Tuesday, 21 October 2008
Two well know celebrity, suffering from Parkinson’s disease, and the late founder of Parkinson's society in Negeri Sembilan Mr Lloyd Tan Pao Chan
Parkinson's disease is named after the English physician Dr. James Parkinson, who described it in 1817. However there is a much earlier description of Parkinson's disease among the writings of Leonardo da Vinci, in the Royal collection at Windsor Castle in England.
Parkinson's disease (PD) is a slowly progressive condition resulting from a deficiency in the brain of a chemical called dopamine
Dopamine is one of many chemical messengers (called neurotransmitters) in the brain that allow nerve cells to communicate with each other. Without it, messages from the brain to the muscles are disrupted. Over a period of time symptoms appear that include:
Tremor (shaking) when the body and limbs are at rest
Slowness and difficulty beginning a voluntary movement, such as standing up from a chair or turning around, and difficulty with fine precise movements such as doing up buttons. (called bradykinesia)
Muscle stiffness, also called rigidity, and Difficulty with maintaining balance (called postural instability)
The amount of dopamine in the brain is reduced in Parkinson's disease because some of the nerve cells that produce it are destroyed.
The small group of nerve cells affected in Parkinson's disease nerve cells lies deep in the brain, in a region called the substantia nigra or (black substance), a part of the brain involved in initiating movement. It is situated near the center of the brain and contains a clump of dark cells that manufacture dopamine.
Substantia nigra or (black substance)
Facts About Parkinson's Disease
· The incidence of Parkinson's disease is increasing at a rate that is faster than the population is aging.
· Parkinson's disease affects an estimated 1 in 1,000 people over age 55.
· Parkinson's disease affects about 1 in 100 people age 65 and older.
· Some 20 percent of people with Parkinson's disease may be diagnosed under the age of 50.
· About 8 percent to 10 percent of people with Parkinson's disease may be diagnosed under the age of 40. Well-known people who have had or have Parkinson's disease include Pope John Paul II, Francisco Franco, Muhammad Ali, Yasir Arafat, Janet Reno, Sir Michael Redgrave, Adolf Hitler, Vincent Price, Morris Udall, Margaret Bourke White, Pierre Elliot Trudeau, and Michael J. Fox.
· There has been excellent progress with research into the treatment of Parkinson's disease. This includes stem cell technology in which very basic cells are grown in the laboratory, and can be easily cultivated into large populations. Researchers have succeeded in turning these stem cells, in the laboratory, into dopamine producing nerve cells, like those cells in the substantia nigra of the brain that produce dopamine.
· Human trials have already begun and been published using retinal epithelial cells, and human trials using stem cells for the treatment of Parkinson's disease should begin in the foreseeable future.
What Causes Parkinson's Disease ?
Deep inside the brain, in an area of the brain called the basal ganglia, are nerve cells that normally control a person's voluntary movement and coordinate changes in person’s posture.
Basal ganglia and substantia nigra
When the brain sets in motion an action that results in lifting an arm, for instance, the basal ganglia signals and transmits messages to the other parts of the brain.
Those messages are forwarded as electrical impulses along and between nerve pathways by the chemical messenger called dopamine, which is made in the area of the brain called the substantia nigra. The message passes on to the basal ganglia and down the spinal cord to the muscles used to lift the arm.
The basal ganglia are normally rich with this chemical called dopamine which has been delivered from a nearby area in the brain called the substantia nigra where the dopamine is manufactured.
· In people with Parkinson's, the nerve cells in the substantia nigra (where the dopamine is made) die, and the surviving cells do not produce enough dopamine.
· The symptoms of Parkinson's will begin when 80 percent of dopamine production from this area of the brain is lost. We do not know why some previously normal nerve cells die causing dopamine levels to fall.
· Parkinson's is known to occur in some families, (10 percent to 15 percent of Parkinson's disease may be inherited) and several genes, have been identified in the last decade that appear to be associated with Parkinson's and undoubtedly more will be discovered as research continues. However, not all familial Parkinson's disease is inherited and in these cases it may occur as a result of a shared environment and a common susceptibility.
· When Parkinson's disease is inherited, it tends to occur in people under fifty years of age. However, this does not mean that everyone who develops Parkinson's under the age of fifty has inherited the disease.
· The majority of people with have what is called sporadic disease, which means it occurs in the absence of a family history with no known cause.
· Researchers feel that there may be more than one cause of disease.
· There is renewed interest in the possibility that a virus might be one cause of Parkinson's. Parkinson's was a complication of the influenza pandemic that occurred after World War 1. This virus disappeared in the early 1930s, before it could be identified. Animal studies support this, and two studies in humans showed that Parkinson's is much more common in people who work and live in close contact with others.
· The most recent study involved confirmed earlier findings that teachers and members of the medical profession carry twice the risk. The last study found no increase in Parkinson's in welders.
· A recent study described three statistically significant clusters of people who worked together and who developed Parkinson’s within a similar time frame. One involved 4 members of a TV cast and crew (4 subjects out of 120) one a group of professors (4 subjects out of 30) and one a group of people in the office of a garment factory (3 out of 7). The authors do not speculate on the cause but each group worked in an environment with artificial ventilation.
· There are still some scientists who think that "free radicals" may contribute to the damage to the nerve cells. These are toxic substances made in the body as a result of normal chemical reactions. Some people with Parkinson’s have increased levels of iron in the brain, which is part of the oxidation process. The implication of these findings is unclear. The use of vitamin E in Parkinson’s as a putative free radical trapping agent is no longer recommended; indeed a recent study from the UK suggests that mega doses of vitamin E may be toxic.
· Aluminum toxicity. Aluminum is one of the most abundant minerals found on earth,and one of the most toxic to humans. Aluminum damages nervous systems in both infants and adults. It is implicated in anemia, osteomalacia, glucose intolerance, memory deficits, and Alzheimer's, Lou Gehrig's (amyotrophic lateral sclerosis), and Parkinson's diseases. Scientists do not yet understand whether aluminum is a primary cause of Alzheimer's or is accumulated in the brain as a result of a malfunction caused by the disease. They do know, however, that aluminum wreaks havoc on human nervous systems and should be avoided.
