A skin abscess (boil) is the most common form of abscess that is encountered, but abscesses may also occur in the internal organs, such as the liver, kidneys, appendix, brain or lungs. Tooth abscesses are fairly common and so are abscesses of the tonsils or its surrounding tissues.

Cause of Abscess Formation

Infection is the most common cause of abscess formation. The white blood cells attack the invading organisms and try to localize the infection and thus an abscess is formed, with pus as its focal point. The most common invading organisms are Staphylococcus aureus and streptococcus, which may enter through a break in the skin or a hair follicle. Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is a type of staphylococcus bacteria which is resistant to the penicillin group of drugs and has been found to be increasingly involved in producing abscesses of the skin and deeper tissues.

Abscesses in the internal organs may occur due to infections already present in some organ and as a result of spread through the blood or lymphatic system.

Apart from infection, a foreign body such as a piece of glass or a thorn may also be the cause of an abscess.

Pilonidal abscess (which occurs in the crease of the buttocks) may be an example of a type of abscess which may occur easily in a Parkinson’s disease patient because of restricted movements while sitting and lying down, often for prolonged periods.

Signs and Symptoms

Symptoms will vary according to the site of the abscess but the common signs and symptoms may be an inflamed, red mass of variable size, painful to the touch and occasionally with a point which may be draining pus. A throbbing toothache is usually felt in case of a tooth or gum abscess. An abscess may be accompanied by fever, headache, abdominal pain and tenderness or other toxic symptoms, especially if it involves an internal organ.

Prevention and Treatment

Parkinson’s disease patients should be vigilant in  maintaining good personal hygiene and bring even minor cuts and injuries or a small boil to the attention of their doctor.

A hot compress applied over a small abscess may help but in no circumstances should the abscess be pressed upon too hard or a pin or needle inserted in an attempt to drain it at home.

Incision and drainage by a doctor is the most effective form of treatment for an abscess. Usually, antibiotics have no role unless the abscess has drained. An antibiotic and a pain reliever may be given after draining an abscess but a patient with Parkinson’s disease should not take any medicines without the attending doctor’s advice because of the possibility of drug interactions.

Safety Tips for Maintaining Balance

A few simple safety tips that both the patient and caregivers should bear in mind will diminish the risk of serious injuries due to falls.

• Always keep one hand free when walking. This will allow you to grab on a chair when about to fall and will allow you to break the force of the fall.
• Try to swing both arms as much as possible while walking. This increases balance and stability when moving.
• Try to lift the feet while walking to prevent shuffling and chances of tripping.
• While standing and walking, keep legs slightly apart. This improves stability by distributing weight evenly and over a larger area through the legs and feet.
• Breaking down the sequence of walking and carrying out each sequence consciously may help to walk steadily.
• Certain cues may be used while walking to prevent freezing.
• Wearing correct footwear is important. Low heeled shoes are best.
• Move slowly when getting up from the sitting to the standing position and wait a few seconds before starting to walk.
• While turning do it slowly, taking a slightly curved path.
• Avoid getting distracted when walking.
• Use walking aids such as walking sticks or frames if necessary.

Safety Tips around the House

Since most Parkinson’s patients are confined to the home, it is important that the housekeepers and home owners take the necessary measures to minimize injuries. Simple measures like the following may go a long way in assisting a Parkinson’s patient.

• Floors should be smooth without being slippery.
• Special care should be taken to see that the walking area is free. Small objects coming under the feet can be very dangerous.
• Care should be taken to see that children and pets do not come in the way when the person is walking.
• Furniture should be in their proper places with enough space around them to be able to move around easily.
• Placing small rugs on the floor should be avoided.
• Enough lighting in all places and night lights in the bathroom and hallways are a must.
• Light switches should be within easy reach from the bed.
• Avoid using the stairs as much as possible. Hand rails should be there on both sides of the stairs.
• Extension cords and wires on the floor should be avoided as much as possible to prevent chances of tripping over them.
• Walking aids should be placed nearby and within easy reach of the patient.
• Emergency phone numbers, especially of family members or neighbors who may be called if necessary, should be programmed in the mobile phone and land phone for easy accessibility.
• Fire hazards such as heaters, candles or oil lamps should not be around.
• Grip bars should be placed at strategic positions around the house and especially in the bathroom around the toilet, bathtub and shower areas.
• Use non-skid bath mats and bath chair or stool in the shower.

