brain, spinal cord, and nerve disorders
Parkinson Disease (PD)
Treatment of Parkinson Disease
General measures to manage symptoms Physical and occupational therapy Levodopa/carbidopaand other drugs Sometimes surgery (including deep brain stimulation) General measures used to treat Parkinson disease can help people function better. Many drugs can make movement easier and enable people to function effectively for many years. The mainstay of treatment for Parkinson disease is Levodopapluscarbidopa Other drugs are generally less effective thanlevodopa, but they may benefit some people, particularly iflevodopais not tolerated or is inadequate. However, no drug can cure the disease. Two or more drugs may be needed. For older people, doses are often reduced. Drugs that cause or worsen symptoms, particularly antipsychotic drugs, are avoided. The drugs used to treat Parkinson disease can have troublesome side effects. If people notice any unusual effects (such as difficulty controlling urges or confusion), they should report them to their doctor. They should not stop taking a drug unless their doctor tells them to. Deep brain stimulation, a surgical procedure, is considered if people have advanced disease but no dementia nor psychiatric symptoms and drugs are ineffective or have severe side effects. Various simple measures can help people with Parkinson disease maintain mobility and independence: Continuing to do as many daily activities as possible Following a program of regular exercise Simplifying daily tasks—for example, having buttons on clothing replaced with Velcro fasteners or buying shoes with Velcro fasteners Using assistive devices, such as zipper pulls and button hooks Physical Therapy (PT) and Simple changes around the home can make it safer for people with Parkinson disease: Removing throw rugs to prevent tripping Installing grab bars in bathrooms and railings in hallways and other locations to reduce the risk of falling For constipation, the following can help: Consuming a high-fiber diet, including such foods as prunes and fruit juices Exercising Drinking plenty of fluids Using stool softeners (such assennaconcentrate), supplements (such aspsyllium), or stimulant laxatives (such asbisacodyltaken by mouth) to keep bowel movements regular Difficulty swallowing may limit food intake, so the diet must be nutritious. Making an effort to sniff more deeply may improve the ability to smell, enhancing the appetite. Traditionally,levodopa, which is given withcarbidopa, is the first drug used to treat Parkinson disease. These drugs, taken by mouth, are the mainstay of treatment for Parkinson disease. But when taken for a long time,levodopamay have side effects and become less effective. So some experts have suggested that using other drugs first and delaying use oflevodopamight help. However, evidence now indicates that the side effects and reduced effectiveness after long-term use probably occur because Parkinson disease is worsening and are not related to when the drug was begun. Still, becauselevodopamay become less effective after several years of use, doctors may prescribe another drug for people under 60, who will be taking drugs to treat the disease for a long time. Other drugs that may be used includeamantadineanddopamineagonists (drugs that act likedopamine,stimulating the same receptors on brain cells). Such drugs are used because production ofdopamineis decreased in Parkinson disease. Levodopareduces muscle stiffness, improves movement, and often substantially reduces tremor. Takinglevodopaproduces dramatic improvement in people with Parkinson disease. The drug enables many people with mild disease to return to a nearly normal level of activity and enables some people who are confined to bed to walk again. rarely helps people who have other disorders that can cause symptoms similar to those of Parkinson disease ( Parkinsonism ), such as Levodopais adopamineprecursor. That is, it is converted intodopaminein the body. Conversion occurs in the basal ganglia, wherelevodopahelps compensate for the decrease indopaminedue to the disease. However, beforelevodopareaches the brain, some of it is converted todopaminein the intestine and in the blood. Havingdopaminein the intestine and blood increases the risk of side effects such as vomiting, orthostatic hypotension, and flushing.Carbidopais given withlevodopato preventlevodopafrom being converted todopaminebefore it reaches the basal ganglia. As a result, there are fewer side effects, and moredopamineis available to the brain. Domperidone can be used to treat the side effects oflevodopa(and other antiparkinsonian