Parkinson's Disease

Topic Overview

What is Parkinson's disease?

Parkinson's disease affects the way you move. It happens when there is a problem with certain nerve cells in the brain.

Normally, these nerve cells make an important chemical called dopamine. Dopamine sends signals to the part of your brain that controls movement. It lets your muscles move smoothly and do what you want them to do. When you have Parkinson's, these nerve cells break down. Then you no longer have enough dopamine, and you have trouble moving the way you want to.

Parkinson's is progressive, which means it gets worse over time. But usually this happens slowly, over a period of many years. And there are good treatments that can help you live a full life.

What causes Parkinson's disease?

No one knows for sure what makes these nerve cells break down. But scientists are doing a lot of research to look for the answer. They are studying many possible causes, including aging and poisons in the environment.

Abnormal genes seem to lead to Parkinson's disease in some people. But so far, there is not enough proof to show that it is always inherited.

What are the symptoms?

The four main symptoms of Parkinson's are:

• Tremor, which means shaking or trembling. Tremor may affect your hands, arms, legs, or head.
• Stiff muscles.
• Slow movement.
• Problems with balance or walking.

Tremor may be the first symptom you notice. It is one of the most common signs of the disease, although not everyone has it. More importantly, not everyone with a tremor has Parkinson's disease. Tremor often starts in just one arm or leg or only on one side of the body. It may be worse when you are awake but not moving the affected arm or leg. It may get better when you move the limb or you are asleep.

In time, Parkinson's affects muscles all through your body, so it can lead to problems like trouble swallowing or constipation. In the later stages of the disease, a person with Parkinson's may have a fixed or blank expression, trouble speaking, and other problems. Some people also have a decrease in mental skills (dementia).

People usually start to have symptoms between the ages of 50 and 60, but in some people symptoms start earlier.

How is Parkinson's disease diagnosed?

Your doctor will ask questions about your symptoms and your past health and will do a neurological exam. A neurological exam includes questions and tests that show how well your nerves are working. For example, your doctor will watch how you move, check your muscle strength and reflexes, and check your vision. In some cases, your doctor may have you try a medicine. How this medicine works may help your doctor know if you have Parkinson's disease. He or she will also ask questions about your mood.

There are no lab or blood tests that can help your doctor know whether you have Parkinson's. But you may have tests to help your doctor rule out other diseases that could be causing your symptoms. For example, you might have an MRI to look for signs of a stroke or brain tumor.

How is it treated?

At this time, there is no cure for Parkinson's disease. But there are several types of medicines that can control the symptoms and make the disease easier to live with.

You may not even need treatment if your symptoms are mild. Your doctor may wait to prescribe medicines until your symptoms start to get in the way of your daily life. Your doctor will adjust your medicines as your symptoms get worse. You may need to take several medicines to get the best results.

Levodopa (also called L-dopa) is the best drug for controlling symptoms of Parkinson's disease. But it can cause problems if you use it for a long time or at a high dose. Sometimes doctors use other medicines to treat people in the early stages of the disease. This lets them delay the use of levodopa. But other medicines have more side effects and don't control symptoms as well as levodopa. And the long-term problems caused by medicine are the same, no matter what medicine is used first.¹ The decision to start taking medicine, and which medicine to take, will be different for each person with Parkinson's disease. Your doctor will be able to help you make these choices.

In some cases, a treatment called deep brain stimulation may also be used. For this treatment, a surgeon places wires in your brain. The wires carry tiny electrical signals to the parts of the brain that control movement. These little signals can help those parts of the brain work better.

There are many things you can do at home that can help you stay as independent and healthy as possible. Eat healthy foods. Get the rest you need. Make wise use of your energy. Get some exercise every day. Physical therapy and occupational therapy can also help.

How will Parkinson's disease affect my life?

Finding out that you have a long-term, progressive disease changes your life. It is normal to have a wide range of feelings. You may feel angry, afraid, sad, or worried about what lies ahead. It may help to keep a few things in mind:

• No one can know for sure how your disease will progress. But usually this disease progresses slowly. Some people live for many years with only minor symptoms, such as a tremor in one hand.
• Many people who have Parkinson's disease can and do keep working for years. As the disease gets worse, you may need to change how you work. You can get support to learn ways to adapt.
• It is important to take an active role in your health care. Learn all you can about the disease. Find a doctor you trust and can work with. Go to all your appointments, and get all the treatment your doctor suggests.
• Depression is common in people who have Parkinson's. If you feel very sad or hopeless, talk to your doctor or see a counselor. Antidepressant medicines can help.
• It can make a big difference to know that you are not alone. Ask your doctor about Parkinson's support groups, or look for online groups or message boards.
• Parkinson's affects more than just the person who has it. It also affects your loved ones. Be sure to include them in your decisions. Help them learn about the disease and get the support they need.

