- Email: [email protected]
Management of extrapyramidal disease in the family medicine clinic
Brain Reseurch Bulletin, Vol. 11, pp. 163-166, 1983. 0 Ankho International Inc. Printed in the U.S.A.
Management of Extrapyramidal Disease in the Family Medicine Clinic ORENE W. PEDDICORD
Department
of Family Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX 79430
PEDDICORD, 0. W. Management of extrapyramidal disease in the family medicine clinic. BRAIN RES BULL ll(2) 163-166, 1983.-h extrapyramidaldisease there is need for continuing care by the primary family physician over the years. The patient will need medication checks, emotional support, and be educated on how to perform tasks of everyday living. There is great emotional impact on the family. The family’s understanding of medication and ilhtess is essential in order to foster independence. Care of the chronically ill will become an increasing problem as the mean age of the population rises. General considerations
Negative attitudes
Neutralizing reactions
Positive reactions
Supportive therapy
possible since another fear is becoming a dependent invalid. The family’s understanding of the medication, the natural history of the disease, and the complications does much to lessen the fear and dread. This is crucial to the patient’s well being. The dependent patient ultimately becomes hostile due to his feelings of helplessness and hopelessness. This hostility is directed to the family members as well as the physician. At all times the patient should be preserved with as much autonomy as can be safely maintained. The recognition of overdose or under medication, as well as the recognition of symptoms which do not relate to Parkinsonism, is imperative by the patient and family members. Oftentimes such recognition will enable a phane call rather than an office call to rectify the problem. The physician should try to keep the medication lists as current and readily available as possible to avoid both confusion and drug-drug interaction toxicity. An acute awareness of the drug-drug interaction and the side effects of all current medication is essential to avoid as much iatrogenic disease as possible. There are certain attitudes and responses that are universal in all chronically ill or disabled. These consist of initial negative and neutralizing reactions which are followed by positive reactions. These are summarized in Table 1.
THE diagnosis and treatment of extrapyramidal disease is often accompanied by continuing care over the years by the patient’s family physician. If the patient presents undiagnosed and untreated, a full workup is done to consider all factors and concomitant conditions before diagnosis is made. A careful and detailed history is essential to rule out prior medical insults, drug use, alcohol use, trauma, military duty overseas, travel to foreign lands, parasites, long-term use of any psychotropic drug, toxic chemicals, and heavy metal exposure [l, 5, 13-15, 211. A genetic history is important also, along with work history, in particular, dealing with pesticides, fertilizers, and plastics [3, 7, 10-12, 18, 191. if extrapyramidal disease is suspected, the patient is referred to a neurologist to confirm the diagnosis and to initiate the medications with the clinic then providing the tiercare. There are a number of drugs that are in use currently in medicine that cause the same type of symptoms are primary Parkinson’s disease. By nature of the disease, which is one of chronic progressive degeneration [2,4,9, 16, 17, 191, the patient will need much more care in the form of medication checks, emotional support, and simply how to perform tasks of everyday living which are taken for granted 161. The emotional impact of the diagnosis of Parkinsonism on the patient, the family, and in some cases the employer, is devastating, e.g., airline pilot. The patient usually thinks he has been sentenced to a slow agonizing death in utter abandonment. He fears the loss of his family’s love and respect and is humiliated by shaking and drooling. As eating-becomes difficult, there .is social withdrawal. All the fears have real basis. Families do tend to abandon members with chronic or debilitating illness. Therefore, the therapists try to address this factor by insuring that the patient and family understand the illness and become conversant with the types of medications and their effect. There is much reassurance which accompanies this type of understanding making the patient more independent [8]. It is crucial to allow the patient as much autonomy as
NEGATIVE REACTIONS it should be noted that the care of the chronically ill will become an increasing problem as the mean age of the population rises and the use of psychoactive drugs increases. Furthermore, there are certain alterations in metabolic rate and biological half life of drugs as a function of age. For example, as the human organism ages there is a general trend for prolonged retention of drugs in the body to have more prolonged biological activity and generally to produce a more powerful clinical and toxic effect [20]. Therefore, hazards and toxicity of medication, including psychotropic drugs, should be considered when administered to the geriatric patient. The el-
163
‘I’ABLE I ATTITUDES
AND TYPE OF RESPONSES
IN THE CHRONICALLY
Neutrahzing
Negative Reactions (I) Gross confusion and uncertainty. (2) Panic, free floatmg anxiety and nightmares. (3) Fear of loss of sanity. of dymg, and of the physical and emottonal and financial burden. Fear of being different, which is shame. Shame is harder to diswage than guilt.