It is advisable that a home caregiver have sufficient knowledge on emergency care and first aid and be able to identify the signs and symptoms of a fracture or concussion to ensure that appropriate medical attention is sought after a fall or injury.

Before starting a home exercise program, you should consult with your doctor to verify the following :

• The type of exercise best suited for your individual case.
• Exercises that should be avoided.
• The duration and intensity of your exercise schedule.
• Any physical restrictions that may limit the extent of your program.
• Referral to a physiotherapist to guide you with your exercise program.

Physiotherapy is one of the most effective means of relaxing rigid and frozen muscles in Parkinson’s disease but keeping the cost factor in mind, it is advisable for the physiotherapist to make a home visit once or twice a week and set a daily home exercise program you can follow on your own everyday. A Parkinson’s disease patient’s fitness level, general health and symptoms should be kept in mind before starting an exercise program. The exercise plan advised will need to focus on :

• Difficulties with mobility or walking.
• Joint or muscle pain hampering day to day activities.
• Problems associated with balance.
• Difficulty in performing daily tasks such as eating, bathing, and dressing.
• Problems with speech and handwriting.

Types of Home Exercises for Parkinson’s Disease

Certain types of exercises may help, such as :

• Stretching . Simple stretches can be done anywhere and help to keep the body flexible and mobile. They should be done throughout the day, each exercise repeated three times, and holding the stretch for three to five full breaths.
• Strength training exercises with light weights can be done at home. They help to improve balance and co-ordination by strengthening muscles, and also increase resistance to fractures by strengthening bones.
• Aerobic exercises such as walking, cycling, dancing, or swimming help to maintain general health and well being of the patient. While walking, the patient should practice heel to toe placement of the feet, longer strides for walking and short steps with feet apart while turning, and swinging the arms by the side.
• Aquatic exercises performed in a warm pool give excellent results regarding improvement in muscle tone, increasing range of motion, and helping to reduce pain and stiffness. The buoyancy of the water helps to improve balance and posture without the risk of falling.
• Exercises to involve movement of the limbs in full range improve flexibility and mobility.
• Singing loudly, reading aloud, making faces in the mirror, or chewing help to strengthen the facial and jaw muscles.
• Yawning helps by opening the throat and helps with swallowing problems as well as clear speech.
• Practicing Tai chi and yoga exercises can help to improve strength, balance, and flexibility, as well as reduce stress and joint pains.

Exercises should be stopped at any point if you are feeling unwell or if in pain and further exercises should only be resumed after consulting with your doctor.

Patient Compliance

Patient compliance means taking the medicines on time and in the prescribed doses. There are different types of drugs with multiple doses and formulations, each with variable rates of absorption, which makes it imperative that the prescribed medicines are taken on time and without altering the dosage except under medical supervision. Unwillingness or inability to adhere to this may lead to exacerbation of symptoms or development of other complications, and may affect the doctor’s monitoring of the disease progression leading to further prescription of anti-Parkinson’s medicines.

Causes of Patient Non-compliance

There are a number of reasons that patients may not comply with their prescription of Parkinson’s drugs. These include :

• Ignorance about the importance of taking medicines on time and in the correct doses.
• Unavailability of medicines.
• Cost of medicines.
• Trying alternative therapies.
• Side effects of drugs, as well as concerns about drug interactions.
• Patients may feel that they do not need the dose increase that the doctor prescribed.
• Patients do not decrease the dose of medicine, even if advised by the doctor, in the misconception that their condition will worsen if they do so.
• Multiple dose regimens may make compliance difficult.

Complications of Patient Non-compliance

• Overuse of medicines may cause psychiatric problems and increase motor complications.
• If medicines are not taken as prescribed, the smooth flow of dopamine in the brain is interrupted, leading to irregular control of symptoms.
• Missing a dose by even 15 or 30 minutes may result in an “off” period which may last for several hours.

