have to give yourself time to heal (remember everyone heals at different rates so don’t compare yourself to others and don’t rush it). Especially, when dealing with Parkinson’s healing takes TWICE as long whether it be physical or emotional.

Second, just as you would not ignore an oozing gaping wound (I hope), you should not neglect deep sadness or depression if it last more than a week. Yes, it is entirely possible to die of a broken heart literally, the emotions can be so severe and overwhelming a person’s heart can actually deflate like a balloon suddenly losing all its air! (more common among elderly and sick, frail individuals).

Sometimes we set ourselves up to fail or become isolated by the actions we take. We neglect ourselves by putting everyone else’s needs first and we go from exhilaration to exhaustion!
We are so involved with people doing advocacy work, being role models that we neglect to take care of ourselves. We neglect to listen to our bodies needs and don’t get enough rest to replenish our dopamine stores. Just like when you are recovering from a physical injury, you have to take it easy and favor the injured body part -eat well rest as much as the body requires. The same when dealing with an emotional pain you must tend to the wound to help it heal. Furthermore, when you have PD not only does healing take twice as long but the body uses up an extraordinary amount of dopamine to ensure healing, so if this supply is not met the consequences can be disastrous not only stunting heal process but more importantly the lack of dopamine will leave one unsatisfied feeling no pleasure in life. Compound this feeling with exhaustion and people are often set up for slippery slope which can lead to a one way ticket out if we are not careful. This was my case when I became very overwhelmed; I had not allowed myself sufficient time to recover from my physical ailments before adding a lot of emotional strain.

The exhaustion leads to fatigue and weariness both mentally and physically which then begin to wear down the natural defenses. The immune system begins to falter and weaken when you are tired and stressed and poorly rested. Subsequently, fatigue begins to strip our courage away while making us more aware of our flaws and vulnerabilities; hence increasing feelings of depression and decreasing self worth.

Once courage is gone, fear begins to set in. The combination of fear and pure exhaustion invites hopelessness to creep into our thinking, skewing our judgment and giving an erroneous feeling that all options are GONe and there is no Way out!
What happens next is that we retrieve further into our shells becoming even more isolated.
So, when we need others support the most, the fear of failure, anxiety, and a sense of inadequacy sends us running in the opposite direction. In other words…you feel “is BAD and I do t see a solution in sight!”


Therefore, when you are down it is NOT the time to GO at IT ALONE! You MUST reach for God, people that love you and lift you up and support you to help you get back on your feet. Remember to REST! Stay still! I often think about it from a doctors perspective …when we need to do surgery or a procedure on someone who is very ill in order to remove the offending cause like a tumor or mend a deep wound we need them to be very, very still to be able to administer anesthesia and then remove or mend the problem….same goes with our emotional wounds we MUST remain very still and have the true healer and physician apply its healing anesthesia to remove the pain.
Resting and being still will help you get a new world perspective, self-perspective and more importantly God perspective and realize that we cannot go at it alone…


When the pain is gone and you are well rested can you again rebuild and claim your courage!
Remember, when you feel your defenses are down and are feeling overwhelmed instead of retrieving run to your friends and your GOD and also extremely important to make sure that during these times of stress dopamine supply is increased and in abundance even if temporarily along with an antidepressant and /or anti-anxiolytic – this combination will help minimize the feeling of displeasure, and pain and help people cope better with the physical and emotional aspects of their isolation while they rest and regain their strength.

Don’t GIVE UP try AGAIN tomorrow!!

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Dr. M. De Leon is a movement disorder specialist on sabbatical, PPAC member and research advocate for PDF (Parkinson’s Disease Foundation); Texas State Assistant Director for PAN (Parkinson’s Action Network). You can learn more about her work at http://www.facebook.com/defeatparkinsons101 you can also learn more about Parkinson’s disease at www.pdf.org or at www.wemove.org; http://www.aan.org, http://www.defeatparkinsons.blogspot.com All materials here forth are property of Defeatparkinsons. without express written consent, these materials only may be used for viewers personal & non-commercial uses which do not harm the reputation of Defeatparkinsons organization or Dr. M. De Leon provided you do not remove any copyrights. To request permission to reproduce release of any part or whole of content, please contact me at defeatparkinsons101@yahoo.com contributor http://www.assisted-living-directory.com

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DYSKENESIAs: The Dreaded “D” Word in Parkinson’s: By Dr. De Leon