Reacttons
Intellecutal denial of illness in current function or future complicatiom, (2) Withdrawal from emotional activity with resultant to apathy, blandnecs and paastvity (3) Euphoric converston unpleasant affect
of
(4) Perception of the sttuatton as a relief from responsibility and competitive tension of normal life.
(4) Feelings of vulnerability to rejection and physical attacli. (5) interpretation of disability as a punishment for past misdeeds.
(5) Isolation of 105s through reorganizatton of values to decentralize the physical conditton m the total personality.
(6) Suicidal thoughts 17) Uncontrolled hostility inward and outward
(6) Identification of the disability as a paid up debt for past srn\.
(8) Feeling of rejection of family and friends.
These ali serve to manage threats aroused and relieved the pressure of anxiety and depression
(9) Vtewing the diability as an unjust fate.
1L.L AND DISABLED
PATfEN
Posittve Reactron(l) Development of fantasie\ of glorious future accomplishments ;rnd \ucce\\ (2) Perceptton of disahtlttie~ ah new chance to correct error’\ of the past. (3) Identification of self a\ one who fully appreciates and under-
(4) Grati~cation~ associated with assisting others who are disabled through inspiration and example
151 Identification of self a\ one selected for spiritual trial through personal suffering.
(61 Development of a set of posittve values still available in nonphystcal aspects of theu existance 1201.
(IO) Feelings that there will be a permanent loss of adult status. (11) Worry and concern over the availability of needed physical assistance
derly are more susceptible to all these side effects because of their decreased ability to withstand stress, their already impaired organ system, their decreased metabolism, and their modified pharmacological response to drugs [20]. SUPPORTIVE
THERAPY
The major goals are to keep the patient physically and mentally active and to promote independence in tasks of everyday living as long as possible [6,8]. Since one of the most pressing fears that the patient has is to be rejected by his family and friends, inform the family members who are in the home in all facets of the disease and in all of the medication, and reassure them that with their continued support. the patient can live at home and can perform his daily tasks with a minimum amount of their physical assistance [6,8]. The relationship with the family should be carried on in counseling over a period of time and should be reiterated as often as the family needs reassurance. The patient who has no immediate family or substitute
(surrogate) family presents a severe problem, and initiation of a group therapy or club for parkinsonian patients is very beneficial. Knowing they are better than some, worse than others, but above all not alone with the disease, is very therapeutic. This also aids in resocializing these patients. In urban areas where this support is already available there is usually another aid which the treatment team represents. This consists of physician, nursing personnel, physiotherapist, psychologist, social worker and others. This also aids in sharing the responsibility for the enormous amount of time and interaction these patients deserve if their lives are to continue in a productive manner. A plan for physical therapy can help the patient with stretching, active and passive exercises, gate training, turning around, getting up off the floor if he falls. and this offers considerable psychological support to the family also [gf. Availability of an occupational therapist may also help with environmental adaption and facilitate functional disability accommodation. There are certain modific&ions that can be
MANAGEMENT
OF EXTRAPYRAMIDAL
165
DISEASE
made in the home to adapt to patient needs, such as stair railings, wall railings, bathtub and toilet and grab bars and raised toilet seats that can help with everyday living [8]. The family should be informed about these items and the patient should be instructed to continue his daily activities, such as food preparation, clothing and dressing, and similar independent tasks [8]. Availability of a community nurse or public health nurse for regular visits on specific times and occasions or perhaps contact with a phone call is reassuring for the patient. The patient’s response and performance suffer after the initial 5 to 6 years. Thereafter, the symptoms become troublesome which is probably due to the side effects of the drugs. After the patient becomes totally disabled, and the limitations of the drug and the potential side effects outweigh the benefits, there is an occasion where the patient is referred to