Frequently Asked Questions

Cause

Low levels of dopamine, a brain chemical (neurotransmitter) involved in controlling movement, cause symptoms of Parkinson's disease. The shortage of this brain chemical occurs when nerve cells in a part of the brain (substantia nigra) that produces dopamine fail and deteriorate. The exact cause of this deterioration is not known.

The links between Parkinson's disease and factors such as genetics, aging, toxins in the environment, and free radicals are all under investigation. Although these studies are beginning to provide some answers, experts do not know the exact cause of the disease.

Studies are ongoing to determine whether there is a genetic cause of Parkinson's disease. Only a small percentage of people with Parkinson's disease have a parent, brother, or sister who has the disease; however, abnormal genes do seem to be a factor in a few families where early-onset Parkinson's disease is common.

Symptoms

The type and severity of symptoms experienced by a person with Parkinson's disease vary with each individual and the stage of Parkinson's disease. Symptoms that develop in the early stages of the disease in one person may not develop until later-or not at all-in another person.

The most common symptoms include:

• Tremor, or shaking, often in a hand, arm, or leg. Tremor caused by Parkinson's disease occurs when the person is awake and sitting or standing still (resting tremor) and subsides when the person moves the affected body part.
• Stiff muscles (rigidity) and aching muscles. One of the most common early signs of Parkinson's disease is a reduced arm swing on one side when the person is walking that is caused by rigid muscles. Rigidity can also affect the muscles of the legs, face, neck, or other parts of the body and may cause muscles to feel tired and achy.
• Slow, limited movement (bradykinesia), especially when the person tries to move from a resting position. For instance, it may be difficult to get out of a chair or turn over in bed.
• Weakness of face and throat muscles. Talking and swallowing may become more difficult, and the person may choke, cough, or drool. Speech becomes softer and monotonous. Loss of movement in the muscles in the face can cause a fixed, vacant facial expression, often called the "Parkinson's mask."
• Difficulty with walking (gait disturbance) and balance (postural instability). A person with Parkinson's disease is likely to take small steps and shuffle with his or her feet close together, bend forward slightly at the waist (stooped posture), and have trouble turning around. Balance and posture problems may result in frequent falls. However, these problems usually do not develop until later in the course of the disease.

Tremor is often the first symptom that people with Parkinson's disease or their family members notice. Initially, the tremor may appear in just one arm or leg or only on one side of the body. The tremor also may affect the chin, lips, and tongue. As the disease progresses, the tremor may spread to both sides of the body, although in some cases the tremor remains on just one side.

Emotional and physical stress tend to make the tremor more noticeable. Sleep, complete relaxation, and intentional movement or action usually reduce or stop the tremor.

Although tremor is one of the most common signs of Parkinson's disease, not everyone with tremor has Parkinson's disease. Unlike tremor caused by Parkinson's disease, tremor caused by other conditions gets better when your arm or hand is not moving and gets worse when you try to move it. The most common cause of non-Parkinson's tremor is essential tremor, a treatable condition that is often wrongly diagnosed as Parkinson's disease.

Other symptoms

Parkinson's disease can cause a variety of other symptoms. These can be disabling and may include:

• Decreased dexterity and coordination. Changes in handwriting are common, with writing becoming smaller. Athletic abilities decline, and daily activities such as dressing and eating become more difficult.
• Cramps in the muscles and joints.
• Oily skin or increased dandruff.
• Digestive and urinary problems. Constipation is common. Controlling urination (incontinence) may be difficult, and urination may be frequent and at times urgent. Drugs used to treat Parkinson's disease may help or may sometimes make these symptoms worse.
• Problems with involuntary or automatic body functions, such as increased sweating, low blood pressure when the person stands up (orthostatic hypotension), and problems with sexual function. These symptoms may also be caused by Parkinson's-plus conditions or drugs used to treat Parkinson's disease.
• Freezing, a sudden, brief inability to move. It most often affects walking.

