Expert: Mary Gordon - 3/12/2011

Question
Dear Mary,
Thanks very much for having answered several of my questions in the last few years. Need your help again. During a routine check up last week, the doctor thought my mother(age 70-diagnosed with Alzheimer's over 3 years ago) has developed some signs of  parkinsons. Her right hand trembles a bit(we did tell him that her wrist had been broken and fixed 3 years ago and she rarely used her right hand and that it was very weak and that trembling  of that hand has been a constant from the last 3 years).  Also her walk has become a bit of a shuffle, she walks like she's going to topple over. He thinks thats also a sign of P. He's prescribed  new medication, which he would like us to try for the next one month. On googling however I found that this drug causes hallucinations, confusion and worse, urinary retention. My mother has stopped talking completely, is incontinent and is very fragile, though she goes for walks with us a couple of times and eats well. She's already having problems drinking water and swallowing tablets. But she's reasonably peaceful and comfortable. I do not want her to be troubled in any way, especially if this is due to a new drug that is in any case not going to cure her. I am most uncomfortable giving her a drug that will cause confusion and urinary retention, because she has stopped talking and I can't imagine how we'll know  if she's in pain or uncomfortable or troubled.
Please tell me what's the alternative?  I know her disease is progressive and she's not going to get better.. why then must we give her drugs that we already know will cause her harm and not much good--since she's not going to get better in any case, whether it is Parkinson's  or not, since she has alzheimer's. We do give her Donamem.. since it's the only drug that has been prescribed. My brother and I are in a dilemma. Do advice and tell us what you think we should do. As always, thanks very very much for taking out time to do this.

Answer
Hi Nimi, as you probably know, Alzheimer's is not just a disease that impacts cognition and memory. It causes global brain damage. The part of the brain governing motor skills (the parietal lobe) is affected, so muscular coordination and balance are damaged. The brain and body don't communicate well. The person has trouble picking up his or her feet to walk and may be unsteady or begin to stoop. Eventually, if they survive to the natural end of dementia, they will lose their ability to walk entirely, they can develop stiffness and rigidity and tremors. All this stuff gets called  extrapyramidal symptoms (EPS) - basically, unusual movement (or lack of movement!).  

It is very common by middle to later Alzheimer's to develop a shuffle. They take small steps and don't lift their feet. The person may also start to lean when they walk, become very unsteady and be in danger of falls. Do try to keep your mom moving; don't let a shuffle cause her to give up walking. It sounds like you are doing what you can on that front. Exercise has been shown to reduce the risk of falls even in people with dementia. As you can guess, no exercise means weaker muscles, which means they get more unsteady and move less - it's a spiral.

Other things you can do are make sure she has shoes that fit well and have soles that are neither too slick nor too ridged and built-up. Some sport shoes (like thick soled sneakers) actually contribute to falls because the person can't sufficiently lift their foot, causing them to trip on the "fat" rubber toes and heavy treads. You can also provide a walker for added support. You will likely have to repeatedly remind her to use the walker, or she will forget - my mother in law never could learn to use a cane, but she did have a walker with wheels she used, and I do think it reduced her risk of falls.  It is also very important to remove throw rugs and clutter and small furniture from pathways. People with Alzheimer's get tunnel vision, so they may not see things they could trip over. They also can't judge distances, so they can try to sit down when they are too far from the chair.

Your mom may well have Parkinson's as well, or even Lewy Body dementia, which also causes Parkinson's symptoms. It is not uncommon to have more than one thing going on at once. Given how advanced your mother's Alzheimer's is, I'm not sure what the benefit of treating potential Parkinson's is, particularly when there are concerns about side effects that may cause discomfort or distress. Parkinson's also causes mental deterioration.

Only you can decide if she may benefit from a trial of a medication. You could give it a try and stop if there any bothersome symptoms. However, I am not convinced (nor are you) that she actually has Parkinson's or will benefit in anyway, even if she does have Parkinson's. Her walking will go down hill no matter what. What is the doctor hoping to achieve? Her Alzheimer's is quite advanced.

I think the Donamen she's on might actually a combination medication containing both memantine and donepezil. You might want to confirm that with the doctor, as the two combined are pretty much the best option available for Alzheimer's treatment there is at the moment.  The two together work better than either alone, so sounds like she's on the best choice out there.

I'm thinking of you. If I were you, I would be asking the same questions, and I doubt I would bother trying the medication. At this point, it should be all about her comfort, peace, serenity. Anything that may cause her any kind of distress is worth avoiding, particularly if the benefit is questionable. Even if it helped potential Parkinson's, she would have the same physical issues from the Alzheimer's alone.

Mary