Managing Advanced Parkinsons Disease
Advanced Parkinsons disease, stage 4 or 5 of the Hoehn and Yahr Scale, is characterized by very limited mobility without assistance, severe motor deficits, risk of falls, and cognitive and psychotic problems. With the advent of L-dopa and other dopaminergic treatments, the progression of PD has become markedly slower however, over the years treatment loses its efficacy, while a number of complicationssuch as motor fluctuations and dyskinesiadevelop, probably due to the progressive loss of dopaminergic neurons and their striatal and cortical connections. These complications are observed in 50% of patients after 5 years of disease and in 80% of patients after 10 years of treatment .
Treatment of the advanced stages of PD is entirely different from earlier stages. Early treatment is geared towards symptom relief and prevention of motor symptoms. During the later stages, the palliative care model is introduced to provide the patient with comfort and support. In the advanced stages, the focus of treatment shifts to treating nonmotor symptoms using a more supportive and palliative approach .
My Brother Who Was Diagnosed With Parkinson’s Disease Last Year Has No Appetite And Has Been Losing Weight Over The Past Three Years Is This Common With Pd If So What Can He Do To Get His Appetite Back
Lisa M. Shulman, MD, FAAN, responds:
Weight loss is fairly common in people with Parkinson’s disease, although the reason for it is unknown. In most cases patients report losing weight in spite of a robust appetite and using high-calorie supplements.
Confirm a Connection
The first step in managing the problem would be to confirm that your brother’s weight loss is associated with PD. Losing weight can be connected to many medical conditions, so it’s important to encourage your brother to see a primary care physician for a thorough evaluation to exclude other causes and factors.
Rule Out Depression
In addition to various medical conditions that can cause weight loss, emotional problems such as depression can also be contributing factors. Depression occurs in about one-third of PD patients. If depression is the problem, suggest that your brother see a therapist or psychiatrist, who will determine if he needs a prescription for an antidepressant. Depression in PD is treated with many of the same medications prescribed for the general population of people with depression.
Consult a Nutritionist
If your brother’s doctor doesn’t identify any other causes for his weight loss, you may want to consult a nutritional specialist who can review your brother’s diet and suggest modifications, including high-calorie supplements.
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Strategies For Maintaining A Stable Body Weight In Pd
As weight gain may be desirable or deleterious, the patients individual situation should be thoroughly evaluated. Before intervention the following factors should be assessed:
Actual BMI and previous weight loss, normal weight, previous fluctuations of body weight, and eating disorders.
Estimation of pre- and post-surgery EE: motor symptoms, dyskinesia, physical activity.
Actual alimentation, eating habits, and eating disorders.
Psychological assessment: apathy, depression, hyperactivity.
Quality of sleep .
In DBS patients, nutritional intervention has been shown to be effective and should be performed routinely . As weight gain occurs essentially in the first months after surgery, information and dietetic guidance of the patient should start before surgery. As energy requirement is often diminished after successful surgery, an energy-reduced diet should take place and be maintained lifelong. Patients should be encouraged to control their body weight regularly, to supervise their alimentation, and to practice regular physical exercise. These measures should be considered as an adaptation of lifestyle rather than short-time diet.
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Why Do People With Parkinsons Lose Weight
People who have parkinsons disease notice a reduction in the weight. The reason behind the weight loss is unknown. However, the weight loss is apparent and occurs in early or late stages of the Parkinsons disease. The reason behind the decline in weight is because the individual is receiving less intake of calorie than the requirement. The individual suffering from Parkinsons disease loses the calories at a high rate due to hyperkinetic moments, such as tremors. Therefore, it is essential for the person who has Parkinsons disease to follow a healthy and balanced diet that will ensure that the patient does not show a significant weight loss.
