Parkinson's Disease

Condition Basics

What is Parkinson's disease?

Parkinson's disease is a problem with certain nerve cells in the brain that control movement. The disease affects the way you move. It can include tremors, slow movement, stiffness, and problems with balance. Parkinson's disease gets worse over time. But usually this happens slowly, over years.

What causes it?

Low levels of dopamine, a brain chemical that helps control movement, cause symptoms of Parkinson's disease. Low levels happen when nerve cells in a part of the brain that makes dopamine break down. The exact cause of this breakdown isn't known. Scientists are studying possible causes, such as aging and poisons in the environment.

What are the symptoms?

The main symptoms of Parkinson's disease are tremors, stiff muscles, slow movement, and problems with balance or walking. Other symptoms include pain, depression, and sleep problems. Symptoms differ from person to person. Over time, the disease affects muscles all through your body. This can lead to trouble with swallowing, speech, and vision.

How is it diagnosed?

Your doctor will ask questions about your symptoms and past health and do a neurological exam. This exam checks to see how well your nerves are working. There are no blood tests that can diagnose Parkinson's. But you might have tests, such as an MRI, to help rule out other diseases that could be causing your symptoms.

How is Parkinson's disease treated?

At this time, Parkinson's disease can't be cured. You may decide to wait to start medicines if your symptoms aren't bothering you. You may get occupational therapy, physiotherapy, or speech therapy to help you function better. Exercise can also help. Brain surgery, such as deep brain stimulation, may be an option.

Cause

Normally, nerve cells in the brain make an important chemical called dopamine. Dopamine sends signals to the part of your brain that controls movement. It lets your muscles move smoothly and do what you want them to do. When you have Parkinson's, these nerve cells break down. Then you no longer have enough dopamine, and you have trouble moving the way you want to.

No one knows for sure what makes these nerve cells break down. But researchers are studying many possible causes, including aging and poisons in the environment.

Symptoms

Symptoms of Parkinson's disease differ from person to person. Tremor (shaking) may be the first symptom you notice. It's one of the most common signs of the disease, although not everyone has it.

Tremor often starts in just one arm or leg or on only one side of the body. It may be worse when you're awake but not moving the affected arm or leg. It may get better when you move the limb or you're asleep.

Other common symptoms include:

• Stiff muscles.
• Slow movement.
• Problems with balance or walking.
• Pain.

In time, Parkinson's affects muscles all through your body. It can lead to problems like trouble swallowing or constipation.

Some people with Parkinson's have depression. In the later stages of the disease, they may have a fixed or blank expression, trouble speaking, and other problems. Some people also lose mental skills (dementia).

What Happens

The course of Parkinson's disease varies, but it can include tremors, slow movement, stiffness, and problems with balance or walking. It may also include pain, depression, sleep problems and other non-movement symptoms. Parkinson's disease gets worse over time.

Mild symptoms

Tremor is often the first symptom. Early on, tremor and other symptoms occur in just one arm or leg or on only one side of the body. Changes in posture, walking, and facial expressions may occur. Other movement symptoms may include stiffness and moving slowly. Symptoms may not cause trouble in your daily life.

Moderate symptoms

With time, symptoms usually spread to both sides of the body. As the disease gets worse, movement is usually slower. Poor coordination may be a problem. Tasks such as writing, shaving, or brushing teeth may be hard. Changes in handwriting are common. Stiff muscles may cause pain or changes in posture.

Over time, Parkinson's medicines may not work as well. And they can cause side effects that include other movement problems or behaviour changes. Changing doses or medicines may help.

Changes in posture and balance may get worse. A person with Parkinson's tends to walk in a stooped manner with quick, shuffling steps. Sometimes the person may freeze. This is a sudden, brief inability to move. It most often affects walking. Falls may be common.

The disease can affect many of the muscles used for chewing and swallowing. This can lead to problems with eating, as well as drooling and choking. It can also affect the muscles that are used for speech. This can lead to low or soft speech, unclear speech sounds, and other problems.

Problems with sexual function and drive are common in people with Parkinson's disease. You may:

• Have trouble getting or keeping an erection.
• Have vaginal dryness or urinate during sex.
• Have muscle stiffness that can make sex difficult.

