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Are tremors in legs, difficulty walking and hallucinations symptoms of Parkinson's disease?

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Posted on Wed, 25 May 2016
Question: doctor
my mother was diagnosed with mild parkinsons disease almost 3 years ago.reason was movement of lower jaw on rest and involuntary mid finger movement on the left hand.these two symptoms present only on rest .
our local physician started her with syndopa 110 mg 1 per day and after 15 days of medicine, these symptoms gone and we were continuing with 1 syndopa for almost 2 years.she was moving around walking. writing etc and wa sfine with this apart from her age related tiredness.
last XXXXXXX end (2015 ) while she was about to sit on bed.she heard a noise on the back and started feeling some pain that night onwards.after 10 -15 days of some treatment with analgesiscs ec pain was not going and ortho asked us to do MRI of spine. MRI revealed L4 Compression fracture and ortho opined that the treatment for the same is calcium and Vitamin D supplements and she was advised bed rest for 6 weeks excepts for getting up for food and toilet.
ortho said there was no damage to any nerves etc.
she had a review after 8 weeks with X ray and said to continue with calcium and vitamin D. she was having some pain and the pain was managed with Ugesic tablet in the morning and dolo 650 in the evening.we managed this and slowly pain in the back got reduced.
During this time her movement started getting affected and she managed to walk after that only with walker and was unable to walk with a stick which she was used to earlier.MOST IMPORTANTLY she started getting hallucinations and started saying some one seen around etc when no one was around.since she was having pain during this time the normal sleeping pill ATIVAN dosage of 1 mg per night was given. earlier we used to give only half of 1 mg per night.
we went to Appolo pain clinic to have a second opinion reg the compression fracture since she was unable to alk on her own.
Doctor there opined after seeing the MRI and opined that the treatment so far given were right and no need of any vertebroplasty and asked us to continue the same treatment-mild pain killers with Vitamin D.doctor asked our mom to walk in the corridor using walker and she walked.Doctor opined that its only fear and she has to be motivated to walk.THERE we told the doctor reg hallucinations and after checking her hand .holding her hand etc-- HE was of the opinion that treatment as given--syndopa and attivan shd be tapered off and removed and that is the reason for this Hallucinations.
we informed our local physician reg the same and though he was not agreeing but asked us to try to reduce and see.we did reduce the syndopa from 1 at a dose to half & half per day to half per day.he introduced another drug which was having propanolol and another combination to control the tremors also.( even earlier My mom used to experience mild tremors on both the legs which used to start by 4PM and releive on its own by 8PM.).when we started using this there was no significant reduction in the tremors and slowly it started increasing.
with this we DECIDED to meet a qualified NEURO PHYSICIAN in chennais leading hospital and NEURO also said this is not parkinsons and that is the reason she is getting hallucination s etc . becoz of increas in tremor my physician increased syndopa to 2 per day.
so again syndopa was decreased to one per day and then to half per day.Neuro advised us to stop propanolol immediately as giving it for elders is not advisable.
she wasinstead put on TRigabantein 100 mg with starting of 1/2 -1/2 -1/2. and increase the dosage to 1/2-1-1/2.
this happened during last august end.
after tapering of syndopa my mom started getting very rigid and felt that whole body is getting heavy etc. and another symptom started coming back-- lower jaw--precisely lip movement heavily on rest.
so we again visited the neuro .on further examining neuro admitted that this is called senile parkinsons and we need to get back to syndopa,
this time he suggested to use syndopa plus 1/2-1/2-1/2 for 10 days and then to increase to 1-0-1 per day.along with trigabantein 1/2-1/2-1/2.
for the lip movement he suggested pacitane- 2 mg--1/4-0-1/4 per day.(SET END )
with the above medications the lower lip involunatary movement is arrested and another MAJOR side effect started in the NIGHT--heavy hallucinations. this hallucinations is like she will et up in the night sleep suddenly at around 2 pm or 3pm and started to even cry saying that w e have shifted her to some other house when she was on sleep to some other house and wanted to get back to our home urgently.this used to happen only in the night. It was creating very big problm for us in dealing with her at that age in the night. BUT ONCE morning come say at around 5.30 or 6AM she will get alright.during this time she wa s on 1 mg of ativan.itused to be very difficult for us. PL NOTE even during this period the tremors on both legs which used to come at around 4PM used to come still and last till 9PM.one of the day as per our physician we increased attivan to 2 mg to make her sleep and the result was very disastrous. that night severe problem in blabouring etc.these were happening in whole of october.
pl note during night shefelt very thirsty and throat used to get dried.
my neighbour is a dentist and on knowing all this he suggested us to modify the drugs.
he was also of the opinion that this s not at all parkinsons but unfortunately patient is responding-reg stiffnes etc.he advised us to stop attivan immediatly .and replace attivan with stresnil-.25mg per night.and also to decrease the pacitane dosage to only 1/4 per day.along with syndopa plus-2 per day and 1/2 of gabapentin in morning and night.
BELEIVE ME DOCTOR this started working and she started to getting sleep in the night and wtever she was blabouring in the night- getting up etc XXXXXXX started reducing and stopped.This started working from NOV end.
By december end we again visited same neuro and informed him the whole happening.while he asked us to continue the same--syndopa plus 2 per day and gabapentin-1--1.,he advised us to start using quitipine-25mg-1/2 per night for proper sleep.this was going on for another 2 months till XXXXXXX
we again visited end XXXXXXX --reason-- the TREMORS in both the legs started increasing and suddenly the temors started spreading to hands also.Pl note the tremors come by around 4pm only and lasts till 8PM.
so now neuro suggested us to increase the syndopa plus dosage to 3 per day.1-1-1 and gabapentin to 1-0-1.and was of the opinion that we may have to increase the SYndopa plus dosage to 4 per day also. this tremors occur only by 4pm and goes till 9PM. since tremors are increasing when we called up he increased trigabantein 100 mg to 3 per day.1-1-1.
now my mom is on
syndopa plus -1-1-1
trigabantein----1-1--1
pacitane 2mg--1/4-0-0.
stresnil .25 mg---0-0-1/2
quitipine-----25mg--0-0-1/2.
with this dosage for the last 20 days also there is some evidence of lower episode of tremors.but halluciations have started increasing- she is saying some one around etc while there is no one. nowadays she is not even able to walk with walkers and and always on bed. though she get s up for food .toilet etc.
NOW SHE IS SAYING THESE TREMORS ARE AFFECTING HER a lot creating panic .fear etc.tremors are mainly on both legs and by the time it sets in both the foot starts flapping-- sometimes looks like restless leg also. both the foot flapps on rest when she is on bed.and not when she is on sleep.
doctor. what is this real problem?
any suggestion for reducing /adding any medicine?
she is unable to even walk with walker nowadays and very badly the hallucinations have started coming back.
she is 89 now and weighs 40 kg .she has been low weight always. we took complete blood test recently thro thyo care package and all parameters are within normal.
she takes renerve plus injection 1 per week.
what is this problem? except tremors she does not have any other symptom which generally parkinson people has..
are these drugs only treatment for tremors?now that halluinations have started again....
when she was on syndopa 1 tablet per day --2 years back--- she never had all these problems... (even that time thsi tremor used to come but mildly--it still follows 40pm to 9pm and nowadays when it comes even the Blood pressure shoots up.
are we on the right track of medications?
her movement is totally reduced these days...
and no back pain for that comppression fracture nowadays.