There will be other contributing factors apart from Parkinsons disease that is responsible for weight loss. These factors include:
Difficulty in Swallowing: Difficulty in swallowing, which discourages the intake of solid food, especially when the disease reaches the final stage
Loss of Interest in Food: Loss of appetite due to the occurrence of the disease and depression
Difficulty in Eating: Difficulty in consuming food due to the side effects produced by the Parkinsons disease such as tremors and bradykinesia, which is a symptom that reduces the initiation of movement.
Improper Feeding: Mental disturbances or dementia, which is another side effect produced by Parkinsons disease that leads to the development of improper feeding.
Foods Containing Saturated Fat And Cholesterol
Some studies suggest that dietary fat intake may increase the risk of Parkinsons.
Although having a higher intake of cholesterol can elevate a persons Parkinsons risk, having a higher intake of polyunsaturated fatty acids may reduce the risk.
Therefore, a person with Parkinsons may wish to reduce their intake of cholesterol to help control the symptoms of the condition. They may also wish to reduce the amount of saturated fat in their diet.
However, further studies are required to explore the link between dietary fat and Parkinsons.
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Enteric Nervous System And Gastrointestinal Disorders
Gastrointestinal functions are regulated by the enteric nervous system, a neuronal network organized in two plexuses, myenteric and submucosal, which control gut motility and secretion .
In PD, the enteral nervous system is affected by alpha-synucleinopathy which may explain the high incidence of gastrointestinal disorders, beginning in pre-motor stages of the disease. The most frequent symptom is chronic constipation affecting up to 89% of PD patients . The primary cause for constipation is impaired peristalsis with slow colonic transit due to neurodegeneration of myenteric neurons, which may be modulated by dopamine . In some patients, constipation is secondary to abnormal coordination of the rectoanal reflex with paradoxical contraction of the puborectalis muscle, which leads to defecatory dysfunction . Loss of serotonergic neurons in raphe nucleus is thought to be involved in this clinical feature . Gastroparesis is characterized by slowed emptying of food into the small bowel leading to postprandial fullness, early satiety, nausea, vomiting, and bloating . Gastrointestinal disorders affect the quality of life and may limit food intake thus contributing to mal- and under-nutrition in PD .
What Should I Eat Before And After I Exercise
In the same way that theres no one diet for anyone, the timing of your meals before and after exercise will largely depend on you. While its important to limit your protein intake after taking your carb/levodopa, if you want a pre-workout snack, you can choose something light and carbohydrate-based, as this wont interfere with the absorption of your medicine. After you work out, it may be a good time for a protein-rich snack, so long as it is eaten at least 30 minutes before your next dose of medicine. With that framework, the exact type and timing of snacks before and after exercise is something that you can experiment with and talk to your doctor about.
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Weight Changes In Parkinsons Disease
PD may cause a person to gain weight or to lose weight. Changes to weight can have negative effects on a persons overall health. Weight gain, which may occur due to lack of movement and exercise, can lead to being overweight. This increases the risk of heart disease and high blood pressure and puts extra stress on joints.2,3
Weight loss can lead to losing muscle mass and strength. This may increase the risk of infection or osteoporosis. Progressive, unintended weight loss is a major feature of the progression of PD.2,3
There are several strategies that can help people with PD to manage their weight. This includes eating a balanced diet with a variety of foods and getting regular exercise. A doctor or registered dietitian can provide specific strategies aimed at either gaining or losing weight.3
Eating When Youre Tired
If you donât have energy for meals later in the day, you can:
Pick foods that are easy to fix, and save your energy for eating. If you live with your family, let them help you make your meal.
Look into a delivery service. Some grocery stores have them. Or you can check if you might be able to get food delivered from your local Meals on Wheels program for free or for a small fee.
Keep healthy snack foods on hand, like fresh fruit and vegetables or high-fiber cold cereals.
Freeze extra portions of what you cook so you have a quick meal when you feel worn out.
Rest before you eat so you can enjoy your meal. And eat your biggest meal early in the day to fuel yourself for later.
