Apathy impulsivity and motivation with parkinson's nwpf 2011

©2011𝑀𝑜𝑛𝑖𝑞𝑢𝑒𝐺𝑖𝑟𝑜𝑢𝑥 ,𝑀𝐷

Opposite Ends of the Spectrum

Apathy and ImpulsivityParkinson’s

Monique Giroux, MDMovement Disorders NeurologistIntegrative Medicine and Holistic

HealthMedical Director Northwest

Parkinson’s Foundation


Overview

Understanding apathy and impulsivity

Why focus on these symptoms Strategies

Medical Checklist Personal Checklist


UNDER-DRIVE VS

OVER-DRIVE

Initiation of actionGoal or result driven action


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.”


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


Understanding Apathy Apathy

“Lack of motivation” Components

Behavioral - reduced initiative or drive

Cognitive - reduced interestEmotional - “indifference”


Pseudo- Apathy

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

Stressors Change in Performance


Impulsivity Opposite End of the Spectrum

Initiation of action Goal or results driving action


Understanding Impulsivity “Decreased 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.


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


APATHY AND IMPULSIVITY IMPAIR ABILITY TO ACHIEVE

TAKE BACK CONTROL MEDICAL CHECKLISTPERSONAL CHECKLIST


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


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


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


Apathy Checklist- Disease

Adaptation to Change Movement Efficiency- PT, OT Medicines- too much, too little DBS


Impulsivity Checklist- Disease

Review with your healthcare provider

Review medicines- Dopamine Agonists?

Cognitive Abilities- Avoid multitasking, Simplify

DBS


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 placeThe Personal Checklist


Personal Checklist

Positive Commitment Know Yourself Success and Barriers Choose the right tasks/set the

right environment Have Fun Get Support Use Resources


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.


Personal ChecklistKnow Yourself

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


Personal ChecklistSuccess and Barriers

Success

Interest Shared Interest/

Concern Support Positive

body/disease change

Stamina

Barriers

Fatigue Time Interest Pain Depression,

Apathy Ability


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


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


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


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


Inspiration and Support

Virtual Wellness Centerwww.nwpf.org/wellness


Motivational Tools

Virtual Wellness Centerwww.nwpf.org/wellness

Health & Medicine

Apathy impulsivity and motivation with parkinson's nwpf 2011