Coastal Neurological
Medical Group, Inc.

View Points: A JOURNEY TOWARD WELL BEING.

Dee Silver M.D.

For over 44 years I have done clinical research, clinical trials and seen thousands of patients, focusing on the neurodegenerative disorders such as Parkinson’s Disease, Alzheimer’s and Multiple Sclerosis, all possibly manifesting impairment of balance, movements and cognition. A person’s genetics, life style, age and chance, will be a great influence on ones Quality of Life and health status as they age and risk significant medical illnesses that most of us will acquire. A key to a better aging life is to avoid accumulating medical deficits such as obesity, nicotine addiction, alcoholism, diabetes, hypertension, stroke and heart disease. The more fragile ones health is mentally and physically, the more likely a person will experience anxiety, depression, apathy, fatigue and reduced activities of daily living. Learn to avoid accumulating mental and physical disadvantages that will deteriorate health care status and increase your family’s health care burden. Avoid or reduce health deficits that compromise you and your family as you journey through life. Learn to change a detrimental life style early in life by being an advocate for your future well being.

DEFINITION OF TERMS ANXIETY, APATHY, FATIGUE, FRAILTY AND FEAR OF FALLING

Anxiety is defined as a distress or uneasiness of mind (psychological state) caused by fear, danger, perceived pending misfortune or where outcome of an event is uncertain. It is a state of apprehension and psychic tension.

Apathy is defined as a decrease in goal-directed behavior, withdrawal, loss of motivation, interest, feelings, preception and emotions. There is neglect of grooming, eating and cleaning. The person does not appear to be concerned about this loss. Apathy is often overlapped with anxiety, depression, dementia and fatigue. It said to occur in 50% of Parkinson’s disease patients.

Fatigue is usually a constant; however, it can be an intermittent state of weariness, decreased energy, reduced mental capacity, which affects physical and emotional well-being. It is related to:

  1. Habits, lifestyle, routines, use of substances such as alcohol, cigarettes, caffeine and reduced activity.
  2. Medical problems are associated with fatigue often having some chronicity.
  3. Psychological associated symptoms are anxiety, depression, dementia, stress and apathy.

Frailty is accumulated deficits and is significantly related to age. It is a nonspecific state of increased risk. Often multisystem diseases are present with gradual increase of these diseases with time and age. Physical and emotional deficits are the key factors. Frailty brings about reduced quality of life, activities of daily living, increased hospitalization and increased costs, and increased office visits. It is related to attention, concentration, function, mobility and balance.

Fear of falling is a perceived state. Duration and severity depend on a possible related injury and prior history of anxiety. It is usually transient. Its severity is related to the injury that has been the event that brought about the fear of falling. Psychological trauma (fear of falling) is self-imposed. The decline or severity of the state is outside the realm of injury or disabilities. It is associated with reduced healthcare status, quality of life and if unchecked it is related to functional decline. It is related to anxiety, depression, and dementia and there is often a discrepancy between the physical ability and functioning.

WELLBEING IN PARKINSON’S DISEASE (IPD)

The Wellbeing in Idiopathic Parkinson’s Disease ( IPD) is determined by Quality of Life (QOL) and Activities of Daily Living (ADL). Certain scales or measurements determine QOL and ADL. These are measures (UPDRS and PDQ39) of motor control and non-motor symptoms as well as cognition. The neuropsychiatric (NP) signs and symptoms are somewhat included, but measurements are difficult; however, their symptoms can be very detrimental to a patient’s QOL and ADL. A patient today with IPD can live 20 years or more after the diagnosis of IPD if they avoid comorbidities such as cancer, diabetes, obesity, hypertension, vascular disease (stroke and heart disease), and renal and pulmonary disease. Some of these are determined by genetic predisposition, but many are related to habits and lifestyle. Trauma (like falls with head injury and fractures) reduce QOL, ADL, and survival. Hence, trauma such as head injury and falls must be avoided and if possible, prevented. Much of this comorbidity (additional disease) accumulates deficits and is associated with accumulated motor and non-motor deficits which affect QOL and ADL. Accumulated deficits may be genetically determined in part, but even these are influenced by our lifestyle. To avoid or delay much of these deficits, a healthy lifestyle should be established early in life since most of these diseases or comorbidities have early pathophysiological changes 10 or more years before clinically obvious. This is certainly the case in neurodegenerative diseases such as IPD and Alzheimer’s (DAT). Brain changes occur years before the symptoms appear.

At the recent American Academy of Neurology (AAN) in April, multiple studies documented in animal models and in patients that exercise not only gives better scores on Parkinson’s measurement (UPDRS) but also on QOL and ADL measurements. Exercise results in better motor strength, balance, gait, conditioning and endurance, which always benefits the patients. This exercise must be done almost daily and to near maximum heart rate (60 to 80% Max HR). Exercise and a healthy diet benefits most comorbidities.