· In some cases, the cause is known. Parkinsonism can be a consequence of some medications (used to treat psychiatric illness or control nausea). A small group of people developed Parkinsonism as a result of a known toxin called MPTP, found in an illegal synthetic opiate-derivative street drug and sold in California in the early 1980s.
What Are The Signs And Symptoms Of Parkinson's Disease?
Parkinson's disease has classic signs and symptoms, but they do not all appear at the same time or to the same degree. Some people are more troubled by one than another. The condition can vary significantly between individuals, for example how the disease progresses, and how well someone responds to the drugs, etc. Therefore, people with PD should never compare themselves with others who have PD.
Parkinson captivity on wheelchair
These Are The Four Major Signs Of PD:
In about 70 percent of people with PD, this is the earliest symptom to appear. It is a tremor that occurs in a limb when it is at rest. The tremor starts in one arm or leg on one side of the body and can progress to include the other side of the body. It usually remains more pronounced on one side of the body. Although socially distressing, the tremor does not usually interfere with activities of daily life, and it tends to disappear with voluntary movement (picking up a cup, for example). Often, medications do not completely control tremor. Fatigue, emotional stress, and worrying about the tremor can make it worse in the short term.
This describes increased tone or stiffness in the muscles when they are at rest. Joints may sometimes feel locked. The lack of mobility often causes muscle fatigue and ache. Rigidity usually responds well to treatment.
Slowness of movement. This condition is called bradykinesia. Fine movements become clumsy, for example, doing up buttons. Typically, it is often hard to begin a movement, for example, getting up from a chair, or there may be an abrupt stopping of ongoing movement such as when turning corners or going through doorways. This symptom is the most disabling, but it responds well to treatment.
Normally, reflexes allow us to make rapid adjustments to changes in the body's center of gravity when standing or walking. These reflexes become impaired in people with PD who may eventually be at risk for falls. Medication may help, but rehabilitation therapy is most valuable.
There are also a number of symptoms associated with PD. Not all people will experience them to the same degree. They include:
A changed facial expression.
Because the facial muscles that normally create expression don't move as well, people with PD sometimes appear to look uninterested or sad when they are not. This is known as hypomimia.
A soft voice.
This is known as hypophonia. People with PD may have difficulty being heard, particularly on the phone. In addition, the rhythm of the voice can be affected, and words may be spoken in a monotone.
Small, cramped handwriting.
Writing may be normal size for the first few words and then will trail off and get smaller. This is known as micrographia.
Painful stiffness, for example affecting the shoulder or calves, is a common early feature of PD. Painful cramps can also affect some people, sometimes as a result of too much medication and sometimes too little. The physician will want to know when the cramps occur in relationship to the timing of the drugs. Successful treatment of PD symptoms can lead to improved mobility, but can sometimes aggravate existing arthritis.
Everyday tasks take longer to complete when one has PD. It is hard to do two things at once. Sleep may also be disturbed. When combined, these problems often contribute to the tiredness experienced by many. It also takes a while for people with PD to learn to pace themselves to avoid reaching the end of a day without feeling exhausted. Some people experience a noticable benefit in their symptoms after a good nap or a sleep.
Research indicates that up to 50 percent of patients with PD can experience a period of depression during their illness. Depression in PD is caused by disturbed brain chemistry, and it can be triggered or made worse by stressful situations in life. Depression may occur at any time during the illness. But if depression is present when the person is first diagnosed with PD, it sometimes gets better on its own when PD symptoms start to improve with treatment.
Depression may, however, need some treatment itself. The most important first step is for the person with PD to be able to admit to being depressed and seek appropriate help. Today's antidepressants are safe and well tolerated, and most can be taken very successfully with antiparkinson drug therapy. There may be mild side effects early in treatment (dry mouth, dizziness, drowsiness), but these usually disappear with time. Full benefit from treatment for depression can take from four to six weeks. Patience, determination, and family support are needed while the right dose level is achieved.
PD and the drugs used for its treatment contribute to constipation. Severe constipation can lead to a medical emergency. If constipation continues to be a problem, it is important to seek medical help.
Intellectually, people with PD usually remain normal. But because speech and everyday tasks take longer to execute, it may appear that they lack comprehension or understanding - when actually they know exactly what they want to do but are unable to process their thoughts or actions in a timely manner. Some 30 percent of patients with PD, however, do develop dementia - the loss of cognitive and intellectual functions without impairment of perception or consciousness. Dementia can also lead to disorientation, a flattened mood, impaired memory, judgment, and intellect.
Nice To Know:
A few important comments before describing the medications for Parkinson's Disease
Drug therapy for Parkinson's disease, and the choice of drugs used for the treatment of Parkinson's disease, should be a joint decision between the person with Parkinson's disease and the physician, based on the severity of symptoms and their impact on quality of life.
· It is emphasized that treatment for Parkinson's disease should always be individually tailored for each person.
· Never compare your treatment schedules with those of other people with Parkinson's Disease. You are all different.
· Properly selected medications with the correctly tailored dose form the mainstay of treatment of Parkinson's Disease.
Drugs currently used to treat Parkinson's Disease make movement easier and can prolong function for many years. Medications aim to replace or mimic the missing chemical dopamine, in the brain.
The following are the medications used in the treatment of Parkinson's Disease. Each will be considered below.
Levodopa with carbidopa:
Levodopa, with benserazide,: ProlopaTMin Canada and MadoparTMin Europe
entacapone (ComtanTM), TasmarTM)
pramipexole,MirapexTM), ropinerole( RequipTM), bromocriptine( ParlodelTM), pergolide ( PermaxTM)
How It Works
Levodopa (L-dopa for short) has been used successfully in the treatment for Parkinson’s Disease for over 30 years. It remains the most effective treatment for Parkinson’s Disease.
L-dopa is a natural chemical found in animals and plants. When L-dopa is formulated for drug use, the generic name levodopa is used.
In patients with Parkinson’s Disease the cells in the brain that produce dopamine die (for more details see what causes Parkinson’s Disease LINK). Levodopa works by being taken up by the surviving dopamine-producing cells in the brain, and is converted by these cells into dopamine.