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Nutritional Issues In Parkinsons Disease
Nutritional status is a major factor influencing the well being of any individual who lives with a chronic neurological disease. Nowhere is this truer than for those dealing with Parkinsons disease . Poor nutritional status can result in, as well as contribute to, many of the common complaints seen in Parkinsons disease. For example, in those individuals with swallowing problems the effects of malnutrition become magnified. It may ultimately lead to worsening motor symptoms, increased weakness resulting in falls and possibly serious bone fractures. Thus, it is incumbent upon the physician taking care of those with PD to pay close attention to nutritional status and to seek assistance from dietetic professionals whenever necessary. Simple measures used to assess nutritional status include taking the patients weight at each visit and utilizing various blood and urine tests as well as obtaining a thorough patient history.
Obstacles to proper nutrition which some people with PD may experience include constipation, swallowing and chewing problems, delayed gastric emptying, loss of sense of smell and taste, dry mouth, depression, dementia, nausea, and gastroesophageal acid reflux . Some of these problems are intrinsic to PD itself, while others are a result of the medications and still others may be related to both. I will attempt to address some of these problems in the paragraphs that follow.
Concluding Remarks And Future Perspectives
Increasing evidence has suggested weight loss is commonly observed in patients with PD. Notably, with the global epidemic of obesity and increased application of modern therapeutic measures such as dopamine agonists and DBS, normal weight even overweight may be also frequently reported in PD patients nowadays. An early identification of patients at risk of weight loss might be of some help to develop measures to prevent weight loss. Recently, only two groups of researchers have assessed profile of weight changes in PD patients among PD subtypes . According to the studies, the anosmic group and non-tremor dominant subtypes are associated with weight loss in PD among the different phenotypes respectively. Hence, early detection of olfaction impairment may be predictions for weight loss in the early phase of PD although further corroboration is needed in the future.
Weight loss is not an independent pathogenesis but seems to be coupled with PD pathogenesis as demonstrated in AD . In AD, weight loss is one of the criteria for the clinical diagnosis of dementia. Likewise, in the context of PD, weight loss may precede the motor symptoms and be considered as an index for disease progress. To address the crosstalk between weight loss and PD is quite necessary and metabolic manipulation may provide a therapeutic alternative in the treatment of PD in the future.
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I Was Telling Someone At My Parkinsons Support Group About The Pains I Have In My Stomach And He Mentioned Something Called Gastric Emptying What Is It And If Thats My Issue What Can I Do About It
Gastric emptying or gastroparesis relates to a delayed movement of food from the stomach to the intestines that can cause stomach pains, bloating, nausea and feelings of uncomfortable fullness after only a bite or two of food. Its not known whether this condition is associated with Parkinsons itself or levodopa treatment, but whether it is or isnt, there are a few things you can do to address your symptoms such as trying smaller but more frequent meals of easy-to-eat anti-inflammatory foods and limiting caffeine, alcohol, grains and dairy. Currently, there is no medication for gastric emptying that is compatible with people with Parkinsons, but you can talk to your doctor and your nutritionist about other possible strategies and treatments.
Serotonergic And Noradrenergic Modulation Of Energy Metabolism And Appetite
Other aminergic systems such as serotonergic or noradrenergic systems are mutually connected with the hypothalamus and may influence homeostatic metabolic regulation. Both systems are affected by alpha-synucleinopathy . The noradrenergic locus coeruleus as well as serotonergic neurons express high amounts of orexin receptor and dense orexin fiber projections . Loss of LC neurons had been described in PD . In the 6-OHDA rat model, degeneration of LC produces a transient drop in body weight which could be reversed by DBS-STN . This had led to the hypothesis that weight variations in PD could be modulated by noradrenergic interaction between LC, STN, and hypothalamus .
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Weight Loss And Parkinsons Disease
Dad used to tell us that he has two sets of clothes: a normal set and a set of skinny clothes that emerge when he gets sick.
Dad was diagnosed with ulcerative colitis in his 30s, and the illness caused him to lose a startling amount of weight. He was thin to begin with, but the disease found ways to take more away.