the surgeon for consideration of thalamotomy, but this is rare at this time [6]. Increasing the patient’s independence may be facilitated by considering a goal-oriented strategy. This may reside in increasing the strength and range of motion and to improve the balance and control in walking. In addition, independent dressing and eating and encouragement of socialization are recommended along with the use of physical therapy. Increasing passive and active range of motion will also increase confidence. The appearance of bradykinesia, rocking back and forth, will make walking difficult. Maintaining distance between both feet and pushing against the arms of the chair will facilitate standing up. The use of blocks under the back legs of chairs to tip forward slightly will be helpful. Similarly the use of velcro closures for shirts instead of buttons, or the use of zippers, will increase the patient’s independence. Moreover, the use of loafers instead of shoes will eliminate the tying procedure. Slow speech, clear enunciation, reading aloud and singing should be encouraged [8]. Attention should be given for improving the patient’s medication response. This can be summarized by informing the patient that both nausea and vomiting usually disappear after the first few months, and encourage the patient to take his medication and give it a chance. Drugs should be administered after meals with a glass of milk or antacid. Also, reduce the amount of protein in the diet since protein is levodopa binder [14]. Also, good nutrition is hampered by anorexia. Explanation should be given to the patient on hypotension, a common occurrence in some patients during the first few weeks of levodopa treatment, which usually disappears in time. The patient is encouraged to get up very slowly, and the use of elastic stockings or support hose can help with hypotension. Monitoring of the blood pressure
lying and sitting every four hours and reporting any significant change should be made. Reassure the patient that color changes in the secretions may develop, i.e., darkening of the urine, salivas, perspiration, which is not harmful. Measures are to be taken in cases of appearances of cardiac signs, arrythmias, agitation, insomnia, or confusion. However, involuntary movements, a hallmark of Parkinson’s disease and other extrapyramidal diseases, are tolerated during favorable clinical response of drug therapy [8]. Impaired nutrition and general health can be managed in the parkinsonian patient by considering the choice of food, e.g., feeding the patient his most favorite food, and by the use of modest amounts of protein to minimize the effectiveness of levodopa. The use of fiber is recommended to prevent constipation. Use of fluids and semisolids are the easiest foods to eat. Exercises should be maintained [8], and the use of condom or sanitary pad to control urinary incontinence is suggested. Performance of special physical exercise and certain practices for short periods of time are recommended for the parkinsonian patient. These include techniques to avoid falling and to maintain proper gait for adequate walking. For example, lifting of toes with every step taken, and spreading of the legs apart (10 inches) when walking or turning will provide a wide base, a better stance, and will prevent falling. The use of small steps with feet widely separated and avoidance of crossing of legs during turning will provide greater safety in turning. Daily practicing of body balance, e.g., rapid excursions of the body, movement in opposite directions, will ensure good body balance performance. Lifting of toes to eliminate muscle spasm during periods of foot muscle fixation may be helpful for continuation of movements. Moreover, swinging of arms freely during walking gives the impression of reducing body weight on the legs, lessens fatigue, and loosens the arms and shoulders. The rise with “lightning speed,” to overcome the “pull of gravity,” may facilitate standing up from a sitting position. Conversely, sitting down should be done slowly, with body bent sharply forward, until seat is reached. This should be practiced at least 12 times a day. In cases where body lists to one side, carrying of a shopping bag loaded with weights in the opposite hand is helpful to decrease the bend. Maintenance of finger movements, i.e., paper tearing, or playing the piano, is recommended. Any task that’s difficult, such as buttoning a shirt or getting out of bed, if practiced 20 times a day, becomes easier thereafter [8]. Also, practicing in front of a mirror may facilitate the performance of given tasks to encounter speech, facial, or chewing difficulties.