Problems with sleep, mood, and thought also are common in people who have Parkinson's disease.

• Problems falling asleep or staying asleep (insomnia) can result from anxiety, depression, or physical restlessness. People with Parkinson's disease may not be able to sleep well because they cannot easily turn over or change position in bed.
• A person with Parkinson's disease may slowly become more dependent, fearful, indecisive, and passive. The person may talk less often than he or she used to, withdraw from family and friends, and remain inactive unless encouraged to move about. Depression is very common in people with this disease and can be caused by chemical changes in the brain or can be a reaction to having a disabling disease. Depression often improves with proper treatment.
• Up to one-third of people with Parkinson's disease may develop dementia and confusion, similar to Alzheimer's disease, late in the course of the disease. Depression can further contribute to memory loss and confusion. Memory loss, hallucinations (seeing or hearing things that aren't really there), and vivid dreams may sometimes be caused by drugs taken to treat Parkinson's disease.

There is a variety of other conditions with similar symptoms. Some of these may be reversible.

What Happens

The symptoms and the course of Parkinson's disease can vary a great deal from person to person. There is no known cure for Parkinson's disease. However, drugs, surgery, exercise, and lifestyle changes can relieve some symptoms of the disease.

Emotions may also affect symptoms. Anxiety, tension, and unhappiness may make symptoms worse. Relaxing usually reduces symptoms. Sometimes during stress, a person with Parkinson's disease has a "paradoxical outburst." This results in a short symptom-free period when the person may be able to move normally.

Treatment may help control symptoms during the early stages of Parkinson's disease and is usually started as soon as symptoms begin to affect a person's ability to work or do daily activities. For instance, a right-handed person with tremor only on the left side may not feel limited by the symptoms and may not feel the need to take drugs until symptoms get worse. A person who cannot do his or her job because of symptoms may want to begin treatment sooner than someone who does not work or whose symptoms do not affect his or her ability to work.

• Symptoms of Parkinson's disease typically begin appearing between the ages 50 and 60. They develop slowly and often go unnoticed by family, friends, and even the person who has them.
• A small number of people have symptoms on only one side of the body that never progress to the other side.

Drugs can control symptoms to some extent, but as the disease progresses, drugs may become less effective. Parkinson's disease also can cause a variety of complications as it advances.

What Increases Your Risk

Risk factors for Parkinson's disease are difficult to identify because the cause of the disease is unknown. Advancing age is the only known risk factor for typical Parkinson's disease (not including early-onset Parkinson's). Most instances of Parkinson's disease occur after age 50, although the illness does occur in people between the ages of 30 and 50, or in rare cases at a younger age.

A very small number of people with Parkinson's have a close relative who also has the disease, but it does not appear that a family history of typical Parkinson's disease significantly increases your risk of developing the disease. Having a family history of the disease is a more significant risk factor in cases of early-onset Parkinson's disease, but this form of the disease is not common.

Some research suggests that long-term exposure to certain environmental factors such as pesticides, chemicals, or well water may increase a person's risk of developing Parkinson's disease, but this has not been proven.

There are many other causes of parkinsonism, which is a group of symptoms that includes tremor, muscle stiffness, slow movement, and unsteady walking. Parkinsonism mimics Parkinson's disease, but in fact is not Parkinson's disease.

When To Call a Doctor

Call 911 or other emergency services immediately if you have sudden weakness, numbness, loss of balance, altered speech, or vision problems. These could be signs of a stroke. The symptoms of Parkinson's disease develop slowly over months.

If you think you may have symptoms of Parkinson's disease, see your doctor. Urgent medical care is not needed if you have had a tremor for some time. However, you should discuss the tremor at your next doctor's appointment. If a tremor is affecting your daily activities or if it is a new symptom, see your doctor sooner.

If you have been diagnosed with Parkinson's disease, call your doctor if:

• You notice any significant change in your symptoms, such as severe episodes of freezing-a sudden loss of mobility-which may affect walking.
• Your response to your medicine changes.
• Any other complications occur.
• You have symptoms of depression.
• You or your family notice that you have problems with memory and thinking ability.

If you have been diagnosed with Parkinson's disease, you will need to see members of your health care team regularly (every 3 to 6 months, or as directed) for adjustments in your treatment as your condition changes.

