Symptom Diary

Understanding Your Parkinson’s Medications:
Peak Dose, Fluctuations, and Dyskinesias

Dopamine and Parkinson’s Disease
People with Parkinson’s Disease (PD) have lower levels of a brain chemical called dopamine. Dopamine helps control movement. Medications like levodopa help replace dopamine in your brain.
Levodopa comes in different forms and each person responds to it a little differently. Every time you take levodopa, your brain gets a “boost” of dopamine. Our goal is to keep your symptoms under control all day by keeping a steady dose of dopamine available in your brain.

ON and OFF times
Many people with PD notice when their medication starts working (“ON time”) and when it wears off (“OFF time”).

• During ON time, you may move more easily, with less stiffness, slowness, or tremor.
• During OFF time, your symptoms may return or get worse.
  Not everyone feels a clear difference between ON and OFF times. That’s okay. We look for these changes by watching you in the clinic and adjusting your medications to improve your day-to-day function.

How We Think About Adjusting Medications

Peak Dose

• This describes how well your symptoms are controlled when your medications are at their best.
• If your symptoms do not improve enough, we may increase the amount of medication, not just how often you take it.

Motor Fluctuations

• These describe how long your medications last between doses.
• You may notice your symptoms coming back before your next dose (“wearing off”), or you may wake up stiff and slow before your first dose of the day (“morning OFF”).
• We often treat this by giving medication more often or adding medicines that help your dose last longer.

Dyskinesias

• These are extra movements that you can’t control, like twisting, writhing, or fidgeting. They are not tremors, although they can look similar.
• They usually happen when your medication is at its strongest (“peak dose”), but can also occur when it’s kicking in or wearing off.
• Dyskinesias aren’t dangerous and often don’t bother the person having them. Sometimes we need to accept mild dyskinesia to keep other symptoms under control.
• You can help by noting when these movements happen in relation to when you take your medication. Taking a short video can help us too.

Tracking Your Symptoms
We make medication decisions based on how you feel at different times of the day. Let us know:

• When your symptoms improve or return
• If you notice side effects like extra movements or cramping
• How long it takes for your medication to start working

Here’s a sample Parkinson’s Diary to help you track how you’re doing. Write down:

• When you take each dose
• When you feel ON (medication working)
• When you feel OFF (symptoms return)
• When you notice dyskinesias (extra movements)

Pay attention to when your Parkinson’s symptoms are present, absent, improved, or worsened at specific times of the day. Symptoms can be a consequence of your medications kicking in, medications wearing off, excessive medication doses, or inadequate medication doses. Depending on the symptoms you notice and their timing related to when you take your medications, adjustments can be made that include changing the dosage, changing the frequency of your dosage, and/or adding additional medications.

PARKINSON SYMPTOMS DIARY
Below is a sample template for a Parkinson’s Disease diary that can be used to help determine how well your medications are working. It is important to note what times you take your medications and at what dosage. The most common ON symptoms are dyskinesias, but rarely dystonia can occur (painful cramping in hands, fingers, ankles, feet, or toes). The most common OFF symptoms are your typically Parkinson’s symptoms (slowness, stiffness, tremor, etc.). Other OFF phenomenon includes dystonia, anxiety, depression, thinking/memory impairment, or pain.

Author Mick Reedy, MD, is a Movement Disorders Specialist with
Inova Parkinson’s and Movement Disorders Center (IPMDC)