Ulcerative colitis became more manageable for my dad as time moved forward. He put on a healthy amount of weight and chose his food based on desire rather than necessity. With the help of my mom and his friends, he was able to nurse himself back to health.
But for the next 34 years, his two sets of clothing would hang in the corner of his bedroom closet because he never was certain when his health might change. Today, Parkinsons disease is back to challenge this strategy. And Dads skinny clothes are making an appearance.
Theres A Lot Of Information Out There About The Link Between The Gut And Brain And Inflammation In Diseases Such As Parkinsons And Alzheimers Whats Important For Me To Know About It And What Are Some Of The Healthiest Anti
The bottom line is that despite increasing evidence that theres an association between Parkinsons and gut health, our understanding is incomplete.
Studies have found that there are lower levels of Prevotella, a good gut bacteria in people with Parkinsons and higher levels of inflammatory bacteria, but more research is needed to understand the connection to Parkinsons. Still, eating a diet rich in anti-inflammatory foods is generally found to be beneficial for your overall health and theres no harm in including anti-inflammatory foods in your diet if you can tolerate them.
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No Matter What I Do I Keep Gaining Weight Whats Happening And What Can I Do About It
Weight gain is another common side effect that can occur from a decreased ability to exercise or as a result of gastric emptying, in which you may feel like youre uncontrollably gaining weight despite not eating much. The discrepancy may have to do with your body going into starvation mode as it tries to recalibrate your energy input and output. Again, the best course of action is to speak with your doctor about a weight loss plan that aligns with your specific issues and goals. Also, you might consider an anti-inflammatory diet if youre suffering from weight gain associated with gastric emptying.
Why Worry About Weight Loss Associated With Pd
Weight loss has been linked to a poorer quality of life and more rapid progression of PD. The reasons for this are two-fold. On the one hand, as outlined in the list above, weight loss can be a hallmark of advancing disease as it could be a consequence of more swallowing difficulties, worsened mobility, more impaired gut function etc.
On the other hand, having weight loss can further lead to poorer health. Inadequate food intake can contribute to malnutrition and vitamin deficiencies. Malnutrition can subsequently be the cause of increased susceptibility to infection, increased fatigue and increased frailty. The situation can spiral with more fatigue and frailty causing a further decrease in activity and function.
Osteoporosis, or porous and fragile bones, is more common in under-weight people since bone structure is dependent on weight-bearing. Since osteoporotic bones are more prone to fracture during a fall, this too can be a contributor to more disability and frailty. Bottom line is that it is important for your health to maintain a healthy weight.
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Complications In Advanced Pd
While worsening of motor function and drug-induced motor complications represents a major challenge in patients with mid-stage to advanced disease, in the advanced stage of PD the most troublesome and distressful complications are usually nonmotor symptoms, including psychiatric and cognitive disorders, autonomic disturbances, and sleep disorders that significantly increase the need for supportive care. Unfortunately, these symptoms are frequently neglected in clinical practice due to limited consultation time, perception of the patient and caregivers that their symptoms are unrelated to the disease, or insufficient awareness of the clinicians, who generally focus on motor symptoms .
Proper supporting care becomes increasingly important in advanced PD. Rehabilitative and support services for patients and family become key interventions as the disease reaches its more debilitating stages and pharmacologic or surgical treatment becomes less relevant. Management of motor and nonmotor complications in advanced PD requires careful and ongoing assessment of whether symptoms are a side effect of medication or related to the progression of the disease .
Medication Issues
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End of Dose Wears Off Symptoms in Advanced PD |
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Systems affected |
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Progression of motor symptoms Dystonia |
Fragmentation of Dosing
Dopamine Agonists Contraindicated
L-dopa and Dietary Proteins
Motor Issues
Dyskinesias
Dystonia
Freezing
Nonmotor Complications
Hallucinations, Delusions, Psychosis
Depression and Anxiety