Watchful Waiting

If you notice a tremor developing, watch and record its development. Discuss it with your doctor at the next possible opportunity. A written description will help your doctor make a correct diagnosis. In writing your description, consider the following questions:

• Did the tremor start suddenly or gradually?
• What makes it worse or better?
• What parts of your body are affected?
• Have there been any recent changes in the medicines you are taking or how much you are taking?

For more questions that will help your doctor make an accurate diagnosis, read about medical history and Parkinson's disease.

Who To See

The following health professionals can help diagnose or treat Parkinson's disease:

• Family doctor
• Internist
• Neurologist

Other health professionals who may be involved in your care include:

• Physical therapist.
• Occupational therapist.
• Speech therapist.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

A diagnosis of Parkinson's disease is based on your medical history and a thorough neurological exam. Your doctor also may check your sense of smell. Sometimes, your doctor will have you try a medicine for Parkinson's disease. If that medicine helps your symptoms, it may help the doctor find out if you have Parkinson's disease.

There are no lab tests that can diagnose Parkinson's disease. If your symptoms and the doctor's findings during the examination are not entirely typical of Parkinson's disease, certain tests may be done to help diagnose other conditions with similar symptoms. For instance, blood tests may be done to check for abnormal thyroid hormone levels or liver damage. An imaging test (such as a CT scan or an MRI) may be used to check for signs of a stroke or brain tumor.

Another type of imaging test, called PET, sometimes may detect low levels of dopamine in the brain, a key feature of Parkinson's disease. However, PET scanning is not commonly used to evaluate Parkinson's disease because it is very expensive, is not available in many hospitals, and is only used experimentally.

Early Detection

For some diseases, doctors can do tests to look for problems or diseases before you have any symptoms. This is called screening. But there is no screening test for Parkinson's disease at this time.

Treatment Overview

No known treatment can stop or reverse the breakdown of nerve cells that causes Parkinson's disease. However, drugs can relieve many symptoms of the disease. Surgery also can be effective in a small number of people to treat symptoms of Parkinson's disease.

Treatment is different for every person, and the type of treatment you will need may change as the disease progresses. Your age, work status, family, and living situation can all affect decisions about when to begin treatment, what types of treatment to use, and when to make changes in treatment. As your medical condition changes, you may need regular adjustments in your treatment to balance quality-of-life issues, side effects of treatment, and treatment costs.

Parkinson's disease causes a wide range of symptoms and complications. This topic covers the overall management of the disease. This topic does not discuss managing specific symptoms.

Initial treatment

If your symptoms are mild, you may not need treatment for Parkinson's disease. Your doctor may wait to prescribe treatment with drugs until your symptoms begin to interfere with your daily activities. Additional treatment methods (such as exercise, physical therapy, and occupational therapy) can be helpful at all stages of Parkinson's disease to help you maintain your strength, mobility, and independence.

If you do need drugs at this point, there are several options. Levodopa is considered the "gold standard" of treatment for Parkinson's disease. But levodopa can have negative effects when used long-term. Because of this, dopamine agonists such as pramipexole and ropinirole often are used first. Other non-dopamine drugs may be used early in the course of the disease. These include amantadine, monoamine oxidase inhibitors (such as selegiline), and anticholinergics (such as trihexyphenidyl). As the disease progresses, levodopa will likely need to be added.

Early in the disease, it might be helpful to take pills with food to help with nausea, which may be caused by some medicines taken for Parkinson's disease. Later in the disease, taking the medicines at least one hour before meals (and at least two hours after meals) may help them work better.

Your doctor, other health professionals, or Parkinson's disease support groups can help you get emotional support and education about the illness. This is important both early and throughout the course of the disease.

Ongoing treatment

As Parkinson's disease progresses, the symptoms usually become more disabling. Most people develop mild to moderate tremor. Movement is often slow and limited due to muscular rigidity and the slowing down and loss of automatic and spontaneous movement (bradykinesia). Treatment in this stage is determined by weighing the severity of the symptoms against the side effects of drugs.