Levodopa is combined with carbidopa, (Sinemet CRTM, SinemetTM and is the main treatment for Parkinson’s Disease. (Another preparation, levodopa in combination with benserazide, is available in Canada, Europe and other parts of the world.)
Combining carbidopa or benserazide with levodopa has several benefits:
Carbidopa or benzerazide prevent levodopa from being converted to dopamine outside the brain.
They allow more levodopa to enter the brain where it is needed.
They help to reduce or prevent the side effects of dizziness and nausea.
The combination is usually started with low, but increasing doses, until the best effect is achieved. Levodopa never loses its effectiveness, although with increasing disability the dose required to control symptoms is also enough to precipitate unwanted side effects.
Nice To Know:
Levodopa is considered the "gold standard" of Parkinson’s Disease therapy, and it is more effective when combined with carbidopa or benserazide. But despite that success, some of the levodopa in a given dose is converted to dopamine outside the brain, where it is not needed, rather than in the brain where it is needed, due to the action of an enzyme, in the body called COMT.
There are now drugs that block the COMT enzyme. They are called COMT inhibitors because they inhibit the action of this enzyme. This makes each dose last longer.
Need To Know:
· Levodopa/carbidopa tablets are referred to by two numbers. The large number is the amount of levodopa, in milligrams, in each tablet. The small number is the amount of carbidopa in each tablet, also measured in milligrams.
Levodopa/carbidopa is available as:
Sinemet CRTM (controlled-release drug)
· 200/50 peach oval scored
· 100/25 pink oval
Sinemet CRTM is a controlled-release tablet of levodopa/carbidopa.
· Tablets should not be chewed or crushed.
· The 200/50 can be split, but not the 100/25.
· The total daily dose of Sinemet CRTM may be significantly higher than standard SinemetTM, due to absorption differences.
· For some patients, a "booster" dose of immediate-release SinemetTMmay be required in the morning or late afternoon.
· Sinemet CRTMappears to cause less dizziness and nausea than immediate release SinemetTM.
Immediate Release (Standard) SinemetTM
· 100/25 yellow oval scored
· 100/10 pale blue oval scored
· 250/25 darker blue oval scored
· The blue immediate release tablets are increasingly less often used by neurologists
Physicians may use either the SinemetTM or Sinemet CRTM preparation for their patients as soon as therapy is needed. The slow, steady release of the drug into the brain by the controlled-release Sinemet CRTM preparation may be better for remaining dopamine cells than the abrupt delivery of the SinemetTM (similar to a soaker hose versus a fire hydrant).
The immediate-release and controlled-release SinemetTMpreparations are best started slowly, increasing by small amounts until the required dosage is reached.
A starting dose may be one-half of a tablet once a day increasing to three to four times a day.
This dose can be increased every four to seven days as tolerated.
Both medications can sometimes cause nausea and dizziness when they are started.
At high doses, they may cause involuntary movements (dyskinesias) and confusion. All side effects are dose-dependent (disappear when the drug is reduced or stopped).
Physicians are somewhat divided as to whether anitparkinson drugs should be taken on an empty stomach or with food. Taking the tablet with food will reduce the likelihood of side effects. Sinemet CRTM should always be taken with food for proper absorbtion. Patients should follow the recommendations of their neurologist.
Side Effects of Levodopa:
Levodopa preparations are not without side effects. The most common include nausea, vomiting, low blood pressure, involuntary movements, and, at higher doses in the elderly and frail, confusion.
Nausea and vomiting can be a problem as the drug is being introduced. This is because the dose of carbidopa is not large enough to control these side effects. Ironically, the nausea and vomiting often get better as the levodopa/carbidopa dose is increased. The controlled-release preparation, Sinemet CRTM, is absorbed more slowly and far less likely to cause early side effects. Taking the drug with a light meal or snack can also help these side effects.
Involuntary movements (dyskinesias) writhing, jerking, or free flowing movements and nodding can occur. The rate at which dopamine "turns over" in a person's brain cells may determine whether or not they will develop dyskinesia,. Dyskinesia can only be controlled effectively by lowering the dose of levodopa or, in some severe cases, surgery.
Other drug side effects include:
This happens when Parkinson's symptoms begin to recur before the next scheduled dose of drug, due to progression of the disease. When this happens, it is easy to think that the drug is making your symptoms worse - for a while after you take the next dose, your symptoms can continue to worsen until the next dose 'kicks in'. This happens because the drug takes a while to be absorbed and reach your brain.
These can be improved by the addition of a COMT inhibitor, or a dopamine agonist
These are unpredictable fluctuations in response to drug therapy that may last up to several hours. They are thought to be due to a combination of levodopa dosage and progression of symptoms. The dopamine storage cells may lose their capacity to retain the dopamine delivered by the medication.
These can usually be improved with lower, more frequent doses of the drug, the use of a controlled release drug or with the addition of a dopamine agonist.
COMT Inhibitors medications
COMT inhibitors are a new class of drug that allows even more levodopa to enter the brain, by blocking an enzyme in the body called COMT. COMT stands for Catechol-O-Methyltransferase. This enzyme is responsible for most of the levodopa in a given dose being converted to dopamine outside the brain (where it is not needed).
Entacapone, (ComtanTM) is able to inhibit one of the COMT enzymes responsible for the breakdown of dopamine in the body, resulting in greater and more sustained blood levels of dopamine when given together with carbidopa/levodopa.
Entacapone is administered together with each dose of carbidopa/levodopa. It prolongs the duration of levodopa, benefit, is easy to use, and provides quick results. There is a possibility that a person will experience the side effects of too much levodopa, which can then be controlled by reducing the levodopa or entacapone dose or spacing out the dosing regimen. The primary indication for the use of entacapone is for the treatment of the wearing-off effect.
(Tasmar TM), is another COMT inhibitor that has proved to be very useful as an add-on medication for the treatment of Parkinsonâ€™ Disease, but had the serious side effect of fatal liver damage in a few individuals. Although it has been officially withdrawn in Europe and Canada, is still used in some patients in the U.S. and a very few in Canada who continue to do well on the medication without evidence of liver damage.
