Remaining Issues In The Pharmacotherapy Of Later Parkinson’s Disease
Although many believe dopamine agonists to be the most effective agents to use as adjuvant therapy, this conclusion is not evidence based. We require further data comparing agonists, COMT inhibitors, and selegiline in terms of quality of life and health economics. This is the subject of the second part of the PD MED trial . Further information is also required on when to use apomorphine infusions, particularly in relation to surgical treatment. Answers should be generated in part from the PD SURG trial .
Managing Depression In Parkinsons Disease
People with Parkinsons, family members and caregivers may not always recognize the signs of depression and anxiety. If you are experiencing depression as a symptom of Parkinsons, it is important to know it can be treated.
Here are some suggestions:
- For information and support on living well with Parkinsons disease, contact our Information and Referral line.
- As much as possible, remain socially engaged and physically active. Resist the urge to isolate yourself.
- You may want to consult a psychologist and there are medications that help relieve depression in people with Parkinsons, including nortriptyline and citalopram .
What Causes Parkinsons Disease
Parkinsons disease occurs when nerve cells in an area of the brain called the substantia nigra become impaired or die. These cells normally produce dopamine, a chemical that helps the cells of the brain communicate . When these nerve cells become impaired or die, they produce less dopamine. Dopamine is especially important for the operation of another area of the brain called the basal ganglia. This area of the brain is responsible for organizing the brains commands for body movement. The loss of dopamine causes the movement symptoms seen in people with Parkinsons disease.
People with Parkinsons disease also lose another neurotransmitter called norepinephrine. This chemical is needed for proper functioning of the sympathetic nervous system. This system controls some of the bodys autonomic functions such as digestion, heart rate, blood pressure and breathing. Loss of norepinephrine causes some of the non-movement-related symptoms of Parkinsons disease.
Scientists arent sure what causes the neurons that produce these neurotransmitter chemicals to die.
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Caregiving For People Living With Parkinsons
Caring for a loved one with PD can be a challenging job, especially as the disease progresses. Former caregivers of a loved one with PD suggest doing the following : Get prepared, Take care of yourself, Get help , Work to maintain a good relationship with your loved one, and Encourage the person with PD for whom you care, to stay active.
Preparing for caregiving starts with education. Reading this fact sheet is a good start. More resources are available to you in theResources section of this fact sheet. Early Parkinsonâs disease usually requires more emotional support and less hands-on care. It is a good time for family members/caregivers to educate themselves about the disease.
Surgery And Deep Brain Stimulation
Deep brain stimulation is a treatment for Parkinsonâs disease that uses an implantable pacemaker-like device to deliver electrical pulses to parts of the brain involved in movement. The DBS system consists of leads precisely inserted into a specific brain target, the neurostimulator implanted in the chest, and extension wires that connect the leads to the neurostimulator. Though implantation of the system requires a neurosurgical procedure, the treatment itself consists of long-term electrical stimulation. Advantages of DBS include its ability to reduce the high doses of medications , its adjustability , and its reversibility DBS was approved by the Food and Drug Administration as a treatment for PD in 2002 and according to Medtronic , more than 80,000 patients have undergone DBS surgery worldwide.
Typical candidates are those who have motor fluctuations or periods of âoffâ time with troublesome symptoms alternating with periods of âonâ time with good symptom control, and also with possible periods of excessive movement .
Not all patients with Parkinsonâs disease are good candidates for treatment with DBS. Approximately 10â20% of patients considered for possible treatment with DBS include those:
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Diagnosis And Management Of Parkinsons Disease
There are no diagnostic tests for Parkinsons. X-rays, scans and blood tests may be used to rule out other conditions. For this reason, getting a diagnosis of Parkinsons may take some time.
No two people with Parkinsons disease will have exactly the same symptoms or treatment. Your doctor or neurologist can help you decide which treatments to use.