The symptoms of Parkinson's disease change as the disease progresses. Because of this, your doctor will adjust your drugs to deal with the symptoms as they appear. Levodopa is the most commonly used drug for Parkinson's disease. It works better than any other drug used to treat Parkinson's disease symptoms and has fewer side effects. But after using levodopa for over 5 years, many people start to have problems with motor complications (times when the medicine suddenly stops working or when you have uncontrollable jerking movements). Because of this, your doctor may prescribe dopamine agonists such as pramipexole or ropinirole to delay the point at which you need to begin taking levodopa. Studies have suggested that this may delay the onset of levodopa's side effects.² But in the longest study done, people who started treatment with a dopamine agonist had just as many problems with motor fluctuations at 14 years as people who started treatment with levodopa.¹ Your doctor may also prescribe levodopa along with a dopamine agonist.

Apomorphine (Apokyn) is a fast-acting dopamine agonist used to treat occasional episodes of immobility associated with Parkinson's disease. Apomorphine can be injected under the skin when muscles become "stuck" or "frozen" and you are unable to rise from a chair or perform daily activities. Treatment with occasional Apokyn shots may make it possible to decrease the regular amount of other medicines you are taking for Parkinson's disease. This may reduce the risk of side effects, such as twitching and other uncontrolled movements.³ Apokyn can be taken with an antinausea drug to prevent side effects of severe nausea and vomiting.

There are many measures you can take at home to make dealing with the symptoms of Parkinson's disease easier. Simplify your daily activities so that you have the energy for those that are most necessary, and arrange your furniture and other commonly used items so that it is easier for you to move around and get to things in your home. This can help keep you functioning independently.

Getting regular exercise and eating a healthy, balanced diet are important parts of treating Parkinson's disease. Exercise can help you maintain your strength, coordination, and endurance, as well as control your weight and reduce the likelihood that you will become constipated. And although a balanced diet is important, people who take levodopa should talk to their doctor about when to eat protein, because levodopa may not work as well if you take it at the same time that you eat protein.

Depression is common in people with Parkinson's disease. Recognizing and dealing with depression is an important part of home treatment. There are medicines that can help the symptoms of depression in people with Parkinson's disease.

Treatment when the condition gets worse

A person in the advanced stages of Parkinson's disease is significantly limited in movement and activity. Symptoms can change daily, and the side effects of drugs can limit their effectiveness. Your doctor may change your drug in order to deal with the symptoms as they arise.

A speech therapist can suggest breathing and speech exercises that can help you overcome the soft, imprecise speech and monotone voice that develop in advanced Parkinson's disease. Changing how and what you eat can help you overcome problems with eating. For example, sitting upright, taking small bites and sips, and eating moist, soft foods can help you avoid nutrition problems and lessen your chance of choking. Keeping your chin up, swallowing often, and not eating sugary foods can help reduce drooling.

Freezing, or motor blocks, can be dealt with through purposeful movement. Stepping toward a specific target on the ground and making your first step a precise, long, marching-style stride can help you overcome freezing episodes. A physical therapist or occupational therapist may be able to offer some helpful advice to improve your walking and reduce your risk of falling.

Other common symptoms that appear during Parkinson's disease include depression and sexual dysfunction. Talk to your doctor about ways to overcome these problems. There are medicines that can help these symptoms in people with Parkinson's disease.

You or your family members may notice that you begin to have problems with memory, problem solving, learning, and other mental functions. When these problems keep you from doing daily activities, it is called dementia. There are medicines that can help treat dementia in people with Parkinson's disease.

Surgeries such as deep brain stimulation or, less commonly, pallidotomy may be done during this stage of the disease.

Prevention

There is no known way to prevent Parkinson's disease.

Research has shown that people who eat more fruits and vegetables, high-fiber foods, fish, and omega-3 rich oils (sometimes known as the Mediterranean diet) and who eat less red meat and dairy may have some protection against Parkinson's disease. But the reason for this is still being studied.⁴

Home Treatment

Taking drugs for Parkinson's disease

Drugs for Parkinson's disease are prescribed with specific instructions about when to take them. It is important to follow your doctor's instructions concerning how and when to take your drugs so that they will be effective and safe. See the Medications section of this topic for more information on specific drugs.

Increasing, decreasing, or stopping the medicines you are taking may cause big changes in your symptoms and can be dangerous. Even if a medicine doesn't seem to be working, when you stop taking it, your symptoms of Parkinson's disease may be worse.