STALEVOÂ®TM Is a drug that contains a combination of Levodopa,/carbidopa (Sinement Â®TM) and entacapone (COMTANÂ®TM)
STALEVO 50Â®TM, containing 12.5 mg carbidopa, 50 mg levodopa, and 200 mg entacapone
STALEVOÂ® 100TM, containing 25 mg carbidopa, 100 mg levodopa, and 200 mg entacapone
STALEVOÂ® 150TM, containing 37.5 mg carbidopa, 150 mg levodopa, and 200 mg entacapone
STALEVOÂ®TM can be used instead of carbidopa/levodopa and COMTAN by patients taking those medicines as separate tablets.
Dopamine agonists, are medications that imitate the action of dopamine in the brain and cause nerve cells to react as if dopamine, were present. Unlike levodopa, they do not require conversion to dopamine to work.
Currently there are four dopamine agonists available:
1. Pramipexole (Mirapex TM)
2. Ropinirole, (RequipTM)
3. Bromocriptine (ParlodelTM)
4. Pergolide (PermaxTM)
· Pramipexole dihydrochloride and Ropinirole Hydrochloride are non-ergot dopamine agonists.
· Bromocriptine and pergolide are ergot-derived dopamine agonists. Ergot is a fungus that grows on grasses, and rye in particular. It produces alkaloids that are used in a wide range of drugs.
· Pramipexole (Mirapex Â®) TM or Ropinirole TM(RequipÂ®) may be used as a "first line" treatment, that is, as the main treatment, particularly for people with young onset (under 50) Parkinsonâ€™s Disease.
· Dopamine agonists are now frequently added to levodopa early in treatment, before levodopa side effects first occur, to extend the duration of benefit between each dose.
These drugs may also be used to replace some levodopa if its side effects have become unmanageable. When given together with levodopa, symptom control between doses lasts longer, and wearing-off reactions, on-off effects , and dyskinesias can be reduced.
Dopamine agonists can cause stomach upset, nausea and vomiting, and dizziness from lowered blood pressure when first started and, at high doses, confusion or hallucinations. These side effects are dose-dependent and reversible.
The best results are achieved when the agonist is started in a low dose, increasing by half a tablet until the required dose is reached. These drugs should be taken with food to minimize side effects and can be taken at the same time as other antiparkinson drugs.
Pergolide has recently been associated with cardiac valve disease in patients taking the drug for a long time. If you are on this drug discuss whether you should switch to another with your physician
Bromocriptine and pergolide can both cause fibrotic changes in the lungs after prolonged use but these symptoms are reversible if the drug is stopped. They also can cause a condition in the lower legs that makes them red, hot, and painful (erythromelalgia).
At the time ropinerole and pramipexole were first marketed there were reports of patients falling asleep while driving when taking one of these drugs. Some countries banned people taking the drugs from driving. Two major published studies have since shown that in certain people any drug used to treat Parkinson's disease can produced daytime sleepiness and so everyone should be aware of this possibility whatever treatment they are on.
The antibiotic CIPRO ®TM should be used with caution by patients taking ropinerol.
Other Medications Useful In Parkinson’s Disease
Other medications that are useful in treating Parkinson’s Disease include the following:
Amantadine (Symmetrel TM) is available as a 100 mg soft red gelatin capsule or a syrup. This drug can be used as early treatment for rigidity,. For many years, the action of amantadinewas not understood. It has recently been shown to be a glutamate antagonist and to be effective at reducing dyskinesias. This is now its major role in the treatment of Parkinson’s Disease
Amantadine can cause lightheadedness and confusion and a red "spider's web" mottling on the legs (lividoreticularis). It should be used with caution in the elderly and those with urinary problems. It should not be stopped abruptly after prolonged use.
Anticholinergic drugs (such as benztropineCogentinorTMtrihexyphenidyl Artane TM) or antihistamines, used in the treatment of allergy symptoms (such as diphenhydramine) may be used alone in the early stages of treatment, if tremor, is the major problem. These medications are more useful in treating tremor than the slowness and stiffness.
In older, frail individuals, side effects that include confusion, blurred vision, and urinary retention often limit the usefulness of these drugs.
The use of this drug has declined in the last five years. This drug has a modest action. It works by slowing the breakdown of dopamine in the brain by inhibiting one of the enzymes responsible for the breakdown of dopamine (called monoamine oxidase B). It comes in 5 mg tablets and the daily dose must not exceed 10 mg. If used as initial treatment, selegiline may delay use of levodopa by about a year but should be stopped when more treatment is needed. There are reports suggesting that it should not be used in conjunction with levodopa. It can have a mild antidepressant effect.
The major side effect is insomnia (because it converts to amphetamine in the brain), and lack of sleep is extremely detrimental to a person with Parkinson’s Disease. Even though selegiline has few side effects, it has the potential to enhance side effects associated with levodopa if they are taken together.
Many of the drugs described above are now available in generic forms.
PARKINSON'S DISEASE: What do you do if you have to go into hospital?
Anyone with Parkinson’s Disease needing to go into hospital or have surgery is encouraged to be well informed about how to ensure good management of your Parkinson’s Disease while in hospital.
While it is easier to plan in advance for pre-scheduled admissions to hospital for elective surgery' (for e.g. hip replacement, heart, prostate or bladder surgery, emergency hospital admissions pose greater challenges (for e.g. hip surgery after a fall/fracture, pneumonia, infection, bowel impaction or stroke). Be aware that trips to emergency rooms for the management of increased dyskinesia or prolonged off periods are best avoided. These episodes will eventually resolve spontaneously and it is better to stay at home in a calm, safe environment.
WHEN CONSIDERING SURGERY
Day surgery is generally no problem for a Parkinson’s Disease patient. However, some procedures, such as cataract surgery or some dental procedures, where you would normally be awake, may pose a problem if your tremor or dyskinesia create too much movement. You should bring this to the attention of the surgeon before the date of the procedure is set. It is important to ensure that you know how your GP, surgeon and neurologist (if you see one) will coordinate the care of your Parkinson’s Disease, with your procedure.
Please watch the following web sites:
Gene therapy for Parkinson’s
An experimental treatment for Parkinson’s disease seemed to improve symptoms — dramatically so, for one 59-year-old man — without causing side effects in an early study of a dozen patients.