There is evidence that neuropsychiatric signs and symptoms affect QOL. These NP symptoms are depression, apathy, anxiety, fatigue, frailty, and fear of falling. These symptoms can have a profound effect on QOL and ADL. Depression occurs in 30% to 50% of IPD pre-diagnosis and probably higher after the diagnosis. Mild cognitive impairment (MCI), occurs in 10% to 20% of patient at the time of diagnosis. MCI is loss of memory for recent events without signs of DAT. In IPD, cognitive impairment at 8 to 10 years after the diagnosis occurs in 60% to 80% of patients. It appears to be more prominent in patients who are older, and had the disease longer, have neuropsychiatric symptoms and are at higher dosages of medication. Pathologically, cognitive impairment in IPD is a mixture of Lewy body pathology (DLB), DAT, and vascular changes.

In order to recognize NP symptoms, we have to understand how they are defined. Anxiety is defined as a distress or uneasiness of mind (psychological state) and causes of anxiety are fear, danger, perceived pending misfortune or where the outcome of an event is uncertain. It is a state of apprehension and psychic tension. Apathy is defined as a decreased in goal-directed behavior, loss of motivation and interest, loss of feelings and emotion, and often overlapped with anxiety, depression, dementia, and fatigue. Anxiety occurs in about 50% of Parkinson’s disease patients. Fatigue is usually a constant state and occurs in 70% to 80% of patients with IPD. However, it can be an intermittent state of weariness, decreased energy and reduced mental capacity; all of which affects physical and emotional well being. Fatigue is related to many aspects of the person’s life. Habits, lifestyle, routines, use of substances such alcohol, cigarettes, caffeine, and reduced activity are often related to fatigue. Chronic medical problems are often associated with fatigue. Psychologically associated signs and symptoms are anxiety, depression, dementia, stress, and apathy.

Frailty is accumulated health deficits, which affects healthcare status and is often significantly related to age. It is a non-specific state of an awareness of increased risk. Often multisystem diseases are present with gradual increase of these diseases’ burdened with time and age. Physical and emotional deficits are key factors to frailty. Frailty brings about reduced QOL, ADL, increased hospitalization, increased healthcare cost, and increased office visits. Frailty is associated with reduced attention, concentration, function, mobility, and balance.

Fear of falling is a perceived state. Duration and severity depend on related injury and prior history of anxiety. It is usually transient and its severity is related to the injury that has preceded the event and brought about the fear of falling. Psychological trauma (fear of falling) is self imposed. The decline or severity of the state is usually outside the realm of injury and disability. It is associated with reduced healthcare status, QOL, and if unchecked, it is related to significant functional decline. There is a discrepancy between physical ability and functioning.

Exercise, healthy diet, non-smoking, and weight loss all reduce the chances of acquiring cumulated comorbidity and hence acquiring deficits and reduction in healthcare status.

These entities or deficits that affect QOL and ADL need to be recognized and discussed. The foundation for therapy is optimized, pharmacological management and if needed, psychological counseling. Exercise, conditioning, reassurance, adequate sleep, support, possibly counseling, and medication will help reduce the impact of the above symptoms on the patient and on the caregiver’s QOL.

CHRONIC TRAUMATIC ENCEPHALOPATHY (CTE)

Chronic traumatic encephalopathy is a clinical entity which is secondary to repetitive trauma of various degrees of severity. Most of the history of trauma is probably multiple and includes grade III concussions which involves loss of consciousness. It certainly can involve more severe trauma. There is an uncertainty as to the number of traumas it takes and the severity of the traumas to develop CTE. The patients with CTE have a progressive, gradually worsening clinical condition which is associated with multiple types of signs and symptoms. The most important is behavioral changes. The patient can develop behavior and personality changes that are gradually progressing. These behavior changes can be associated with depression, irritability, impulsiveness, apathy, fatigue, anxiety, and even suicide. The severity of the depression has a wide spectrum that may involve signs and symptoms of depression which can be crying spells, weight loss, reduced appetite, sleep disturbances, withdrawal, and suicidal ideation. Parkinsonism is often seen in patients with CTE. Patients will develop a symmetrical rigidity, bradykinesia or akinesia and often will develop masked fascies along with stoop posture and flexion of the extremities and shuffling with walking. Balance difficulty with posture instability can also be seen. Dementia is the symptom that may occur later in the disease and is usually preceded by behavioral changes. There is memory loss, especially recent memory loss. Attention span is reduced. Appropriate social awareness and the usual conscientious behavior is often reduced. There is significant executive dysfunction with visual and social changes. There is loss of processing speed and judgment may become inappropriate. Reasoning is affected and problem solving is significantly changed. Generally, in CTE, the symptoms develop gradually and progress over years and can occur years to decades after the trauma. The PET scan will often be abnormal, especially in the temporal areas, but sometimes also in the frontal area. The pathology is that of Tau pathology without significant beta-amyloid changes such as senile plaques. The Tau pathology is usually seen in the tips of the temporal lobe in the hippocampus and also in the frontal superficial cortical area. CTE is obviously a diagnosis by exclusion and these patients must be worked up to rule out a metabolic, endocrine or a structural abnormality. The spinal fluid will usually be normal but if levels of amyloid and Tau are obtained, the amyloid is usually in normal range and the Tau is elevated. Most importantly, structural lesions such as stroke, subdural’s and tumors need to be ruled out.