REFERENCES I. Ahmed, I. Basal ganglia calcification: An effect of long-term ohenothiazine theranv. J Kans Med Sot 80: 554. 1979.
6. Gelbart, A. 0. and W. Hamiton. Parkinson’s disease.
2. Burt, A. A., K. A. &gdee and F. E. James. Some extrapyramidal motor signs in cases of undifferentiated amentia. Eur Ncurol
7. G&lee, G. P. Succinylcholine-induced hyperkalemia in a patient with Parkinson’s disease. An&h Analg J9: 444-446, 1980. 8. Gresh, C. Helpful tips you can give your patients with Parkinson’s disease. Nursing 10: 26-33, 1980. 9. Hill, J. W. In practice, Parkinson’s disease. NZ Med J 90: 300-
19: 258-261, 3.
1980.
Calne, D. B. Genetic basis for Parkinson’s called unlikely. Prac
News
Fum
11: S8, 1981.
4. Came, D. and T. Eisler. The pathogenesis and medical treatment of extrapyramidal disease. Med C/in North Am 63: 715727, 1979. 5. Davis, G. C., A. Williams, S. Markey, M. Elbert, E. Caine, C. Reichert and I. Kopin. Chronic parkinsonism secondary to intravenous injection of meperidine analogues. Psychiatry Res 1: 249-254, 1979.
Phvsician
23: 12bl89.
Am Fum
1981.
304,1979. 10.
Howdle, P. D., I. Bone and M. S. Lesowsky. chorea secondary to malabsorption. Postgrad 563,
1 I.
Hypocalcaemic Mud J 55: 56&
1979.
Khilnani, G., A. K. Swaroop, R. K. Goyal and R. N. Mathur. Extrapyramidal reactions due to chloroquin and phenothiazincs. J Assoc Physicians India 27: 731-734, 1979.
12. Klawans. H. L., C. Goetz and S. Perlik. Presymptomattc and early detection in Huntington’s disease. Ann Nrurol 8: 343-347, 1980. 13. Lautin, A., M. Stanley, B. Angrist and S. Gershon. Extrapyramidal syndrome with sodium valproate. Br Med J 2: 103% it!J36, 1979. 14. Lesser, R. P., S. Fahn, S. R. Snider, L. Cote, W. P. Isgreen and R. E. Barrett. Analysis of the clinical problems in parkinsonism and the complications of long-term levodopa therapy. Nerrrolc’,q.~29: 1253-1260. 1979. 15. McLean, D. R., H. Jacobs and B. W. Mielke. Methanol poisoning: A clinical and pathological study. Ann Neural 8: 161-167. 1980. 16. Pascu. I., L. Popoviciu, M. Tudosie, P. Waitsuk and C. Sipos. Clinical and biochemical aspects in hepatocerebral degeneration. Rer, Roumanian Med Neural Neural Psyhiutry (Bucw) 17: 207-213. 1979.
17. Poser. C. M.. M. Alter, R. Currier and S. Hunter. Common demyelinating and degenerative diseases and extrapyramidal disorders. Arch Npurol 36: 759-770. 1979 18. Propert. N. Presymptomatic detection of Huntington’s dtsease. Med J Aust 1: 609-612. 1980. 19. Schneider, E.. P. A. Fischer. P. Jacobi, H. Becker and H. Hacker. The significance of cerebral atrophy for the symptomatology of Parkinson’s disease. J Ncurol Sc,i 42: 187-197. 1979. 20. Schontz, F. C. Severe chrome Illness. In: Ps~c~hc~/o~~c~c~/ pru< ticcs bcirh the Physical/y Disuhlrd. edited by J. F. Garrett and E. S. Levine. New York: Columbia Umversity Press. 1973. 21. Sol. P., B. Pelet and J. P. Guignard. Extrapyramidal side-effects of phenothiazines. Lancet 2: 802. 1980.