Dancing, dystonic, discombobulated, distraught these are all ways people with Parkinson’s feel when contemplating the possibility of a life with dyskenesias after the initial shock of receiving a diagnosis. Yet, the reality is very different in my experience and to those who have studied dyskenesia epidemiology. Patients have been so fearful of Levodopa to the point of either avoiding medications all together or worse seeking help from a physician thus prolonging their diagnosis and making their disease symptoms worst and decreasing their chances for a good quality of life. Even when patients agree to start medications some have had have great trepidation in increasing the doses or stayed only with Dopa agonist despite severe side effects as some of you might have read the story of a young man with PD who was afraid of starting Levodopa compounds so even though he was experiencing severe side effects in the form of unprecedented gambling with the Dopa agonist, he continued to take the point of almost losing everything including his marriage. It was until he was on the verge of losing it everything that he cherished that he reluctantly agreed to stop taking the Dopa agonists and go on Levodopa to find out it made all the difference in the world. He is now putting back his life together and his symptoms seem to be better controlled according to his blog. Few things that might help you as a patient or caregiver decide which path to take early on when deciding on agonists vs. Sinemet or a Levodopa compound by whatever name you may know it in your country. First, remember Levodopa is your friend NOT your enemy! As I have stated in previous blogs and according to all of the new literature release on the subject- Levodopa is both neuroprotective and neurotrophic. By starting early treatment with this compound in the disease can actually be extremely beneficial since it appears to retard disease in ways that agonists do not. But, like I mentioned in my previous blog this like dopa agonists all have their own unique side effects. The key is learning how to balance their intake and when to use what and in what amounts. Dopa agonists have more sleep attacks, blood pressure problems over all as well as more potential for weight gain and water retention and in men gambling and other OCD behaviors but less risk of dyskenesias. As far as dyskenias are concerned it is interesting to note that the concern and fear is highest for all patients men and women alike independent of age at time of diagnosis or at early onset but as time goes on and disease progresses the concern with dyskenesias decreases. Even in the face of dyskenesias, patients who have these do not seem to mind them when asked out right, it is actually the wearing off and suddenly being unable to move that causes the anxiety and trouble when the disease advances. Dyskenesia look bad as do tremors but if you ask a patient are they bother most do not even notice them or care they have them is the spouses or family members or doctors which get concerned. I have set across many patients and friends with varying degrees of dyskenesia all of whom had told me that the movements did not bother them in the least and some were not even aware until I pointed out as to what I was referring to as an involuntary moment known as a dyskenesia. They all then proceed to state however, they did not like the feeling of being stiff and unable to move so rather be like this. Tremors like dyskenesia should be treated only when they are causing problems for the patient and interfering with activities of daily living. The excess movement is okay unless causing severe weight loss or gait balance difficulties…but what worries most physicians about dyskenesia is that once a patient develops these fluctuations, this is an indication of poor medication regulation by the body and brain which can result in sudden wearing off leading to more devastating problems like falling, chocking, and pain. The truth is that the fear is greater than the actual reality once it sets in and although it is believed that 80% of PD patients develop these within 5-10 years after diagnosis, it is important to know that women are more likely to develop this phenomena compared to their male counterparts secondly these can be delayed if agonists are started early or in combination with Levodopa compounds, other risks are younger onset of disease and duration and doses of Levodopa. Since, young onset PD in women seems to have the highest risk of developing dyskenesias, perhaps these are the ones to delay levodopa some and /or give much smaller doses in combination with dopa agonists or use levodopa with COMT inhibitors to prolong or extend the life of Levodopa compounds thus reduce the total amount consumed and decrease fluctuations. This has worked well for me in treating patients in past. Further, maybe we as physicians need to change our early treatment strategy based on gender and potential for dyskenesias weighting the risk compared to other more serious side effects like gambling. Next time you know of someone diagnosed with PD or a physician suggest that you or a friend start taking Levodopa don’t shy or run away from idea simply on the basis of being afraid of developing dyskenesias. Discuss the issues in detail with your physician most importantly the need for combination therapy to maximize medications benefits and minimize side effects of each always taking into account your gender and what we have learned thus far about how different genders respond to different medications. But above all, remember that NO TREATMENT is ONLY going to Harm you in the long run and shorten your independence and DECREASE your Quality of life. So imperfect treatment is BETTER than No TREATMENT at all!!

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Dr. M. De Leon is a movement disorder specialist on sabbatical, PPAC member and research advocate for PDF (Parkinson’s Disease Foundation); Texas State Assistant Director for PAN (Parkinson’s Action Network). You can learn more about her work at http://www.facebook.com/defeatparkinsons101 you can also learn more about Parkinson’s disease at www.pdf.org or at www.wemove.org; http://www.aan.org, http://www.defeatparkinsons.blogspot.com All materials here forth are property of Defeatparkinsons. without express written consent, these materials only may be used for viewers personal & non-commercial uses which do not harm the reputation of Defeatparkinsons organization or Dr. M. De Leon provided you do not remove any copyrights. To request permission to reproduce release of any part or whole of content, please contact me at defeatparkinsons101@yahoo.com contributor http://www.assisted-living-directory.com

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