Parkinson's Disease

The Secret of Great Health Care

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Parkinson's Disease

In the United States, about 500,000 people have Parkinson’s disease, but many patients afflicted with the disease have not been diagnosed. The incidence of the disease increases with age, over 30% of the patients over 90 exhibiting signs and symptoms of the disease. Parkinson’s disease is associated with an imbalance of the chemicals in the brain, which causes the symptoms of the disease: tremor, stiffness, slow movement and postural instability.

Causes

Chemical changes in the brain are responsible for Parkinson’s disease. The part of the brain that makes dopamine, a chemical that is in charge of smooth movement, is destroyed. The decrease in dopamine results in abnormal nerve function and consequently impaired movement.

Parkinsonism is a condition that mimics Parkinson’s disease. Certain toxins – Agent Orange or carbon monoxide poisoning – are associated with parkinsonism. Medications lead to a reversible form of the parkinsonism including certain drugs to control psychosis, drugs to treat seizures and a drug called metoclopramide (Reglan).

Two occupations are associated with parkinsonism: boxing and welding. Metals given off by welding can lead to parkinsonism. Trauma to the head has the potential to lead to Parkinson’s disease but less than one percent of people who sustain a serious head injury will develop parkinsonism. Complications

Parkinson’s disease does not directly lead to death but the complications of the disease can. Slowing down of the muscles used to swallow can result in aspiration pneumonia. Immobility and the resultant bed rest set the body up for bed sores and blood clots. Unsteadiness increases the risk of falls, which can lead to fracture. Severe tremor and/or slow movement limits the ability to eat and perform other activities of daily living (ADL). Inability to perform ADL contributes to multiple complications such as weight loss, increased depression and improper hygiene, which increases risk for infection. Patients with Parkinson’s disease typically live 15-25 years from diagnosis to death.

Signs and Symptoms

Symptoms start subtly and progress slowly with the onset of symptoms to the time of diagnosis averaging 2-10 years. Typically, the first symptom is tremor, which affects the upper extremities, is one sided, slow, worse at rest and the fingers look like they are rolling a pill. With time the tremor becomes bilateral.

Those with Parkinson’s disease move slowly and have difficulty with walking and balance. The individual suffering from Parkinson’s disease walks with a shuffling gait and minimal arm movement. Decreased blink rate is another common manifestation of the slow movement, which can contribute to dry eyes.

Slow movement affects muscles of the digestive tract and results in impaired swallowing and constipation. Slowed swallowing mechanics sets the body up for pneumonia. Sialorrhea, better known as drooling, is a feature of advanced Parkinson’s disease and results not from increased production of saliva but from decreased swallowing allowing saliva to accumulate in the mouth.

Parkinson’s disease is also characterized by stiffness, which can lead to an aching discomfort in the back, hip, shoulders, and neck. The stiffness, slow movement and unsteadiness increases risk for falls.

Parkinson’s disease is associated with a variety of miscellaneous complications. Loss of ability to smell and fatigue are common and often precedes the diagnosis of Parkinson’s. Micrographia, or writing very small, is common. Patients with Parkinson’s speak in a low voice that is hard to hear. Reduced facial expression is common in those with Parkinson’s disease. Dementia becomes more prevalent as the disease progresses and occurs in about 30% of patients with Parkinson’s disease. The onset of dementia occurs 10-15 years from the onset of the diagnosis.

Restless leg syndrome (RLS), which is the uncomfortable aching sensation occurring at night that leads to an irresistible urge to move the leg, is a frequent problem in Parkinson’s disease. The sensation is described as a twitching, burning, stabbing, creeping, or aching sensation that is felt deep in the legs. Getting up to walk or dopamine therapy with levodopa or a dopamine agonist provides relief for RLS.

Table 17: Signs and symptoms of Parkinson's disease

Tremor

Slow movement

Stiffness

Falls

Reduced facial expression

Soft voice

Limited arm swing with walking

Shuffling gait

Small handwriting

Drooling

Depression

Aching muscle pain

Lack of smell

Constipation

Dementia

Diagnosis

The diagnosis of Parkinson’s disease is based on findings of the history and physical exam performed by the health care provider but a definitive diagnosis can only be made on autopsy. Magnetic Resonance Imaging (MRI) is done not to diagnosis Parkinson’s disease, but to rule out other conditions. Other conditions need to be ruled out because many conditions can look like Parkinson’s disease including stroke, hydrocephalus (fluid overload in the brain), stroke or brain tumor. Treatment

