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Parkinson's diseaseBy Mayo Clinic staff
Original Article: http://www.mayoclinic.com/health/parkinsons-disease/DS00295
Parkinson's disease is a progressive disorder of the nervous system that affects your movement. It develops gradually, sometimes starting with a barely noticeable tremor in just one hand. But while tremor may be the most well-known sign of Parkinson's disease, the disorder also commonly causes stiffness or slowing of movement.
In early stages of Parkinson's disease, your face may show little or no expression, or your arms may not swing when you walk. Your speech may become soft or slurred. Parkinson's disease symptoms worsen as your condition progresses over time.
Although Parkinson's disease can't be cured, medications may markedly improve your symptoms. In occasional cases, your doctor may suggest surgery to regulate certain regions of your brain and improve your symptoms.
Parkinson's disease symptoms and signs may vary from person to person. Early signs may be mild and may go unnoticed. Symptoms often begin on one side of your body and usually remain worse on that side, even after symptoms begin to affect both sides. Parkinson's signs and symptoms may include:
- Tremor. Your tremor, or shaking, usually begins in your limb, often your hand or fingers. You may notice a back-and-forth rubbing of your thumb and forefinger, known as a pill-rolling tremor. One characteristic of Parkinson's disease is tremor of your hand when it is relaxed (at rest).
- Slowed movement (bradykinesia). Over time, Parkinson's disease may reduce your ability to move and slow your movement. This may make simple tasks difficult and time-consuming. Your steps may become shorter when you walk, or you may find it difficult to get out of a chair. Also, your feet may stick to the floor as you try to walk, making it difficult to move.
- Rigid muscles. Muscle stiffness may occur in any parts of your body. The stiff muscles can limit your range of motion and cause you pain.
- Impaired posture and balance. Your posture may have become stooped, or you may have balance problems as a result of Parkinson's disease.
- Loss of automatic movements. In Parkinson's disease, you may have a decreased ability to perform unconscious movements, including blinking, smiling or swinging your arms when you walk. You may no longer gesture when talking.
- Speech changes. You often may have speech problems as a result of Parkinson's disease. You may speak softly, quickly, slur or hesitate before talking. Your speech may be more of a monotone, rather than with the usual inflections.
- Writing changes. Writing may appear small and become difficult.
Medications typically markedly reduce many of these symptoms. These medications increase or substitute for a specific signaling chemical (neurotransmitter) in your brain: dopamine. People with Parkinson's disease have low brain dopamine concentrations.
When to see a doctor
See your doctor if you have any of the symptoms associated with Parkinson's disease — not only to diagnose your condition but also to rule out other causes for your symptoms.
The cause of Parkinson's disease is unknown, but several factors appear to play a role, including:
- Your genes. Researchers have identified specific genetic mutations that can cause Parkinson's disease, but these are extremely uncommon, except in rare cases with many family members affected by Parkinson's disease. However, certain gene variations (polymorphisms) appear to increase the risk of Parkinson's disease, but with a relatively small risk of for each of these genetic markers.
- Environmental triggers. Exposure to certain toxins or environmental factors increase the risk of later Parkinson's disease, but the risk is relatively small.
In summary, there is much work to be done to identify the factors causing Parkinson's disease.
Many changes occur in the brains of people with Parkinson's disease, including:
- The presence of Lewy bodies. Clumps of specific substances within brain cells are microscopic markers of Parkinson's disease. These are called Lewy bodies, and researchers believe these Lewy bodies hold an important clue to the cause of Parkinson's disease.
- A-synuclein is found within Lewy bodies. Although many substances are found within Lewy bodies, scientists believe the most important of these is the natural and widespread protein called a-synuclein. It's found in all Lewy bodies in a clumped form that cells can't break down. This is currently an important focus among Parkinson's disease researchers.
Risk factors for Parkinson's disease include:
- Age. Young adults rarely experience Parkinson's disease. It ordinarily begins in middle or late life, and the risk continues to increase with age.
- Heredity. Having a close relative with Parkinson's disease increases the chances that you'll also develop the disease. However, your risks are still small unless you have many relatives in your family with Parkinson's disease.
