Parkinsons Disease And Movement Disorders Center
Wang Ambulatory Care Center
Parkinsons Disease and Movement Disorders Center8th Floor, Suite 835
To schedule an appointment:
Appointments can be scheduled by calling:
Prior to your first appointment, ask your primary care physician or referring doctor to fax pertinent medical records to the office.
Translation services are available. Please inform us if you need the assistance of a translator.
If you are a new patient to Mass General:
What to bring to your appointment:
- Your registration card, insurance card, and co-pay
- Any medical records and MRI scans that have not been sent to the office
- List of your current medications
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What We Treat In South Florida
The specialists at The Pauline Braathen Neurological Center provide high quality care and treatment for complex neurological conditions. Using a multidisciplinary approach that brings together a team of specialists, we offer medical management and innovative surgical options for patients diagnosed with a variety of movement disorders including:
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Important Points About The New Medications
With multiple new medications available for the treatment of PD, there is more hope than ever that Parkinsons symptoms can be successfully managed for many years. A few things to consider:
- For people whose symptoms are difficult to control, these new treatments are welcome additions to what was previously available and many people with PD have been using these new medications with significant benefit.
- On the other hand, many of the newly-approved medications have the same mechanisms of action as older medications so they are not breaking new ground in treating symptoms.
- In addition, for some people, the effect on symptoms may be mild or not substantial.
These caveats may mean that your physician has not suggested a medication change for you. It is also important to note that despite all the new medications, carbidopa/levodopa remains the most potent medication to treat the motor symptoms of PD.
If your doctor does choose to try one of the new options, there may be multiple paths that your doctor can take when contemplating a medication adjustment. Often trial and error is the only way to determine the best medication regimen for you, so you may need to practice some patience as you work together with your doctor to determine what works or doesnt work.
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Multidisciplinary Movement Disorders Clinic
Patients who come to the Movement Disorders Clinic are seen by a movement disorders specialist, a neurologist who has extra training in evaluating and treating a person with Parkinsons disease. There are no blood or imaging tests that can confirm Parkinsons disease, so diagnosis is based on visible signs and symptoms, which are reviewed during a medical history and neurologic examination.
What Are Parkinsons Hallucinations
Symptoms of psychosis occur in up to 50% of people with Parkinsons disease.
Parkinsons disease psychosis is considered a neuropsychiatric condition. This means it involves neurology and psychiatry . While the psychosis involves mental health symptoms, they are caused by Parkinsons disease, which is a disease of the nervous system.
Psychosis in Parkinsons disease comes in two forms:
- Hallucinations: Sensory experiences that are not really happening
- Delusions: False beliefs not based on reality
These symptoms can be debilitating and scary for the people experiencing them. They can interfere with a persons ability to care for themselves and to relate to other people.
Psychotic symptoms in Parkinsons disease are associated with increased caregiver distress, risk of hospitalization and nursing home placement, and healthcare costs.
A study suggests the presence of hallucinations and delusions in people with Parkinsons disease is a predictor of mortality .
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New Medications For Off Time
A number of new medications approved recently are designed to reduce OFF time. These medications fall into two major categories:
- Medications that lengthen the effect of a carbidopa/levodopa dose
- Medications that are used as needed if medication effects wear off
Well give specific examples below. In general, new medications that extend the length of a carbidopa/levodopa dose are used if OFF time is somewhat predictable and occurs prior to next dose. New medications that are used as needed are most beneficial when OFF time is not predictable.
New medications that lengthen the effect of a dose of carbidopa/levodopa
- Istradefylline is an adenosine A2A receptor antagonist which was approved in the US in 2019 as an add-on therapy to levodopa for treatment of OFF time in PD. Unlike many of the other medications, it has a novel mechanism of action and is the first medication in its class to be approved for PD. It acts on the adenosine receptor, which modulates the dopaminergic system, but is not directly dopaminergic. The drug was developed in Japan and underwent clinical trials both in Japan and in the US.
- Opicapone is a catechol-O-methyltransferase inhibitor that is taken once a day. It was approved in the US in 2020 as an add-on therapy to levodopa for motor fluctuations.
New formulations of levodopa designed to be used as needed if medication effects wear off
Other medications used as needed if medication effects wear off
Side Effects And Problems With Dopamine Agonists
Common side effects of dopamine agonists include:
- Nausea and vomiting
- Hallucinations or delusions and confusion
- Existing dyskinesias becoming more troublesome initially
If you are taking Cabergoline , Pergolide or Bromocriptine your neurologist or GP will have to arrange a chest CT scan or ultrasound of your heart yearly as over time these medications may affect heart or lung tissue.
This precaution does not apply to the other dopamine agonists available in Australia.
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Speech And Occupational Therapy
Parkinsons disease can lead to slurred speech and difficulty swallowing. A speech and language therapist can provide muscle training techniques that may help overcome some of these problems.