The gene therapy treatment involved slipping billions of copies of a gene into the brain to calm overactive brain circuitry.
More than half a million Americans have Parkinson’s. They endure symptoms that include tremors, rigidity in their limbs, slowness of movement and impaired balance and coordination. Eventually they can become severely disabled.
Active Tremor Control Therapy
The Active Tremor Control Therapy is a wire that is placed within the brain of an individual who is suffering from Parkinson's disease. This device is connected to a pacemaker-like generator, which will create an electrical pulse within the individual's brain. The generator is implanted within an area close to the collarbone and, when a tremor is coming on, all the individual must do is wave a handheld magnet directly over the pulse generator. Once the individual does this, the generator releases an electrical shock in the area of the brain that causes the tremors. This electrical shock actually blocks the tremors from surfacing. after this device is implanted within the body of someone with Parkinson's, the symptoms practically disappear. Individuals are able to eat and drink without being disrupted with uncontrollable tremors.
No side effects from treatment The Lancet paper reports that over a year, patients showed no side effects from the procedure. What’s more, they showed improvements in an overall assessment of symptoms like tremors, stiffness and walking problems.
If surgery is recommended, discuss with the surgeon:
· Benefits & risks of the procedure
· Tests & procedures involved
· Expected outcomes and odds of success
· Potential complications
· Length of hospital stay
· Alternatives to surgery. Is there a more conservative approach?
· Alternatives to general anaesthesia
· Alternatives to admission
· Then you can make an informed choice.
For surgery requiring a general anesthetic, your anti-Parkinson medication may be stopped the night before surgery. Alternatively you may be allowed to take an early morning dose of Sinemet with the least amount of water. Ask if it is possible to be first on a morning surgery list to avoid long periods without medication.
Parkinson’s Disease medication timing in hospital
Ask your doctor to send your drug regimen and schedule with your hospital admitting orders before hospital admission. Also, bring your medications with you in the original bottles. Bring several copies of your list of daily Parkinson’s Disease medications and schedule to hospital. If, for example, you take your medication three times daily, write the times taken. Otherwise it mat be interpreted as taken every 8 hours.
If you are on an experimental Parkinson’s Disease drug bring your own supply and a letter about the study.
Discuss with your doctor the possibility of getting authorization to administer your own medication if you have frequent doses or as needed doses.
Contraindicated drugs & side effects
Supply a list of all allergies to the hospital
For pain control, Morphine tends to be better tolerated for those with Parkinson’s Disease versus Demerol. Demerol, pre-medication and drugs used for anesthesia can cause severe confusion, which may take a few days to a few weeks to resolve even in people who are not normally confused.
For post operative nausea ask not to be given dopamine antagonist drugs such as Reglan or Maxeran (metoclopramide) or Compazine or Stemetil (prochlorperazine) for nausea. Gravol is a useful drug choice and can be given both by mouth, suppository and injection. (Domperidone only prevents the nausea associated with antiparkinson drugs).
If you become confused post-operatively it could be drug or anaesthesia induced or the result of dehydration, constipation or an infection. Avoid all conventional anti-psychotic drugs such as haloperidol, respiridone, and olanzapine. Quietapine (Seroquel) is the only safe antipsychotic drug for Parkinson’s patients.
For bladder or prostate problems, anti-cholinergic drugs often help relieve muscle spasms after surgery, but these can cause confusion, constipation and retention of urine.
Re-starting anti-Parkinson medication after surgery
In most cases you can restart your anti-Parkinson drugs as soon as you are fully awake, and able to sit up and swallow.
Anti-Parkinson drugs cannot be given during surgery.
THE IMPACT OF HOSPITAL STAYS AND PROCEDURES ON PARKINSON’S DISEASE
Stress reduces energy for healing and will make all Parkinson’s Disease symptoms worse. Use the stress management skills that work for you, such as breathing exercises, relaxing music on a walkman, and optimism
Different diet, inadequate fluid and lack of mobility can lead to constipation, which can be severe. Bring a bowel management protocol with you
Do not be surprised if you aren't always clear about what is going on. Different staff on different shifts and medical jargon can all create uncertainty. Ask questions and seek clarification.
Medication complications can disrupt mobility and mental status, and delay recovery. Family caregivers need both a support system and a key hospital contact person.
Communicating your needs
Staff may not have much Parkinson’s Disease experience, so discuss these issues with the nurse:
· On/off fluctuations are not intentional
· The importance of taking Parkinson’s medications on time. Most hospitals allow nurses a window of time in which they can deliver medications. Delayed drug delivery can disrupt your Parkinson’s Disease and delay your recovery.
· Physical and mental slowness associated Parkinson’s Disease
· Speech problems may affect intercom use
· Hand dexterity may affect eating/hygiene
· Bed turns, transfers and walking assistance may be required
· Hospital stays increase the risk of falling and fractures for those with Parkinson’s Disease.
Restoring Mobility and Rehabilitation during hospital recovery
Patients with Parkinson’s Disease need to restore their mobility as quickly as possible to avoid complications such as pneumonia, deep vein clots, urinary tract infections, and increased rigidity.
Physiotherapy should be ordered by your doctor following surgery for chest therapy to ease ribcage rigidity and risk of lung complications as well as body mobility exercises. There are inpatient and outpatient geriatric programs commonly used by patients needing assessment and rehabilitation services.
Discharge planning, If necessary:
Ensure that you and your family understand the medical team's follow up plans.
Discuss the following with appropriate staff members ,home nursing care, rehabilitation therapy and caregiver respite needs, concerns arising about the need for ongoing facility care, The hospital social worker can provide links to the community health department.
Living With Parkinson's Disease
People with mild Parkinson's disease who take medication often regain a relatively ordinary activity level.
Continue regular daily activities.
This is important to help maintain mobility. In the early stages of PD, such normal movement should be maintained to the fullest extent possible. Do all you can to remain mobile and active.
Lead as normal a life as possible; don't restrict activities you're able to do.
A regular exercise program that involves some stretching and weight bearing (short of becoming exhausted) is beneficial because, as motor function becomes more impaired, an exercise program or physical therapy may help maintain or reestablish physical conditioning.
