Parkinson's disease

The symptoms of Parkinson's disease vary from person to person. Early signs may be subtle and can go unnoticed for months or years. Symptoms typically begin on one side of the body and usually remain worse on that side. Parkinson's signs and symptoms may include:

• Tremor. The characteristic shaking associated with Parkinson's disease often begins in a hand. A back-and-forth rubbing of your thumb and forefinger, known as pill-rolling, is common. However, many people with Parkinson's disease do not experience substantial tremor.
• Slowed motion (bradykinesia). Over time, Parkinson's disease may reduce your ability to initiate voluntary movement. This may make even the simplest tasks difficult and time-consuming. When you walk, your steps may become short and shuffling. Or your feet may freeze to the floor, making it hard to take the first step.
• Rigid muscles. Muscle stiffness often occurs in your limbs and neck. Sometimes the stiffness can be so severe that it limits the range of your movements and causes pain.
• Impaired posture and balance. Your posture may become stooped as a result of Parkinson's disease. Imbalance also is common, although this is usually mild until the later stages of the disease.
• Loss of automatic movements. Blinking, smiling and swinging your arms when you walk are all unconscious acts that are a normal part of being human. In Parkinson's disease, these acts tend to be diminished and even lost. Some people may develop a fixed staring expression and unblinking eyes. Others may no longer gesture or seem animated when they speak.
• Speech changes. Many people with Parkinson's disease have problems with speech. You may speak more softly, rapidly or in a monotone, sometimes slurring or repeating words, or hesitating before speaking.
• Dementia. In the later stages of Parkinson's disease, some people develop problems with memory and mental clarity. Alzheimer's drugs appear to alleviate some of these symptoms to a mild degree.

No definitive tests exist for Parkinson's disease, so it can be difficult to diagnose, especially in the early stages. And parkinsonism — the symptoms of Parkinson's disease — can be caused by many other types of problems. Examples include:

• Other neurological disorders. Essential tremor, dementia with Lewy bodies, multiple system atrophy and progressive supranuclear palsy each feature some symptoms common to Parkinson's disease.
• Drugs. Antipsychotic medications — such as chlorpromazine (Thorazine) and haloperidol (Haldol) — block dopamine, as do anti-nausea drugs like prochlorperazine (Compazine) or metoclopramide (Reglan). If you take any of these drugs, you may develop parkinsonism, although it is reversible when the drug is stopped.
• Toxins. Exposure to carbon monoxide, cyanide or certain other toxins can produce symptoms similar to Parkinson's disease.
• Head trauma. Both solitary head injuries and the repetitive variety of head trauma common in boxing have been linked to Parkinsonism, although risks are small.
• Structural problems. Strokes or fluid buildup in the brain (hydrocephalus) may occasionally mimic Parkinson's disease.

A diagnosis of Parkinson's disease is based on your medical history and a neurological examination. As part of your medical history, your doctor will want to know about any medications you take and whether you have a family history of Parkinson's. The neurological examination includes an evaluation of your walking and coordination, as well as some simple hand tasks.

A diagnosis of Parkinson's is most likely if you have:

• At least two of the three cardinal Parkinson's symptoms — tremor, slowing of motion and muscle rigidity
• Onset of symptoms on only one side of the body
• Tremor more pronounced at rest, for example, when your hands are resting in your lap
• Strong response to levodopa, a Parkinson's drug

Your initial response to Parkinson's treatment can be dramatic. Over time, however, the benefits of drugs frequently diminish or become less consistent, although symptoms can usually still be fairly well controlled. Your doctor may recommend lifestyle changes, such as physical therapy, a healthy diet and exercise, in addition to medications. In some cases, surgery may be helpful.

Medications
Medications can help manage problems with walking, movement and tremor by increasing the brain's supply of dopamine. Taking dopamine itself is not helpful, because it is unable to enter your brain.

• Levodopa. The most effective Parkinson's drug is levodopa, which is a natural substance that we all have in our body. When taken by mouth in pill form, it passes into the brain and is converted to dopamine. Levodopa is combined with carbidopa to create the combination drug Sinemet. The carbidopa protects levodopa from premature conversion to dopamine outside the brain; in doing that, it also prevents nausea. In Europe, levodopa is combined with a similar substance, benserazide, and is marketed as Madopar.

As the disease progresses, the benefit from levodopa may become less stable, with a tendency to wax and wane ("wearing off"). This then requires medication adjustments. Levodopa side effects include confusion, delusions and hallucinations, as well as involuntary movements called dyskinesia. These resolve with dose reduction, but sometimes at the expense of reduced parkinsonism control.

• Dopamine agonists. Unlike levodopa, these drugs aren't changed into dopamine. Instead, they mimic the effects of dopamine in the brain and cause neurons to react as though dopamine is present. They are not nearly as effective in treating the symptoms of Parkinson's disease. However, they last longer and are often used to smooth the sometimes off-and-on effect of levodopa.

This class includes pill forms of dopamine agonists, pramipexole (Mirapex) and ropinirole (Requip), as well as a patch form, rotigotine (Neupro). Pergolide (Permax) has been withdrawn from the market because of its association with heart valve problems. A short-acting injectable dopamine agonist, apomorphine (Apokyn), is used for quick relief.

The side effects of dopamine agonists include those of carbidopa-levodopa, although they're less likely to cause involuntary movements. However, they are substantially more likely to cause hallucinations, sleepiness or swelling. These medications may also increase your risk of compulsive behaviors such as hypersexuality, compulsive gambling and compulsive overeating. If you are taking these medications and start behaving in a way that's out of character for you, talk to your doctor.