Early in the disease, it might be helpful to take pills with food to help with nausea, which may be caused by some medicines taken for Parkinson's disease. Later in the disease, taking the medicines at least one hour before meals (and at least two hours after meals) may help them work better. Some medicines for Parkinson's disease don't work as well if you take them at the same time you eat food with protein in it, like meat or cheese. The protein can block the medicine and keep it from working as well as it should.

Living with Parkinson's disease

Early on, Parkinson's disease may not greatly disrupt your life. But for most people, the disease becomes more disabling over time. Home treatment can help you adjust as the disease progresses and help you remain independent for as long as possible. The quality of your life may depend in part on your ability to continue working, maintain a home, care for your family, and remain independent. Adaptive devices such as canes or walkers may become necessary as the disease progresses.

Aspects of home treatment that are important for a person with Parkinson's disease include:

• Modifying your activities and your home, such as simplifying your daily activities and changing the location of furniture so that you can hold on to something as you move around the house.
• Eating healthy foods, including plenty of fruits, vegetables, grains, cereals, legumes, poultry, fish, lean meats, and low-fat dairy products.
• Exercising and doing physical therapy, which have benefits in both early and advanced stages of the disease.
• Dealing with tremor, which may include putting a little weight on the hand to help reduce tremor and restore control.
• Improving speech quality by working with a speech therapist (also called a speech-language pathologist).
• Reducing problems with eating and drooling by changing how and what you eat.
• Dealing with "freezing" by various means, such as stepping towards a specific target on the ground.
• Dealing with sexual function problems. Talk to your health professional about your specific issues. He or she may be able to suggest a change in your treatment, such as a change in your medicine or exercise.
• Dealing with depression. If you are feeling sad or depressed, ask a friend or family member for help. If these feelings don't go away, or if they get worse, talk to your doctor. He or she may be able to suggest someone for you to talk to or give you medicine that will help.
• Dealing with dementia. Dementia is common late in Parkinson's disease. Symptoms may include confusion and memory loss. If you or a family member notice that you are confused a lot or have trouble thinking clearly, talk to your doctor. There are medicines that can help dementia in people with Parkinson's disease.

Make every effort to preserve your general health. Proper diet, rest, wise use of energy, and practical and emotional support from your family, friends, and doctor can all be very helpful.

Medications

Medicines are the most common treatment for Parkinson's disease. The goal is to correct the shortage of the brain chemical (neurotransmitter) dopamine, which causes the symptoms of Parkinson's disease. Treatment with drugs is usually started when symptoms become disabling or disrupt a person's daily activities.

Treatments may differ based on a person's symptoms and age and how the person responds to a certain drug. Drugs often improve symptoms, but they also may cause side effects. It may take some time to find the best combination of drugs for a particular person.

Currently, levodopa is considered the most effective drug for controlling symptoms of Parkinson's disease and for many years was the preferred drug for treating newly diagnosed people.⁵ However, because long-term use of levodopa at high dosages often leads to motor complications that can be difficult to manage, sometimes doctors use the newer dopamine agonists (such as pramipexole and ropinirole) to treat people during the early stages of Parkinson's disease. Using these drugs in the early stages of the disease may allow treatment with levodopa to be delayed. But dopamine agonists have more side effects and don't control symptoms as well as levodopa. And in the long-term, the same amount of people have motor complications no matter what medicine is used first.¹

The question of whether it is better to use levodopa or a dopamine agonist as initial treatment has not been fully resolved. The choice will most likely be different for each person. Levodopa controls symptoms more effectively than dopamine agonists in most people. And levodopa has fewer side effects than dopamine agonists. But concern about the long-term effects of early and high-dose levodopa use is leading some experts to recommend initial treatment with dopamine agonists, especially in people who are younger than 60. As the disease progresses, your doctor may also prescribe levodopa along with a dopamine agonist. It is important to work with your doctor to find the medicines that work the best for you.

Apomorphine (Apokyn) is a fast-acting dopamine agonist used for treating occasional episodes of immobility associated with Parkinson's disease. Apomorphine can be injected under the skin when muscles become "stuck" or "frozen" and you are unable to rise from a chair or perform daily activities. Treatment with "as needed" apomorphine shots may make it possible to decrease the doses of other medicines you are taking for Parkinson's disease. This may reduce the risk of side effects, such as twitching and other uncontrolled movements. Work with your doctor to decide the right combination of medicines and doses for you. It may also be possible to take a regular dose of levodopa and a dopamine agonist, supplemented with apomorphine shots when needed instead of regularly adjusting the dose of oral drugs. Apomorphine can be taken with an antinausea drug to prevent side effects of severe nausea and vomiting.