Management of Extrapyramidal Disease in the Family Medicine Clinic ORENE W. PEDDICORD
Department
of Family Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX 79430
PEDDICORD, 0. W. Management of extrapyramidal disease in the family medicine clinic. BRAIN RES BULL ll(2) 163-166, 1983.-h extrapyramidaldisease there is need for continuing care by the primary family physician over the years. The patient will need medication checks, emotional support, and be educated on how to perform tasks of everyday living. There is great emotional impact on the family. The family’s understanding of medication and ilhtess is essential in order to foster independence. Care of the chronically ill will become an increasing problem as the mean age of the population rises. General considerations
Negative attitudes
Neutralizing reactions
Positive reactions
Supportive therapy
possible since another fear is becoming a dependent invalid. The family’s understanding of the medication, the natural history of the disease, and the complications does much to lessen the fear and dread. This is crucial to the patient’s well being. The dependent patient ultimately becomes hostile due to his feelings of helplessness and hopelessness. This hostility is directed to the family members as well as the physician. At all times the patient should be preserved with as much autonomy as can be safely maintained. The recognition of overdose or under medication, as well as the recognition of symptoms which do not relate to Parkinsonism, is imperative by the patient and family members. Oftentimes such recognition will enable a phane call rather than an office call to rectify the problem. The physician should try to keep the medication lists as current and readily available as possible to avoid both confusion and drug-drug interaction toxicity. An acute awareness of the drug-drug interaction and the side effects of all current medication is essential to avoid as much iatrogenic disease as possible. There are certain attitudes and responses that are universal in all chronically ill or disabled. These consist of initial negative and neutralizing reactions which are followed by positive reactions. These are summarized in Table 1.
THE diagnosis and treatment of extrapyramidal disease is often accompanied by continuing care over the years by the patient’s family physician. If the patient presents undiagnosed and untreated, a full workup is done to consider all factors and concomitant conditions before diagnosis is made. A careful and detailed history is essential to rule out prior medical insults, drug use, alcohol use, trauma, military duty overseas, travel to foreign lands, parasites, long-term use of any psychotropic drug, toxic chemicals, and heavy metal exposure [l, 5, 13-15, 211. A genetic history is important also, along with work history, in particular, dealing with pesticides, fertilizers, and plastics [3, 7, 10-12, 18, 191. if extrapyramidal disease is suspected, the patient is referred to a neurologist to confirm the diagnosis and to initiate the medications with the clinic then providing the tiercare. There are a number of drugs that are in use currently in medicine that cause the same type of symptoms are primary Parkinson’s disease. By nature of the disease, which is one of chronic progressive degeneration [2,4,9, 16, 17, 191, the patient will need much more care in the form of medication checks, emotional support, and simply how to perform tasks of everyday living which are taken for granted 161. The emotional impact of the diagnosis of Parkinsonism on the patient, the family, and in some cases the employer, is devastating, e.g., airline pilot. The patient usually thinks he has been sentenced to a slow agonizing death in utter abandonment. He fears the loss of his family’s love and respect and is humiliated by shaking and drooling. As eating-becomes difficult, there .is social withdrawal. All the fears have real basis. Families do tend to abandon members with chronic or debilitating illness. Therefore, the therapists try to address this factor by insuring that the patient and family understand the illness and become conversant with the types of medications and their effect. There is much reassurance which accompanies this type of understanding making the patient more independent [8]. It is crucial to allow the patient as much autonomy as
NEGATIVE REACTIONS it should be noted that the care of the chronically ill will become an increasing problem as the mean age of the population rises and the use of psychoactive drugs increases. Furthermore, there are certain alterations in metabolic rate and biological half life of drugs as a function of age. For example, as the human organism ages there is a general trend for prolonged retention of drugs in the body to have more prolonged biological activity and generally to produce a more powerful clinical and toxic effect [20]. Therefore, hazards and toxicity of medication, including psychotropic drugs, should be considered when administered to the geriatric patient. The el-
163
‘I’ABLE I ATTITUDES
AND TYPE OF RESPONSES
IN THE CHRONICALLY
Neutrahzing
Negative Reactions (I) Gross confusion and uncertainty. (2) Panic, free floatmg anxiety and nightmares. (3) Fear of loss of sanity. of dymg, and of the physical and emottonal and financial burden. Fear of being different, which is shame. Shame is harder to diswage than guilt.
