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VideoJug: Parkinson's Basics

Parkinson's Basics
What is Parkinson's?

What is the history of Parkinson's?

What are some of the other names for Parkinson's?

It's generally called Parkinsons Disease and nothing else these days, but in the past, it was sometimes referred to as a palsy, or a shaking palsy. In one area where the name Parkinsons Disease remains sort of archaic is for medicare billing purposes; it's still listed as Paralysis agitans, and I'm not sure why that persists.
How many people have Parkinson's?

Who is at most risk for getting Parkinson's?

There are some other things that have come up along the way, but the only risk factor identified has been age. It does affect men more than women at a ratio of about three men for every two women. There may be some racial differences as well. But again, it's mostly age and not anything else clearly that places people at risk for Parkinsons disease.
Who is qualified to diagnose Parkinson's?

What are some other diseases that are mistaken for Parkinson's?

Probably most commonly would be essential tremor. We think of these as being distinctly different, but their clinical overlap can be substantial in some cases. It can be a head-scratcher to try to distinguish these two things. There are other so called degenerative diseases, or neuro-degenerative diseases. Things where parts of the brain are beginning to malfunction, usually in association with age, that can sometimes mimic findings in Parkinsons disease. These are usually far less common than Parkinsons disease but they still do show up.
What's the difference between essential tremor and Parkinson's?

Essential tremor is not regarded as a neurodegenerative disease, meaning that when we look at the brains of people with essential tremor there's not structural change that has been identified. Even when you look carefully, if you take sections from the brain of somebody with essential tremor who has passed away and look at it under a microscope, we don't see any kind of structural change. So there's some sort of chemical or circuit anomaly that is contributing to essential tremor, but it is not causing a structural change; no loss of certain brain cells or neurons that we do see in Parkinsons disease. The clinical presentation is often different. The tremor of Parkinsons disease is most often on one side of the body, right or left side, initially, then later, perhaps after a couple of years it may show up on the opposite side. The tremor of Parkinsons disease is classically thought of as being at rest when people are not using their hands. In contrast, essential tremor usually begins on both sides, both hands, and is more evident to people when they are actually using their hands, when they go to put a key in a lock or lift a cup of coffee to their lips for example, or eat soup with a spoon, then the tremor becomes apparent, but at rest the tremor is much less or even absent.

VideoJug: Parkinson's Symptoms

Parkinson's Symptoms
What is 'parkinsonism'?

Parkinsonism is a broad term. Parkinsons Disease refers to one kind of disorder that causes Parkinsonism. There are other things that can cause Parkinsonism. Parkinsons Disease infers a very specific process in the brain leading to that problem of Parkinsonism, meaning slowness of movement, maybe stiffness of movement, and a change in walking. Parkinsonism is the constellation of symptoms or findings that look like Parkinsons Disease. There are many things that can cause Parkinsonism, including Parkinsons Disease. Sometimes medications can do that. Medications such as metoclopramide, also called Reglan, or prochlorperazine, known as Compazine, these things can, in some people, some sensitive people, mimic the findings of Parkinsons Disease or cause Parkinsonism. Parkinsonism could be caused by multiple small strokes accumulated over time. In certain parts of the brain when it's injured by a stroke, that can lead to the same sort of constellation of symptoms and signs. Specifically, a shuffling type of walking, or alteration of walking, slowness of movement, a sense of stiffness of movement. Parkinsonism may also include tremor, but not necessarily. Parkinsonism broadly refers to slowing of movement and alteration of walking.
What is 'tremor,' in relation to Parkinson's?

Tremor is the single most common symptom that drives people to see the doctor in the first place, where they ultimately receive a diagnosis of Parkinsons disease. Tremor is a rhythmic shaking, usually of a limb, and in Parkinsons disease initially usually of a hand or both hands. The head is rarely affected in terms of shaking. The tremor - and this is an important point - refers to a rhythmic movement, a shaking - not necessarily to any involuntary movement, but this rhythmic movement.
What is the difference between 'internal tremor' and 'external tremor'?

Internal tremor is what people feel, but we can't as a clinician see it. People will say, I feel as if I am shaking inside myself, but it is not visible to the patient nor to the clinician. I suspect that's simply a subtle tremor that's not visibly detectible either by the clinician or by the patient. It's a manifestation of the same process. It's just not obvious.
What is 'bradykinesia'?

Bradykinesia simply refers to slowness of movement. In medicine, we like words that have multiple syllables, but bradykinesia means slow movement.
What is 'akinesia'?

Akinesia is a reduction of movement, a reduction of spontaneous movements. All of us move naturally when we're seated or talking or we adjust our posture or we have change in our facial expressiveness. Akinesia literally means an absence of movement, but we use it to refer to a reduction of spontaneous movements.
How is dexterity affected by Parkinson's?

Dexterity, or an alteration of dexterity, is often a very early finding in Parkinsons disease. People will notice, for example, that they're having difficulty with their handwriting. It's a very indication that something might be wrong. Handwriting becomes less legible and perhaps smaller in size, and other small movements of the fingers, just this sort of finger tapping type of movement, is often affected early in the course of Parkinsons disease. It can be showing itself in the daily routines in subtle ways, such as fastening buttons or doing other small motor movements.
What is 'rigidity' in relation to Parkinson's?