People can manage their Parkinsons disease symptoms through:
- seeing a Doctor who specialises in Parkinsons
- medication
- multidisciplinary therapy provided for example, by nurses, allied health professionals and counsellors
- deep brain stimulation surgery .
Supplements For Parkinsons Disease Management
Many people with Parkinsons take supplements as part of their health routines. In a study of supplement habits in people with PD, the following supplements appear to be associated with a decreased rate of progression of PD symptoms.
CoQ10 is an important antioxidant that helps our cells make energy. Because mitochondrial dysfunction and impaired cellular energy metabolism are implicated in the development of Parkinsons disease, it makes sense to ensure that you areat the very leastnot deficient. One of the ways to do this is to supplement regularly with an over-the-counter CoQ10 supplement. In animal studies, CoQ10 supplementation has even been shown to halt or reverse the progression of Parkinsonian symptoms.
5MTHF stands for 5-methyl-tetrahydrafolate. Its a methylated form of folate thats thought to be more bioavailable than folic acid. Many people with PD take this as a part of the protocol recommended at the beginning of this article to maximize the effectiveness of some Parkinsons medications.
Turmeric, resveratrol, and quercetin are thought to protect cell membrane health mostly via their antioxidant capabilities. Antioxidants quench free radicals that would normally damage the fatty lining of every single cell in our bodies. By doing this, they protect cell membrane health and preserve the ability of our cells to manufacture energy and signal to each other appropriately.
References:
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Ensure You’re Getting Enough Sleep
Like a healthy diet, a regular sleep schedule is a crucial part of your overall well-being. Your symptoms may make sleeping a challenge. People with Parkinson’s can experience insomnia, sleep apnea and discomfort that keeps them awake. Try to set regular waking and sleep hours. Exercise during the day may also help you get enough rest at night. If necessary, talk to your doctor about safe sleep aids.
Drug Therapy And Research
If the disease progresses beyond minor symptoms, drug treatment may be indicated. Drug therapy for Parkinsonâs typically provides relief for 10â15 years or more. The most commonly prescribed medication is L-dopa , and this helps replenish some of the depleted dopamine in the brain. Sinemet, a combination of levodopa and carbidopa, is the drug most doctors use to treat Parkinsonâs disease. Recent clinical studies have suggested, in the younger person, the class of drugs called âdopamine agonistsâ should be used prior to levodopa-carpidopa except in patients with cognitive problems or hallucinations. In those older than 75, dopamine agonists should be used cautiously because of an added risk of hallucinations.
Other drugs are also used, and new drugs are continually being tested. It is common for multiple drugs to be prescribed because many of them work well together to control symptoms and reduce side effects. Contrary to past beliefs, starting Sinemet in newly diagnosed people does not lead to early symptoms of dyskinesia . Current knowledge is that the disease progression causes dyskinesias, not a âresistanceâ to the drug.
Quality of life studies show that early treatment with dopaminergic medications improves daily functioning, prevents falls, and improves a personâs sense of well-being.
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Remaining Issues In The Pharmacotherapy Of Early Parkinson’s Disease
In spite of the plethora of recent work addressing dopamine agonist monotherapy, many questions still remain. A change in practice to using agonist monotherapy for every new case of Parkinson’s disease would double or treble the cost of treatment immediately. Is this worth it from the National Health Service’s perspective in terms of cost effectiveness, and from the patient’s perspective in terms of quality of life? Is agonist monotherapy neuroprotective and/or is levodopa toxic? It has been suggested that agonist monotherapy delays motor complications until levodopa is introduced, then complications accelerate until they are as severe as they would have been if an agonist had never been given. No data on this are available from the existing trials so this possibility remains. The recent agonist monotherapy trials included predominantly younger patients with Parkinson’s disease: ropinirolemean age 63 years pramipexolemean age 61 years pergolidemean age 59 years. So the results of these trials should not be generalised to the elderly population in whom further data are required before recommendations can be made. Similar questions are outstanding regarding selegiline monotherapy in terms of its effects on quality of life, cost effectiveness, and neuroprotection.
