Parkinson's Disease
By Dr. Isadore Rosenfeld
from Parade Magazine August 2001

Parkinson's Disease is the fourth most common "neurodegenerative" affliction of the elderly and, along with Alzheimer's, one of the most dreaded.  It affects about one in 1000 people over 40, and 1% of everyone over 65.  The average age of onset is 57 years.

Both sexes are equally vulnerable.  Those with blood relations who developed Parkinson's at a younger age are more likely to come down with it.  Some studies indicate that Americans of European decent are more prone to Parkinson's than those of African or Asian heritage. And there is a higher incidence of the disease in rural areas, especially where well water is drunk and pesticides are used.  On the other hand, moderate caffeine intake appears to reduce the risk of Parkinson's in both sexes—so drink coffee or tea.

The first breakthrough in the treatment of Parkinson's was the discovery in the late 1950s that it occurs when there is a deficiency in the brain of a chemical called "dopamine".  Dopamine cannot be replaced, because the brain is protected by a "barrier" that prevents most substances from reaching it.  However, "levodopa" a precursor of dopamine, does reach the brain, where it is transformed into dopamine.  Levodipa is the basic treatment for millions of patients with Parkinson's.

SYMPTOMS

There is no specific test for Parkinson's.  However, the typical symptoms and a physical exam almost always are enough to make the diagnosis.

The first signs of the disease are mild tremors of a hand, arm or leg, in that order.  The tremors are aggravated by stress or fatigue and are most pronounced when the body is at rest.  They lessen when the patient is reaching for something, and the tremors disappear during sleep.

Over time, patients with the disease also develop rigidity and tenseness of the muscles, which leaves then stiff and able to move only slowly and with difficulty.  The face may become expressionless, the voice low and monotonous, with halting speech or stuttering.

Parkinson's sufferers also tend to shuffle; their steps are short: they keep their arms flexed at the waist and don't swing them.  Their balance is so bad that they often run when starting to walk so as not to fall.  Their handwriting is small and hard to read.  They may have trouble speaking, swallowing or sleeping.  Many become seriously depressed, and about half end up demented in much the same way as someone with Alzheimer's.  In the end, many are totally dependent on a caregiver.

STANDARD TREATMENT 

The most widely used anti-Parkinson's drug is a combination of "carbidopa" and "levodopa", marketed as Sinemet.  However, the drugs often lose their effectiveness over time, usually within two to five years.  The longer you use them and the higher the dose, the more likely they are to cause jerky movements of the body.  They also may lower blood pressure when you stand up, and they can produce hallucinations and delirium.  So, it's important to find the right dosage.

The most recent recommendation for treating Parkinson's is that "dopamine agonists" should be tried before Sinemet is begun.  These medications make dopamine more effective, so you require less levodopa and can thus avoid its side effects.  The best-known are "bromocriptine" and "pergolide", but there are newer and probably more effective medications, such as "pramipexole" and "ropinirole.

NEW APPROACHES, NEW HOPE

The good news is that Parkinson's often progresses at an unpredictable pace.  Patients, may function  satisfactorily even after several years.  So, if you're diagnosed, don't give up.  Keep coping... for two reasons: First, your symptoms may not progress quickly.  Second, we're on the verge of breakthroughs that may well come in time to help you.  The most promising, though controversial, appear to be gene and stem-cell therapy, as well as, the transplanting of fetal cells that make dopamine.

Meanwhile, when drugs alone aren't working to reduce the tremors, muscle rigidity and abnormal movement of Parkinson's, doctors can surgically create lesions in the brain to help alleviate symptoms. (Michael J. Fox had such a surgery.) And in a new procedure called "deep brain stimulation" (DBS), a high-frequency current is delivered to the brain via an electrode connected under the skin below the collarbone and powered by a battery pack.  It does not destroy tissue, and the degree of stimulation can be adjusted.  But patients who have surgery or DBS must continue taking medication as well.

OTHER MEDICATIONS

In addition to treatment with dopamine agonists and Sinemet, these drugs are used:

*In mild cases of Parkinson's, "amantadine (Symmetrel), an anti-viral medication, is       used alone or with Sinemet.

*Patients with early Parkinson's may benefit from "selegiline (Eldepryl), "entacapone" or "tolcapone"; they prevent the breakdown of dopamine in the brain by certain enzymes.

*In Parkinson's, decreased dopamine in the brain results in a relative surplus of the neurotransmitter "acetylcholine".  Drugs that reduce the amount of acetylcholine can help when taken with levodopa. The most widely used are "trihexyphenidyl" (Artane), and "benztropine" (Cogentin), but they have side effects.

WHAT YOU CAN DO FOR YOURSELF

Besides taking your medications...

• Exercise.  Stay active to maintain muscle mass and healthy circulation.
   
• Watch what you eat.  Cut food into easy-to-chew portions.  Eat lots of fiber (whole grains, fruits and vegetables) and drink at least eight glasses of water daily to avoid constipation.  If it occurs, use a mild laxative.  Suck hard candy or chew mint gum to reduce salivation and drooling.
   
• Change your lifestyle. Use a cordless phone.  Or use a speakerphone or headset so you can talk hands-free.  Get an intercom system or a walkie-talkie to communicate in the house. Wear silk pajamas and use satin sheets to make turning in bed easier.  Use a large, felt-tip pen if your handwriting is small and difficult to read.  If your jaw clamps shut while sleeping, ask you dentist to fit you with a protector to prevent biting your tongue.  Buy clothing with Velcro closures.  Use a cane when necessary.

FALL-PROOF YOUR HOME-AND YOURSELF

Don't wax your floors or use throw rugs on the bathroom floor that can make you slip.  Carpets should have skid-proof backing.  Don't walk on bare floors in socks, slippers or stockings.  Wear low-heeled shoes with nonskid soles.  Take showers; they are safer than tub baths.  Buy a raised toilet seat with arm rails to help you get off the seat more easily.  Use soap-on-a-rope; it's easy to pick up if dropped.  Buy an inexpensive "grabber" to pick things up from the floor.