Reacttons
Intellecutal denial of illness in current function or future complicatiom, (2) Withdrawal from emotional activity with resultant to apathy, blandnecs and paastvity (3) Euphoric converston unpleasant affect
of
(4) Perception of the sttuatton as a relief from responsibility and competitive tension of normal life.
(4) Feelings of vulnerability to rejection and physical attacli. (5) interpretation of disability as a punishment for past misdeeds.
(5) Isolation of 105s through reorganizatton of values to decentralize the physical conditton m the total personality.
(6) Suicidal thoughts 17) Uncontrolled hostility inward and outward
(6) Identification of the disability as a paid up debt for past srn\.
(8) Feeling of rejection of family and friends.
These ali serve to manage threats aroused and relieved the pressure of anxiety and depression
(9) Vtewing the diability as an unjust fate.
1L.L AND DISABLED
PATfEN
Posittve Reactron(l) Development of fantasie\ of glorious future accomplishments ;rnd \ucce\\ (2) Perceptton of disahtlttie~ ah new chance to correct error’\ of the past. (3) Identification of self a\ one who fully appreciates and under-
(4) Grati~cation~ associated with assisting others who are disabled through inspiration and example
151 Identification of self a\ one selected for spiritual trial through personal suffering.
(61 Development of a set of posittve values still available in nonphystcal aspects of theu existance 1201.
(IO) Feelings that there will be a permanent loss of adult status. (11) Worry and concern over the availability of needed physical assistance
derly are more susceptible to all these side effects because of their decreased ability to withstand stress, their already impaired organ system, their decreased metabolism, and their modified pharmacological response to drugs [20]. SUPPORTIVE
THERAPY
The major goals are to keep the patient physically and mentally active and to promote independence in tasks of everyday living as long as possible [6,8]. Since one of the most pressing fears that the patient has is to be rejected by his family and friends, inform the family members who are in the home in all facets of the disease and in all of the medication, and reassure them that with their continued support. the patient can live at home and can perform his daily tasks with a minimum amount of their physical assistance [6,8]. The relationship with the family should be carried on in counseling over a period of time and should be reiterated as often as the family needs reassurance. The patient who has no immediate family or substitute
(surrogate) family presents a severe problem, and initiation of a group therapy or club for parkinsonian patients is very beneficial. Knowing they are better than some, worse than others, but above all not alone with the disease, is very therapeutic. This also aids in resocializing these patients. In urban areas where this support is already available there is usually another aid which the treatment team represents. This consists of physician, nursing personnel, physiotherapist, psychologist, social worker and others. This also aids in sharing the responsibility for the enormous amount of time and interaction these patients deserve if their lives are to continue in a productive manner. A plan for physical therapy can help the patient with stretching, active and passive exercises, gate training, turning around, getting up off the floor if he falls. and this offers considerable psychological support to the family also [gf. Availability of an occupational therapist may also help with environmental adaption and facilitate functional disability accommodation. There are certain modific&ions that can be
MANAGEMENT
OF EXTRAPYRAMIDAL
165
DISEASE
made in the home to adapt to patient needs, such as stair railings, wall railings, bathtub and toilet and grab bars and raised toilet seats that can help with everyday living [8]. The family should be informed about these items and the patient should be instructed to continue his daily activities, such as food preparation, clothing and dressing, and similar independent tasks [8]. Availability of a community nurse or public health nurse for regular visits on specific times and occasions or perhaps contact with a phone call is reassuring for the patient. The patient’s response and performance suffer after the initial 5 to 6 years. Thereafter, the symptoms become troublesome which is probably due to the side effects of the drugs. After the patient becomes totally disabled, and the limitations of the drug and the potential side effects outweigh the benefits, there is an occasion where the patient is referred to