doctor
Answered by Dr. Sudhir Kumar (6 hours later)
Brief Answer:
Her condition looks like a Parkinson's plus syndrome.

Detailed Answer:
Hi,

Thank you for posting your query.

I have noted your mom's history and treatment details (thanks for providing a comprehensive detailed information).

I agree that it is not the typical Parkinson's disease (PD). In PD, the tremors are more in hands as compared to the legs. Also, it starts on one side of body and affects the other side after about three years. In addition, there is slowness of movements, and stiffness of arms/feet in PD. Her features are not like typical PD.

There are a few similar condition (which have features similar to PD). They are called as Parkinsonism or Parkinson's plus syndrome. Common examples are diffuse Lewy body disease (DLBD) and progressive supranuclear palsy (PSP). Her features are more like DLBD, as hallucinations are common in this condition.

Unfortunately, Parkinson plus syndrome patients worsen rapidly (as compared to PD) and also do not appropriately respond to Syndopa (either they do not improve or have a lot of side effects).

Further confirmation of diagnosis may require PET CT brain.

Treatment is mainly to make her comfortable, as the disease can not be cured and the progression can not be stopped. Qutipin can be used to suppress hallucinations. Sleeping medicine may be used in low dose. Syndopa should either be stopped or given in a low dose.

Physiotherapy and counselling by a psychologist would also help.