Rigidity is an important point. It's a change in tone. Many of us who are not in health care or are not physicians or clinicians, don't think about tone, but it's a very important concept to neurologists. Tone is simply the sense of resistance that people have in the movement of their limbs. I check this routinely on the examination of my patients, looking for alterations in tone. Sometimes its quite subtle, but I can detect it, and somebody who does this a lot in the daily routine of their work develops a sensitivity to change of tone. People with Parkinsons, or Parkinsons Disease, do have a change in the tone of their limbs, which can be detected on a clinical examination. Moreover, patients may complain about it in a way that theyll express as, I feel stiff, I feel rigid, not necessarily at the outset but at a later time during the course of Parkinsons Disease, people may develop a sense of stiffness. However, early on it can often be detected by a clinician whos sensitive to it.
What is 'frozen shoulder' and how does it relate to Parkinson's?

Frozen shoulder is increasingly being recognized as sometimes a very early presenting complaint in Parkinsons disease. People will come in talking to their doctor, complaining to their doctor that they feel stiff or have a sense of pain in their shoulder. And it may be, when it's early, not recognized for what it is, meaning a symptom or manifestation of Parkinsons disease. People thought maybe they have a rotator cuff problem, or they're having some sort of orthopedic or arthritic problem in their shoulder, when in fact it's a consequence of the stiffness that's occuring on that limb. Again, in Parkinsons disease, it usually shows up first just on one side, so people will come in complaining of "my shoulder is stiff", or "I'm slow", or "I have this sense of pain in my shoulder", and with Parkinsons disease it actually improves.
What is 'dyskinesia'?

How does Parksinson's affect the skin?

There are skin changes associated with Parkinson's disease. It is an intriguing point because we really don't know why. People can get a ruddy red rash on their face or their scalp or even other body parts. They may have a sense of increased oiliness on their face as well.
How does Parkinson's affect body weight?

Maintence of weight is a problem that occurs with Parkinsons disease. People tend to lose weight without even trying. It doesn't neccessarily correlate to the severity of the disease but people can drop 20, 30, 50 pounds in the course of a year or two without even trying. The source of this is not entirely clear. It may be due to changes in sense of appetite. It may be related to the difficulty with swallowing that people are less likely to eat and drink food and water. But people can lose weight. Also, as people are sedentary they tend to have a reduction of muscle mass as well which is associated with weight loss.


VideoJug: Parkinson's Effects On The Brain

Parkinson's Effects On The Brain
What is the 'substantia nigra'?

Substantia nigra is a very small part of the brain that sits at the top of the section called the brain stem. It's about half the size of your thumbnail, but it's a crucial part for the normal maintenance of mobility and it is the site classically in the destruction of brain cells in Parkinsons disease. These are where a large number of Dopamine-synthesizing brain cells are located and are being lost by whatever this process of Parkinsons disease is.
What is a 'Lewy body,' and how does it factor into Parkinson's?

A Lewy body is—it's Lewy, L-E-W-Y, which is the name of a pathologist who recognized a microscopic finding in the brain tissue of people with Parkinsons disease. If you take a piece of the brain and stain it in a certain way and look at it under a microscope, one can find this spherical-looking clump of what turns out to be abnormal protein within the actual neuron - the neuron being the brain cell that's affected by Parkinsons disease. It still, to this day, is regarded as one of the very key features in terms of confirming the diagnosis by tissue analysis. We don't do this in clinical practice; we don't do brain biopsies, but if we are wondering about the diagnosis of somebody after they've passed away, for example, the way that diagnosis is confirmed is by identifying Lewy bodies in a microscopic analysis of the brain.
What hallucinations are associated with Parkinson's?

There are many side effects that the medications that are used to treat the symptoms of Parkinsons disease can create; and one of them includes hallucinations. The hallucinations that are caused by these medications are usually visual in form, they're sometimes auditory - people will hear things that are not actually there, or they can be what are called olfactory, or people will smell things that are not actually there. But far and away, the most common hallucination is of a visual nature, and people see very well formed hallucinations. They will see people in their home that are not actually present. They may see bugs on the floor, they may see an animal scurrying in the corner of the room or they may see their deceased parents sitting on the couch. These things are not uncommon, it's estimated that about a third of people who are treated for Parkinsons disease will experience these side effects at some point. They're not always as disruptive as they might sound to be, although if they continue over time, they can evolve into more troubling and frightening symptoms in some cases. Often, people who have these hallucinations are able to identify them as exactly that. They realise that this is a medication side effect, that the person is not exactly or truly there. On occasions, people don't have insight retained. They don't recognize that this is a medication side effect and not real, and in that circumstance it can at least be bewildering and sometimes downright frightening to people, if they think that there's a stranger in the home who may intend to do them harm. It can cause a great deal of difficulty for people.
What is 'dopamine,' and how does it relate to Parkinson's?