Medication Choices

Several drugs may be used to treat Parkinson's disease at different stages of the disease.

In general, treatment of early Parkinson's starts with:

• Levodopa and carbidopa.
• Dopamine agonists (bromocriptine, pramipexole, ropinirole).
• COMT inhibitors (entacapone, tolcapone).
• MAO-B inhibitors (rasagiline, selegiline).
• Amantadine.
• Anticholinergic agents (benztropine, trihexyphenidyl).

What To Think About

All drugs used to treat Parkinson's disease can cause unpleasant side effects. An ideal drug regimen controls your symptoms without causing side effects that you cannot tolerate. Doctors generally will try one drug at a time, starting with low doses, to minimize side effects.

Increasing, decreasing, or stopping the medicines you are taking may cause big changes in your symptoms and can be dangerous. Even if a medicine doesn't seem to be working, you may have an increase in the symptoms of Parkinson's disease when you stop taking it.

Early in the disease, it might be helpful to take pills with food to help with nausea, which may be caused by some medicines taken for Parkinson's disease. Later in the disease, taking the medicines at least one hour before meals (and at least two hours after meals) may help them work best. Some medicines for Parkinson's disease don't work as well if you take them at the same time you eat food with protein in it, such as meat or cheese. The protein can block the medicine and keep it from working as well as it should.

Long-term use of Parkinson's disease medicines can cause motor fluctuations. These include sudden changes in your response to the drug (called the on-off response) and involuntary twitching and writhing movements (dyskinesias).

A possible serious side effect of taking medicines for Parkinson's disease is excessive daytime sleepiness. Sudden and overwhelming sleepiness without awareness of falling asleep is often referred to as a "sleep attack." These attacks, especially if they occur while driving, can pose a great threat to people with Parkinson's disease. Talk to your doctor about the dangers of driving while taking these drugs.

Drugs for Parkinson's disease can also cause risk-taking behavior such as uncontrollable gambling and shopping and an inappropriate increase in sexual activity. These changes in behavior can be very upsetting and difficult for family and friends to understand. If you or a family member sees this kind of behavior in you, talk to your doctor about it right away.

Changing the amount of the drug and using combinations of different drugs may help to manage these problems.

Surgery

Brain surgery may be considered when drugs fails to control symptoms of Parkinson's disease or cause severe or disabling side effects.

Deep brain stimulation (DBS) is a technique for treating Parkinson's disease. It affects movement by using electrical impulses to stimulate a target area in the brain. The electrical impulses are generated by wire electrodes surgically placed in the brain. Deep brain stimulation may be used in addition to therapy with levodopa or other drugs when drugs alone do not control symptoms adequately. This technique is the preferred surgical method of treating most cases of advanced Parkinson's disease. It does not destroy brain tissue and has fewer risks than older, more destructive surgical methods, such as pallidotomy and thalamotomy.⁶

Deep brain stimulation (DBS) neither cures Parkinson's disease nor eliminates the need for medicine. DBS of the thalamus is done to treat disabling tremor caused by Parkinson's disease. Procedures that stimulate the subthalamic nucleus and the globus pallidus control a wider range of symptoms (in addition to tremor) and are used more often than stimulation of the thalamus.

Pallidotomy and thalamotomy are rarely done anymore. They involve the precise destruction of very small areas in the deep part of the brain that cause symptoms.

Neurotransplantation surgery is an experimental procedure being studied for the treatment of Parkinson's disease. It involves implanting cells that produce dopamine into the brain. Information about the effectiveness of neurotransplantation is limited, and it is not a proven treatment or a realistic option for most people at this time.

Surgery Choices

Deep brain stimulation

Pallidotomy

Thalamotomy

Neurotransplantation

What To Think About

A neurologist with special training in Parkinson's disease is most often the best kind of doctor to make a decision about surgery. If you might benefit from surgery or deep brain stimulation, your neurologist can refer you to a brain surgeon with experience doing these operations.

