Parkinson’s disease (PD) is a nervous system disorder that gradually effects a person’s ability to move. For most people with PD (8 out of 10), the symptoms begin after age 60, but for some (2 out of 10) it may begin between ages 21 and 50. People with the sleep disorders like REM sleep behavior disorder (RBD) are more likely to develop PD.
Although subtle changes in speaking or smelling may happen first, most people’s first sign of the disease is shaking of one or the other arm, hand, or fingers, also called a tremor. Over time this turns into muscle stiffness; slowed movements, also called bradykinesia (braid-ee-ki-knees-huh); and difficulty with balance. How long that takes is very different for each individual and depends highly on what medical treatment each person receives.
In addition to movement issues, also called motor symptoms, later in the disease, people with PD have what are called nonmotor symptoms—the most disturbing of which for many people are changes in thinking, apathy, and disconnection from reality in the form of hallucinations and delusions (seeing or believing things that are not real).
Many people with PD also have depression, anxiety, and difficulty with sleeping, which can all be treated. When these issues are successfully treated, the quality of life for people with PD and their loved one’s improves.
We don’t know yet why it happens or what starts the disease process, but we do know that a specific type of brain cells—the ones that use the chemical dopamine to communicate with other cells—degenerate and die off in PD. As a result, all brain cells and processes that rely on dopamine, called the dopaminergic system, are affected. This is why the major form of treatment (see below) is to effect dopamine in some way.
Because there is no simple test to determine that a person does or doesn’t have PD, a neurologist will ask many questions about a person’s symptoms and family history. The doctor will also do a detailed physical examination and measure reflexes, tremor, or difficulty walking. The doctor will want to know how a person sleeps and if he or she has noticed any changes in voice, facial movements, tingling, pain, constipation or changes in thinking. The doctor may order images of the brain with MRI to show that other illnesses are not causing the symptoms. The doctor may also order a specialized imaging study called a dopamine-transporter (DaT) scan which can show changes in the dopaminergic system in the brain.
If the doctor thinks PD is the problem, she or he will likely prescribe dopamine-modulating therapy to see if that improves symptoms. If it does, the diagnosis of PD is considered confirmed. If treatment with dopamine does not help, the physician will look for other causes of the symptoms or conditions that mimic PD called atypical parkinsonism.
Dopamine can be replaced with the combination drug levodopa-carbidopa. Levodopa is a chemical that the body converts to dopamine. Carbidopa is a drug that helps prevent that conversion from happening before levodopa gets to the brain where it is needed. The movie Awakenings, starring Robin Williams tells the story of how levodopa treatment was developed.
After years of treatment (usually), a person’s response to levodopa-carbidopa lessens. When this happens, the symptoms may return when dopamine is lowest in the body, termed the OFF period. The dose of levodopa-carbidopa can be increased to help with the returned symptoms, but if there is too much dopamine, a person might have movements they can’t control, called dyskinesia (disk-eye-knees-zhuh). Doctors may use combinations of levodopa-carbidopa with drugs called dopamine agonists that mimic the activity of dopamine in the brain. Monoamine oxidase inhibitors (MAO-Is) or catechol-O-methyltransferase (cat-ih-kohl meth-ill trans-fur-ace) both slow the breakdown of dopamine and can also be helpful. Other drugs that reduce tremor called anticholinergics (ant-eye-kohl-in-er-gicks) or amantadine may be helpful too.
People who responded well to medication that have become less effective with time may be candidates for surgical procedures to help manage PD symptoms. A procedure called deep brain stimulation (DBS) in which electrodes are implanted in the brain to deliver current that activates the dopaminergic system can be considered. A newer technique called magnetic resonance guided focused ultrasound can be used to treat tremor in people with PD. Another surgical procedure allows for a continuous infusion of a gel form of carbidopa/levodopa directly into the intestine where it is absorbed. This way the medication almost never wears off.
Unfortunately, these treatments do not slow or cure PD, but the good news is that all of these treatments can improve symptoms and quality of life for people with PD.
Getting enough sleep is essential for brain health for all people with and without neurologic diseases. People with PD often have difficulty sleeping, or insomnia and sometimes have trouble with specific sleep disorders. It is a good idea for people with PD to discuss sleep with their health care team at every visit and even see a sleep specialist.
The best proven treatments for insomnia are a good sleep hygiene, consisting of:
If it all of those measures do not improve sleep, a specific behavior change plan called cognitive-behavioral therapy-insomnia is also proven to help people overcome insomnia.
Many studies have shown that moderate-to-vigorous exercise can improve symptoms of PD. A doctor may be able to prescribe physical therapy. A physical therapist can help people learn to exercise safely and teach them exercises that are specifically designed to help people with PD. These specific exercises are called BIG Therapy and Parkinson’s Wellness Recovery.
There is no special diet shown to improve symptoms of PD, however, eating a diet high in fiber and drinking plenty of water can help with the constipation that many people with PD experience.
Treating Depression and Anxiety
It is common for people with chronic diseases, especially the ones that effect the brain, to experience anxiety or depression. Discussing feelings of sadness, hopelessness, or worries that don’t go away with loved ones and with the health care team can help. These problems can be treated, and often when they are, other aspects of living with an illness become easier.
Staying Socially Active
There are a few new studies showing that staying connected to family and friends has benefits for people with PD. There is also some evidence that remaining socially connected can help maintain thinking abilities. Remaining involved with family, friends and community is another way to live well with PD.
Healthy Cognitive Aging
There are evidence-based tools for staying sharp throughout the lifespan.
Brian K. Lebowitz, PhD, ABPP-CN; Elizabeth Londen, PhD; and Thomas Preston, PhD, ABPP-CN
Moving the Mouse With the Mind
Braingate technology allows patients with tetrapalegia to move a computer cursor by thinking about it.
Leigh R. Hochberg, MD, PhD
James P. Orengo, MD, PhD; and David R. Murdock, MD
Stanley Jones P. Iyadurai, MD, PhD, FAAN
Michelle L. Dougherty, MD, FAAN, FAES