Dopamine is a naturally-occuring brain chemical that we all have and need, and one of the key features, again identified quite some time ago is that in the brains of people with Parkinsons disease the production of dopamine is diminished. There is a lowering of the concentration in the brain of someone with Parkinsons disease. The consequences of this are that the symptoms emerge; that people do develop slowness or stiffness or tremor as a consequence of this reduction of the synthesis of dopamine. The reason dopamine is reduced is that the brain cells, the neurons that are creating dopamine or that are principally responsible for the synthesis of dopamine, are reducing in number.


VideoJug: Causes Of Parkinson's

Causes Of Parkinson's
What causes Parkinson's?

The simple answer to what causes Parkinsons is that we still don't know. There are leading theories and a lot of research focusing on these theories but we still don't have, with certainty, identification to what's causing Parkinsons disease.
What happens to the substantia nigra in persons who have Parkinson's?

What role do genetics play in acquiring Parkinson's?

For the majority of cases of Parkinsons disease, they don't clearly run in families, in any kind of predictable fashion that we usually think about diseases that run in families. Increasingly, there are genes that are identified that may place people at risk for developing Parkinsons disease. To have that gene alone doesn't mean necessarily that somebody will get Parkinsons disease but it may enable them, under certain circumstances, to develop Parkinsons disease. One is called Parkin, P-A-R-K-I-N, which is found more often in younger people with Parkinsons disease, but also people who are of the typical age to get Parkinsons disease. They have other names, like PINK, not referring to the color, but they are acronyms of biochemical disorders. There's something else called LRRK, too, again referring to some enzymes that are influenced by this disease process.
What role do toxins or illicit drugs play in causing Parkinson's?

What diseases or physical conditions can cause Parkinson's?

There are other things that can look like Parkinsons disease, but not really cause Parkinsons disease by our definition of having those specific brain changes present. Other disorders - there's something called normal pressure hydrocephalus which we think comes as a completely different entity, but it looks like Parkinsons disease sometimes. People who have multiple small strokes may look as though they have Parkinsons disease, but there's no other process that we know of that creates identical changes in the brain, as does Parkinsons disease.
What role do viruses and bacteria play in Parkinson's?

What role does race play in Parkinson's?

What is a 'parkinsonian personality'?

VideoJug: Early Phases Of Parkinson's

Early Phases Of Parkinson's
What signs of tremor do people have in the early phases of Parkinson's?

What signs of rigidity do people have in the early phases of Parkinson's?

In the early phases of Parkinson's disease, rigidity is not often a complaint that people have. I may be able to detect it on their examination, but it's not something that they sense specifically themselves. They may, in certain circumstances, have a sense of stiffness. This “frozen shoulder” concept may be a manifestation of rigidity in some people, but it's not across the board; it's not everybody.
How does early phases Parkinson's affect dexterity?

Dexterity is often changed in the early presentation of Parkinson's disease. People will notice that their handwriting has changed. The ability to fasten buttons can become a bit more difficult, especially those on the collars or sleeves; those tiny buttons that are hard for all of us get harder still when dexterity is impaired. People will notice that just their small movements of their fingers are more awkward in their daily routine.
How does early phase Parkinson's affect posture?

Posture may or may not be changed early in the course of Parkinsons disease. People may notice a little bit of a stoop or a little bit of a lean to one side, but not necessarily everyone. It's usually not a conspicuous finding in early Parkinsons disease, nor does it ever necessarily happen to everyone, even later in Parkinsons disease.
How does early phase Parkinson's affect body movement?

Bradykinesias happens in a slowing in movements. All of us, as we grow older, may get somewhat slower, but people with Parkinsons or even more likely their spouses or other people closer to them will recognize that they are slowing down. It is a little bit slower to get out of a car, a little bit slower or harder to get out of the bed or out of a chair. Slowness in other daily tasks may be evident to the person or to those around them.
How does early phase Parkinson's affect balance?

Balance may not be affected at all in early Parkinsons. Usually it's not. If people have a sense of unsteadiness, it is usually not at the initial presentation and occurs later.
How does early phase Parkinson's affect the face?

These are subtle changes, but may be noticeable to people around a person who is affected - a reduction of the spontaneous facial expressiveness that we all have. People may have the appearance of seeming thoughtful or even stern or angry. Or even depressed. But it's not really conveying mood, it's just a reduction of these normal facial expressions that we all have. It's sometimes called a masked face or a poker face, an appearance that people may develop.
How does early phase Parkinson's affect the voice?

This is an early manifestation in many people with Parkinsons disease that the voice may be a little bit more monotone in it's quality, less inflected. All of us, again, as we speak we have this sort of normal up and down to our voices, and that can be changed in people with Parkinsons disease. It's more of the same tone throughout. Also, volume can be affected so that a person's speech can be reduced in volume, and they're asked to repeat things more often.
What are the sexual effects of early Parkinson's?

Sexual problems are quite common in Parkinsons disease and it's been studied mostly in men, I suppose because it's simply easier to study this in men. But it can be manifested as erectile dysfunction or lack of, or reduction of, sexual interest as well.
What emotional problems are common during early phase Parkinson's?