- Sex. Men are more likely to develop Parkinson's disease than are women.
- Exposure to toxins. Ongoing exposure to herbicides and pesticides may put you at a slightly increased risk of Parkinson's disease.
Parkinson's disease is often accompanied by these additional problems, which are variably treatable:
- Thinking difficulties. You may experience cognitive problems (dementia) and thinking difficulties, which usually occur in the later stages of Parkinson's disease. Such cognitive problems aren't very responsive to medications.
- Depression and emotional changes. Many people with Parkinson's disease may experience depression. Receiving treatment for depression can make it easier to handle the other challenges of Parkinson's disease. You also may experience other emotional changes, such as fear, anxiety or loss of motivation.
- Sleep problems and sleep disorders. People with Parkinson's disease often may have sleep problems, including waking up frequently throughout the night, waking up early or suddenly falling asleep during the day, or rapid eye movement sleep behavior disorder — acting out your dreams. Medications may help your sleep problems.
- Bladder problems. Parkinson's disease may cause you to experience bladder problems, including being unable to control urine or having difficulty urinating.
- Constipation. Many people with Parkinson's disease develop constipation primarily due to a slower digestive tract.
- Sexual dysfunction. Some people with Parkinson's disease may notice a decrease in sexual desire or performance.
Preparing for your appointment
You're likely to first see your family doctor or a general practitioner. However, you may then be referred to a doctor who specializes in nervous system disorders (neurologist).
Because there's often a lot of ground to cover, it's a good idea to arrive well prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your doctor.
What you can do
- Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
- Write down key personal information, including any major stresses or recent life changes.
- Make a list of all medications, vitamins and supplements that you're taking.
- Ask a family member or friend to come with you, if possible. Sometimes it can be difficult to remember all of the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
- Write down questions to ask your doctor.
Your time with your doctor is limited, so preparing a list of questions ahead of time will help you make the most of your time together. For Parkinson's disease, some basic questions to ask your doctor include:
- What's the most likely cause of my symptoms?
- Are there other possible causes for my symptoms?
- What kinds of tests do I need? Do these tests require any special preparation?
- How does Parkinson's disease usually progress?
- Will I eventually need long-term care?
- What treatments are available, and which do you recommend for me?
- What types of side effects can I expect from treatment?
- If the treatment doesn't work or stops working, do I have additional options?
- I have other health conditions. How can I best manage these conditions together?
- Are there any restrictions on my activity?
- Is there a generic alternative to the medicine you're prescribing me?
- Are there any brochures or other printed material that I can take home with me? What websites do you recommend?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:
- When did you first begin experiencing symptoms?
- Have your symptoms been continuous or occasional?
- Does anything seem to improve your symptoms?
Tests and diagnosis
No tests exist to diagnose Parkinson's disease. Your doctor will diagnose Parkinson's disease based on your medical history, a review of your signs and symptoms, and a neurological and physical examination. Your doctor sometimes may order tests to rule out other conditions that may be causing your symptoms.
In addition to your examination, your doctor may give you carbidopa-levodopa, the most effective Parkinson's disease medication. Significant improvement with this medication often will confirm your diagnosis of Parkinson's disease. You must be given a sufficient dose to show the benefit, as low doses for a day or two aren't reliable.
Treatments and drugs
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|Deep brain stimulation|
Parkinson's disease can't be cured, but medications can help control your symptoms, often dramatically. In some later cases, surgery may be advised. Your doctor also may recommend lifestyle changes, especially ongoing aerobic exercise. In some cases physical therapy that focuses on balance and stretching also is important.
Medications can help you manage problems with walking, movement and tremor by increasing your brain's supply of dopamine. However, dopamine can't be given directly, as it can't enter your brain.
You may have significant improvement of your symptoms after beginning Parkinson's disease treatment. Over time, however, the benefits of drugs frequently diminish or become less consistent, although symptoms usually can continue to be fairly well controlled.