An occupational therapist can help identify everyday tasks that can be challenging and work with the person to find practical solutions.
This may include new strategies for dressing, preparing meals, performing household chores, and shopping. Adaptations to the home environment can also make daily living easier.
For people with Parkinsons disease, deep brain stimulation may help manage:
- an electrode inside the part of the brain that controls movement
- a pacemaker-like device, or neurostimulator, under the skin in the upper chest
- a wire under the skin connecting the neurostimulator to the electrode
The neurostimulator sends electrical impulses along the wire and into the brain via the electrode. These impulses can prevent symptoms by interfering with the electrical signals that cause them.
There is a small risk of brain hemorrhage, infection, and headaches. Some people may see no improvement, or their symptoms may worsen. There may also be discomfort during stimulation.
Nevertheless, the AAN considers this treatment safe and effective for specific people and say any adverse effects are usually mild and reversible. Anyone considering this treatment should discuss the pros and cons with a healthcare professional.
Causes Of Parkinson’s Disease
The causes of Parkinsons disease are still greatly unknown. Scientists who have studied this disorder estimate that 10-15% of cases come from genetics after seeing a series of genetic mutations that were common in Parkinsons patients.
Doctors suspect that environmental factors and lifestyle choices may have effects on the severity of Parkinsons disease symptoms. Exposure to chemicals like pesticides may increase the likelihood of developing Parkinsons disease. On the other hand, a good diet and regular exercise may decrease your chances.
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Impulsive And Compulsive Behavior
Some people taking dopamine agonists may experience problems with impulsive or compulsive behaviours. For example an increased desire to gamble or engage in sexual activity. These behaviours often develop slowly so may not seem to be a problem immediately. It is important for both the person living with Parkinsons and their family to be aware of this side effect. If affected by this side effect, a reduction in dose or stopping the medication will stop the behaviour.
Managing Medication Interactions And Side Effects
All prescribed medications can have potential side effects, including those used to treat Parkinsons. Some things you think are symptoms of Parkinsons may actually be side effects of medication. Some peoples side effects will have a big impact on their lives and have to be kept under control along with the symptoms.
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An Approach To The Treatment Of Parkinsons Disease
No treatment can arrest or slow neurodegeneration in Parkinsons disease. The aim is to relieve symptoms and avoid the complications of therapy.
Early Parkinsons disease
Many studies have shown that early treatment with dopamine agonists reduces the incidence of dyskinesia.1Fewer motor fluctuations were shown in some but not all of the studies. We recommend a dopamine agonist as the first treatment in younger patients who have mild disease and no cognitive deficit. It is necessary to add levodopa within 1-5 years in most patients. In more severe disease, treatment begins with levodopa but a dopamine agonist may be added to keep the daily dose of levodopa in the lower range if there is no cognitive deficit. Dopamine agonists are used infrequently and with caution in patients more than 70 years old because of the risk of neuropsychiatric adverse effects and postural hypotension. They are contraindicated in the presence of dementia.
Isolated resting tremor is rarely disabling, but if it interferes with function it can usually be managed with levodopa. When this is ineffective at low to moderate doses, the addition of an anticholinergic can sometimes be useful.
Patients with motor fluctuations
Role of physical therapy and surgery
Levodopa: The Most Effective Drug For Treating Parkinsons
Levodopa, also known as L-DOPA, has long been, and continues to be, the most effective drug in treating Parkinsons disease symptoms. Most people with Parkinsons disease will take this drug at some point. There are side effects that can occur with Levodopa including nausea, fatigue and orthostatic hypotension. Often these side effects can be successfully treated so that Levodopa can be tolerated better. In addition, as the disease progresses and the brain has less ability to produce and process dopamine, dyskinesias, or involuntary movements can develop from Levodopa.
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What Should I Know About Parkinsons Disease And Medications
There have been rapid and remarkable changes over the past decade in treating Parkinsons disease . The development of new medicines and the understanding of how best to use them and the older drugs have significantly improved the quality of life for people with the disease.
There is currently no treatment that has been proven to affect the disease progression or development of medication that can slow the disease process. There are two general approaches to the treatment of PD improve the symptoms with medications and engage in physical therapy. Most patients with PD can be adequately treated with medicines that alleviate their symptoms. For the approximately 15% of patients for whom medicines are not sufficiently effective, new, highly effective, and safe surgical treatments are available.
Choices about medicines made early in the course of the disease have a strong impact on the long-term course of the illness. Therefore, you should seek the advice of doctors specially trained in treating PD even when the illness is only suspected. Movement disorders specialists are neurologists who have completed their training in neurology and have received special advanced training in treating PD and other related diseases.
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Symptom Fluctuations And Dyskinesia Often Occur As The Disease Progresses
The pathophysiology of PD is complex. Degeneration of dopaminergic neurons in the substantia nigral leads to hallmark motor symptoms of bradykinesia, rigidity, and tremor.5,6 Treatments for motor symptoms address striatal dopamine depletion the cornerstone of treatment remains levodopa, the metabolic precursor of dopamine.7 Degeneration in other pathways involving multiple neurochemicals also occurs and leads to a variety of nonmotor symptoms.