Depression and anxiety, which often go hand in hand, can be another very early occurance in Parkinsons disease. There have been some studies focusing on exactly that question. Does that occur prior to the appearance of some of the motor findings in Parkinsons disease? It may be present early on in the course, and may be again, a clue that something is going on along the lines of Parkinsons disease. Not everybody with depression is developing Parkinsons disease, obviously, but it can be an early symptom with Parkinsons disease.
What kind of pain does a person feel in the early phases of Parkinson's?

Pain is increasingly recognised as being a feature of Parkinsons disease. Pain against a non-specific symptom, so somebody who has a limb pain does not necessarily develop Parkinsons disease. A frozen shoulder is often a painful symptom, or people may have aching or a vague sense of discomfort in their limbs, which is probably a manifestation of rigidity or this impaired mobility associated with Parkinsons disease that may improve with medication.
What are treatment goals during the early phases of Parkinson's?

What are the side effects of drug treatments during early phase Parkinson's?

There are a lot of side effects that can occur with the medications for Parkinsons disease. Most commonly, I would alert people to things like nausea or drowsiness, or in some cases a sense of light-headedness or dizziness as a consequence of blood pressure being reduced by some of these medications.


VideoJug: Moderate Phases Of Parkinson's

Moderate Phases Of Parkinson's
What signs of tremor do people have in the moderate phases of Parkinson's?

The tremor may become more persistent, or increase in amplitude, be more prevalent during the course, and a bit more troubling to people as time goes by. But we're talking about years in the course of Parkinsons Disease. So just a more persistently present tremor, and maybe a bit more conspicuous to people, and troubling to them, as well. People may notice the tremor when they're just out for dinner with their friends. It's not that tense a situation, but people are socially on, and alert, and even during happy moments, the tremor may become more apparent. When people are watching the Super Bowl, and are energized and rooting for their team, the tremor may become more apparent. People who are giving public presentations, or at work and speaking before a group of people, they may not be nervous. This may be something that they've been doing for years. But all of us, when we're talking to a group, are on, and anticipating the situation. The adrenaline levels go up a bit. In that circumstance, people do have increase of tremor, at least temporarily. When the situation is over, things calm down and the tremor will subside again.
What signs of rigidity do people show the moderate phases of Parkinson's?

They may feel a sense of stiffness, again, getting up out of a chair, or just moving in and out of a car. They sense feeling stiff on doing so. Or getting in and out of their clothes they may have a sense of stiffness, or sense of awkwardness caused by that rigidity in getting their arm into a sleeve of their shirt or their blouse.
How does moderate phase Parkinsons affect dexterity?

Somebody with moderate Parkinsons disease, dexterity may make it very difficult to fasten buttons. They made occasional assistance from their spouse, and particularly fastening the smaller buttons of the collars or their sleeves. On occasions people may need some assistance cutting certain foods that are tougher to cut. Certain kinds meats, for example, things that are awkward for all of us to cut may be harder still in someone with increased rigidity in moderate Parkinsons disease.
How does moderate phase Parkinsons affect posture?

The posture change in moderate Parkinsons disease can be subtle to the patient who has it, but spouses or others around them may notice, say, a stooped posture, and leaning forward while standing and walking. There may also be a tilt of one shoulder being held higher than the other while walking or standing, and sometimes these postural changes also contribute to back pain.
How does moderate phase Parkinsons affect body motion?

They might be slower in their daily routine - slower walking, slower getting up and moving about, slow in dressing and bathing and doing their normail daily routine, and they'd be slower in general fashion.
How does moderate phase Parkinsons affect the face?

The facial changes in moderate Parkinsons Disease may involve just a lessening further of facial expressiveness. People may have not exactly a fixed expression on their face, but it may be conveyed as distinctly less expressive in conversation - a sense that the patient does appear to be sad or depressed or angry in some fashion, more persistently during the course of the day. I have to emphasize this doesn't affect everybody. I certainly have lots of patients who have what I would call moderate Parkinsons Disease, who are still pretty good at their facial expressiveness. But in some people, it will be exacerbated as the disease changes over time.
How does moderate phase Parkinsons affect the voice?

What are the sexual effects of moderate Parkinson's?

The sexual concequences can be the same as in early Parkinsons disease, with difficulty with performance with erectile disfunction. This is a pretty common feature among men with Parkinsons disease, and frankly it's a pretty common feature among men as we age. People above the age of 70, men above the age of 70, have erectile dysfunction fairly commonly - even more so in people with Parkinsons disease. Again, interest in sexual activity may decline with Parkinsons disease, as the disease continues.
What signs of restlessness do people show in moderate phase Parkinson's?

A feeling of inner restlessness may occur in people with Parkinsons disease, especially if their medicines are not lasting quite long enough. There's this phenomonon of so called end of dose wearing off when people take a medication, and it doesn't quite reach until their next scheduled dose. When it starts going down, they may have sort of a vague, hard to define sense of being ill at ease, which can be improved upon in many people by more frequent dosing, or alternating their medication regimen in some way.
What emotional problems are common during moderate phase Parkinson's?