Figure 3
Summary of the design of the PD MED trial . COMT, catechol-O-methyltransferase MAOB, monoamine oxidase B.
A Word About Natural Dopamine Replacement
Clients often ask me if they can use mucuna pruriens to help treat their PD instead of dopaminergic pharmaceuticals like Levodopa. The answer is that it depends.
Mucuna is a plant that contains significant amounts of L-Dopa. Some studies suggest that it can be as effective as Levodopa for controlling motor symptoms in PD and that it can have fewer side effects. These studies have mainly been conducted in remote areas where access to pharmaceutical medications is limited.
Currently, mucuna is not available as a prescription. This means that it is not subject to the same purity and safety regulations as pharmaceutical drugs are in the U.S. Taking it means that youre accepting the risk that it might be contaminated or that it may contain more or less of a product that is on the label. It also isnt covered by insurance, so the cost of taking mucuna daily is often prohibitive for many of my clients when compared to the cost of Levodopa.
If youre willing to accept these risks and drawbacks, then mucuna could be a good herbal medicine for you to include in your PD treatment program. You have to work closely with a doctor to determine and continually adjust your ideal dose of it.
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Impulsive And Compulsive Behaviour
Some patients who take dopamine agonists can experience problems controlling impulsive or compulsive behaviour .
Impulsive behaviour refers to the inability of patients to resist carrying out certain activities, some of these activities could be harmful to themselves or others. In many cases, this behaviour is out of character.
Compulsive behaviour refers to an overwhelming urge to act in a certain way to reduce the worry or tension this urge produces. This behaviour can be expressed in a number of ways, including addictive gambling, impulsive shopping, binge eating and hypersexuality.
Nurses who suspect a patient might be experiencing compulsive or impulsive behaviour should discuss the issue with the patient and the patients neurologist or GP as soon as possible.
Adjust Your Drug Dose
Side effects like dyskinesia might be due to the amount of levodopa youre taking. Ask your doctor whether you can lower your dose enough to prevent side effects while still managing your Parkinsons symptoms. It might take some trial and error to get the dose just right.
Another option is to switch to an extended-release form of dopamine. Because the drug releases more slowly into your blood, it prevents the dopamine spikes and valleys that can trigger dyskinesia.
You might also need to add more of a drug. For example, adding extra carbidopa to levodopa can cut down on nausea.
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Surgery For People With Parkinsons Disease
Deep brain stimulation surgery is an option to treat Parkinsons disease symptoms, but it is not suitable for everyone. There are strict criteria and guidelines on who can be a candidate for surgery, and this is something that only your doctor and you can decide. Surgery may be considered early or late in the progression of Parkinsons. When performing deep-brain stimulation surgery, the surgeon places an electrode in the part of the brain most effected by Parkinsons disease. Electrical impulses are introduced to the brain, which has the effect of normalising the brains electrical activity reducing the symptoms of Parkinsons disease. The electrical impulse is introduced using a pacemaker-like device called a stimulator. Thalamotomy and pallidotomy are operations where the surgeon makes an incision on part of the brain. These surgeries aim to alleviate some forms of tremor or unusual movement, but they are rarely performed now.
Common Medications For Parkinsons Disease
There are several medications on the market that seek to control the symptoms of Parkinsons disease. Since no two people experience this condition in the same way, doctors closely evaluate patients to determine which combination of medicine has the best potential for controlling their unique symptoms. Some medications prevent enzymes in the brain from breaking down dopamine, while others increase dopamine levels or complete the same actions as dopamine.
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Incidence Of Parkinsons Disease
Its estimated that approximately four people per 1,000 in Australia have Parkinsons disease, with the incidence increasing to one in 100 over the age of 60. In Australia, there are approximately 80,000 people living with Parkinsons disease, with one in five of these people being diagnosed before the age of 50. In Victoria, more than 2,225 people are newly diagnosed with Parkinsons every year.