Best wishes,

Dr Sudhir Kumar MD DM (Neurology) XXXXXXX consultant Neurologist
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Sudhir Kumar (17 hours later)
Doctor
thanx so much for your reply.I have the following questions for which expect clarifications
1) even after increasing syndopa plus from 2 per day to 3 per day the tremors which essentially start by 4PM and leaves by say around 8 or 9Pm is not reducing.sundopa plus we give morning at 10.30AM-- 3,30Pm--- 8.30PM.
after the night dose at 8.30Pm and then morning dose at 10.30 AM... the tremors on both legs start by 3.30 or 4PM only.why this tremors follow this timing every day??Is syndopa a treatment for this tremors-- ( this tremor doesnot make her body shake--rather it creates a sort of severe pulling of nerves which starts on both the legs/calf muscles. we put one big pillow on her legs that time.that gives some releif.and she sets stable somwhat this time if we put Air conditioner on.
why this tremor/pulling of nerves down happens at that time inspite of 3 syndopa plus in a day??
2) what for TRigabantein 100 is given?? what is this medicines role? now she is taking this medicine also 3 times a day.will trigabantein reduce tremors/pulling of nerves???
3) by reducing syndopa plus & trigabantein by 1 tablet
per day and adding 1/4 of pacitane (2mg) in the afternoon before the tremor starts help?? ( this was suggested by our local physician but without checking with neuro we have not tried yet.)
sometimes when the pulling of nerves /tremors happen vigorously the BP also shoots upto 180 plus.
even today morning my mom told me that if not for the tremor/pulling of nerves down-- she will be fine. ( she does not have problem of holding/standing etc.
HOW to STOP this tremor?
4) what would ne your suggestion/opinion for reducing syndopa plus dosage??
kindly go through my questions given above and give your opinion doctor for srl no 1 to 4.
and I forgot to mention one important side effect--severe constipation. any suggestions doctor.
Thanks & Best regards
XXXX XXXXXXX
doctor
Answered by Dr. Sudhir Kumar (6 hours later)
Brief Answer:
Syndopa would not be very helpful.

Detailed Answer:
Thank you for getting back and providing more information. The replies to your queries are below:

1. As mentioned in my first reply, we do not expect much improvement in tremors or other symptoms in Parkinson's plus syndromes with Syndopa (unlike in PD, where good improvement occurs). There is no specific reason for an increase in tremors in evenings.

2. Trigabantin helps in reducing pain, burning or tingling of nerve origin. It has no effect on tremors.

3. Pacitane may help reduce tremors in some people, so it can be tried once. However, side effects of pacitane such as dryness of tongue and mouth can be worrisome. We need to examine the "tremors" to decide which medicine would help her the most.

4. In my opinion, syndopa plus may be stopped or it can be given at a low dose such as 1/2 or 1 tablet two times daily.

Best wishes,

Dr Sudhir Kumar MD DM (Neurology)
Above answer was peer-reviewed by : Dr. Raju A.T
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Are tremors in legs, difficulty walking and hallucinations symptoms of Parkinson's disease?

Brief Answer: Her condition looks like a Parkinson's plus syndrome. Detailed Answer: Hi, Thank you for posting your query. I have noted your mom's history and treatment details (thanks for providing a comprehensive detailed information). I agree that it is not the typical Parkinson's disease (PD). In PD, the tremors are more in hands as compared to the legs. Also, it starts on one side of body and affects the other side after about three years. In addition, there is slowness of movements, and stiffness of arms/feet in PD. Her features are not like typical PD. There are a few similar condition (which have features similar to PD). They are called as Parkinsonism or Parkinson's plus syndrome. Common examples are diffuse Lewy body disease (DLBD) and progressive supranuclear palsy (PSP). Her features are more like DLBD, as hallucinations are common in this condition. Unfortunately, Parkinson plus syndrome patients worsen rapidly (as compared to PD) and also do not appropriately respond to Syndopa (either they do not improve or have a lot of side effects). Further confirmation of diagnosis may require PET CT brain. Treatment is mainly to make her comfortable, as the disease can not be cured and the progression can not be stopped. Qutipin can be used to suppress hallucinations. Sleeping medicine may be used in low dose. Syndopa should either be stopped or given in a low dose. Physiotherapy and counselling by a psychologist would also help. Best wishes, Dr Sudhir Kumar MD DM (Neurology) XXXXXXX consultant Neurologist