Pharmacy & Therapeutics - October 2008 - (Page 593)

Medical Management of Parkinson’s Disease during the day. It is unclear whether these symptoms are related to PD or to the medications used to treat PD. Patients should never take over-the-counter sleep aids without consulting a physician. alone. Several symptoms of PD are similar to the symptoms of depression (e.g., loss of interest in activities, fatigue, change in weight, and social withdrawal). This similarity can result in an underdiagnosis of depression in those with PD. Furthermore, patients might not even recognize that they are depressed. On a more positive note, depression is treatable and can be controlled with a combination of antidepressant medications and cognitive-behavioral therapies. If left untreated, depression can have serious negative consequences, interfering with cognition and, consequently, with quality of life. Cognitive Changes PD is a complex condition accompanied by numerous symptoms. Primary symptoms involve changes in movement, but other symptoms can occur as well. Changes in one’s ability to think, reason, and remember may develop, and many factors can contribute to these differences.26 Cognitive changes can affect patients’ everyday lives as much as, and sometimes more than, the physical (motor) effects of PD.27 Even though physicians are increasingly recognizing the importance of addressing cognitive and other nonmotor symptoms, many still primarily focus on treating physical symptoms and cognitive changes may remain undertreated or untreated. An accurate assessment of cognitive changes is needed in order to establish an appropriate treatment strategy. Thinking. Bradyphrenia, or a slowing of the ability to think, can occur.26 Just as it takes more time to rise from a chair, patients may need more time to respond intellectually. It takes longer to process information, and this can lead to frustration for both patients and caregivers. Bradyphrenia may be misinterpreted as intentional behavior, a lack of interest, or even stubbornness, but it is important to understand that changes in the brain are the cause of the symptom. Pressuring an individual who is having problems of cognition creates stress and usually makes matters worse. Patients may find it difficult to think of other ways of doing things or to shift from one topic to another. These changes in cognition may be mistaken as intentional, and the individual may be labeled as being rigid or inflexible. In some patients, a portion of the brain involved in this type of thinking can be affected. Memor y. Memory remains relatively unaffected in PD, although some individuals may have trouble remembering where and when particular events occurred if they are not given a cue. For example, patients recall information much better if they are given multiple choices to select from, and they benefit from using cues more than people of a similar age without PD. Language. Significant language changes are uncommon in PD, but subtle changes may occur. Speech often becomes slower, and spontaneous speech is reduced. Patients might not initiate conversations as often, if at all. These changes can be misinterpreted as indifference and can result in poor communication. Dementia. Significant and dramatic changes in memory, reasoning ability, language, and attention may develop in a small number of patients.27,28 As people age, the risk of a progressive decline in the ability to think and remember increases. If dementia develops, patients need increased care and supervision. Depression. Depression is another possible cause of cognitive changes in patients with PD, and it is more common in these patients than in the general population; 25% of PD patients experience depression within one year of the onset of PD symptoms.26 The development of depressive symptoms is unlikely to be a result of difficulty adjusting to the diagnosis Adverse Drug Reactions As will be discussed later, many types of medications are available to control PD symptoms. However, managing the symptoms of PD becomes increasingly difficult as the illness progresses. The development of adverse effects and changes in the steady response to medications pose numerous challenges to patients, their families, and health care providers. Unfortunately, changes in cognitive ability can be a potential side effect of all drugs used to treat PD. Therefore, patients must know which side effects are associated with the drugs they are taking. If cognitive decline is experienced, a health care provider should be notified immediately. Summary Some patients with PD experience changes in mood and cognitive ability. The most common changes include slowed thinking and processing of information. A decreased ability to generate new ways of solving problems may be apparent. While changes in memory are less frequent, some people with PD forget where and when the information was obtained but remember the information itself. Dementia develops in some patients, and advancing age is a risk factor. Depression is often underdiagnosed in these patients. Regardless of the type of cognitive changes experienced, accurate assessment is essential if symptoms are to be treated. PATIENT ASSESSMENT Early symptoms of PD are subtle and occur gradually.1 Patients may be tired, or they may experience a general malaise. Some may feel a little shaky or have difficulty getting out of a chair. They may notice that they speak too softly or that their handwriting looks cramped and spidery. They may lose track of a word or thought, or they may feel irritable or depressed for no apparent reason. This early period may last a long time before the more classic and obvious symptoms appear. Friends or family members may be the first to notice changes. They may see that the person’s face lacks expression and animation (“masked face”) or that the person remains in a certain position for a long time or does not move an arm or leg normally. Perhaps they see that the person seems stiff, unsteady, and unusually slow. The onset of symptoms may go unnoticed for several years. Early signs include stiffness of fingers or a stiff shoulder accompanied by stiff muscles. Pain may be a feature.20,23 Symptoms usually only affect one side of the body for one to two years and then spread to the other side. Tremor is often noticed first and usually provokes the initial visit to the doctor. How- Vol. 33 No. 10 • October 2008 • P&T® 593

Table of Contents Feed for the Digital Edition of Pharmacy & Therapeutics - October 2008

Pharmacy & Therapeutics - October 2008 Contents Editorial Medication Errors Prescription: Washington New Drugs/Drug News/ New Medical Devices Drug Forecast Medical Management of Parkinson’s Disease Why Is Health Care Regulation So Complex? The Next President’s Prescription for Action on Drugs Trends in Managing Multiple Sclerosis Product Profiler: Sancuso®

Pharmacy & Therapeutics - October 2008

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