Depression is a problem in any stage of Parkinsons disease, at any point that it needs to be thought about and, if present, attended to. It doesn't necessarily increase as the disease changes or as years go by. It's something that I think about all the time in my patients, whether it's somebody recently diagnosed or who's had it for ten years or fifteen years.
What kind of pain does a person feel in the moderate phase of Parkinson's?

Pain may be more of an issue as stiffness increases and slowness increases, and, again, I think we need to be more attentive to this in our evaluation of people with Parkinsons Disease when they come in to see us for their visits. Often it can be improved by the adjustment of medication.
How can the autonomic system be impaired during moderate phase Parkinson's?

The autonomic nervous system controls many of our routine functions of our body that we don't think about. Things like adjustment of our blood pressure and our pulse, things like production of saliva or sweating, and also bladder and bowel function. Unfortunately, this is also affected in Parkinsons disease, so that people with Parkinsons disease pretty commonly have bladder dysfunction; they have urgency and frequency of urination. And that torments them; that's a very troubling symptom. Constipation, unfortunately, is a very common finding in Parkinsons disease as well. Some people have difficulty with excessive sweating, particularly at nighttime. They may have drenching sweats that causes them to have to change their pyjamas or their sheets once or more during the course of the night. This is sometimes related to the medications not working long enough, and there's some literature supporting the idea that additional medication or extending the duration of medication will help alleviate the sweating.
How does moderate phase Parkinsons affect swallowing?

Swallowing is affected in Parkinsons disease, and very commonly so. What people notice mostly is that things are just a little bit slower and harder to go down. They have to think about it more, maybe chew their food a little bit more completely than they had been accustomed to in the past. Most people don't develop swallowing problems to the point that they are having serious problems with this. It does happen on occasion, but that's uncommon. The more common problem is just sort of a slowness, and a difficulty, occasional coughing, or choking with eating or drinking as a consequence of the swallowing difficulties.
How does moderate phase Parkinsons affect sleep?

What treatments are available for moderate phase Parkinson's?

What are the side effects of drug treatments for moderate phase Parkinson's?

Medication side effects can include things like nausea or drowsiness, or sense of lightheadedness due to low blood pressure. But even more so, if the medications need to be increased during the course of the disease, these things can become more prominent. Other things may occur with certain medications. Visual hallucinations occur in about one third of people with Parkinsons disease at some point. They're not necessarily terribly disruptive but they could be at some point, so I'd make note of those and caution people about that potential side effect. Some of these medications may produce some personality changes. People may develop so-called compulsive behaviors or impulse control disorder, where they have a tendency to engage in activities that they wouldn't do otherwise; things like increased interest in gambling, spending, shopping, eating or even some sort of sexual change that may occur as a consequence of the medications.


VideoJug: Advanced Phases Of Parkinson's

Advanced Phases Of Parkinson's
What is the advanced phase of Parkinson's?

When we talk about advanced Parkinsons disease, we are talking about something that's not exactly defined, but most of us who are engaged in the treatment of Parkinsons disease think about people who are having a poor response to medication - the medication doesn't work very well or it may work for a very short period of time and require a lot of dosing during the course of the day. Or, people are requiring more and more medication - not just the individual doses are higher or the number of doses are higher, but even other medications being added in, using two, three, four different medications in trying to maintain mobility for people with Parkinsons disease. In some cases, in a case that I would describe as advanced, having diminishing success in accomplishing that. I want to emphasize that advanced Parkinsons disease is not a natural outcome for everybody with this diagnosis, that some people never develop the scenario that I just described. People can do very well indefinitely with a medication regimen, so not everybody's going to find themselves in this situation. In addition, as the number of medications are increased to try to maintain symptom control, we run into problems with increase of side-effects as a consequence of the medication. These things, such as involuntary movements and the visual hallucinations, or the blood pressure disturbance or drowsiness induced by medication, all of these things become increasingly difficult for people and the clinician, the treating clinician. So it gets tougher and tougher to come up with a medication regimen that both keeps people mobile and doesn't create other problems that are worse than the things that we're trying to treat.
What signs of tremor do people show in advanced phase Parkinson's?

Somebody with advanced Parkinson's disease may have a tremor that is simply persistent, that is poorly controlled throughout much of the day. This is highly variable, as one of the issues with Parkinson's disease is that no two people are exactly the same. Some people have a lot of tremors, some people have almost no tremors, some people have a lot of stiffness and others none. Somebody that I would call having advanced Parkinson's disease does not necessarily have tremor as a prominent symptom.
What signs of rigidity do people show in advanced phase Parkinson's?

In advanced Parkinsons disease, rigidity may be one of the features that are increasingly difficult to control. That is, recurring more often during the course of the day, that the medications simply aren't adequate despite increase doses, despite increase numbers of medication. The drug regiment is not adequate to keep the rigidity at bay or under control to the satisfaction of the patient.
How does advanced phase Parkinson's affect dexterity?

Some people with advanced Parkinsons Disease may have a great deal of difficulty in their daily activities, because of dexterity. They may have a great deal of difficulty in cutting their own food, in brushing their teeth, in combing their hair, for example, and may require increased assistance in these fundamental daily activities.
How does advanced phase Parkinson's affect posture?