Quitting Parkinson’s Disease Drugs

Often patients of Parkinson’s disease decide to stop taking drugs because of misconceptions about dangers of taking medications for prolonged periods. Some people think that levodopa may speed the progression of Parkinson’s disease although there is no truth in this theory. Other patients are not ready to accept that they will have to be on medication for the rest of their lives. There is another misconception that drugs stop acting after a few years. This is not correct, although doses may need to be increased due to progression of the disease. Another common reason for quitting drugs is to try alternative therapies, like homeopathic or herbal remedies, which they feel will work better for them.

Dangers of Trying Alternate Therapies

• Herbal medications are often effective since they may contain levodopa but it should be remembered that this levodopa exists along other compounds and some toxic side effects are possible.
• The exact dose of herbal remedies cannot be controlled due to varying levels of compounds among each season’s cultivation. This is very important since exact dose of the drug is crucial for proper control of symptoms and each patient’s dose is tailor-made for him alone.
• Unknown drug interactions.
• There is no standard quality control.
• Patients may be ill-informed about the effect of alternative therapies and their supposed efficacy.

However complementary therapies should not be totally avoided, provided that you have discussed it with your medical doctor and considering these alternative remedies for other aspects of your health, rather than for the treatment and management of Parkinson’s disease.

Dangers of Quitting Anti-Parkinson’s Drugs

• Symptoms, which were previously controlled, will become exacerbated.
• Increase in muscle stiffness.
• Fever
• Confusion
• Development of other complications.

Types of Skin Problems in Parkinson’s Disease

• Oily skin. There is excessive oiliness of the skin on the face, especially on the forehead and on the sides of the nose, making the skin look greasy and shiny.
• Dandruff. The scalp may become oily, resulting in greasy hair and dandruff.
• Seborrheic dermatitis. Inflammation of the skin may occur, causing the skin to become red and itchy, with a tendency to flake.
• Dry skin. In some cases there is extreme dryness of the skin due to too little perspiration.
• Excessive sweating. Too much perspiration can be a distressing symptom.
• Night sweats are quite common in patients with Parkinson’s disease.

Causes of Skin Problems in Parkinson’s Disease

Skin problems may occur as a result of Parkinson’s disease and improper functioning of the autonomic nervous system, or sometimes as a side effect of anti-Parkinson drugs.

• The sebaceous glands in the skin produce sebaceous matter or sebum, which help to protect the skin and keep it supple. Excessive production of sebum may occur in Parkinson’s disease and the areas that contain more sebaceous glands, such as on the forehead, beside the nose, and scalp are more severely affected. This causes oily skin and dandruff and in extreme cases the skin may become red, inflamed and itchy. Heat may exacerbate this problem.
• In Parkinson’s disease, sweat glands may produce too little or too much sweat, causing problems of dry skin or excessive perspiration. Anti-Parkinson drugs also have side effects causing too much sweating (with medicines such as levodopa), or too little sweating (due to anticholinergics).

Treatment of Skin Problems in Parkinson’s Disease

• For oily and greasy skin, standard treatments, such as using a neutral soap (unscented glycerin soap) and washing the skin twice daily with warm water and rinsing with cold water, do help. It is preferable to use gels since they are water based, than creams which are oil based. In more severe cases, a cream containing sulfur and salicylic acid may give better results.
• Various lotions and shampoos are available for treatment of dandruff. Selenium or selenium sulfide containing products may give good results.
• Seborrheic dermatitis may need treatment with lotions containing a steroid such as adrenocorticotrophic hormone, or a ketoconazole containing cream. Coal tar shampoo may be effective for forehead and eyebrows.
• Taking lukewarm showers, wearing light cotton clothes in summer, and drinking plenty of water and liquids are helpful in combating the effects of excessive perspiration. Excessive sweating may sometimes be due to side effects of anti-Parkinson drugs such as levodopa or can occur during the “wearing off” period of levodopa treatment -adjusting the dose, using a controlled release levodopa preparation, or COMT inhibitors may help. Beta-blockers, anticholinergics, or use of astringents containing glutaraldehyde also help in some cases.
• Too little perspiration may be helped by reducing the dose of anti-Parkinson medicines such as anticholinergics.