Your doctor may prescribe medications, which may include:
Carbidopa-levodopa (Parcopa). Levodopa, the most effective Parkinson's disease medication, is a natural chemical that passes into your brain and is converted to dopamine. Levodopa is combined with carbidopa, which protects levodopa from premature conversion to dopamine outside your brain, which prevents nausea. In Europe, levodopa is combined with a similar substance, benserazide (Madopar). Side effects include nausea or a drop in blood pressure when standing (may result in faintness).
After years, as your disease progresses, the benefit from levodopa may become less stable, with a tendency to wax and wane ("wearing off"). Also, you may experience involuntary movements (dyskinesia) after taking higher doses of levodopa. Your doctor may lessen your dose or adjust the times of your doses to control these effects.
Dopamine agonists. Unlike levodopa, dopamine agonists don't change into dopamine. Instead, they mimic dopamine effects in your brain. They aren't as effective in treating your symptoms as levodopa. However, they last longer and may be used with levodopa to smooth the sometimes off and on effect of levodopa.
Dopamine agonists include pramipexole (Mirapex) and ropinirole (Requip). A short-acting injectable dopamine agonist, apomorphine (Apokyn), is used for quick relief.
The side effects of dopamine agonists are similar to carbidopa-levodopa, but also include hallucinations, swelling, sleepiness or compulsive behaviors such as hypersexuality, gambling and eating. If you're taking these medications and you start behaving in a way that's out of character for you, talk to your doctor.
- MAO B inhibitors. These medications include selegiline (Eldepryl, Zelapar) and rasagiline (Azilect). They help prevent the breakdown of brain dopamine by inhibiting the brain enzyme monoamine oxidase B (MAO B). This enzyme metabolizes brain dopamine. Side effects are uncommon, but may rarely include nausea or headaches. When added to carbidopa-levodopa, these medications can increase the risk of hallucinations. These medications can't be used in combination with most antidepressants or certain narcotics, due to potentially serious reactions. Check with your doctor before taking any additional medications with a MAO B inhibitor.
- Catechol O-methyltransferase (COMT) inhibitors. Entacapone (Comtan) is the primary medication from this class. This medication mildly prolongs the effect of levodopa therapy by blocking an enzyme that breaks down levodopa. The side effects are primarily those due to an enhanced levodopa effect, including an increased risk of involuntary movements (dyskinesias). Tolcapone (Tasmar) is another COMT inhibitor that is rarely prescribed due to a risk of serious liver damage and liver failure.
- Anticholinergics. These medications were used for many years to help control the tremor associated with Parkinson's disease. Several anticholinergic medications are available, including benztropine (Cogentin) and trihexyphenidyl. However, their modest benefits are often offset by side effects such as impaired memory, confusion, hallucinations, constipation, dry mouth and impaired urination.
- Amantadine. Doctors may prescribe amantadine alone to provide short-term relief of symptoms of mild, early-stage Parkinson's disease. It also may be added to carbidopa-levodopa therapy for people in the later stages of Parkinson's disease, to help control involuntary movements (dyskinesia) induced by carbidopa-levodopa. Side effects may include a purple mottling of the skin, ankle swelling or hallucinations.
Deep brain stimulation. In deep brain stimulation (DBS), surgeons implant electrodes into a specific part of your brain. The electrodes are connected to a generator implanted in your chest that sends electrical pulses to your brain and may help improve many of your Parkinson's disease symptoms. Your doctor may adjust your settings as necessary to treat your condition. Surgery may involve risks, including infections, stroke or brain hemorrhage.
Deep brain stimulation is most often a procedure to treat people with advanced Parkinson's disease who have unstable medication (levodopa) responses. DBS can help stabilize medication fluctuations, reduce or eliminate involuntary movements (dyskinesia), reduce tremor, reduce rigidity, and improve slowing of movement. DBS is very effective in controlling erratic and fluctuating responses to levodopa or for controlling dyskinesias that can't be controlled with medication adjustments. However, it's not helpful for treating problems that don't respond to levodopa therapy, apart from tremor (tremor may be controlled even if not very responsive to levodopa).
Lifestyle and home remedies
If you've received a diagnosis of Parkinson's disease, you'll need to work closely with your doctor to find a treatment plan that offers you the greatest relief from symptoms with the fewest side effects. Certain lifestyle changes also may help make living with Parkinson's disease easier.