How Can I Avoid Burnout
Here are a few tips to help you avoid caregiver burnout.
- Learn everything you can about Parkinsons disease. Youll be better equipped to manage your loved ones care if you know what to expect and understand what strategies are most helpful.
- Dont try to take on every aspect of the persons care yourself. Make a list of tasks that need to be done. Then, delegate them to friends, family, and members of your community who are willing to help. You can hire people to help around the house so you dont have to do it all yourself. Your insurance may also pay for part-time caregivers for your loved one with Parkinsons disease.
- Stay organized. Keep a binder of doctors names, medications, and other important information youll need on a daily basis.
- Dont neglect your own health. You cant be any help to your loved one if you get sick. Eat well, exercise, and get enough sleep. Keep up with all of your medical appointments.
- Find your joy. Hold on to the parts of your life that are most important to you such as your job, family, and hobbies. Set aside time each day to do something just for you.
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Assembling A Capable Health Care Team
Developing and maintaining relationships with experts in the field of Parkinsons disease can make life easier and more enjoyable. Your team members and the role or roles they assume are likely to change as your symptoms change and as the disease progresses. Some will go the distance, staying with you throughout your life with Parkinsons. Others will be sprinters, accompanying you as you manage particular symptoms, emotions, or transitions.
Your team can include:
- Movement Disorder Specialist
- Nurse
General Approach To Management
The primary goal in the management of PD is to treat the symptomatic motor and nonmotor features of the disorder, with the objective of improving the patients overall quality of life. Appropriate management requires an initial evaluation and diagnosis by a multidisciplinary team consisting of neurologists, primary care practitioners, nurses, physical therapists, social workers, and pharmacists., It is also important that the patient and his or her family have input into management decisions.
Effective management should include a combination of nonpharmacological and pharmacological strategies to maximize clinical outcomes. To date, therapies that slow the progression of PD or provide a neuroprotective effect have not been identified., Current research has focused on identifying biomarkers that may be useful in the diagnosis of early disease and on developing future disease-modifying interventions.,
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How Is Parkinsons Disease Diagnosed
Diagnosing Parkinsons disease is sometimes difficult, since early symptoms can mimic other disorders and there are no specific blood or other laboratory tests to diagnose the disease. Imaging tests, such as CT or MRI scans, may be used to rule out other disorders that cause similar symptoms.
To diagnose Parkinsons disease, you will be asked about your medical history and family history of neurologic disorders as well as your current symptoms, medications and possible exposure to toxins. Your doctor will look for signs of tremor and muscle rigidity, watch you walk, check your posture and coordination and look for slowness of movement.
If you think you may have Parkinsons disease, you should probably see a neurologist, preferably a movement disorders-trained neurologist. The treatment decisions made early in the illness can affect the long-term success of the treatment.
What Are The Different Stages Of Parkinsons Disease
Each person with Parkinsons disease experiences symptoms in in their own unique way. Not everyone experiences all symptoms of Parkinsons disease. You may not experience symptoms in the same order as others. Some people may have mild symptoms others may have intense symptoms. How quickly symptoms worsen also varies from individual to individual and is difficult to impossible to predict at the outset.
In general, the disease progresses from early stage to mid-stage to mid-late-stage to advanced stage. This is what typically occurs during each of these stages:
Early stage
Early symptoms of Parkinsons disease are usually mild and typically occur slowly and do not interfere with daily activities. Sometimes early symptoms are not easy to detect or you may think early symptoms are simply normal signs of aging. You may have fatigue or a general sense of uneasiness. You may feel a slight tremor or have difficulty standing.
Often, a family member or friend notices some of the subtle signs before you do. They may notice things like body stiffness or lack of normal movement slow or small handwriting, lack of expression in your face, or difficulty getting out of a chair.
Mid stage
Mid-late stage
Standing and walking are becoming more difficult and may require assistance with a walker. You may need full time help to continue to live at home.
Advanced stage
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