the surgeon for consideration of thalamotomy, but this is rare at this time [6]. Increasing the patient’s independence may be facilitated by considering a goal-oriented strategy. This may reside in increasing the strength and range of motion and to improve the balance and control in walking. In addition, independent dressing and eating and encouragement of socialization are recommended along with the use of physical therapy. Increasing passive and active range of motion will also increase confidence. The appearance of bradykinesia, rocking back and forth, will make walking difficult. Maintaining distance between both feet and pushing against the arms of the chair will facilitate standing up. The use of blocks under the back legs of chairs to tip forward slightly will be helpful. Similarly the use of velcro closures for shirts instead of buttons, or the use of zippers, will increase the patient’s independence. Moreover, the use of loafers instead of shoes will eliminate the tying procedure. Slow speech, clear enunciation, reading aloud and singing should be encouraged [8]. Attention should be given for improving the patient’s medication response. This can be summarized by informing the patient that both nausea and vomiting usually disappear after the first few months, and encourage the patient to take his medication and give it a chance. Drugs should be administered after meals with a glass of milk or antacid. Also, reduce the amount of protein in the diet since protein is levodopa binder [14]. Also, good nutrition is hampered by anorexia. Explanation should be given to the patient on hypotension, a common occurrence in some patients during the first few weeks of levodopa treatment, which usually disappears in time. The patient is encouraged to get up very slowly, and the use of elastic stockings or support hose can help with hypotension. Monitoring of the blood pressure
lying and sitting every four hours and reporting any significant change should be made. Reassure the patient that color changes in the secretions may develop, i.e., darkening of the urine, salivas, perspiration, which is not harmful. Measures are to be taken in cases of appearances of cardiac signs, arrythmias, agitation, insomnia, or confusion. However, involuntary movements, a hallmark of Parkinson’s disease and other extrapyramidal diseases, are tolerated during favorable clinical response of drug therapy [8]. Impaired nutrition and general health can be managed in the parkinsonian patient by considering the choice of food, e.g., feeding the patient his most favorite food, and by the use of modest amounts of protein to minimize the effectiveness of levodopa. The use of fiber is recommended to prevent constipation. Use of fluids and semisolids are the easiest foods to eat. Exercises should be maintained [8], and the use of condom or sanitary pad to control urinary incontinence is suggested. Performance of special physical exercise and certain practices for short periods of time are recommended for the parkinsonian patient. These include techniques to avoid falling and to maintain proper gait for adequate walking. For example, lifting of toes with every step taken, and spreading of the legs apart (10 inches) when walking or turning will provide a wide base, a better stance, and will prevent falling. The use of small steps with feet widely separated and avoidance of crossing of legs during turning will provide greater safety in turning. Daily practicing of body balance, e.g., rapid excursions of the body, movement in opposite directions, will ensure good body balance performance. Lifting of toes to eliminate muscle spasm during periods of foot muscle fixation may be helpful for continuation of movements. Moreover, swinging of arms freely during walking gives the impression of reducing body weight on the legs, lessens fatigue, and loosens the arms and shoulders. The rise with “lightning speed,” to overcome the “pull of gravity,” may facilitate standing up from a sitting position. Conversely, sitting down should be done slowly, with body bent sharply forward, until seat is reached. This should be practiced at least 12 times a day. In cases where body lists to one side, carrying of a shopping bag loaded with weights in the opposite hand is helpful to decrease the bend. Maintenance of finger movements, i.e., paper tearing, or playing the piano, is recommended. Any task that’s difficult, such as buttoning a shirt or getting out of bed, if practiced 20 times a day, becomes easier thereafter [8]. Also, practicing in front of a mirror may facilitate the performance of given tasks to encounter speech, facial, or chewing difficulties.
