Below is a List of Common Motor or Movement-related Symptoms:
Bradykinesia (“slow movements”), which can manifest as:
- Slowness of walking and other movements
- Trouble with dexterity
- Reduced armswing or stride length
- Delayed reactions physically
- Reduced facial reactions (“masked face”)
- Softer or slurred speech
- Smaller handwriting
- Delayed responses mentally
- Stiffness of limb(s)
- Sometimes associated with pain
- Tremor in one or both limbs with the limb at rest
- Sometimes also tremor with holding a posture or with actions
- Usually asymmetric
Imbalance, loss of balance reflexes
- May fall backwards
Non-motor Associated Symptoms
- Lightheadedness from blood pressure dropping upon standing
- Urinary difficulties such as increased frequency, increased urgency, trouble making it to the bathroom on time (incontinence)
- Cognitive difficulties including dementia
- Sleep disturbances, vivid dreams, acting out dreams, REM sleep behavior disorder (RBD)
- Gastrointestinal changes such as constipation, delayed stomach emptying, loss of sense of smell or taste (may precede symptoms by many years)
PD is a “clinical diagnosis,” meaning based on the patient’s exam and history. There is no blood test for PD. MRI is sometimes done to exclude other conditions that can mimic PD, but is not necessary if the clinical signs are consistent with the disease.
Saint John’s is pleased to offer DaTscan, a new functional imaging technique which accurately distinguishes between Parkinson’s tremor and other causes of tremor.
The best form of treatment is exercise, exercise, exercise! Depending on the patient, this may mean physical therapy, participation in PD-specific exercise classes, working with a personal trainer, use of fitness videos, or independent exercise. The idea is to tailor the medical and surgical treatment to maximize the ability of the patient to exercise. Speech therapy can also be helpful for slow, soft, or slurred speech.
Medications can boost the amount of dopamine, a brain chemical (“neurotransmitter”) in a number of ways:
- Levodopa (gets converted in the brain into dopamine). This is the mainstay of treatment and is most effective but also most likely to cause motor complications
- Sinemet® is the brand name for carbidopa-levodopa and is available in both immediate-release (IR) and controlled-release (CR or ER) formulations. However, the controlled-release formulation is not as predictable in absorption compared to the IR formulation and has not been proven to reduce “off” time. RytaryTM is the brand name for a new formulation of carbidopa-levodopa and is a new type of drug delivery with microcapsules within a capsule, resulting in a truly controlled release and a duration of action about an hour longer than immediate-release carbidopa-levodopa. Rytary capsules can be gently opened and sprinkled on applesauce, making it a good alternate for patients who cannot swallow medications. Carbidopa-levodopa can cause nausea, lightheadedness upon standing, hallucinations, psychosis, intense urges, and dyskinesia. These side effects can often be alleviated with dose adjustments. Both medications are typically taken 3 times per day to begin with and as the disease progresses the frequency is increased to 5 or 6 times per day.
- Dopamine agonists work on the same receptors as dopamine. Imagine the dopamine receptor as the lock and dopamine as the key. Dopamine agonists are like a different key for the same lock. Mirapex® is the brand name for pramipexole; Requip is the brand name for ropinirole; and the Neupro® patch is the only transdermal Parkinson’s medication. This can be useful for patients who are unable to swallow. Dopamine agonists have a lower risk of motor complications than levodopa but a higher risk of sleepiness, impulse control disorders (compulsive behaviors) and swelling in the legs.
- MAO-B inhibitors reduce metabolism of dopamine, thereby boosting the amount of dopamine in the brain. Azilect® (rasagiline) is a once-a-day medication; Eldepryl (selegiline) is taken twice a day. Effectiveness for motor symptoms is milder. Side effects include high blood pressure, insomnia and abdominal pain. They can be used by themselves or with levodopa.
- COMT inhibitors reduce metabolism of levodopa, thereby boosting the amount of dopamine in the brain. They only work when taken with levodopa. Brand names include Comtan (entacapone) and Stalevo (a combination of carbidopa, levodopa and entacapone). They improve the duration of action of levodopa but can make dyskinesias worse and may cause confusion or diarrhea.
- Amantadine is an antiviral medication (also used for the flu) which modulates the release of dopamine and can help for tremor or dyskinesias, but can cause swelling in the legs, depression or anxiety symptoms, and blurry vision. Artane (trihexyphenidyl) blocks the acetylcholine system which is in imbalance with the dopamine system, thereby improving the flow of dopamine. This medication is primarily useful for patients with tremor and for the small subset of PD patients who have dystonia, but can cause confusion, anxiety, depression, dry mouth, constipation, dry eyes.
- Treatment for non-motor symptoms includes: Exelon (rivastigmine) for Parkinson’s related dementia and NuplazidTM (pimavanserin) for Parkinson’s related psychosis and hallucinations.
Surgical treatment of PD is advised when the disease progresses and the medications are no longer controlling the symptoms of PD adequately.
- Levodopa still works, but the brain’s response to the medication becomes less predictable. Levodopa may take longer to kick in and may wear off earlier, requiring patients to take medication more frequently during the day. Higher doses of levodopa are associated with abnormal involuntary movements, known as dyskinesias (this does not include tremor). Unpredictable medication effect results in “OFF” time when patients feel stiff, rigid, stuck, frozen, slow, or fatigued, compared to “ON” time when movements are smooth and closer to normal.
- Treatment options as the disease progresses include taking levodopa more frequently; making the medication last longer by adding medications to reduce the metabolism of levodopa; adding or changing to long-acting forms of levodopa (Sinemet CR, Rytary); or adding or changing to long-acting forms of dopamine agonist (Neupro patch). Amantadine can be added to reduce dyskinesia. When these options have been considered and implemented, it’s time to consider deep brain stimulation surgery (DBS).
- Deep brain stimulation (DBS)