Learn about Parkinson's associated symptoms of apathy, impulsivity an tips to overcome these problems and stay motivated for positve lifestyle change

1. Opposite Ends of the SpectrumApathy and ImpulsivityParkinson’s Monique Giroux, MD Movement Disorders Neurologist Integrative Medicine and Holistic Health Medical Director Northwest Parkinson’s Foundation

2. Overview Understanding apathy and impulsivity Why focus on these symptoms Strategies Medical Checklist Personal Checklist

3. Under-drive vs over-drive Initiation of action Goal or result driven action Impulsivity Apathy

4. Apathy and ImpulsivityBiological Cause Brain Circuits mediate reward behavior -striatal limbic, anterior cingulate, mesolimbic and mesocortical brain areas Dopamine - major neurotransmitter in this circuitry- “Dopamine promotes what we think of as wanting.”

5. 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

6. Understanding Apathy Apathy “Lack of motivation” Components Behavioral - reduced initiative or drive Cognitive - reduced interest Emotional - “indifference”

7. Pseudo- Apathy Facial Expression Slowed Cognition or Movement Poor Stamina Fear, Social Phobia and other Stressors Change in Performance

8. Impulsivity Opposite End of the Spectrum Initiation of action Goal or results driving action Impulsivity Apathy

9. Understanding Impulsivity “Decreased control or insight” Failure to resist an impulse not in one’s best interest Behavioral – repetitive act- i.e. gambling Cognitive – repetitive thoughts – i.e. rumination Emotional – i.e. emotional rewards or good feeling.

10. 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

11. Apathy and impulsivity impair ability to aCHIEVETakEback control Medical ChecklistPersonal Checklist

12. 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

13. 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

14. 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

15. Apathy Checklist- Disease Adaptation to Change Movement Efficiency- PT, OT Medicines- too much, too little DBS

16. Impulsivity Checklist- Disease Review with your healthcare provider Review medicines- Dopamine Agonists? Cognitive Abilities- Avoid multitasking, Simplify DBS

17. Apathy and Impulsivity“So What Now” First Step is Awareness Second Step is to treat underlying issues Third Step is to determine if its worth ‘fixing’ Fourth Step is to set an action plan in place The Personal Checklist

18. Personal Checklist Positive Commitment Know Yourself Success and Barriers Choose the right tasks/set the right environment Have Fun Get Support Use Resources

19. 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.

20. Personal ChecklistKnow Yourself What you value What you like Diary Learn from the past Be patient, accept ups and downs Practice Positive Self- Talk

21. Personal ChecklistSuccess and Barriers Success Barriers Interest Shared Interest/ Concern Support Positive body/disease change Stamina Fatigue Time Interest Pain Depression, Apathy Ability

22. 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

23. 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

24. 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

25. 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

26. Virtual Wellness Center www.nwpf.org/wellness Inspiration and Support

27. Motivational Tools Virtual Wellness Center www.nwpf.org/wellness