FATIGUE

In Parkinson’s disease, fatigue is significantly associated with reduction in quality of life and increased distress in one’s life. The frequency of fatigue in Parkinson’s disease is 40% before motor signs and 80% after the diagnosis. Fatigue, in many situations, is associated with reduced mobility, emotional well-being, physical function, social interaction and vitality. Depression is probably the strongest risk factor for quality of life in patients with Parkinson’s disease. Fatigue is a concept based on the patient’s own perceived state of energy or lack of energy. Fatigue is a constant state of weariness that the patient experiences. The patients have reduced energy, mental capacity is reduced and it affects the physical and emotional aspects of the patient’s well-being. Fatigue differs from sleepiness, but often fatigue is a desire to sleep and there is a reduction in motivation. A loss of conscientiousness and inattentiveness is certainly present. Fatigue is often closely related to habits and the person’s lifestyle and routine. Routines such as excessive alcohol, excessive caffeine use, smoking, reduced activity, reduced sleep and excessive medication are often related to fatigue. Medical disorders associated with fatigue are many including, but not exclusive, renal, hypertension, heart disease, stroke, diabetes, thyroid disease, obesity, psychological diseases, sleep disorders and obstructive sleep apnea. Fatigue is very closely associated with psychological problems such as anxiety, apathy, grief, depression and stress. Studies have shown that fatigue is associated with more advanced disease of any kind and more with advanced aging. Exercise is probably of benefit in treating fatigue.

FRAILTY

Frailty and accumulated deficits (lack of or defect) and health status compromise in patients are very interrelated. Frailty is a nonspecific state of increased risk. Frailty is associated with multisystem disease, is somewhat age related and there may not be specific existing known diseases. Specific factors in frailty are difficult to determine, but they are often related to attention, concentration, function, mobility, balance, cognition, depression, apathy and continence. What role these play in daily activities results in the degree of frailty. It is important to avoid accumulation of deficits, especially multi-organ health deficits (i.e.-diabetes, hypertension, stroke or heart disease, lung, renal, liver, neurodegenerative disease or orthopedic compromise). Accumulation is a dynamic process and usually is a greater burden with aging. Some studies show, however, that age alone can have little or minimal impact on deficits.

Appropriate lifestyle to reduce accumulated disease or deficits is paramount. The rule generally is the more diseases you have, the more frailty you have, both emotionally and physically and the greater the chance is that you will have more medical problems in the future , hence accumulation of more deficits. Patients with frailty have more signs and symptoms, disabilities, diseases and laboratory abnormalities that indicate diabetes, vascular disease, renal failure, liver diseases. Increased frailty is a very significant indicator that the patient will have greater doctor visits, hospitalizations, and/or institutionalization and earlier death. Frailty is a very considerable cost burden and stress to the caregivers and the family. Women accumulate more deficits than men as they grow older, yet men have a higher mortality rate.

It is important to have an awareness in early age of a life style that will reduce disease development and hence reduce accumulation of deficits and disease as you grow older. Encouragement and psychological counseling sometimes are very beneficial along with exercise, a positive environment and mental stimulation.

FEAR OF FALLING

Fear of falling is a psychological trauma (fear of falling) and is a self-imported decline outside the realms of the actual disability or injury. After falling, the majority of elderly people will have a short period of time that involves anxiety and is related to their fear of falling. 15% of the falls are associated with fractures or injuries and the patient has awareness that falling can have significant consequences. The duration and severity after the fall is often related to accumulated deficits, which include the patient’s prior life journey. This includes medical and neurodegenerative diseases, prior fractures and emotional status that is present at the time of falling. Depression, anxiety, physical ability, and apathy are all related to the degree of fear of falling. Fear of falling has a discrepancy between the physical ability and the functioning that is possible and it is frequently seen in elderly people often more with increasing age and this discrepancy is causally related to social, emotional, and environmental factors that exist at that time. About 50% of people who fall (fallers) have fear of falling and many of them (25%) avoid activities for a period of time. Older age is a very common factor in an increasing incidence of fear of falling. There is a definite concern for self-efficacy, meaning the individual’s perception of the capabilities they have with a particular domain of activities or their propensity to fall in certain activities. There is a great deal that depends of one’s own deficit and this appraisal is modified by memory, balance, rigidity, slowness, and ability to avoid falls or avoid injury. There are a number of scales such as the Falls Efficacy scale. They help to categorize and rate how the patient will be in their fear of falling and how much they will have for dependency on their family or an agency. An older patient who is in their 80s to 90s often have accumulated frailty and accumulated deficit. Parkinson’s, DAT, MS, FTD, chronic illness, depression, anxiety, memory loss all reduce the patient’s ability to prevent or avoid falls and injuries.

Treatment is based upon the status of the patient with regard to above-mentioned associated signs and symptoms. Often treatment with behavior modification, physical therapy, reassurance and occupational therapy will help fear of falling. These will give the patient significant confidence in avoiding falls and improvement in their fear of falling syndrome.

Dee Silver M.D. 5/30/12

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Coastal Neurological Medical Group
9850 Genesee Avenue
Suite 860
La Jolla, CA 92037
Tel: 858.453.3842
Fax: 858.535.9390

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