Severe symptoms

After years, muscle stiffness, slow movement, tremors, and balance get worse. Walking becomes very hard. Some people may need to be in a wheelchair or bed most of the day. They will need help with most or all of the tasks of daily living.

There may be other movement problems. These can get somewhat better with changes to the person's medicine.

Mild changes in thinking may occur in earlier stages of Parkinson's disease.Dementia, hallucinations, and delusions may develop in many people who have late-stage Parkinson's disease. Dementia symptoms may include confusion, getting lost, and memory loss. Some Parkinson's medicines can make this problem worse.

When to Call a Doctor

If you develop a tremor

Urgent medical care isn't needed if you've had a tremor—shaking or trembling—for some time. But you should discuss the tremor at your next doctor's appointment.

If a tremor is affecting your daily activities or if it's a new symptom, see your doctor sooner.

A written description will help your doctor make a correct diagnosis. In writing your description, consider the following questions:

• Did the tremor start suddenly or gradually?
• What makes it worse or better?
• What parts of your body are affected?
• Have there been any recent changes in the medicines you take or how much you take?

If you have Parkinson's disease

If you have been diagnosed with Parkinson's, call your doctor if:

• You notice any significant change in your symptoms, such as severe episodes of freezing—a sudden loss of mobility—which may affect walking.
• Your response to your medicine changes.
• Any other symptoms occur, such as constipation, sexual problems, or incontinence.
• You have symptoms of depression, such as feeling sad or losing interest in daily activities.
• You or your family notice that you have problems with memory and thinking ability.

Exams and Tests

Your doctor will ask questions about your symptoms and your past health and will do a neurological exam. This exam includes questions and tests that show how well your nerves are working. For example, your doctor will watch how you move and check your muscle strength and reflexes. The doctor may check your vision.

Your doctor also may check your sense of smell and ask you questions about your mood.

In some cases, your doctor will have you try a medicine for Parkinson's disease. If that medicine helps your symptoms, it may help the doctor find out if you have the disease.

There are no lab or blood tests that can help your doctor diagnose Parkinson's. But you may have tests to help your doctor rule out other diseases that could be causing your symptoms. For example, you might have an MRI to look for signs of a stroke or brain tumour.

An imaging test called a DaTscan may be done to help make the diagnosis.

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Treatment Overview

There is no cure for Parkinson's disease. But there are many treatments that can help your symptoms and improve your quality of life. You may decide to wait to start medicines if your symptoms aren't bothering you.

Your age, work status, family, living situation, and medical history can all affect decisions about when to start treatment, what types of treatment to use, and when to make changes in treatment. As your health condition changes, you may need regular changes in your treatment. You and your doctor will consider quality-of-life issues, side effects of treatment, and treatment costs.

You'll need to see your health care team to adjust your treatment as your condition changes. Your doctor, other health professionals, or Parkinson's support groups can help you get emotional support and education about the illness. This is important both early and throughout the course of the disease.

Treatments for Parkinson's include:

Medicines.

Levodopa and dopamine agonists are the main medicines for Parkinson's disease. Doctors sometimes use other medicines to treat people in the early stages of the disease or as supplements to later treatment. There are also medicines to help with the non-movement symptoms like urinary problems and constipation.

Surgery.

Brain surgery, such as deep brain stimulation, may be an option. It may be used when medicine can't control symptoms or causes severe or disabling side effects. For this treatment, a surgeon places wires in the brain. The wires carry tiny electrical signals to the parts of the brain that control movement. These little signals can help those parts of the brain work better.

Speech therapy.

Speech therapists use breathing and speech exercises to help you overcome speech problems like the soft speech and monotone voice that can develop with Parkinson's disease. They can also help you improve problems with eating, swallowing, and drooling.

Exercise and physiotherapy.

Therapists may help you improve your walking and reduce your risk of falling. They can also give you exercises to improve your posture, strength, and flexibility. Exercise is an important treatment for this condition. Walking can be a good choice. Check to see if an exercise class for people with Parkinson's is available in your area.

Occupational therapy.

Therapists can help you learn new ways to do things for yourself so you can stay independent longer. For example, they can help you make simple changes so you can move around your house more easily. They can also help you make daily activities easier. These may include things like bathing and dressing.

Treatment for thinking problems.

You or your family members may notice that you start to have problems with memory, problem solving, learning, and other mental functions. When these problems keep you from doing daily activities, it's called dementia. There are medicines that can help treat dementia in people with Parkinson's.