Surgery most often becomes a treatment option for people when Parkinson's disease progresses to the point that drugs can no longer control symptoms adequately. With advanced disease, existing symptoms may get worse, or a person may develop new symptoms that drugs cannot control. (However, when a person has severe one-sided tremor, deep brain stimulation [DBS] may be considered much sooner because this symptom often responds better to DBS than to medicine.)

People who have extremely advanced Parkinson's or who have other serious conditions (such as heart or lung disease, cancer, or kidney failure) are not usually good candidates for surgery. Surgery is usually not considered for people who have dementia or psychiatric disorders.

Surgery is not a cure for Parkinson's disease. Drugs are usually still necessary after surgery, but surgery can reduce the number and amount of drugs needed to control symptoms. This reduces the side effects caused by drugs while at the same time controlling symptoms.

Other Treatment

Physical therapy, speech and language therapy, and occupational therapy can all be helpful for people with Parkinson's disease.

There are no high-quality studies to support the use of any medicine that is sure to slow or prevent the progression of Parkinson's disease. There has been some evidence that the antioxidant coenzyme Q10 may slow the progression of some symptoms of Parkinson's disease.⁷ But other research has not proved any benefit.⁸

Several nutritional therapies have been suggested as treatments for Parkinson's disease. None of these has been proven effective. However, it is important to maintain general health and to eat a balanced diet.

Before attempting any complementary treatment, such as a special diet, talk with your doctor about the safety and potential side effects of the treatment. Sharing information with your doctor can help you both decide whether a treatment is safe and effective. Complementary treatments should not replace the use of drugs to treat Parkinson's disease if you are a candidate for treatment with these drugs.

Depression that does not respond to drugs may improve with electroconvulsive therapy (ECT). ECT can also improve movement for a short period of time, though the reason for this improvement is not understood.

In March 2007 the National Institutes of Health (NIH) National Institute of Neurological Disorders and Stroke (NINDS) announced that they are starting a large clinical trial to see if the nutritional supplement creatine can slow the progression of Parkinson's disease. Results from this study are expected within 5 to 7 years.

Other Places To Get Help

Organizations

References

Citations

1. Katzenschlager R, et al. (2008). Fourteen-year final report of the randomized PDRG-UK trial comparing three initial treatments in PD. Neurology, 71(7): 474-480.

2. Clarke CE, Moore AP (2007). Parkinson's disease, search date November 2006. Online version of BMJ Clinical Evidence. Also available online: http://www.clinicalevidence.com.

3. Stacy M, Factor S (2004). Rapid treatment of "off" episodes: Will this change Parkinson's disease therapy? Neurology, 62(6, Suppl 4): S1-S2.

4. Sofi F, et al. (2008). Adherence to Mediterranean diet and health status: Meta-analysis. BMJ. Published online September 11, 2008 (doi:10.1136/bmj.a1344).

5. Miyasaki JM, et al. (2002). Practice parameter: Initiation of treatment for Parkinson's disease: An evidence-based review. Neurology, 58(1): 11-17.

6. Samii A, et al. (2004). Parkinson's disease. Lancet, 363(9423): 1783-1793.

7. Shults CW, et al. (2002). Effects of coenzyme Q10 in early Parkinson disease. Archives of Neurology, 59(10): 1541-1550.

8. Storch A, et al. (2007). Randomized, double-blind, placebo-controlled trial on symptomatic effects of coenzyme Q10 in Parkinson's disease. Archives of Neurology, 64(7): 938-944.

Other Works Consulted

• Deuschl G, et al. (2006). A randomized trial of deep-brain stimulation for Parkinson's disease. New England Journal of Medicine, 355(9): 896-908.

• Miyasaki JM, et al. (2006). Practice parameter: Evaluation and treatment of depression, psychosis, and dementia in Parkinson disease (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 66(7): 996-1002.

• Pahwa R, et al. (2006). Practice parameter: Treatment of Parkinson disease with motor fluctuations and dyskinesia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 66(7): 983-985.

• Siderowf A, Stern M (2003). Update on Parkinson disease. Annals of Internal Medicine, 138(8): 651-658.

• Suchowersky O, et al. (2006). Practice parameter: Diagnosis and prognosis of new onset Parkinson disease (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 66(7): 968-975.

• Suchowersky O, et al. (2006). Practice parameter: Neuroprotective strategies and alternative therapies for Parkinson disease (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 66(7): 976-982.

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