Some people with advanced Parkinsons disease will have a more marked postural change. The lean or stoop can be more severe, causing additional difficulties with balance and mobility, for example. That's a hard feature to correct with medications or with surgery, the postural change that occurs in some, not in everyone but some with Parkinsons disease, and particularly advanced Parkinsons disease.
How does advanced phase Parkinson's affect body movement?

In advanced Parkinsons disease, body movement is further affected. People are having increased slowness, increased stiffness, perhaps increased tremor, making it all the more difficult to get through their daily activities without assistance. In some cases people will need a hired caregiver to help them with daily activities such as dressing, or bathing, or eating.
How does advanced phase Parkinson's affect balance?

Balance problems, when they occur in Parkinsons Disease, and they don't always, but they may, usually occur later in the course in Parkinsons Disease, many of us think of this as being a component of advanced Parkinsons Disease, where people have been falling, and frequently. So that people, when they're getting up to walk across the room just to answer the phone or go to the bathroom, they'll fall. This is of great concern because of the obvious implications of hip-fracture or other kinds of injury, which I do see, unfortunately, occasionally in my patients. So that balance problem does become a feature for some, as the disease progresses over time.
How does advanced phase Parkinson's affect the face?

How does advanced phase Parkinson's affect the voice?

In advanced Parkinsons disease, speech may become very difficult to understand. The intelligibility may markedly be reduced, causing people to repeat themselves. I would find that uncommon, but it does occur unfortunately in some cases with more severe or advanced Parkinsons disease. In advanced Parkinsons disease, speech may become unintelligible, in some cases where a large part of it may become unintelligible. It can be a very difficult problem in advanced Parkinsons disease.
What are the sexual effects of advanced phase Parkinson's?

In advanced Parkinsons disease, sexual difficulties are continued and it may become impossible for people with more severe manifestations of Parkinsons disease. Again, this usually falls along the lines of impaired libido, and impaired erectile functioning.
How does advanced phase Parkinson's affect mental health?

People with Parkinsons disease do sometimes develop cognitive decline or impairment along the lines of developing dementia. It correlates mostly to the severity of the motor findings, and also age. It's not necessarily correlated to the duration of the disease - how long somebody's had it. Somebody who is 85 or 80, with severe Parkinsons, meaning a lot of difficulty with mobility, somebody requiring a lot of assistance in the daily routine would be more likely to have these kinds of problems; cognitive decline and frank dementia.
What kind of pain does a person feel in advanced phase Parkinson's?

In advanced Parkinsons, pain can also be present as rigidity increases, and as mobility declines. People may have other appearances of pain in the form of a sense of stiffness, also because of reduced mobility - discomfort of the limbs because of not moving very much.
How can the autonomic system be impaired by advanced phase Parkinson's?

How does advanced phase Parkinson's affect swallowing?

Swallowing and drooling both can become increasingly problematic in advanced Parkinsons disease. Occasionally, people have swallowing difficulties to the point that they actually aspirate food or liquid into their lung. Instead of swallowing it into their stomach, they put it into their lung instead, which is a serious complication. It can lead to aspiration pneumonia, which in some cases can be a life-threatening problem. Some people need adjustment of the type of food that they eat, and in rare cases, even use of a feeding tube is undertaken by patients who are agreeable to do so. The tube is placed directly through the abdominal wall into the stomach or into the intestine to deliver food and water that way. Drooling can also be a problem, not necessarily in advanced Parkinsons disease, but even early in Parkinsons disease, drooling can be an issue that's troubling to people. Sometimes it's just present at night; people will notice that they're drooling on their pillow more or during the day, they'll have a little bit of saliva running out of the corner of their mouth. It does not necessarily coordinate to motor severity.
How does advanced phase Parkinson's affect sleep?

Sleep is a problem throughout the course of Parkinsons disease, and people with advanced Parkinsons disease will continue to have difficulties with fragmented sleep at night and may for a number of reasons have more difficulty with somnolence, or excessive drowsiness during the course of the day. This again is probably due largely to the disease itself, but as medications are increased to try to better control symptoms of Parkinsons disease, the sleep inducing side effects or the drowsy side effects of the medication may become more of a problem.
What treatments are available for advanced phase Parkinson's?

In advanced Parkinsons disease we use the same medications that we use in earlier stages or less severe Parkinsons disease - we just use them more often. Actually, as the disease progresses in some people we may, in fact, ultimately reduce the number of medications. If the medications are not achieving the effect of improving quality of life and are creating side effects like hallucinations or difficulties of disturbance of maintaining the blood pressure, then in that situation I might recommend reducing medications with the goal of maximizing the quality of life, and not necessarily eliminating all of the symptoms. If the medications, in the judgement of the patient, their spouse and also the clinician are causing more trouble than good then in that setting I might suggest reducing medications.


VideoJug: Diagnosis Of Parkinson's

Diagnosis Of Parkinson's
How long will I have Parkinson's before people notice?