Types of Eye Problems in Parkinson’s Disease

• Blurred vision or difficulty in focusing may be due to difficulty in moving the eyes or due to the side effects of Parkinson’s drug therapy, especially anticholinergics. This problem may occur on starting treatment with anticholinergics, but normally improves over time. It may also occur with long-term treatment with anticholinergics or after some dose adjustments.
• Double vision usually occurs in Parkinson’s disease due to problems in moving the eyes in alignment from side to side, such as when reading. This occurs as a result of impaired coordination and fatigue of the muscles moving the eyeballs.
• Excessive tearing (lachrymation) of the eyes.
• Dry eyes is caused by reduced blinking of the eyes.
• Difficulty in moving the eyes may be manifested in two ways : (i) difficulty in starting a movement of the eyes or (ii) problem with moving the eyes quickly when following a fast moving object. Instead of moving smoothly, the eyes move in a slow and jerky way. Driving a vehicle may pose difficulties.
• Sensitivity to contrast – there may be difficulty in seeing in dim light, or making out light colored objects against a light background, or difficulty in reading fine print.
• Color vision may be affected for differentiating between slight color differences, especially for shades of blue or blue-green.
• Problem with visuo-spatial orientation or depth perception – the person may have difficulty in assessing the distance between objects and may need to reach out to touch the sides of the wall or objects while walking through a narrow place. This may create problems while walking or driving.
• Glaucoma and anti-Parkinson’s medication – levodopa and anticholinergics should be used with caution in patients with glaucoma.
• Some patients with Parkinson’s disease cannot judge the speed of moving objects, which may be dangerous if driving or trying to cross the street.
• Hallucinations and illusions or visual misinterpretations are more likely to occur in those people who have had Parkinson’s disease for a long time. It may be due to the disease itself or due to anti-Parkinson drugs.
• Blepharospasm or involuntary spasm of the eyelids.

Treatment of Eye Problems in Parkinson’s Disease

• Blurred vision – modification of anticholinergic medicine dose and adjustments in power if wearing glasses.
• Double vision – improves with anti-Parkinson medicines and by resting the eye.
• Dry eyes – using artificial tear drops and avoiding dry, hot and smoky places.
• Difficulty in moving the eyes – usually improves with anti-Parkinson drugs.
• Sensitivity to contrast – improves with treatment by levodopa.
• Color vision – problem may improve with anti-Parkinson medicines.
• Hallucinations – reducing the dose of anti-Parkinson drugs and use of neuroleptics such as clozapine and quetapine.

Types of Speech Problem in Parkinson’s Disease

• Reduced volume of speech which is usually the first change that takes place related to problems with speech. The person tends to speak too softly although he may feel that he is speaking in a normal tone of voice.
• Fading of voice where the initial speech starts in a strong voice but tends to fade as the person keeps on talking.
• Monotonous speech is when the person speaks in a flat voice, with no variation in tone or expression.
• Fast rate of speaking where speech is too fast, with words and sentences running into each other without a break, giving a rushed quality to the speech.
• Hesitation in speaking is when the person has problem in initiating speech, often due to difficulty in word finding.
• Slurred speech where the speech is unclear, with endings being trailed off or omitted.
• Voice quality may become hoarse or tremulous, or there may be indistinct articulation of words.
• Muffling of voice may be  increased due to drooling.
• Repetition where there may be uncontrolled repetition of words or phrases while speaking.

Treatment of Speech Problem in Parkinson’s Disease

• Medication. Treatment with levodopa or levodopa-carbidopa combination to replenish dopamine concentration in the brain do improve symptoms related to voice quality, articulation, and variation in pitch.
• Speech therapy. Dysarthria is improved with traditional speech therapy, and intensive programmes significantly improve volume of speech.
• Besides communication with speech, non-verbal communication is also an important factor. The typical mask-like face of Parkinson’s disease may make expression of feelings difficult for the patient. A speech therapist, if consulted early on in the disease, can help with facial and voice exercises.
• Surgical procedures. Unilateral surgical procedures may improve dysarthria but bilateral procedures often lead to worsening of symptoms.
• Deep brain stimulation. Stimulation of subthalamic nucleus help by improving certain types of speech problem, but decrease of intelligibility may be a side effect of surgery.
• Collagen injection into vocal cords.
• Devices to help with speech like :

1. Palatal lift apparatus – to lift the soft palate and prevent air from escaping during speech.
2. Personal amplifier – to increase volume of voice.
3. TTY telephone relay system – a telephone with a keyboard, where speech can be typed and read out by a relay operator.
4. Low technology devises – such as notebooks and language devices.
5. High technological communication devices and speech enhancers – computers with voice synthesizers and communication devices.