REFERENCES I. Ahmed, I. Basal ganglia calcification: An effect of long-term ohenothiazine theranv. J Kans Med Sot 80: 554. 1979.
6. Gelbart, A. 0. and W. Hamiton. Parkinson’s disease.
2. Burt, A. A., K. A. &gdee and F. E. James. Some extrapyramidal motor signs in cases of undifferentiated amentia. Eur Ncurol
7. G&lee, G. P. Succinylcholine-induced hyperkalemia in a patient with Parkinson’s disease. An&h Analg J9: 444-446, 1980. 8. Gresh, C. Helpful tips you can give your patients with Parkinson’s disease. Nursing 10: 26-33, 1980. 9. Hill, J. W. In practice, Parkinson’s disease. NZ Med J 90: 300-
19: 258-261, 3.
1980.
Calne, D. B. Genetic basis for Parkinson’s called unlikely. Prac
News
Fum
11: S8, 1981.
4. Came, D. and T. Eisler. The pathogenesis and medical treatment of extrapyramidal disease. Med C/in North Am 63: 715727, 1979. 5. Davis, G. C., A. Williams, S. Markey, M. Elbert, E. Caine, C. Reichert and I. Kopin. Chronic parkinsonism secondary to intravenous injection of meperidine analogues. Psychiatry Res 1: 249-254, 1979.
Phvsician
23: 12bl89.
Am Fum
1981.
304,1979. 10.
Howdle, P. D., I. Bone and M. S. Lesowsky. chorea secondary to malabsorption. Postgrad 563,
1 I.
Hypocalcaemic Mud J 55: 56&
1979.
Khilnani, G., A. K. Swaroop, R. K. Goyal and R. N. Mathur. Extrapyramidal reactions due to chloroquin and phenothiazincs. J Assoc Physicians India 27: 731-734, 1979.
12. Klawans. H. L., C. Goetz and S. Perlik. Presymptomattc and early detection in Huntington’s disease. Ann Nrurol 8: 343-347, 1980. 13. Lautin, A., M. Stanley, B. Angrist and S. Gershon. Extrapyramidal syndrome with sodium valproate. Br Med J 2: 103% it!J36, 1979. 14. Lesser, R. P., S. Fahn, S. R. Snider, L. Cote, W. P. Isgreen and R. E. Barrett. Analysis of the clinical problems in parkinsonism and the complications of long-term levodopa therapy. Nerrrolc’,q.~29: 1253-1260. 1979. 15. McLean, D. R., H. Jacobs and B. W. Mielke. Methanol poisoning: A clinical and pathological study. Ann Neural 8: 161-167. 1980. 16. Pascu. I., L. Popoviciu, M. Tudosie, P. Waitsuk and C. Sipos. Clinical and biochemical aspects in hepatocerebral degeneration. Rer, Roumanian Med Neural Neural Psyhiutry (Bucw) 17: 207-213. 1979.
17. Poser. C. M.. M. Alter, R. Currier and S. Hunter. Common demyelinating and degenerative diseases and extrapyramidal disorders. Arch Npurol 36: 759-770. 1979 18. Propert. N. Presymptomatic detection of Huntington’s dtsease. Med J Aust 1: 609-612. 1980. 19. Schneider, E.. P. A. Fischer. P. Jacobi, H. Becker and H. Hacker. The significance of cerebral atrophy for the symptomatology of Parkinson’s disease. J Ncurol Sc,i 42: 187-197. 1979. 20. Schontz, F. C. Severe chrome Illness. In: Ps~c~hc~/o~~c~c~/ pru< ticcs bcirh the Physical/y Disuhlrd. edited by J. F. Garrett and E. S. Levine. New York: Columbia Umversity Press. 1973. 21. Sol. P., B. Pelet and J. P. Guignard. Extrapyramidal side-effects of phenothiazines. Lancet 2: 802. 1980.