Treatment for depression and anxiety.

These conditions are common in people with Parkinson's disease. It's important to be aware of them and get help. Counselling may help you feel better. Medicines can also help with the symptoms of these problems. Parkinson's support groups can help you learn ways to cope with them as well.

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Self-Care

Early on, Parkinson's disease may not greatly disrupt your life. But for most people, the disease becomes more disabling over time. Home treatment can help you adjust as time goes on and help you stay independent for as long as possible.

Making changes to your home and lifestyle

• Changes to your activities and your home may help. For example, simplify your daily activities and change the location of furniture so that you can hold on to something as you move around the house, which can help prevent falls.
• Eat healthy foods. This includes plenty of fruits, vegetables, grains, cereals, legumes, poultry, fish, lean meats, and low-fat dairy products.
• Exercise and do physiotherapy. They have benefits in both early and advanced stages of the disease. Exercise also may slow the worsening/progression of Parkinson's disease.

Improving your motor skills

• Work on your tremor. This may include things like putting a little weight on your hand to help reduce tremor and restore control.
• Improve speech quality by working with a speech therapist (also called a speech-language pathologist).
• Reduce problems with eating and drooling by changing how and what you eat. For example, avoid foods that crumble easily.
• Practice overcoming "freezing" with various techniques, such as stepping toward a specific target on the ground. A physiotherapist may be able to help you with this.

Improving your mood and memory

• Talk to someone about depression. If you are feeling sad or depressed, ask a friend or family member for help. If these feelings don't go away, or if they get worse, talk to your doctor. They may be able to suggest someone for you to talk to. Or your doctor may give you medicine that can help.
• Know the signs of dementia. Dementia is common late in Parkinson's disease. Symptoms may include confusion, getting lost, and memory loss. If you (or a family member) notice that you are confused a lot or have trouble thinking clearly, talk to your doctor. There are medicines that can help.

Helping your non-movement symptoms

• Be open about problems with sex. Talk to your doctor about your specific issues. The doctor may suggest changes that can help. These may include changing your medicine, getting some exercise, or using lubrication.
• Manage constipation. A high fibre diet, staying hydrated, and regular exercise can help.

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Medicines

Medicines are the most common treatment for Parkinson's disease. The goal is to correct the shortage of the brain chemical dopamine. This shortage causes the symptoms of Parkinson's.

Your doctor can help you decide when to start medicine. This may be when symptoms affect your daily life. Symptoms change as the disease gets worse. So your doctor will adjust your medicine as symptoms appear.

Medicines often improve symptoms. But they also may cause side effects. Levodopa works best to control movement symptoms. But after a few years, it can cause movement problems like uncontrollable jerking movements. It also may suddenly stop working. Levodopa is usually combined with carbidopa. Carbidopa decreases the possible side effects from levodopa.

Dopamine agonists also help movement symptoms. They can cause side effects like behaviour changes and sleep attacks (sudden severe sleepiness). Talk to your doctor about what medicine is right for you.

Other medicines may also be used to help control non-movement symptoms, such as pain or depression.

It may take some time to find the best medicines for you.

Several medicines may be used at different stages of the disease. They include:

• Levodopa with carbidopa.
• Dopamine agonists.
• MAO-B inhibitors.
• Amantadine.
• Anticholinergic agents.
• COMT inhibitors.
• Apomorphine.

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Surgery

Surgery may be considered when drugs:

• Don't control symptoms.
• Cause severe or disabling side effects.

The types of surgery include:

• Deep brain stimulation. This uses electrical impulses to stimulate part of the brain. It's the preferred surgery for treating most cases of advanced Parkinson's.
• Levodopa-carbidopa intestinal gel (LCIG) surgery. This surgery places a tube in the intestines. The tube delivers levodopa. It can decrease "off" time and movement side effects.
• Thalamotomy. This surgery destroys a very small area in part of the brain that causes tremor.
• Pallidotomy. This surgery destroys a very small area in a deep part of the brain that causes symptoms.
• MRI-guided focused ultrasound. This uses MRI and ultrasound to destroy brain tissue. It can help with tremor.

Surgery isn't a cure. Drugs are usually still needed after surgery. But you probably won't need as much medicine as before. And you may have fewer side effects.

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