What is Compulsive Behavior?

Compulsive behavior is when a person is unable to control his impulse or desire, or resist a temptation, even though it ultimately harms him or others. This sort of behavior is motivated by the anticipation of intense pleasure and gratification is often seen to be out of character with his previous normal behavior.

Types of Compulsive Behavior in Parkinson’s Disease

• Pathological gambling – recurrent, compulsive and addictive gambling habit which cannot be controlled in spite of its destructive effects and may include experience with casinos, lotteries, internet or television based games and raffles. He may deceive others or even resort to stealing to satisfy this intense urge for gambling, paying no heed to breakdown of relationships or even total bankruptcy. Pathological gamblers often suffer from mood swings, irritability and suicidal tendencies.
• Hypersexuality – this may range from inappropriate sexual thoughts or urges to offensive sexual remarks or actions which are totally out of character with his usual behavior. There may be increasing demands for sexual activity or indiscriminate sexual activity, offensive sexual remarks in public, exhibitionism or cross-dressing. Additional accompanying features such as irritability, mood swing, anger or sleep disturbances may be present.
• Compulsive eating – compulsive or binge eating may not be noticeable in the early stages of Parkinson’s disease and may be thought to be normal behavior.
• Compulsive shopping
• Compulsive hobbyism or punding
• Drug abuse of anti-Parkinson’s medications – addiction to anti-Parkinson’s medications often leads to excessive and inappropriate intake of such medicines, tolerance and psychological dependence, and demand for increase in dopaminergic medication.

More than one compulsive behavior may be present in a patient with Parkinson’s disease and it may occur in

• Advanced cases of Parkinson’s disease.
• Patients on high dose of anti-Parkinson’s medications to control motor functions, especially dopamine agonists, but any anti-Parkinson’s medication may be involved.
• After neurosurgical treatment such as deep brain stimulation.

Treatment of Compulsive Behavior in Parkinson’s Disease

• Treatment is often difficult because the higher doses of anti-Parkinson’s medication needed to control motor symptoms may be the cause of the compulsive behavior.
• Changing from dopamine agonists drugs to levodopa may help because, in some cases, levodopa is less likely to cause this sort of disruptive behavior than dopamine agonists.
• Where compulsive behavior is initiated by an addition or increase in dose of dopaminergic medication, adjusting or reducing the dose or discontinuing the medicine altogether may help.
• Using a different type of dopaminergic medicine may solve the problem.
• Anti-psychotics and antidepressants help to control associated symptoms.
• Control of opportunities to carry out disturbing behavior.
• Psychiatric evaluation or psychiatric hospitalization.

Types of Urinary Disturbance in Parkinson’s Disease

• Frequency is the urge to empty the bladder at very frequent intervals, even when the bladder is not full.
• Urgency is the need to empty the bladder immediately.
• Incontinence is the patient has no control over his bladder, causing small or large amounts of urine to leak out.
• Adult-onset nocturnal enuresis which is bed wetting when asleep.
• Feeling of incomplete emptying of the bladder which increases if the patient is on anticholinergic medicines.
• Hesitancy is the difficulty in starting and then maintaining the flow of urine.

Causes, Effects and Differential Diagnosis

• Urinary disturbances occur both in the daytime and at night, resulting in insomnia and sleep deprivation, leading to extreme fatigue.
• Mobility problems may be aggravated due to reduced dopamine levels at night, making it more difficult for the patient to reach the toilet and it becomes more distressing if he has to empty his bladder many times during the night.
• Prostate enlargement is a common problem in men in the older age group and causes difficulty in emptying the bladder, so specific tests may need to be done to distinguish urinary problems due to an enlarged prostate from that due to Parkinson’s disease.
• Stress incontinence, or leakage of urine while sneezing, coughing, or laughing, is common in women after menopause and has to be distinguished from that due to Parkinson’s disease.

