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Opposite Ends of the Spectrum
Apathy and ImpulsivityParkinsonβs
Monique Giroux, MDMovement Disorders NeurologistIntegrative Medicine and Holistic
HealthMedical Director Northwest
Parkinsonβs Foundation
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Overview
Understanding apathy and impulsivity
Why focus on these symptoms Strategies
Medical Checklist Personal Checklist
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UNDER-DRIVE VS
OVER-DRIVE
Initiation of actionGoal or result driven action
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Apathy and ImpulsivityBiological Cause
Brain Circuits mediate reward behavior -striatal limbic, anterior cingulate, mesolimbic and mesocortical brain areas
Dopamine - major neurotransmitter in this circuitry- βDopamine promotes what we think of as wanting.β
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Understanding Apathy and Impulsivity
Apathy- Lack of Motivation - Assoc with Depression, Fatigue, Cognitive Changes Disease Changes Medications
Dopaminergic Sedatives
DBS - STN stimulation or medicine change
Impulsivity
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Understanding Apathy Apathy
βLack of motivationβ Components
Behavioral - reduced initiative or drive
Cognitive - reduced interestEmotional - βindifferenceβ
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Pseudo- Apathy
Facial Expression Slowed Cognition or Movement Poor Stamina Fear, Social Phobia and other
Stressors Change in Performance
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Impulsivity Opposite End of the Spectrum
Initiation of action Goal or results driving action
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Understanding Impulsivity βDecreased control or insightβ
Failure to resist an impulse not in oneβs best interest
Behavioral β repetitive act- i.e. gamblingCognitive β repetitive thoughts β i.e.
ruminationEmotional β i.e. emotional rewards or
good feeling.
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Impulsivity Control
Hypersexuality, Binge Eating, Impulsive Shopping, Pathologic Gambling, Hoarding, Punding
Medication: 13% people taking PD medications 17% on dopaminergic agonists
Ropinirole (Requip), Pramipexole (Mirapex)
DBS Cognitive Challenges- Multi-tasking and
Prioritizing
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APATHY AND IMPULSIVITY IMPAIR ABILITY TO ACHIEVE
TAKE BACK CONTROL MEDICAL CHECKLISTPERSONAL CHECKLIST
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Apathy Checklist- Mood
Is depression present?- feelings of sadness, depressed mood
Counseling, support, exercise, sleep, antidepressants
Antidepressants- buproprion (Wellbutrin), venlafaxine (Effexor) boost norepinephrine or dopamine
Is anxiety present? Counseling, stress management techniques Mindfulness therapies- deep breathing,
meditation, guided imagery Antidepressants- SSRIs for anxiety with and
without depression
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Apathy Checklist-Fatigue
Are movement problems limiting? PT, OT Motor Fluctuations- Fatigue worse with
wearing off Is Stamina a problem?
Fitness, Exercise Medical Problems
Cardiopulmonary, thyroid, etc. Testosterone deficiency Sleep
Medications- Dopamine agonists
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Apathy Checklist- Cognitive
Are cognitive problems present? Neuropsychological testing
Medical- Vitamin B12, TSH, glucose control Medication- rivastigmine (Exelon) memory enhancing medicines that can improve apathy
Cognitive Strategies- Prioritize and simplify to avoid multitasking
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Apathy Checklist- Disease
Adaptation to Change Movement Efficiency- PT, OT Medicines- too much, too little DBS
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Impulsivity Checklist- Disease
Review with your healthcare provider
Review medicines- Dopamine Agonists?
Cognitive Abilities- Avoid multitasking, Simplify
DBS
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Apathy and ImpulsivityβSo What Nowβ
First Step is Awareness Second Step is to treat underlying
issues Third Step is to determine if its
worth βfixingβ Fourth Step is to set an action plan
in placeThe Personal Checklist
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Personal Checklist
Positive Commitment Know Yourself Success and Barriers Choose the right tasks/set the
right environment Have Fun Get Support Use Resources
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Personal Checklist
Positive Commitment Motivation = Value * Confidence Positive Change Talk
Moving along in direction of change. Not giving something away but drawing something out of the person.
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Personal ChecklistKnow Yourself
What you value What you like Diary Learn from the past Be patient, accept ups and downs Practice Positive Self- Talk
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Personal ChecklistSuccess and Barriers
Success
Interest Shared Interest/
Concern Support Positive
body/disease change
Stamina
Barriers
Fatigue Time Interest Pain Depression,
Apathy Ability
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Personal ChecklistRight tasks/Right
environment
Start simple, start slow. Set realistic goals. Mix it up Habit first. Optimize second. Accessible Motivating environment Interest Inventory- Group,
Indoors, Outdoors
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Personal ChecklistFind Support
People, Internet, Gadgets Talk about it, Write it down, Rehearse it Diary Support, Buddy, Group Establish the Rules Engage your Medical team PT, Personal Trainer
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Personal checklistMake it rewarding
Make it fun- Treadmill or dancing? What makes you happy- Movies,
Laughter Yoga Surround yourself with the right
situation or people to motivate change
Reward yourself Be an agent for change:
Motivate, inspire and encourage others
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Personal ChecklistResources
Calendar- make a list, write it down and keep track
Online exercise tracking system- NWPF virtual team Parkinsonβs, www.nwpf.org/wellnesss
Gadgets Pedometer, Smart Phones, Calorie
counter CDs, self help tape Community Centers, Medical
Facilities, Libraries, Churches, Coffee Shops
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Inspiration and Support
Virtual Wellness Centerwww.nwpf.org/wellness
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Motivational Tools
Virtual Wellness Centerwww.nwpf.org/wellness
