Your Health - Parkinson's Disease

Parkinson's Disease

(PD; Paralysis Agitans; Shaking Palsy)

Definition

Parkinson's disease (PD) is a progressive movement disorder that causes:

Muscle rigidity
Tremor at rest
Slowing down of movements (bradykinesia)
Difficulty moving and gait instability

It is caused by a loss of nerve cells in the brain. This includes loss in an area called the substantia nigra . The loss decreases the amount of dopamine in the brain. Low dopamine results in PD symptoms.

Substantia Nigra—Yellow Section

Causes

Factors that cause the loss may be from the genes, the environment, or some combination of the two. A small amount of people with PD have an early onset form. This type is caused by an inherited gene defect.

Secondary PD has similar symptoms but is caused by several factors such as:

Antipsychotic drugs, such as haloperidol (Haldol), fluphenazine (Prolixin), trifluoperazine (Stelazine), and chlorpromazine (Thorazine)
Cardiovascular drugs such as some calcium channel blockers and antiarrhythmic drugs
Carbon monoxide poisoning
Manganese poisoning
Hydrocephalus
Brain tumors
Stroke
Encephalitis
Meningitis
Intravenous drug abuse of MPTP (a type of neurotoxin)
Reserpine (medicine to treat schizophrenia and high blood pressure)
Insecticide exposure
Trauma
AIDS

Risk Factors

Factors that increase the chance of PD include:

Age: 50 or older
History of polio
Gender: men (slightly more likely to develop PD)
Family members with PD
Nonsmokers
Exposure to toxins, drugs, or conditions listed above
High cholesterol
Melanoma skin cancer

Symptoms

Symptoms of PD begin mildly. They will worsen over time.

Symptoms include:

"Pill-rolling" tremor in the hands
Tremors are present at rest, improve with movement, and are absent during sleep
Stiffness and rigidity of muscles, usually beginning on one side of the body
Difficulty and shuffling when walking
Short steps
Slowness of purposeful movements
Trouble performing usual tasks, due to shaking in hands
Trouble speaking (often speaking with a low volume)
Flat, monotonous voice
Stuttering
Shaky, spidery, or small handwriting
Poor balance
Difficulty with rising from a sitting position
“Freezing”
Anxiety
Seborrhea (a skin problem that causes a red rash and white scales)
Loss of smell
Urinary symptoms (frequency and urgency)
Bowel movement symptoms (straining, constipation)
Tendency to fall
Stooped posture
Increasingly mask-like face, with little variation in expression
Trouble chewing and swallowing
Drooling and excessive salivation
Depression
Dementia
Hallucinations
Difficulty thinking, problems with memory
Decreased sense of smell
Sleep problems such as REM-behavior disorder

Diagnosis

The doctor will ask about your symptoms and medical history. A physical exam will be done. There are no tests to definitively diagnose PD. The doctor will ask many questions. This will help to rule out other causes of your symptoms.

Tests to rule out other conditions may include:

Blood tests
Urine tests
CT scan —a type of x-ray that uses a computer to make pictures of structures inside the head
MRI scan —a test that uses magnetic waves to make pictures of structures inside the head
PET scan —a scan that makes images that show the amount of activity in the brain

Treatment

Currently, there are no treatments to cure PD. There are also no proven treatments to slow or stop its progression. Some medications are used to improve symptoms. Over time the side effects may become troublesome. The medications may lose their effectiveness.

Medications

Medications include:

Levodopa/carbidopa ( Sinemet )
Amantadine (Symmetrel)
Anticholinergics: benztropine (Cogentin) and biperiden (Akineton)
Monoamine Oxidase inhibitors: Selegiline (Eldepryl), Rasagaline(Azilect)
Dopamine agonists: bromocriptine (Parlodel), pergolide (Permax), pramipexole (Mirapex), cabergoline (Dostinex), Rotigotine (Neupro), and ropinirole (Requip)
- Pergolide (Permax) was withdrawn in March 2007. It had a high risk of serious heart valve damage. Cabergoline (Dostinex) has also been linked to this risk.
Apomorphine (Apokyn)
COMT inhibitors: entacapone (Comtan) and tolcapone (Tasmar)

Depression or hallucinations may also occur with PD. Medicine may be given to relieve these. The drugs may include:

Selective serotonin reuptake inhibitors (SSRIs)
Antipsychotic clozapine

These drugs can worsen other symptoms. You will need to be closely followed.

Surgery

Different brain operations are available, and many more are being researched including:

Deep brain stimulation (DBS)—implanting a device to stimulate certain parts of the brain; can decrease tremor and rigidity
Thalamotomy and pallidotomy—destroying certain areas of the brain to improve tremor when medication does not work (not as common as deep brain stimulation)
Nerve-cell transplants (research only)—to increase amount of dopamine made in the brain

Physical Therapy

Therapy can improve muscle tone, strength, and balance. It will include exercises and stretches.

Psychological Support

Join a support group with other people with PD. It will help to learn how others are learning to live with the challenges of PD.

If you are diagnosed with PD, follow your doctor's instructions .

Prevention

There are no guidelines for preventing PD.

RESOURCES:

National Parkinson Foundation
http://www.parkinson.org/

Parkinson's Disease Foundation, Inc.
http://www.pdf.org/

CANADIAN RESOURCES:

Health Canada
http://www.hc-sc.gc.ca/index_e.html/

Parkinson Society
http://www.parkinson.ca/

References:

American Academy of Neurology. American Academy of Neurology website. Available at: http://www.aan.com/professionals/ . Accessed March 3, 2009.

Frank S. Parkinson's disease. In: Gilman S, ed. MedLink Neurology . San Diego, CA: MedLink Corporation. Available at: http://www.medlink.com . Accessed November 8, 2009.

Goetz CG. Textbook of Clinical Neurology . Philadelphia, PA: WB Saunders Company; 1999.

Parkinson's disease. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed/what.php . Accessed November 8, 2009.

Parkinson's disease information page. National Institute of Neurological Disorders and Stroke website. Available at: http://www.ninds.nih.gov/disorders/parkinsons_disease/parkinsons_disease.htm . Updated April 10, 2008. Acessed June 13, 2008.

Parkinsonism. Quick Answers to Medical Diagnosis and Therapy: http://www.accessmedicine.com.ezp-prod1.hul.harvard.edu/quickam.aspx. Accessed November 8, 2009.

Rowland LP, Merritt HH. Merritt's Neurology . 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.

Samii A, et al. Parkinson's disease. Lancet . 2004;363:1783-1793.

Samuels MA, Feske SK. Office Practice of Neurology . Philadelphia, PA: Churchill Livingstone; 2003.

Siderowf A, et al. Update on Parkinson's disease. Ann Intern Med . 2003;138:651-658.

Wider C, Wszolek CK. Movement disorders: insights into mechanisms and hopes for treatments. Lancet Neurology . 2009;8(1):8-10.

4/10/2007 DynaMed's Systematic Literature Surveillance: US Food and Drug Administration. FDA announces voluntary withdrawal of Pergolide products [press release]. March 29, 2007. US Food and Drug Administration website. Available at: http://www.fda.gov/bbs/topics/NEWS/2007/NEW01596.html

11/16/2009 DynaMed Systematic Literature Surveillance DynaMed's Systematic Literature Surveillance: Spinks A, Wasiak J, Bernath V, Villaneuva E. Scopolamine (hyoscine) for preventing and treating motion sickness. Cochrane Database Syst Rev. 2009;(4):CD002851.

Last reviewed November 2009 by J. Thomas Megerian, MD, PhD, FAAP

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.