Treatment of Parkinson’s disease includes modifying the living environment, therapies, medications and surgery

Lifestyle modifications

Modifying the home, often with the help of an occupational therapist, keeps the patient safe and functional.
Placing handrails in the hall and in the bath improves function and reduces falls.
Remove rugs that move or furniture that clutters walking spaces.
Carpeting the house will cushion falls.
Seats with steady backs and high handrails make it easier to get up.
Devices that raise the toilet seat make going to the bathroom safer.
Wearing shoes with Velcro, not laces, make it easier to put on and remove.
As tremor worsens, electric shavers avoid the cuts that occurs with razors.
Wear clothing that are easy to get on and off, avoid clothes with buttons and zippers and use Velcro instead.
Take as much time as needed and sit upright when eating meals.
Thickening liquids make swallowing easier and decrease the risk of aspiration.
Obtaining body weights once a week to assure weight is stable.
Speech therapists aid with swallowing or communication difficulties.

MedicinesWhen symptoms limit activity, medications are used to decrease symptoms and make you more functional. The goals of drug therapy are to improve symptoms and quality of life. Medicines used to treat Parkinson’s disease work by increasing the amount of chemicals in the brain that are lost due to the disease. Levodopa/Carbidopa (Sinemet) is considered by many experts as a first line drug to treat Parkinson’s disease.

Levodopa is the most effective medicine at controlling the signs and symptoms of the disease. Levodopa/carbidopa is most effective at treating stiffness and slow movement and its response to tremor is variable. Levodopa is converted to dopamine in the brain and carbidopa aids levodopa getting into the brain. Without the addition of carbidopa a much higher dose of levodopa would be needed to get the same benefit and side effects would be much more prevalent. The long term use of levodopa in Parkinson’s patients is a question of debate because it may accelerate the loss of dopamine.

High protein diets decrease the absorption of levodopa and can result in fluctuating levels of levodopa. Take levodopa on an empty stomach and do not eat protein until one hour after taking the drug and two hours before. While this drug is best absorbed on an empty stomach, the side effect of nausea sometimes limit its use. Starting the drug slowly and weaning the dose upward to control symptoms can minimize the nausea.

Wearing off, which occurs as the disease progresses, describes the medicine becoming less effective and its effect lasting for shorter intervals. Giving the medicine more frequently, switching to an extended release form or adding other medicines (discussed below) can help combat the wearing off phenomenon. Early side effects include nausea, vomiting and low blood pressure. Dyskinesias are another side effect and describes abnormal movement such as jerking, fidgeting, twisting and turning movement. Its use is not recommended in patients with a history of malignant melanoma or active peptic ulcer disease.

Dopamine agonists, which act directly on the dopamine receptor in the brain, are another popular drug used in the treatment of Parkinson’s disease. Bromocriptine (Parlodel), pramipexole (Mirapex) and ropinirole (Requip) make up this class of medicines.

Some neurologists recommend using dopamine agonists as first line agents especially in younger patients who are more tolerant of the side effects. Side effects are greater with dopamine agonists when compared to levodopa specifically swelling, hallucinations and sleepiness. Dopamine agonists provide less complete symptom control then levodopa/carbidopa. Other side effects include drowsiness, anorexia, nausea, vomiting, headache, decreased blood pressure and hallucination. Take this medicine with meals as it will decrease the side effects.

Selegiline is used to supplement levodopa by extending its life in the brain. This drug can also be used in early Parkinson’s disease when signs and symptoms are mild. Intensification of the side effects of levodopa/carbidopa may occur. Caution must be used with this medications because of the high incidence of drug interactions especially with antidepressants.

Catechol-o-methyltransferease (COMT) inhibitors block an enzyme that breaks down levodopa. It is used in combination with levodopa later in the disease. These drugs can prolong the effect of levodopa/carbidopa and are often given together to combat the wearing off effect.

Entacapone (Comtan) and tolcapone (Tasmar) are the two COMT inhibitors on the market. Side effects include nausea, involuntary movements, discolored urine, back pain and diarrhea. COMT inhibitors decrease the fluctuations associated with levodopa/carbidopa as the disease progresses. The dose of levodopa/carbidopa may need to be decreased to tolerate this medication. Tolcoapone needs to be used with extreme caution, especially in patients with liver failure. Liver function tests should be monitored every two weeks for the first year while on this medication. Because of this concern, entacapone is the more frequently used COMT inhibitor.

