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Page 1: Apathy impulsivity and motivation with parkinson's nwpf 2011

Β©2011π‘€π‘œπ‘›π‘–π‘žπ‘’π‘’πΊπ‘–π‘Ÿπ‘œπ‘’π‘₯ ,𝑀𝐷

Opposite Ends of the Spectrum

Apathy and ImpulsivityParkinson’s

Monique Giroux, MDMovement Disorders NeurologistIntegrative Medicine and Holistic

HealthMedical Director Northwest

Parkinson’s Foundation

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Β©2011π‘€π‘œπ‘›π‘–π‘žπ‘’π‘’πΊπ‘–π‘Ÿπ‘œπ‘’π‘₯ ,𝑀𝐷

Overview

Understanding apathy and impulsivity

Why focus on these symptoms Strategies

Medical Checklist Personal Checklist

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Β©2011π‘€π‘œπ‘›π‘–π‘žπ‘’π‘’πΊπ‘–π‘Ÿπ‘œπ‘’π‘₯ ,𝑀𝐷

UNDER-DRIVE VS

OVER-DRIVE

Initiation of actionGoal or result driven action

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Β©2011π‘€π‘œπ‘›π‘–π‘žπ‘’π‘’πΊπ‘–π‘Ÿπ‘œπ‘’π‘₯ ,𝑀𝐷

Apathy and ImpulsivityBiological Cause

Brain Circuits mediate reward behavior -striatal limbic, anterior cingulate, mesolimbic and mesocortical brain areas

Dopamine - major neurotransmitter in this circuitry- β€œDopamine promotes what we think of as wanting.”

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Β©2011π‘€π‘œπ‘›π‘–π‘žπ‘’π‘’πΊπ‘–π‘Ÿπ‘œπ‘’π‘₯ ,𝑀𝐷

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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Β©2011π‘€π‘œπ‘›π‘–π‘žπ‘’π‘’πΊπ‘–π‘Ÿπ‘œπ‘’π‘₯ ,𝑀𝐷

Understanding Apathy Apathy

β€œLack of motivation” Components

Behavioral - reduced initiative or drive

Cognitive - reduced interestEmotional - β€œindifference”

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Β©2011π‘€π‘œπ‘›π‘–π‘žπ‘’π‘’πΊπ‘–π‘Ÿπ‘œπ‘’π‘₯ ,𝑀𝐷

Pseudo- Apathy

Facial Expression Slowed Cognition or Movement Poor Stamina Fear, Social Phobia and other

Stressors Change in Performance

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Β©2011π‘€π‘œπ‘›π‘–π‘žπ‘’π‘’πΊπ‘–π‘Ÿπ‘œπ‘’π‘₯ ,𝑀𝐷

Impulsivity Opposite End of the Spectrum

Initiation of action Goal or results driving action

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Β©2011π‘€π‘œπ‘›π‘–π‘žπ‘’π‘’πΊπ‘–π‘Ÿπ‘œπ‘’π‘₯ ,𝑀𝐷

Understanding Impulsivity β€œDecreased control or insight”

Failure to resist an impulse not in one’s best interest

Behavioral – repetitive act- i.e. gamblingCognitive – repetitive thoughts – i.e.

ruminationEmotional – i.e. emotional rewards or

good feeling.

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Β©2011π‘€π‘œπ‘›π‘–π‘žπ‘’π‘’πΊπ‘–π‘Ÿπ‘œπ‘’π‘₯ ,𝑀𝐷

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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Β©2011π‘€π‘œπ‘›π‘–π‘žπ‘’π‘’πΊπ‘–π‘Ÿπ‘œπ‘’π‘₯ ,𝑀𝐷

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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Β©2011π‘€π‘œπ‘›π‘–π‘žπ‘’π‘’πΊπ‘–π‘Ÿπ‘œπ‘’π‘₯ ,𝑀𝐷

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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Β©2011π‘€π‘œπ‘›π‘–π‘žπ‘’π‘’πΊπ‘–π‘Ÿπ‘œπ‘’π‘₯ ,𝑀𝐷

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 Impulsivityβ€œSo What Now”

First Step is Awareness Second Step is to treat underlying

issues Third Step is to determine if its

worth β€˜fixing’ Fourth Step is to set an action plan

in placeThe Personal Checklist

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Β©2011π‘€π‘œπ‘›π‘–π‘žπ‘’π‘’πΊπ‘–π‘Ÿπ‘œπ‘’π‘₯ ,𝑀𝐷

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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Β©2011π‘€π‘œπ‘›π‘–π‘žπ‘’π‘’πΊπ‘–π‘Ÿπ‘œπ‘’π‘₯ ,𝑀𝐷

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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Β©2011π‘€π‘œπ‘›π‘–π‘žπ‘’π‘’πΊπ‘–π‘Ÿπ‘œπ‘’π‘₯ ,𝑀𝐷

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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Β©2011π‘€π‘œπ‘›π‘–π‘žπ‘’π‘’πΊπ‘–π‘Ÿπ‘œπ‘’π‘₯ ,𝑀𝐷

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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Β©2011π‘€π‘œπ‘›π‘–π‘žπ‘’π‘’πΊπ‘–π‘Ÿπ‘œπ‘’π‘₯ ,𝑀𝐷

Personal ChecklistResources

Calendar- make a list, write it down and keep track

Online exercise tracking system- NWPF virtual team Parkinson’s, 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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Β©2011π‘€π‘œπ‘›π‘–π‘žπ‘’π‘’πΊπ‘–π‘Ÿπ‘œπ‘’π‘₯ ,𝑀𝐷

Inspiration and Support

Virtual Wellness Centerwww.nwpf.org/wellness

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Β©2011π‘€π‘œπ‘›π‘–π‘žπ‘’π‘’πΊπ‘–π‘Ÿπ‘œπ‘’π‘₯ ,𝑀𝐷

Motivational Tools

Virtual Wellness Centerwww.nwpf.org/wellness


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