• MAO B inhibitors. These types of drugs, including selegiline (Eldepryl) and rasagiline (Azilect), help prevent the breakdown of both naturally occurring dopamine and dopamine formed from levodopa. They do this by inhibiting the activity of the enzyme monoamine oxidase B (MAO B) — the enzyme that metabolizes dopamine in the brain. Side effects are rare but can include serious interactions with other medications, including drugs to treat depression and certain narcotics.
• Catechol O-methyltransferase (COMT) inhibitors. These drugs prolong the effect of carbidopa-levodopa therapy by blocking an enzyme that breaks down levodopa. Tolcapone (Tasmar) has been linked to liver damage and liver failure, so it's normally used only in people who aren't responding to other therapies. Entacapone (Comtan) doesn't cause liver problems and is now combined with carbidopa and levodopa in a medication called Stalevo.
• Anticholinergics. These drugs have been used for many years to help control the tremor associated with Parkinson's disease. A number of anticholinergic drugs, such as trihexyphenidyl and benztropine (Cogentin), are available. However, their modest benefits may be offset by side effects such as confusion and hallucinations, particularly in people over the age of 70. Other side effects include dry mouth, nausea, urine retention — especially in men with an enlarged prostate — and severe constipation.
• Antivirals. Doctors may prescribe amantadine (Symmetrel) alone to provide short-term relief of mild, early-stage Parkinson's disease. It also may be added to carbidopa-levodopa therapy for people in the later stages of Parkinson's disease, especially if they have problems with involuntary movements (dyskinesia) induced by carbidopa-levodopa. Side effects include swollen ankles and a purple mottling of the skin.

Physical therapy
Exercise is important for general health, but especially for maintaining function in Parkinson's disease. Physical therapy may be advisable and can help improve mobility, range of motion and muscle tone. Although specific exercises can't stop the progress of the disease, improving muscle strength can help you feel more confident and capable. A physical therapist can also work with you to improve your gait and balance. A speech therapist or speech pathologist can improve problems with speaking and swallowing.

Surgery
Deep brain stimulation is the most common surgical procedure to treat Parkinson's disease. It involves implanting an electrode deep within the parts of your brain that control movement. The amount of stimulation delivered by the electrode is controlled by a pacemaker-like device placed under the skin in your upper chest. A wire that travels under your skin connects the device, called a pulse generator, to the electrode.

Deep brain stimulation is most often used for people who have advanced Parkinson's disease who have unstable medication (levodopa) responses. It can stabilize medication fluctuations and reduce or eliminate involuntary movements (dyskinesias). Tremor is especially responsive to this therapy. Deep brain stimulation doesn't help dementia and may make that worse.

Like any other brain surgery, this procedure has risks — such as brain hemorrhage or stroke-like problems. Infection also may occur, requiring parts of the device to be replaced. In addition, the unit's battery beneath the skin of the chest wall must be surgically replaced every few years. Deep brain stimulation isn't beneficial for people who don't respond to carbidopa-levodopa.

If you've received a diagnosis of Parkinson's disease, you'll need to work closely with your doctor to find a treatment plan that offers you the greatest relief from symptoms with the fewest side effects. Certain lifestyle changes also may help make living with Parkinson's disease easier. 

Healthy eating
Eat a nutritionally balanced diet that contains plenty of fruits, vegetables and whole grains. These foods are high in fiber, which is important for helping prevent the constipation that is common in Parkinson's disease.

If you take a fiber supplement, such as psyllium powder, Metamucil or Citrucel, be sure to introduce it gradually and drink plenty of fluids daily. Otherwise, your constipation may become worse. If you find that fiber helps your symptoms, use it on a regular basis for the best results.

Walking with care
Parkinson's disease can disturb your sense of balance, making it difficult to walk with a normal gait. These suggestions may help:

• Try not to move too quickly.
• Aim for your heel to strike the floor first when you're walking.
• If you notice yourself shuffling, stop and check your posture. It's best to stand up straight with your head over your hips and your feet eight to 10 inches apart.

Avoiding falls
In the later stages of the disease, you may fall more easily. That's because Parkinson's disease affects the balance and coordination centers in the brain. In fact, you may be thrown off balance by just a small push or bump. The following suggestions may help:

• Don't pivot your body over your feet while turning. Instead, make a U-turn.
• Don't lean or reach. Keep your center of gravity over your feet.
• Don't carry things while walking.
• Avoid walking backward.

Dressing
Dressing can be the most frustrating of all activities for someone with Parkinson's disease. The loss of fine-motor control makes it hard to button and zip clothes, and even to step into a pair of pants. An occupational therapist can point out techniques that make daily activities easier. These suggestions also may help:

• Allow plenty of time so that you don't feel rushed.
• Lay clothes nearby.
• Choose clothes that you can slip on easily, such as sweat pants, simple dresses or pants with elastic waistbands.
• Use fabric fasteners, such as Velcro, instead of buttons

Living with any chronic illness can be difficult, and it's normal to feel angry, depressed or discouraged at times. Parkinson's disease presents special problems because it can cause chemical changes in your brain that make you feel anxious or depressed. And Parkinson's disease can be profoundly frustrating, as walking, talking and even eating become more difficult and time-consuming.

Although friends and family can be your best allies, the understanding of people who know what you're going through can be especially helpful. Support groups aren't for everyone, but for many people, they can be a good resource for practical information about Parkinson's disease.

To learn about support groups in your community, talk to your doctor, a Parkinson's disease social worker or a local public health nurse. Or contact the National Parkinson Foundation or the American Parkinson Disease Association.