People could have symptoms of Parkinsons disease for quite some time before it becomes conspicuous either to themselves or others around them. It could be a period of even a year or two. Sometimes when people have symptoms they start seeking medical attention for vague symptoms as aching of their limbs or just a sense of general not feeling well. There was a study years ago that indicated that on average people were seeing doctors for these kinds of complaints for about two years. The disease itself is probably starting years before the conspicuous manifestation such as tremor. We really don't know how long that period of time is, but there is something happening long before it becomes obvious to people. It's an interesting question, but we don't know exactly how long that time interval is.
When should I see a doctor about Parkinson's disease-like symptoms?

If they're having symptoms that are of concern to either themself or to their spouse or others around them, they should seek medical attention to try to figure out what the problem might represent. There's increasing evidence that early intervention in Parkinsons disease may have a favorable long-term outcome. People who delay treatment, for example, for extended periods of time, lose something that can't be regained by seeking or receiving treatment at a much later date.
What questions does a doctor ask to test for Parkinson's?

When seeing someone for the first time, I would ask them frankly about tremor. I would also ask, particularly the spouse, and I hope the spouse is present at the initial visit, I would ask about any kind of perceived change of voice, of speech volume, of clarity of speech. I would ask about mobility issues. I would ask the patient whether they are having difficulty with fastening these small buttons. Has their handwriting changed? Because again, the handwriting change does occur commonly, and early on. I would ask about walking. Are they having difficulty with walking? Do they tend to drag a foot? I would ask about postural changes. And then again, overall mobility in general. Has the patient, or their spouse, or others close to them, noticed any change in mobility?
What tests are used to diagnose Parkinson's?

What is the physical exam used to test for Parkinson'?

On the physical examination, especially at the time of the first visit, I would be assessing the tone of their neck, arms and legs in a very specific fashion. Again, looking for subtle changes, but perhaps by moving a limb on the other side while I'm checking for change of tone of, say, their their left arm while I'm moving their right arm. I would also look for changes of dexterity with things like finger tapping, hand opening or closing or alternating hand movements to see if there's any change in the patient from right versus left, for example. I would, in most cases, complete a general neurological examination checking reflexes, tapping on the knees and the arms and so forth; and scratching peoples feet. These are part of a standard neurological examination. In most cases, for somebody where I'm suspicious of a diagnosis of Parkinsons disease, I'm going to be focusing on the motor components, meaning the tone and mobility in general. I also watch people walk, which I find is a very important component of the neurological examination. In that, I look for symmetry of shoulder height and arm swing. I also check peoples balance. Again, early on in Parkinsons disease, balance is usually not an issue. But I do check it nonetheless. It's part of the standard Parkinsons examination. I will stand behind them and pull on their shoulders abruptly to see if they have any difficulty with posture or stability. Do I need to catch them? Or, do I need to hold them up? Or, do they take a step backward?
Is there a cure for Parkinson's?

There is no cure for Parkinsons disease. But, I have to add, that is true for so much of medicine. There are few things that we actually cure. We treat most things, and that is also the case with Parkinsons disease. There's no method now, either surgical or using medications to just stop it, to eliminate it, to make it go away, unfortunately. However, we are able to successfully treat it in most cases.


VideoJug: Drug Treatments Of Parkinson's

Drug Treatments Of Parkinson's
What is an 'antiparkinson drug'?

An anti-Parkinson drug is any medication that's used to alleviate the symptoms of Parkinsons disease; not to cure Parkinsons disease, but to improve the symptoms. There are several medications that fall into that category - being an anti-Parkinsons drug - and they are increasing in number.
What are 'anticholinergics'?

What are the side effects to anticholoinergics?

Side effects of anticholoinergic medications can be very troubling. Dry mouth is quite common, blurred vision is another relatively common side effect of these medications. It can also contribute to constipation. They do enter the brain which is their intent, and because of their action being an anticholoinergic, or blocking acetylcholine, it can contribute to some cognitive side effects such as confusion, forgetfulness, or even sometimes hallucinations.
What is 'levodopa'?

The arrival of Levodopa remains one of the triumphs of clinical neuroscience, historically. It was identified in 1959 that people with Parkinson's Disease have a deficiency of dopamine in their brain, and this is a significant factor in the development of the symptoms of Parkinson's Disease - the fact that dopamine is diminished. Now, it's not possible to orally supplement dopamine, because if you take it by mouth, it doesn't get into your brain. That was identified a long time ago. It was figured out that if people give the chemical precursor, the molecule of the brain uses to make dopamine, that will work just as well. Levodopa is exactly that. It's the chemical precursor that the brain uses to synthesize dopamine. People take Levodopa in a tablet form - it's absorbed through their gut, through their intestine, gets into the blood and ultimately does pass into the brain. The brain tissue takes it and synthesizes dopamine from this. The brain cells that remain are working in overdrive, some of the brain cells that have been making dopamine are lost. The ones that remain are working harder to keep that dopamine level up. To encourage that, we give people Levodopa so that the brain cells that are working harder, in overdrive, can have that substrate that they need to make more dopamine. it works quite well.
What are the side effects of levodopa?

