Motor fluctuations

A. Suboptimal or delayed peak response

1. Take Sinemet on an empty stomach

2. Decrease dietary protein and fat around the dose that is delayed

2. Use rapid-dissolving tablet (Parcopa), crush Sinemet, or make liquid Sinemet

3. Substitute standard Sinemet for some of the Sinemet CR

4. Minimize constipation

5. Withdraw drugs with anticholinergic properties

6. Add intermittent subcutaneous apomorphine

B. Optimal peak but early wearing off

1. Decrease dose and increase frequency of standard Sinemet

2. Substitute Sinemet CR for some of the standard Sinemet

3. Add other PD medications (dopamine agonist, MAO-B inhibitor, amantadine, or COMT inhibitor)

C. Optimal peak but unpredictable offs

1. Adjust time of medications with meals and avoid high-protein meals or redistribute the amount of protein in diet

2. Substitute or add rapid-dissolving tablet form or liquid form of Sinemet

3. Add COMT inhibitor

4. Add or try a different dopamine agonist

5. Consider continuous infusion of levodopa (Duodopa), apomorphine, or lisuride

6. Deep-brain stimulation procedure D. Freezing

1. Gait modifications (use visual cues such as walk-over lines, tapping, rhythmic commands, rocking; use rolling walker)

2. Difficult to treat, so adjust current medication up or down based on other PD symptoms a. On freezing—reduce dopamine medications, inject botulinum toxin b. Off freezing, increase Sinemet dose or add dopamine agonists 3. Treat anxiety if present

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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