Motor fluctuations. One of the most challenging aspects of managing PD is the emergence of motor fluctuations. Initially, levodopa has a long duration of response, despite its short pharmacokinetic plasma half-life. However, as the disease progresses, motor fluctuations emerge. Periods when the benefit of a levodopa dose has waned are termed OFF episodes, during which PD motor6 and nonmotor symptoms occur.8 Common types of OFF episodes include wearing off, delayed on, and dose failure.5 The majority of patients with PD will eventually exhibit motor fluctuations, with 14% by 5 years, 39% by 9 years, and 67% by 10 or more years among those taking levodopa .9
AV 1. Rate of Motor Fluctuations, by Disease Duration
Data from Schrag and Quinn9
Delayed on. Patients may discover that the therapeutic onset of a dose of levodopa is delayed.18 This delay can be due to gastroparesis and/or protein effect, and it may be especially common in the morning and around meals.
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Accurate Parkinsons Disease Diagnosis
Parkinsons is challenging to diagnose because symptoms, such as difficulty walking, can be a sign of other movement disorders. Some people have parkinsonism. This group of diseases causes Parkinsons-like symptoms that do not respond to Parkinsons treatments.
At Cedars-Sinai, we consider your health history and perform a nervous system exam before confirming a Parkinsons diagnosis. Our years of experience enable us to detect subtle symptoms that do not show up on other tests.
Tests may include:
Testing your response to a Parkinsons drug, levodopa, allows us to rule out some other movement disorders. Levodopa boosts dopamine levels and is not an effective treatment for other movement disorders. If your symptoms improve with levodopa, you likely have Parkinsons.
We may use this noninvasive imaging test to help rule out Parkinsonian syndrome. This group of disorders causes movement problems similar to Parkinsons but might not stem from the disease. Learn more about DaTscan.
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Current Treatment Options For Motor Fluctuations And Dyskinesia
Clinicians may try a variety of strategies as their patients PD progresses and motor fluctuations and dyskinesias emerge.
Increase IR carbidopa-levodopa dose or dosing frequency. Increasing the dose of IR carbidopa-levodopa may improve motor response but may not prolong the duration of response.13 The interval between doses can be shortened, increasing the number of times that a patient takes medication each day.6 Alternatively, fractionating doses can be tried by lowering each dose but reducing the interval between doses, such that the overall daily dosage does not change.20 With increased frequency of doses, compliance decreases, so patients need to be advised to be careful about taking medications on time.
Switch to extended-release carbidopa-levodopa.CR carbidopa/levodopa was erratic in its absorption and often increased motor complications. The older, sustained-release carbidopa-levodopa has a durational effect similar to that of the immediate-release version,21 and guidelines22 recommended disregarding its use for reducing wearing off.
Adding a monoamine oxidase B inhibitor can reduce catabolism of striatal dopamine and has been shown to reduce OFF time.29 The MAO-B inhibitors include selegiline, rasagiline, and safinamide.30 Side effects are uncommon and include nausea and orthostatic hypotension.
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Types Of Parkinsons Disease Medications
Side Effects And Problems With Levodopa
In the early days of taking levodopa, you may feel sickness or nausea. In most people this will pass as your body adjusts to the medication.
Overtime as Parkinsons progresses the levodopa dose will need to be adjusted. Many people will become more aware that symptoms sometimes return between doses of medication. This is called wearing off and is a sign your dose needs to be adjusted.
As levodopa is absorbed through the gut, constipation or other stomach problems may impact on uptake of the medication. In some people who have had Parkinsons for sometime extra involuntary movements can occur. Your neurologist will be able to help adjust medications to minimise dyskinesia.
Other side effects may include:
Side effects of levodopa can sometimes be improved by changing your dose, the form of the drug or how often you take it. If this doesnt work, other types of drug may be combined with levodopa.
Speak to your GP or specialist about the right treatment for you.
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Finding The Right Medication
Finding the right medication to treat your Parkinson’s symptoms is a process that takes time and effort from you and your doctor. Parkinson’s medications work in different ways. Many are pills that you swallow, but some can be given through skin patches or intestinal infusions. It can sometimes feel like “trial and error” to figure out the best medication, dose and schedule to treat your symptoms. Over time, as symptoms progress or complications arise, your doctor may adjust your medications. This might mean changing your dose or how often you take a drug, or adding or switching medications. Staying in tune with your symptoms and which are most bothersome, and keeping track of how well medication is or is not working can help direct adjustments to your treatment regimen.
Here we describe the different categories of Parkinson’s medications how they work, their potential benefits and common side effects. We also give examples and highlight therapies that have been approved in the last few years with an asterisk.