Parkinson‘s Disease (PD)

Definition of Parkinson‘s Disease (PD)

PD is a degenerative condition affecting the brain which causes various neurologic symptoms, primarily:- Tremor on one or both

sides of the body while the limbs are at rest

- Slowing down of movements (“bradykinesia”)

- Stiffness of the limbs (“rigidity”)

The part of the brain that is affected is called the basal ganglia, which functions like the autopilot of your brain, facilitating subconscious (automatic) movements

The motor (movement-related) symptoms and signs of PD

Bradykinesia (“slow movements”)- Slowness of walking and

other movements- Delayed reactions

physically- Reduced facial reactions

(“masked face”)- Softer or slurred speech- Delayed responses

mentally

Rigidity Rest Tremor Imbalance, loss of balance

reflexes

The possible non-motor symptoms of PD?

Lightheadedness from blood pressure dropping upon standing

Urinary difficulties Gastrointestinal changes Loss of sense of smell or

taste (may precede symptoms by many years)

Anxiety Depression Fatigue Cognitive difficulties Hallucinations Impulse control disorders Sleep Behavior Disorder

The subtypes of PD

Tremor-predominant PD- Earlier onset- Slower progression- Lower risk of cognitive

decline- Tremor may be more

difficult to treat than other symptoms of PD

Postural Instability/ Gait Disorder (PIGD)- Later onset - More rapid progression on

average- Less tremor or no tremor,

more bradykinesia- Higher risk of cognitive

decline

Who gets PD and why?

Risk Factors - Some genetic predisposition- Exposure to environmental

toxins, e.g. pesticides- Oxidative damage (“free

radicals”)- Some degree of neuro-

inflammation

Protective Factors- Caffeine use- Ibuprofen use- Exercise! (Regular moderate-t-

vigoros)- Gout (elevated uric acid levels)- Smoking

7 million people worldwide2% of people over 654% of people over 85

men more than womenusually > the age of 50

The diagnosis of PD

PD is a „clinial 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

Functional imaging Researchers are

looking for “biomarkers”, meaning test that could be done in the blood or spinal fluid

The treatment of PD

The goal is to keep the patient functioning independently as long as possible

The key is to individualize therapy

Treatment of non-motor symptoms

Treatment Modalities for motor symptoms:- Medications- Therapy

Physical Therapy Speech Therapy

- Surgery

The treatment of PD

Exercise/ Physical Activity

Treatment of motor symp-

toms

Treatment of non-motor symptoms

Treatment of motor

symptoms

What are the brain changes that result in the symptoms of PD?

How are motor symptoms of PD treated?

How are motor symptoms of PD treated?

Levodopa (Sinemet) Most effective medication

for slow movements and rigidity: may be less effective for tremor

Common side effects:- Nausea- Lightheadedness, sleepiness,

headache- Confusion- psychosis

How are motor symptoms of PD treated?

Dopamine Agonists (Mirapex and Requip)

Less effective that levodopa Less risk of dyskinesias Less risk of on-off motor

fluctuations

Dopamine releaser: Amantadine

Non-dopamine-related agents: Trihexyphenidyl (Artane)

MAO-B inihibitors

Does it matter which medication is chosen first?

Medications must be customized to each patient’s particular symptoms,

age, risk of side effects, other medications and conditions, and

preferences.

Therapy for PD

Speech therapy Physical Therapy Physical Exercise

- Benefits: Improved quality of life

- Cardiovascular activity- Resistance Training- Balance Training

How are non-motor symptoms of PD treated?

Behavioral symptoms- Dementia:

Rivastigmine (Exelon)- Depression:

Anti-depressants, psychotherapy

Autonomic Nervous System:- Constipation:

Metamucil - Urinary urgency:

oxybutynin (Ditropan)- Impotence:

sildenafil (Viagra)

Swallowing safety Driving safety Medication Safety Sleep-related

symptoms- Insomnia:

Benadryl- REM sleep behavior

disorder:melatonin

The treatment options for advanced PD

Neurosurgery- Deep brain stimulation (DBS)- DBS is not a cure, and does

not benefit gait issues, balance, cognition, freezing

- Benefits: Improved motor control Reduced tremor Improved quality of life

- Risks: Infection of the leads,

extension or battery Hemorrhage Problem with speech,

language and mood

Other neurosurgical options:- Thalamotomy- Pallidotomy- Stem Cell transplantation

No benefit in 2 clinical trials - Gene therapy

Still being studied in clinical trials

Other Options: - Levodopa gel duodenal

infusion Still being studied in clinical

trials

What is the prognosis of PD?

Highly variable from person to person- Some patients survive for 20-30

years, the majority of patients require assistance after 15-20 years

- Memory issues are present in many patients with advanced PD

- Falls, fractures, pneumonia and other infections may contribute to medical issues in advanced stages

Tremor-predominant subtype has a slower progression

Postural instability/ Gait Disorder subtype has a more rapidity progressive course

What is the risk for family members of patients with PD?

The vast majority of cases of PD are not inherited (meaning no one in the family has PD)

Genetic causes of PD exist

The risk of PD in 1st–degree relatives of PD is 2x the risk of PD in 1st-degree relatives of control patients