Walking is excellent, and a 30-minute walk each day can be a realistic goal. Start with a 10-minute walk and build it up in 5-minute increments over the course of several days, according to your tolerance. You should walk when you feel your best and not put it off while you complete household chores, etc. In inclement weather, walk around the house with the radio or CD player on.
It is never too early to seek the advice of rehabilitation specialists for help determining a realistic exercise level, or if you have difficulty with activities of daily living (getting in and out of the tub). It also is helpful if you have problems with balance and safety, difficulties with speech, or for fatigue and stress management. The physical therapist, occupational therapist, and speech language pathologist can each help you maintain function and independence.
If balance is a problem, adaptive training and use of quad-canes or straight canes, and other mechanical aids, can help maintain independence.
Because constipation can result from the PD, or from drugs used to treat the illness , or from inactivity, you should consume adequate food and a high-fiber diet. Dietary supplements such as psyllium or stool softeners can help regulate bowel movements as well.
Need To Know:
It is important to embark on a program of prevention rather than crisis management.
Increase daily fluid intake, especially in hot weather. Families and caregivers may need to reinforce this. At least six cups of liquid should be drunk daily.
Older people may not be able to tolerate large amounts of raw fruit and vegetables, but can usually manage dried fruits, hot prune juice, canned fruits, and soft cooked vegetables, all of which may help to relieve constipation.
Introducing bran or high-fiber cereal into the diet is important, but they should be
started slowly and in small amounts.
Large amounts can cause stomach cramps and excess gas, particularly in people who cannot exercise. Bran should therefore be taken with caution and be accompanied by an increase in fluid intake.
Regular exercise is also important.
Stool softeners, bulk laxatives, and bowel stimulants are the main categories of laxatives available over-the-counter. Any of these may be used if a simple change in diet is not effective.
Good nutrition will help you maintain your best level of health if you have PD. A professional dietitian/nutritionist is your best source of reliable nutrition information.
There is no specific diet for people with PD. Recommended daily allowances of the various food groups can be obtained from a dietitian or from your local health unit.
Sometimes your symptoms can interfere with your eating well. If you are experiencing problems with appetite, chewing or swallowing, weight loss, or constipation, a consultation with a registered dietitian/nutritionist could be very helpful.
For people with difficulty chewing and swallowing:
Smaller frequent meals may be easier to manage than three full-sized meals a day.
Food should be hotter or colder than the inside temperature of the mouth.
Avoid crumbly fibrous food if swallowing is difficult.
Eat in a quiet and relaxed atmosphere in a high backed chair.
Sucking on ice for a few minutes before eating may make swallowing easier (it may also help speech). Iced sodas also promote swallowing. The icy bubbles on the back of the throat help to trigger the swallowing reflex. Sour or acid food may be easier to swallow.
Put a few ice cubes in a blender with a small amount water or juice and blend until the ice is in small fragments. Have some of this chipped ice available throughout the day
Add some liquid to food in your mouth to assist swallowing.
Try to avoid unnecessary stress in your life:
Leading a healthy life, eating regularly, sleeping regularly, and exercising will help keep you fit both mentally and physically.
Many people continue to work although this can be a problem for those who face the public every day, particularly for those who need to speak in a large space (classroom) or are required to supervise in some situations. The executive with a personal secretary to provide protection from the public will find it easier than a schoolteacher.
All symptoms of PD get worse under stress. Therefore, talk to your physician and your employer about managing stress and/or early retirement or reduced working hours if necessary (and possible). Since most people need to continue working for financial reasons, talk to your doctor about regulating your treatment so that it works best while you are on the job - particularly if you work shifts or work either very short or long days. This information will help the doctor to plan the best dosing schedule.
Having PD does not mean you need to stay at home. Many people with PD travel frequently, and long distances, very successfully. You just need to plan a journey more carefully.
Rest the day before and after you travel, particularly if time changes are involved.
Take advantage of any service offered at airports, railroad stations, cruise ship terminals, etc. that allow you to board or exit in advance.
Don't walk miles at airports if there is a moving walkway, motorized cart, or wheelchair service. Save your energy.
If you are traveling by car, stop frequently for some exercise, and don't travel as many miles in a day as you once did. Don't travel for long periods in very hot weather.
Always keep all your medication in their original bottles in your hand baggage. Checked-in baggage may be lost or delayed. Customs officials are suspicious of odd containers containing several unnamed pills.
Making the Most Of Your Team
You need your partner, family and friends on your side. You may have to educate them yourself. Your family may find the adjustment to your diagnosis as difficult as you do.
It is a good idea to seek some professional help if you or anyone else cannot come to terms with the diagnosis. Inability to accept it can generate anxiety that can work against your symptoms and cause friction within the family.
A variety of professionals may comprise your care team:
Your primary care physician will continue to look after your general health and will liaise with your neurologist if you have one. Continue your annual check-ups, and don't assume that every problem with your health is related to PD.
If you attend a specialty PD clinic, there may be a nurse available to provide education and counseling, as well as provide information about how best to manage the disease. Depending on the clinic, the nurse may be your most frequent contact for advice.
If you are depressed or are having difficulty adjusting to your diagnosis and have a high level of anxiety, you might benefit from the help of a psychiatrist. Depression, anxiety, and other disorders may occur in some, but not all, people with PD. They can be disturbances in feelings, thoughts, behaviors, and intellectual functions such as memory. Psychiatrists use several methods of treatment that include verbal therapies (psychotherapy), marital and family counseling, and the use of medications.
A physical therapist can help you with your posture, walking, and balance (to prevent falls), as well as with safe completion of daily activities (getting in and out of bed).
Many people exercise alone, but community-based programs are better because they offer social support and a good reason to get out of the house on a regular basis.
An occupational therapist can offer advice and instruction on adapted equipment, safety promotion at work and at home, conserving energy, problem-solving, and improving mobility. Some offer help with stress management, as well. A consultation with an occupational therapist in your home can be valuable if it needs some adaptation to provide easy access for someone with limited mobility.
A speech-language pathologist can design a program to improve communication - possibly with ways other than speech. If you have a problem with swallowing, either a speech-language pathologist or an occupational therapist may help.
