Parkinson's disease

Parkinson's disease is a progressive disorder of the nervous system that affects movement. It
develops gradually, sometimes starting with a barely noticeable tremor in just one hand. But
while a tremor may be the most well-known sign of Parkinson's disease, the disorder also
commonly causes stiffness or slowing of movement.

In the 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.

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. A tremor, or shaking, usually begins in a 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 a 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, making 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, you may drag your feet as you try to walk, making it difficult to move.
Rigid muscles. Muscle stiffness may occur in any part of your body. The stiff muscles can
limit your range of motion and cause you pain.
 Impaired posture and balance. Your posture may 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.
Speech changes. You 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. It may become hard to write, and your writing may appear small.
Causes

In Parkinson's disease, certain nerve cells (neurons) in the brain gradually break down or die.
Many of the symptoms are due to a loss of neurons that produce a chemical messenger in your
brain called dopamine. When dopamine levels decrease, it causes abnormal brain activity,
leading to signs of Parkinson's disease.

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 uncommon except in rare cases with many family members
affected by Parkinson's disease.

However, certain gene variations appear to increase the risk of Parkinson's disease but with a
relatively small risk of Parkinson's disease for each of these genetic markers.

Environmental triggers. Exposure to certain toxins or environmental factors may

increase the risk of later Parkinson's disease, but the risk is relatively small.
Researchers have also noted that many changes occur in the brains of people with Parkinson's
disease, although it's not clear why these changes occur. These changes include:

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.
 Alpha-synuclein is found within Lewy bodies. Although many substances are
found within Lewy bodies, scientists believe an important one is the natural and widespread
protein called alpha-synuclein (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

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 increases with age. People usually develop the disease around age 60 or
older.
Heredity. Having a close relative with Parkinson's disease increases the chances that you'll
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.
Complications

Parkinson's disease is often accompanied by these additional problems, which may be 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. 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 may also experience other emotional changes, such as fear, anxiety or loss of
motivation. Doctors may give you medications to treat these symptoms.
 Swallowing problems. You may develop difficulties with swallowing as your condition
progresses. Saliva may accumulate in your mouth due to slowed swallowing, leading to
drooling.
Sleep problems and sleep disorders. People with Parkinson's disease often have sleep
problems, including waking up frequently throughout the night, waking up early or falling
asleep during the day.

People may also experience rapid eye movement sleep behavior disorder, which involves
acting out your dreams. Medications may help your sleep problems.

Bladder problems. Parkinson's disease may cause bladder problems, including being
unable to control urine or having difficulty urinating.
Constipation. Many people with Parkinson's disease develop constipation, mainly due to a
slower digestive tract.
You may also experience:

Blood pressure changes. You may feel dizzy or lightheaded when you stand due to a
sudden drop in blood pressure (orthostatic hypotension).
Smell dysfunction. You may experience problems with your sense of smell. You may
have difficulty identifying certain odors or the difference between odors.
Fatigue. Many people with Parkinson's disease lose energy and experience fatigue, and the
cause isn't always known.
Pain. Many people with Parkinson's disease experience pain, either in specific areas of their
bodies or throughout their bodies.
Sexual dysfunction. Some people with Parkinson's disease notice a decrease in sexual
desire or performance.
Tests and diagnosis

No specific test exists to diagnose Parkinson's disease. Your doctor trained in nervous system
conditions (neurologist) 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 may order tests, such as blood tests, to rule out other conditions that may be causing
your symptoms.

Imaging tests such as MRI, ultrasound of the brain, SPECT and PET scans may also be
used to help rule out other disorders. Imaging tests aren't particularly helpful for diagnosing
Parkinson's disease.

In addition to your examination, your doctor may give you carbidopa-levodopa, a Parkinson's
disease medication. You must be given a sufficient dose to show the benefit, as low doses for a
day or two aren't reliable. Significant improvement with this medication will often confirm your
diagnosis of Parkinson's disease.

Sometimes it takes time to diagnose Parkinson's disease. Doctors may recommend regular
follow-up appointments with neurologists trained in movement disorders to evaluate your
condition and symptoms over time and diagnose Parkinson's disease.

Treatments and drugs

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 may also recommend lifestyle changes, especially ongoing aerobic exercise. In
some cases, physical therapy that focuses on balance and stretching also is important. A speech-
language pathologist may help improve your speech problems.

Medications

Medications may help you manage problems with walking, movement and tremor. These
medications increase or substitute for dopamine, a specific signaling chemical (neurotransmitter)
in your brain.

People with Parkinson's disease have low brain dopamine concentrations. 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.

Medications your doctor may prescribe include:

Carbidopa-levodopa. 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 (Rytary, Sinemet), which protects levodopa from
premature conversion to dopamine outside your brain, which prevents or lessens side effects
such as nausea.

Side effects may include nausea or lightheadedness (orthostatic hypotension).

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.