drugs), such as nausea, vomiting, and orthostatic hypotension.Domperidone, likecarbidopa, reduces the amount oflevodopathat is converted intodopaminein the intestine and cardiovascular system (heart and blood vessels), wherelevodopaincreases the risk of side effects. To determine the best dose oflevodopafor a particular person, doctors must balance control of the disease with the development of side effects, which may limit the amount oflevodopathe person can tolerate. These side effects include Nausea Vomiting Light-headedness Involuntary movements (of the mouth, face, and limbs) called dyskinesias Nightmares Hallucinations and paranoia (psychotic symptoms) Changes in blood pressure Confusion Obsessive or compulsive behavior or difficulty controlling urges, for example, resulting in compulsive gambling or uncontrollable spending is needed to maintain movement even though it is causing hallucinations, paranoia, or confusion. In such cases, certain Treatment of mental symptoms (such as After takinglevodopafor 5 or more years, more than half the people begin to alternate rapidly between a good response to the drug and no response—called on-off effects. Within seconds, people may change from being fairly mobile to being severely impaired and immobile. The periods of mobility after each dose become shorter, and symptoms may occur before the next scheduled dose—the off effects. Also, symptoms may be accompanied by involuntary movements due tolevodopause, including writhing or hyperactivity. One of the following can be used to control the off effects for a while: Taking lower, more frequent doses Switching to a form oflevodopathat is released more gradually into the blood (a controlled-release formulation) Adding adopamineagonist oramantadine However, after 15 to 20 years, the off effects become hard to suppress. Surgery is then considered. A formulation oflevodopa/carbidopa(available in Europe) can be given using a pump connected to a feeding tube inserted in the small intestine. The pump deliverslevodopacontinuously, thus keeping the level of drug about the same and making side effects less likely. This formulation is being studied as treatment for people who have severe symptoms that cannot be relieved by drugs and who cannot be treated with brain surgery. This formulation appears to greatly reduce the off times and increase quality of life. Other drugs are generally less effective thanlevodopa, but they may benefit some people with Parkinson disease, particularly iflevodopais not tolerated or is insufficient. Dopamineagonists,which act likedopamine, may be useful at any stage of the disease. They include Pramipexoleandropinirole(given by mouth) Rotigotine(given through a skin patch) Apomorphine(injected under the skin) Side effects may limit the use ofdopamineagonists taken by mouth. In 1 to 2% of people who take them, these drugs may cause compulsive behavior, including compulsive gambling, excessive shopping, and overeating. In such cases, the dose is reduced, or the drug is stopped and another drug substituted. Pramipexoleandropiniroleare given by mouth. They can be used first instead of or withlevodopain people who are under 60 and have early Parkinson disease. However, when used alone. they are rarely effective for more than a few years. Or the drugs can be used withlevodopain people with advanced Parkinson disease. These drugs are usually taken 3 times a day. Daytime sleepiness is a common side effect. Arotigotineskin patch is applied once a day. The patch is worn continuously for 24 hours, then removed and replaced. The patch should be placed in different locations each day to reduce risk of skin irritation.Rotigotineis used alone, early in the disease. Becauseapomorphineis quick-acting, it is used to reverse the off effects oflevodopa—when movement is difficult to initiate. Thus, this drug is called rescue therapy. It is usually used when people freeze in place, preventing them, for example, from walking. Affected people or another person (such as a family member) can inject the drug up to 5 times a day as needed. In some countries,apomorphineis available in a formulation that can be given using a pump to people who have severe symptoms when surgery is not an option. The pump is a small device that can be clipped to a belt or put in a pocket. A small tube from the pump is inserted under the skin.Apomorphineis pumped from the device through the tube under the skin. This system providesapomorphineautomatically on a regular schedule. belong to a class of drugs called Monoamine oxidase inhibitors (MAOIs) (MAO inhibitors). They slow the breakdown of