A nutritionist can help you plan a healthy diet, considering your need to either maintain or reduce your weight. A nutritionist can also offer advice about meal preparation, taking your PD symptoms into account. A nutritionist can be your best source of information about food values.
A social worker might help you solve social, emotional and economic concerns.
Primary care physician
You might benefit from a consultation with a physical therapist even if you are newly diagnosed. This is important if you plan to begin an exercise program or want to know whether you can continue your current sports and exercise. Walking and swimming are excellent activities for people with PD.
However, in the months before diagnosis, you may have noticed some difficulty with exercise or sports, and you might have felt more tired than you once did. These problems often improve when you start medication and can return to your former level of activity. (For instance, one avid golfer only succeeded in scoring a hole-in-one after taking SinemetTM; and thereafter, his golfing friends wanted to take it too!)
What Does The Future Hold For Parkinson's Research And Those With The Disease?
· Great progress has already been made in three distinct realms of PD:
· Increasing knowledge about the causes of PD, including the identification of four genes for PD as well as some clues to environmental causes. (PD is twice as common in people who work closely with other members of the public.)
· Improved disease management that minimizes side effects and maximizes benefit from the available drugs
· Ability to improve function using new surgical treatments
· Advances in imaging procedures have already advanced our knowledge about PD, by allowing researchers to visualize chemical changes as they occur in the brains of living people, where in the past researchers had to rely on postmortem autopsy tissue.
· By charting the rate of cell loss over time with repeated scans in the same individuals, researchers may be able to determine the rate of progression. From this, using mathematical models, they might be able to determine when PD actually began in an individual. Researchers are now, and have been for many years, involved in new clinical trials, technologies, surgical procedures , and drug treatments.
Today's progress may mean tomorrow's prevention or cure, as PD research continues to focus on areas such as:
· functions and anatomy of the motor system and its regulation of movement and relationship to the brain
· PD's possible connection to environmental factors such as viruses and toxins
· genetic factors to determine whether defective genes play a role and whether certain people are genetically susceptible to developing PD
· An adhesive patch that continually supply levodopa to prevent fluctuating response.
· implanting capsules containing dopamine-producing cells into the brain
· development of drugs to delay, prevent, or reverse the disease - some of which are controlled-release formulas.
· Much research is underway studying various techniques to replace the cells that have been destroyed. Research using fetal tissue is fraught with problems including government resistance. Thus alternative and better sources for dopamine-producing cells are being studied. Studies using retinal epithelial cells are already being carried out in humans and early results have been published.
· Of even greater significance is stem cell technology, using basic cells which can reproduce in the laboratory, and can be easily cultivated into large populations. The trick is turning these stem cells into dopamine-producing nerve cells, like those cells in the substantia nigra of the brain that produce dopamine. This has recently been achieved in laboratory experiments. Human trials should begin within the next couple of years.
Are There Any Clinical Trials To Participate In?
There are clinical trials taking place all the time and scientists/researchers are always eager for participants. However many studies have restrictions about how far away subjects can live from the center conducting the trial.
Frequently Asked Questions
Here are some frequently asked questions related to Parkinson's disease.
Q: Should I stop my Parkinson's disease medications before general surgery or an operation?
A: Some neurologists recommend that medications be stopped 12 hours prior to general anesthesia for surgery. If you are on a complicated drug regimen, ask your surgeon prior to surgery to contact the physician responsible for your Parkinson's disease therapy so that your drugs can be given appropriately.
Q: Can I drink alcohol if I am being treated for PD?
A: A modest intake of alcohol is not a problem for people with Parkinson's disease. However, medications should not be taken with alcohol, and you should avoid alcohol altogether while you are building up the dose of a new drug.
Q: Are there any vitamins or minerals that cure Parkinson's disease?
A: Vitamins and minerals certainly contribute to a healthy lifestyle and supplement food intake. However, none have been found to halt the disease process or cure PD.
Q: I have read that I should avoid protein and dairy products in particular?
A: This is untrue for the majority of patients with PD. We all need adequate amounts of all the food groups to maintain health. A protein redistribution diet can be useful in a very, very small number of patients who have fluctuations in response to their standard SinemetTM. This diet should be developed with the cooperation of your dietician and neurologist. If it is not effective in one week, it should be abandoned. It is true that any extra-large meal can cause a delay in gastric emptying and this may make anyone feel sluggish and tired. Most people with PD do better eating more frequent smaller meals with high-energy, easily digestible snacks in-between.
Q: Do I have to stop my PD meds when I'm taking drugs for another illness?
A: Do not stop taking your Parkinson's disease drugs if you have to take medications for another medical problem. You can take antibiotics, painkillers, etc. Bear in mind that if you do get a common viral infection such as a cold or flu, for example, or if you develop another illness that makes you feel unwell, your PD symptoms may be worse for a while because of the extra stress on your body as a result of the added illness. If you are taking ropinerole, and are prescribed CiproTM it is possible that your ropinerole dose may have to be adjusted while you are taking the antibotic as CiproTM can affect absorption.
Putting It All Together
1. Here is a summary of the important facts and information related to Parkinson's disease.
2. Parkinson’s disease (PD) is a slowly progressive condition resulting from a deficiency in the brain of a chemical called dopamine. This deficiency interrupts messages from the brain to the muscles.
3. Parkinson’s disease produces shaking of the body and limbs, slowness and difficulty beginning a voluntary movement, muscle stiffness and difficulty with maintaining balance.
4. The exact cause of Parkinson’s disease is unknown. The condition is known to occur in some families, but not all PD is inherited.
5. The four major signs of PD are tremor, rigidity, slowness of movement, and impaired balance. Some people also will experience a changed facial expression, a soft voice, cramped handwriting, pain, fatigue, depression, and constipation.
6. Parkinson’s disease may be treated with medication or surgery.
7. Medication for PD aims to replace or mimic the missing chemical dopamine in the brain.
8. Surgery for PD aims to destroy small portions of brain tissue or disable nerve cells.
9. Eating nutritious foods, getting enough exercise, managing stress, and remaining active are keys to living with Parkinson’s disease.
10. Great progress has been made in understanding and treating Parkinson’s disease, and research continues to uncover new clues about this condition.