The side effects of levodopa can include things like nausea, perhaps drowsiness. Levodopa can also have an impact on things like blood pressure, lowering blood pressure which could contribute to some people having a sense of lightheadedness or dizziness. Levodopa could also contribute to psychiatric side effects, including things like delusional thinking or hallucinations. Years ago, it was described as potentially bringing out an increased interest in sexuality or hypersexuality, in some people. Not commonly so, but occasionally.
What are 'DDIs'?

These are dopa decarboxylase inhibitors. In the United States, this is carbidopa. When levodopa is given by itself, there are enzymes in the blood that rapidly degrade it, requiring larger doses of levodopa which would cause side effects, especially nausea and vomiting, and low blood pressure. To try to reduce the amount of levodopa that people need to take to get it efficiently to the brain, another drug was added to levodopa - carbidopa - which inhibits these enzymes that degrade levodopa. To get the levodopa to the brain where we want it to work, these other enzymes that are in the blood chewing it up are inhibited by this second medication.
What are the side effects of DDIs?

Side effects of these DDI medications, Carbidopa in the United States, are usually non-existent. They're not troubling the people in the doses that were used in the treatment of Parkinsons Disease. At higher doses, they could conceivably cause nausea, but that's unlikely.
What are 'Dopamine Receptor Agonists'?

Dopamine Agonists are in a sense synthetic dopamine. These are medications that are not converted by brain tissue into dopamine, but they try to mimic that action of dopamine in the brain. They go directly to the receptors for dopamine that are existent in the brain and try to stimulate them, mimicking the action of dopamine. They are reasonably effective in alleviating Parkinsons Disease but they are not quite identical to true natural dopamine. Their efficacy or their ability to alleviate symptoms we think is somewhat slightly inferior to Levodopo or natural dopamine.
What are the side effects of Dopamine Receptor Agonists?

The side effects of Dopamine Agonists can include low blood pressure. It may include nausea, and also drowsiness, and the drowsiness is a concern. I do caution people about this when they start these types of medications. Agonist medications can also create psychiatric side effects including visual hallucinations or delusional thinking - having ideas that are not reality-based.
What are 'COMT inhibitors'?

We spoke about DOPA decarboxylase as an enzyme system in the blood that degrades levodopa. There's a second set of enzymes that also are existent in the blood stream that degrades levodopa. They're called Catecholomethyl transferase, or COMT for short. So, to try to deliver levodopa to the target organ, namely the brain, both of these enzyme systems, the DOPA decarboxylase and the COMT system are inhibited to efficiently deliver levodopa to the brain. COMT inhibitors are also added to levodopa along with carbidopa to block both of these enzyme systems, so that the levodopa is not degraded in the blood before it can get to the brain. This helps get it there more efficiently and also prolongs the action of levodopa once it's ingested.
What are the side effects of COMT inhibitors?

COMT medications may cause side effects by their mechanism of enhancing the effect of Levodopa. By themselves, they're usually pretty well tolerated. They don't cause much in the way of side effects. COMT inhibitors may cause discoloration of urine, making it an orange or amber color, which is of no significance, but if you don't caution people about it, it could be alarming to them if their urine color has changed. Rarely, not often, they cause diarrhea. In about five or ten percent of people who use these medications, they may get diarrhea. One of the COMT inhibitors, specifically tolcapone, has been associated with some nasty liver effects, in a very small number of people. But it did cause liver injury, and in fact, death, in a few patients after it had been more widely used. For that reason, tolcapone is required to have liver function testing accomplished on a monthly basis for six months, and thereafter according to the judgement of the clinician. Also, baseline liver function tests - these are blood tests - prior to starting the medication. In the United States, it's also requested by the FDA that people sign a form acknowledging they're aware of these potential complications of tolcapone, before initiating the medication.
What are MAO inhibitors?

MAO inhibitors are another form of medication that inhibits an enzyme, mostly in the brain (that's the target for inhibition). These are enzymes that degrade dopamine in the brain, and by inhibiting that set of enzymes, the action of dopamine in the brain can be prolonged. MAO inhibition is used as a model therapy with a modest effect on treating the symptoms of Parkinsons disease, by a medication called rasagiline. There are two of them actually - rasagiline and selegiline - and both these medications can be used as a so-called adjunct or added to levodopa, again to try to prolong the effect of somebody taking levodopa, so that they get a longer action, and less of this fluctuation of symptoms during the course of the day.
What are the side effects of MAO inhibitors?

MAO inhibitors in general are well tolerated with very few side effects. Again, they may augment the effect of dopamine in the brain and by doing so bring out dopamine-related side effects, which could include things like dysconesias, these involuntary, squirming movements that the medication, particularly the lividopa, the use could create. There are cautions about the use of MAO inhibitors in conjunction with other medications. There is a caution regarding both of these medications, both rasagiline and salegiline, about using them with anti-depressant medications at the same time, although in my practice I do do this - I just caution people about it. Rasagiline does carry a caution about certain food interactions, these are things like aged cheeses or certain red wines or aged meats. This is really a theoretical concern, and something that has not been observed in clinical practice. Both of these medications, both salegiline and rasagiline, have contraindications of use with certain pain medications at the same time. There are very specific pain medications which are described in the package inserts of both these medications.
What is 'impulse control disorder'?