CatecholO-methyltransferase (COMT) inhibitors(entacapone,opicapone, andtolcapone) slow the breakdown oflevodopaanddopamine, prolonging their effects, and therefore appear to be a useful supplement tolevodopa. These drugs are used only withlevodopa.Tolcaponeis seldom used now because rarely, it damages the liver. However,tolcaponeis stronger thanentacaponeand may be useful if off effects are severe or long-lasting. Some Anticholinergic: What Does It Mean? drugs are effective in reducing the severity of a tremor and can be used in the early stages of Parkinson disease or later to supplement . However, because these drugs are only mildly effective and because many anticholinergic effects are troublesome, these drugs are seldom used to treat Parkinson disease. Nonetheless, Heterocyclic (including tricyclic) antidepressants with anticholinergic effects may be useful in younger people who have depression and Parkinson disease. Amantadine,a drug sometimes used to treat influenza, may be used alone to treat mild Parkinson disease or as a supplement tolevodopa.Amantadineprobably has many effects that make it work. For example, it stimulates nerve cells to releasedopamine. It is used most often to help control the involuntary movements (dyskinesias) that are side effects oflevodopa. If used alone,amantadineoften loses its effectiveness after several months. People with involuntary movements or on-off effects due to long-term use oflevodopamay benefit from deep brain stimulation. Tiny electrodes are surgically implanted in part of the basal ganglia. The electrodes send small amounts of electricity to the specific area of the basal ganglia responsible for the tremors. Magnetic resonance imaging (MRI) or computed tomography (CT) is used to locate the specific area to be stimulated. By stimulating this part, deep brain stimulation often greatly reduces involuntary movements and tremors and shortens the off part of the on-off effects. Deep brain stimulation is available only at special centers. Focused ultrasound surgery uses MRI to identify areas of the brain affected by Parkinson disease. Then concentrated ultrasound waves are applied the targeted area to destroy it. This procedure does not involve invasive surgery. In some countries, doctors surgically remove a small part of the brain that is severely affected or use a tiny electrical probe to destroy that part of the brain. These procedures may lessen symptoms. If these procedures are unsuccessful, deep brain stimulation of a different part of the brain may be done. Transplantation of stem cells into the brain, once thought to be a possible treatment for Parkinson disease, has been shown to be ineffective and to have troublesome side effects. Psychotic and other mental symptoms, whether caused by Parkinson disease itself, a drug, or something else, are treated. —are sometimes used to treat psychotic symptoms in older people with Parkinson disease and dementia. These drugs, unlike other antipsychotics, do not worsen the symptoms of Parkinson disease. They are well-tolerated by younger people and help control the psychotic symptoms that occur in people with Dementia With Lewy Bodies and Parkinson Disease Dementia or that may be caused by some of the drugs used to treat Parkinson disease. ) are sometimes used. They may also help lessen the tremor. However, many other antidepressants are very effective and have fewer side effects. They include Selective serotonin reuptake inhibitors (SSRIs) (SSRIs), such as Treatment of mental symptoms can help lessen problems with movement, improve quality of life, and sometimes delay the need to be put in an institution. Because Parkinson disease is progressive, people eventually need help with normal daily activities, such as eating, bathing, dressing, and toileting. Caregivers can benefit from learning about the physical and psychologic effects of Parkinson disease and about ways to enable people to function as well as possible. Because such care is tiring and stressful, caregivers may benefit from support groups. Eventually, most people with Parkinson disease become severely disabled and immobile. They may be unable to eat, even with assistance. Dementia develops in about one third of them. Because swallowing becomes increasingly difficult, death due to Aspiration Pneumonia and Chemical Pneumonitis (a lung infection due to inhaling fluids from the mouth or stomach) is a risk. For some people, a nursing home may be the best place for care. Before people with this disease are incapacitated, they should establish Advance Directives , indicating what kind of medical care they want at the end of life. 