FOOD, Herbal, Supplement for Parkinson’s
· fenugreek leaves
· angelica or dong-quai
· Ginkgo Biloba
By Kathrynne Holden, MS, RD
Ms. Holden is a registered dietitian specializing in Parkinson's disease. She has published research, books, articles, and manuals on nutrition and PD, including "Eat well, stay well with PD." For more information you may call (USA) 877-565-2665, or 970-224-5066; or visit her website: http://www.nutritionucanlivewith.com/
Beans and Parkinson's disease
In the past few years, I've been increasingly asked for information about fava beans as a source of levodopa. It's clear that many people are trying fava beans without fully understanding their properties. This article is designed to answer questions that have arisen about fava and Parkinson's disease (PD). I hope this may clear up some of the confusion about the bean, and encourage people to discuss its use with their doctors and dietitians.
This bean is a legume called "fava" (fah-vuh), faba, broad bean, and horse bean. Its botanical name is "Vicia faba." There are many species of faba; however, the "faba major"is the bean of concern here. It grows in a long pod, like a giant green bean, with large, flat seeds inside. It has been eaten for thousands of years throughout the world, especially in the Mediterranean region.
How are fava beans related to PD?
Fava beans contain levodopa, the same chemical in Sinemet, Madopar, Dopar, Larodopa, and other levodopa-containing medicines used to treat PD. In fact, the entire fava plant, including leaves, stems, pods, and immature beans, contains levodopa.
The amount of levodopa can vary greatly, depending on the species of fava, the area where it's grown, soil conditions, rainfall, and other factors. It appears that the young pod and the immature (green) beans inside the pod contain the greatest amount of levodopa, and the mature, or dried bean, the least. Three ounces (about 84 grams or cup) of fresh green fava beans, or three ounces of canned green fava beans, drained, may contain about 50-100 mg of levodopa. If using the young pod as well as the beans, the amount of levodopa may be greater than that in the fresh beans alone.
What effect do fava beans have on PD?
Some small studies have shown that the levodopa in fava beans can help control the symptoms of PD, just as medications containing levodopa do. In fact, a few people report that the effects from fava last longer than the effects from medications. Some researchers believe fava beans may contain other substances besides levodopa that could be helpful.
However, although some people report good effects, others find no antiparkinson effect from fava beans at all; and still others report adverse effects, such as nausea and dyskinesia. Much more research needs to be done to determine how effective fava beans may be.
Are there any problems associated with eating fava beans?
Yes, there a number of concerns to be aware of:
Variable levodopa amounts. Because fava plants have varying amounts of levodopa, it's possible to get either too much or too little levodopa. Too little levodopa will not relieve PD symptoms; and too much levodopa can cause overmedication effects, such as dyskinesia - particularly if other PD medications are being used at the same time. Also, the levodopa can cause nausea in some people.
Monoamine oxidase inhibitor (MAOI) use.
MAOIs taken in combination with pressor agents (foods high in dopamine, tyramine and phenylethylamine), can bring about a dangerous, and sometimes fatal, increase in blood pressure. Levodopa in medications or in fava can convert to dopamine in the bloodstream. It should be noted that selegiline is a different type of MAOI (MAOI-type B), and in the amount normally used by people with PD (10 mg daily), it is not thought to pose a risk when used with dopamine. However, people using any MAOI should discuss foods containing pressor agents with their physicians and dietitians.
Favism (G6PD deficiency).
G6PD deficiency is rare, occurring mostly among people of Mediterranean, African, and Southeast Asian descent, but others can be affected as well. Your physician can perform a blood test for G6PD to determine whether you are at risk. If you find you have inherited G6PD deficiency, your dietitian can help you locate other foods that may be of concern, and can help you plan safe and healthful menus. For more information on favism.
Should you eat fava beans if you have Parkinson's disease?
Many people with PD can benefit from use of fava beans. If you'd like to try them, discuss it with your physician first. Besides MAOI use and risk for favism, your doctor may want to adjust the amount and/or timing of your PD medications.
If your doctor agrees that you should try using fava beans, he or she will probably ask you to start out with a very small amount at first, to see what effect, if any, fava has for you. An ounce (about 28 grams, or two tablespoons of beans) a day is probably right for most people to begin with. After a week you should notice whether there is any effect, and if not, your doctor may suggest that you increase the amount. If the fava beans reduce PD symptoms, your doctor may want to adjust your other PD medications.
How often should I eat fava beans?
There is too little information available to give an exact answer; also, each person with PD is different, and has different medication needs. Some people report a half cup (4 ounces, 112 grams) of fava a day, or even every other day, gives good results. Begin with a small amount, increasing gradually under your doctor's supervision, until you find the combination of fava and/or PD medications that's right for you.
Even if fava beans help, you shouldn't eat too much. If you fill up on fava, you'll be too full for other foods, and will miss out on the benefits they offer. A dietitian can help you plan menus that include fava beans and will best meet your personal needs.
Where can I get fava beans?
Fresh pods and/or green fava beans are available in season at specialty produce markets and some specialty foods shops. They may also be found at Middle Eastern markets, some supermarkets, and farmers' markets. Grocery stores may be willing to special order the fresh pods or beans in season, frozen pods/beans, or canned green fava beans, such as produced by Krinos or Cortas. Be sure to specify "green fava beans," not dried or mature beans.
Nutrient information for fava beans
Besides levodopa, fava beans are rich in valuable nutrients. Fava pods with beans are a good source of iron, magnesium, potassium, zinc, copper, selenium, and many vitamins. The beans alone are also good - 3 ounces (98 grams) of cooked fresh beans contain 56 calories, 20 grams carbohydrates, 5 grams protein, 2 grams fiber, and substantial amounts of iron, magnesium, and vitamin C.
How do I prepare fava beans?
The pods, including beans, are best eaten when very young, before a "string" forms along the side. They can be steamed or boiled until tender. Add some olive oil or butter, lemon juice, salt and pepper, and serve as a vegetable side dish, like snow peas.
Sources for fava beans: (Be sure to ask for green, or immature, fava beans, either the beans themselves or the entire pod. The pods may be fresh or frozen; the beans may be fresh, frozen, or canned.)