To identify the cause of bladder and urinary dysfunction a full evaluation of the patient needs to be done, including :

• Medical history
• Comprehensive physical examination
• Urine tests
• Ultrasonography
• Urological examination and relevant tests
• Neurological evaluation

Treatment of Urinary Disturbances in Parkinson’s Disease

Medicines to treat overactive bladder, causing urgency and frequency, are :

Oxybutynin

Tolterodine

Solifenacin

Darifenacin

These are anticholinergic drugs which act on the bladder wall or sphincter.

The above medicines do not help to treat problems with bladder emptying, such as hesitancy, and may aggravate the condition. Medicines such as bethanechol may help in these cases.

Management

Besides medicines, it may be useful to follow some simple procedures to help with the problem, such as :

• Avoiding food or drinks containing caffeine such as certain soft drinks, coffee or chocolate, which act as diuretic.
• Regulating the amount of liquids taken in the evening, especially 4 to 5 hours before going to bed.
• Pelvic floor exercises for stress incontinence.
• Wearing high absorbency pads may be useful, especially at night.
• Wearing easy to remove clothes with few fastenings.

1. Sleep onset problem where  the patient has difficulty in going off to sleep even though he/she may be extremely tired. This is most often associated with depression or anxiety states.
2. Sleep maintenance difficulty where the patient goes off to sleep easily but wakes up frequently at night. This problem is faced very frequently by Parkinson’s disease patients and they may have abrupt and agitated arousal more than five times at night. This leads to tiredness and excessive daytime sleepiness.
3. Excessive daytime sleepiness is caused by inability to sleep properly at night, most often due to waking up several times at night. Dopaminergic medication as part of Parkinson’s drug therapy also contributes to daytime sleepiness in Parkinson’s disease patients.

Causes of Insomnia in Parkinson’s Disease

• Medication – medicines used to treat Parkinson’s disease may cause insomnia due to difficulty in falling asleep or by causing vivid dreams or night terrors.
• Neurodegenerative changes in Parkinson’s disease.
• Periodic limb movements.
• Nocturia – waking frequently to pass urine.
• Inability to turn in bed.
• Sleep-related breathing disorders.
• Pain- generalized aches and pains associated with Parkinson’s disease.
• Pain from agitated pressure point arousal due to less movement in bed.
• Associated with co-existing depression and dementia.
• Increased daytime sleep either due to medications or due to dopamine deficiency in Parkinson’s disease.
• Lack of rapid eye movement or REM sleep, which is associated with deep sleep.
• Nightmares – patients with Parkinson’s disease often suffer from nightmares which prevent them from going back to sleep.
• Hallucinations.
• Age of the patient – Parkinson’s disease occurs in the older age group who, in normal circumstances, often suffer from insomnia.

Management of Insomnia in Parkinson’s Disease

Management of insomnia in patients with Parkinson’s disease should aim at treating the cause of insomnia. Adopting simple measures of sleep hygiene also help.

Sleep Hygiene

This entails simple procedures such as :

• Avoiding sleeping in the daytime.
• Keep fixed time for going to bed.
• Restricting water intake in the late evening and before going to bed.
• Avoiding caffeinated drinks and food before within 4 to 5 hours of bed time such as tea, coffee, soft drinks, and chocolate.
• Avoiding alcohol before sleep – it may cause early onset of sleep but the sleep is more likely to be fragmented.

Treatment of Insomnia in Parkinson’s Disease

Identifying and treating the cause of insomnia is most important.

• Dopaminergic medicines used to treat Parkinson’s disease often cause insomnia by increasing daytime sleep. The dose and time of medicine intake may need to be adjusted.
• Treatment of associated depression or dementia needs to be done. Atypical antipsychotics are often more effective, with lesser side effects.
• Sedatives and tranquillizers may be helpful.

Insomnia can be a frustrating condition to content with and is even more difficult to a patient suffering with a debilitating disease such as Parkinson’s. Caregivers should not pass off insomnia lightly and should take every measure to ensure the Parkinson’s patients comfort by taking complaints such as sleeplessness seriously.