Anticholinergic medicines, Trihexyphenidyl (Artane) and Benztopine Mesylate (Cogentin), target the symptoms tremor and stiffness and have little effect on the slow movement associated with Parkinson’s disease.

They are used alone in early Parkinson’s disease or in combination with levodopa in the later stages. These drugs have many side effects including nausea, constipation, dry mouth, urinary retention, confusion, agitation, drowsiness, and blurred vision. Treatment is begun with the smallest dose and the dose is gradually increased until benefit or intolerable side effects occur. These drugs should not be used in patents with narrow-angle glaucoma, prostatic enlargement and caution must be used in the elderly because of the many side effects.

Amantadine (Symmetral), which is also used to treat the flu, is used alone in early Parkinson’s disease to control symptoms and later in the disease to control abnormal movements and to improve the effect of levodopa/carbidopa. Side effects include nausea, dizziness, restlessness, rash, insomnia, anxiety and confusion but the side effects are uncommon with the recommended dose, 100 mg two times a day.

Dementia, more common in late Parkinson’s disease, is often associated with behavioral symptoms, such as agitation and violent behavior. Treatment with acetylcholinesterase inhibitors or antipsychotic medications can quiet these behaviors. The use of acetylcholinesterase inhibitors (rivastigmine, donepezil and galantamine) needs to be broached with some caution because of the theoretical risk of an increased level of acetylcholine which could worsen Parkinson’s disease.

Behavioral disturbances are often successively treated with the acetylcholinesterase inhibitors but occasionally antipsychotic medicines are needed. Clozapine is probably the most effective medication in treating symptoms but it is not commonly used because of its many side effects. Risperidone (Risperdal), quetiapine (Seroquel), and olanzapine (Zyprexa) are frequently used to treat psychotic features.

As the disease progresses signs and symptoms become more severe. Eventually, signs and symptoms will not be controlled adequately by medicine and require more aggressive treatment.

Deep brain stimulation (DBS) involves placing a thin metal electrode into one of several possible brain targets and attaching it to a computerized generator. This generator is implanted in the chest. DBS is a method to treat severe symptoms. It allows a reduction of medicine but requires close follow up by someone trained with the use of this therapy. DBS does not affect the dopamine levels in the brain but works by giving off an electrical stimulus to stop the signs and symptoms of disease by controlling excessive and abnormally patterned electrical discharges.

Depression is associated with a faster progression of the physical manifestations of the disease. It may result in the loss of the ability to care for oneself. Treatment of depression can lead to an improvement in quality of life. It is not clear if depression is intrinsic to Parkinson’s disease or just associated with the disability.

Health Care Responsibility

Understand the questions listed below to understand your disease. There is a worksheet that you can use when you talk to your doctor.
Complete the Parkinson’s monitoring scale every year and before any doctor appointment where Parkinson’s disease will be evaluated and report it to your doctor to help track your disease. The Parkinson’s assessment will help your doctor track the progression of Parkinson’s disease.
The global functional assessment form in the appendix will help you and your doctor monitor your overall ability to function. It should be completely annually or at any visit that Parkinson’s disease is being evaluated. This form helps the doctor determine the progression of your disease and if any further intervention would be of benefit.
When starting a new medication, monitor your symptoms and side effects on a weekly basis to document the benefit to harm ratio. Parkinson’s is a disease without a cure and no medicine is able to alter the natural course of the disease. The benefits of the medicines need to outweigh the side effects; if they do not then another treatment option should be looked at. The medication monitoring form
listed in appendix will help you and your doctor evaluate if the medicine is doing more good than harm.
Questions

How sure are you about my diagnosis? If there is any uncertainity the use of some diagnostic tests may be indicated.
Are there any specific exercises I should be doing? Exercise is an important aspect of managing chronic diseases. Getting input from your doctor as to the best exercise is recommended.
Are there any support groups? Having support for this chronic disease is beneficial. Getting involved in groups with others who suffer from the same disease has the potential to improve quality of life.
Did you screen me for depression/dementia? These are common conditions that go along with Parkinson’s disease and should be evaluated for.
Are there any other medicines or treatments to help control my disease? Parkinson’s disease is a disease that often requires frequent adjustments of the medications. Stay on top of your medication regime in regaurds to how well they are controlling your symptoms.
What lifestyle interventions are appropriate for improving my quality of life?
Should I see a neurologist? Neurologists are doctors that specialize in diseases of the brain and the nervous system such as Parkinson’s disease. They have special knowledge on how to manage this condition.