Carbidopa-levodopa infusion. The U.S. Food and Drug administration approved a

drug called Duopa in 2015. This medication is made up of carbidopa and levodopa.
However, it's administered through a feeding tube that delivers the medication in a gel form
directly to the small intestine.

Duopa is for patients with more advanced Parkinson's who still respond to carbidopa-
levodopa, but who have a lot of fluctuations in their response. Because Duopa is continually
infused, blood levels of the two drugs remain constant.

Placement of the tube requires a small surgical procedure. Risks associated with having the
tube include the tube falling out or infections at the infusion site.

Dopamine agonists. Unlike levodopa, dopamine agonists don't change into dopamine.
Instead, they mimic dopamine effects in your brain.
 They aren't as effective as levodopa in treating your symptoms. 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), ropinirole (Requip) and rotigotine (given
as a patch, Neupro). A short-acting injectable dopamine agonist, apomorphine (Apokyn), is
used for quick relief.

Some of the side effects of dopamine agonists are similar to the side effects of carbidopa-
levodopa, but also include hallucinations, sleepiness and compulsive behaviors such as
hypersexuality, gambling and eating. If you're taking these medications and you behave 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 may include nausea or insomnia.

When added to carbidopa-levodopa, these medications increase the risk of hallucinations.

These medications are not often used in combination with most antidepressants or certain
narcotics due to potentially serious but rare 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 dopamine.

Side effects, including an increased risk of involuntary movements (dyskinesias), mainly

result from an enhanced levodopa effect. Other side effects include diarrhea or other
enhanced levodopa side effects.

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) or 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 may also be given with carbidopa-
levodopa therapy during the later stages of Parkinson's disease to control involuntary
movements (dyskinesias) induced by carbidopa-levodopa.

Side effects may include a purple mottling of the skin, ankle swelling or hallucinations.

Surgical procedures

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 near your collarbone that sends electrical pulses to your brain and may reduce
your Parkinson's disease symptoms.

Your doctor may adjust your settings as necessary to treat your condition. Surgery involves
risks, including infections, stroke or brain hemorrhage. Some people experience problems
with the DBS system or have complications due to stimulation, and your doctor may need to
adjust or replace some parts of the system.

Deep brain stimulation is most often offered to people with advanced Parkinson's disease
who have unstable medication (levodopa) responses. DBS can stabilize medication
fluctuations, reduce or halt involuntary movements (dyskinesias), reduce tremor, reduce
rigidity, and improve slowing of movement.

DBS is effective in controlling erratic and fluctuating responses to levodopa or for

controlling dyskinesias that don't improve with medication adjustments.
 However, DBS isn't helpful for problems that don't respond to levodopa therapy apart from
tremor. A tremor may be controlled by DBS even if the tremor isn't very responsive to
levodopa.

Although DBS may provide sustained benefit for Parkinson's symptoms, it doesn't keep
Parkinson's disease from progressing.

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 may also help make living with Parkinson's disease easier.

Healthy eating

While there's no food or combination of foods proven to help in Parkinson's disease, some foods
may help ease some of the symptoms. For example, 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.

Exercise

Exercising may increase your muscle strength, flexibility and balance. Exercise can also improve
your well-being and reduce depression or anxiety.

Your doctor may suggest you work with a physical therapist to learn an exercise program that
works for you. You may also try exercises such as walking, swimming, gardening, dancing,
water aerobics or stretching.

Parkinson's disease can disturb your sense of balance, making it difficult to walk with a normal
gait. Exercise may improve your balance. These suggestions may also 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.
Avoiding falls

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:

Make a U-turn instead of pivoting your body over your feet.

Distribute your weight evenly between both feet, and don't lean.
Avoid carrying things while you walk.
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.

Alternative medicine

Some types of alternative medicine may help people with Parkinson's disease, including:

Coenzyme Q10. Early research suggested that high doses of coenzyme Q10 a readily
available supplement may be beneficial for people in the early stages of Parkinson's
disease. However, the benefits appear to depend on taking the supplement for 16 months or
longer.
Massage. Massage therapy can reduce muscle tension and promote relaxation. 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 improve flexibility, balance and muscle strength. Tai chi may also prevent falls. Several
forms of tai chi are tailored for people of any age or physical condition.
 A study showed tai chi may improve the balance of people with mild to moderate Parkinson's
disease more than stretching and resistance training.

Yoga. In yoga, gentle stretching movements and poses may increase your flexibility and
balance. You may modify most poses to fit your physical abilities.
Alexander technique. This technique which focuses on muscle posture, balance and
thinking about how you use muscles may 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 improve your sense of well-being.
Music or art therapy. Music or art therapy may help you to relax. Music therapy helps
some people with Parkinson's disease to improve their walking and speech. Participating in
art therapy, such as painting or ceramics, may improve your mood and help you relax.
Pet therapy. Having a dog or cat may increase your flexibility and movement and improve
your emotional health.
Prevention

Because the cause of Parkinson's is unknown, proven 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.

Some research has shown that regular aerobic exercise may reduce the risk of Parkinson's
disease.
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