Eat a nutritionally balanced diet that contains plenty of fruits, vegetables and whole grains. Eating foods high in fiber and drinking an adequate amount of fluids can help prevent constipation that is common in Parkinson's disease. A balanced diet also provides nutrients, such as omega-3 fatty acids, that may be beneficial for people with Parkinson's disease.
If you take a fiber supplement, be sure to introduce it gradually and drink plenty of fluids daily. Otherwise, your constipation may become worse. If you find that fiber helps your symptoms, use it on a regular basis for the best results.
Walking with care
Parkinson's disease can disturb your sense of balance, making it difficult to walk with a normal gait. These suggestions may help:
- Try not to move too quickly.
- Aim for your heel to strike the floor first when you're walking.
- If you notice yourself shuffling, stop and check your posture. It's best to stand up straight.
- Look in front of you, not directly down, while walking.
In the later stages of the disease, you may fall more easily. In fact, you may be thrown off balance by just a small push or bump. The following suggestions may help:
- Don't pivot your body over your feet while turning. Instead, make a U-turn.
- Don't lean or reach. Keep your center of gravity over your feet.
- Don't carry things while you're walking.
- Avoid walking backward.
Daily living activities
Daily living activities, such as dressing, eating, bathing and writing, can be difficult for people with Parkinson's disease. An occupational therapist can show you techniques that make daily life easier.
Some types of alternative medicine may help people with Parkinson's disease, including:
- Coenzyme Q10. People with Parkinson's disease tend to have low levels of a fat-soluble compound called coenzyme Q10, and some research has suggested it may be beneficial for people in the early stages of Parkinson's disease. You can buy coenzyme Q10 without a prescription in drugstores and natural food stores. Talk with your doctor before taking this supplement to ensure that it won't interfere with any medication you may be taking.
- Massage. Massage therapy can reduce muscle tension and promote relaxation, which may be helpful to people experiencing movement problems associated with Parkinson's disease. These services, however, are rarely covered by health insurance.
- Acupuncture. During an acupuncture session, a trained practitioner inserts tiny needles into many specific points on your body, which may reduce your pain.
- Tai chi. An ancient form of Chinese exercise, tai chi employs slow, flowing motions that may help improve flexibility, balance and muscle strength. Several forms of tai chi are tailored for people of any age or physical condition.
- Yoga. In yoga, gentle stretching movements and poses may increase your flexibility and balance. Most poses can be modified, depending on your physical abilities.
- Alexander technique. This technique, which focuses on muscle posture, balance and thinking about how you use muscles, may help reduce muscle tension and pain.
- Meditation. In meditation, you quietly reflect and focus your mind on an idea or image. Meditation may reduce stress and pain, and help improve your well-being.
- Music therapy. Music therapy may help you to relax. It may help some people with Parkinson's disease to improve their walking and speech.
Coping and support
Living with any chronic illness can be difficult, and it's normal to feel angry, depressed or discouraged at times. Parkinson's disease presents special problems because it can cause chemical changes in your brain that make you feel anxious or depressed. And Parkinson's disease can be profoundly frustrating, as walking, talking and even eating become more difficult and time-consuming.
Although friends and family can be your best allies, the understanding of people who know what you're going through can be especially helpful. Support groups aren't for everyone. However, for many people with Parkinson's disease and their families, support groups can be a good resource for practical information and education about Parkinson's disease. Also, support groups offer a place for you to find people who are going through similar situations and can provide you with support.
To learn about support groups in your community, talk to your doctor, a Parkinson's disease social worker or a local public health nurse. Or contact the National Parkinson Foundation or the American Parkinson Disease Association.
You and your family also may benefit from talking to a mental health professional (psychologist) or social worker trained in working with people with chronic conditions.
Because the cause of Parkinson's is unknown, definitive ways to prevent the disease also remain a mystery. However, some research has shown that caffeine — which is found in coffee, tea and cola — may reduce the risk of developing Parkinson's disease. Green tea also may reduce the risk of developing Parkinson's disease.
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