A patient comes to the clinic diagnosed with PD yet the first indication of illness was hallucinations. Standard patients with PD may experience hallucinations when they are sleep deprived, over-medicated or in advanced stages of illness. The patient's symptoms are readily apparent upon physical examination; cogwheel rigidity exists in the muscles of the arms, there is slowness of movement and the hands exhibit a resting tremor. It has not been two years since diagnosis. The most astounding symptom is the loss of substantial weight in two months. PD patients lose weight over the years, not in sudden drops.

The specialist concedes the patient's symptoms are not typical for PD. He would like the patient evaluated by a neuropsychologist who will evaluate cognition, or mental faculties and access what the deficits are. The family members who have come with the patient attest to the loss of memory, and increased reliance on others to remember, and perform basic functions such as grocery shopping.

He would like to target two issues in the clinical session- he'd like to improve sleeping and ensure the patient is eating adequately. To improve sleeping, he tells the patient to open the drapes during the day, let in the sun and try not to nap. At night, he writes a prescription of the antidepressant, Remeron or its generic, myrtazapine. The medication may take up to a month to have anti-depressant effects, but in the meanwhile, it increases appetite and makes patients sleepy. It is to be taken at night.

The essential difference between Parkinson's disease and Dementia with Lewy bodies is the distribution of the protein masses, called Lewy bodies. While patients with PD also harbor the plaques, they begin low in the brain, eventually migrating to inhabit cells higher in the cortex as the patient becomes demented at end stage illness. In the other scenario, the mental decline evident early on occurs because Lewy bodies have invaded the cortex of the brain and impaired its normal functioning.

She fell between two cars three years ago and just recently finished the final treatment to her jaw and teeth. The accident resulted in a fractured jaw and arm; not simple fractures but compound, and they didn't heal well. The jawbone had to be rebroken, aligned and held in place with a titanium plate. Three years later, she noticed the tremors in her mouth and hands.  At night, she felt her entire body twitching.

The first neurologist the patient saw diagnosed the tremors as Parkinson's disease and prescribed Mirapex. The medication can increase patient compulsivity, and receives blame for instigating gambling habits in people ordinarily not prone to wagers. The husband of the patient vouches that the personality of his spouse changed when she began the drug. Now, when she gets an idea in her mind she must follow it to the end. Delaying or minimizing the chore is insufficient, the patient feels compelled to carry out whatever it is her mind has settled on.

Generally, the rule with prescribing levodopa containing medications is, not to begin treatment with Sinemet in patients younger than 60 years of age, because half all patients treated with levodopa medications develop dyskinesia in three to five years. Dyskinesia is uncontrollable, often fluid movements of the limbs. The patient in her early seventies might have received the drug and been more completely relieved of her symptoms. In the physician's opinion, tremor is really a cosmetic issue, embarrassing to the patient but usually not disabling. The patient admits that when she becomes aware of her tremor there are things she does to subdue it.

The movement disorder specialist would like the patient to begin taking amantadine twice a day for symptoms, because it may slow progression of the disease. He relates he would like to taper to only one Mirapex, right before retiring for the night. He also states that if the patient feels symptoms are worse, she might try a course of Sinemet. Now confused by how many drugs the physician is recommending, the doctor clarifies; always take the amantadine twice a day, take the Mirapex before bed and if worse begin weaning onto Sinemet. Sinemet is one of the drugs best to begin gradually. He writes out a schedule, the first several days the patient takes a single pill at breakfast. After that, the patient steps up to taking a total of two pills, once at breakfast and again at lunch, this continues for several more days. The second step takes the patient up to three pills total, at breakfast, lunch and dinner.

The specialist notes the patient has mild symptoms of PD. She has rigidity in both arms and makes small excursions when performing repetitive fine hand gestures. Strolling in the hallway, the doctor notes her gate is solid and her arm swing full. Perhaps the course of illness will remain mild. He requests the couple return in three months, so he can check the status of the patient and make any changes in medications. Encouraged that she walks for an hour on the treadmill, the doctor emphasizes the role physical activity has in enhancing physical function.