Wednesday, 11 April 2018

Here's How Parkinson's Disease Is Treated

he rate of Parkinson's disease increases with age. (iStockPhoto)
Parkinson's disease is a neurodegenerative disorder that progresses over time and affects the dopamine-producing neurons of a specific part of the brain and causes less dopamine to be present in the brain. Dopamine is important because it helps people move, sleep and learn, as well as sustain memory, behavior, cognition, mood, attention and more.
Parkinson's disease is the second most common neurodegenerative disease in the United States. Approximately 1 million people are living with Parkinson's disease nationwide, and an additional 60,000 Americans are diagnosed every year.
There are four main clinical symptoms that raise concern for Parkinson's disease: resting tremors, slowness of movements, stiffness in the arm and leg and shuffling steps during walking, which results in balance difficulties. If you have three of these four symptoms, a diagnosis of Parkinson's is made.
The rate of Parkinson's disease increases with age, but about 4 percent of people with this disease were diagnosed before age 50. The risk of Parkinson's disease is 1.5 times more likely in men than women.
While there is currently no cure for Parkinson's, a variety of treatment options can help manage symptoms. With the help of a movement disorders doctor, patients can find the most effective treatment plan and experience a good quality of life while living with this disease.
Aside from medications, regularly exercising for at least two and a half hours per week has been shown to slow the decline in mobility and improve a patient's quality of life over two years. The most effective exercise is any intense exercise that raises your heart rate and makes you breathe heavily.
When treating my patients at Montefiore, I counsel them on the variety of treatment options noted below. If you're living with Parkinson's disease, I encourage you to speak with your doctor about these treatment options to see what may work best for you.
Which Medications Are Available?
Below is a list of medication options for the treatment of Parkinson's. Most patients will be prescribed more than one of the medications listed below to address different symptoms and the progression of this condition.
  • The main treatment for Parkinson's disease is Carbidopa/Levodopa. This medication turns into actual dopamine in the brain and makes up for the dopamine being lost by this disease. This medication is very effective at improving motor symptoms. Some brand-name medications include: Sinemet, Sinemet ER and Rytary.
  • Dopamine agonists act like dopamine in the brain and connect to the parts of the brain that natural dopamine would connect to. By doing so, these dopamine agonists create similar effects to natural dopamine and improve movement. Although this medication acts like dopamine, it's not as effective as actual dopamine. Examples of medications within this class include: Pramipexole, Ropinirole, Rotigotine and Apomorphine.
  • MAO-B inhibitors prevent dopamine already in the brain from being broken down. Thus, keeping the dopamine in the brain longer to prolong its benefits. This class of medications is typically given in conjunction with other dopamine agents or given initially, when the Parkinsonian symptoms are mild. Examples of medications in this class include Selegeline, Rasagiline and Safinamide.
  • Anticholinergics help improve tremor only (ex: Benztropine, trihexyphenidyl).
  • Anti-Parkinsonian agents, specifically Amantadine, reduce dyskinetic movements, which are uncontrollable, involuntary movements. These movements are a complication of increased dopamine requirements, or long-term dopamine therapy (ex: Symmetrel, Gocovri).
  • COMT inhibitors prevent the breakdown of levodopa, which is what gets converted into dopamine in the brain naturally. These inhibitors allow more levodopa to reach the brain to get converted into dopamine. COMT inhibitors have to be given in conjunction with carbidopa/levodopa to improve Parkinsonian symptoms (ex: Entacapone, Tolcapone).
What Are the Alternative Therapies?
Aside from medications, there are two surgical options for patients who qualify.
  • Dopamine pump, also known as Duopa. Duopa connects an external pump into the patient's body and allows levodopa to be dispensed directly to the small intestine. The infusion is continuously pumping levodopa throughout the day, over 16 hours, and is turned off while sleeping. This may eliminate the need to take levodopa medications by mouth.
  • Deep brain stimulation surgery. During DBS, an electrode is implanted into the portion of the brain responsible for causing the symptoms of Parkinson's disease. The electrode provides high frequency electrical stimulation to targeted areas and is adjusted to improve symptoms while minimizing side effects. The stimulation is powered by a battery placed within the chest wall, or muscles, similar to a pacemaker. DBS has been Food and Drug Administration-approved to treat: Parkinson's disease, essential tremor, dystonia and obsessive-compulsive disorder.
More About DBS
DBS is most helpful in patients who have had improvement in their symptoms from carbidopa/levodopa. This means that the tremor, slowness or stiffness that was present when they were first diagnosed improves with carbidopa/levodopa. In addition, DBS can improve symptoms for patients: taking carbidopa/levodopa and experiencing irregular improvements of their symptoms, who have debilitating dyskinesias and who have a tremor that does not improve with conventional medications.
If you're interested in getting DBS, make an appointment with a movement disorders specialist. Once it's determined that you're a possible candidate for this therapy, you will undergo a series of evaluations.
A patient typically will undergo an "on" and "off" evaluation to determine the degree of improvement with carbidopa/levodopa. If there is an improvement, the patient qualifies for DBS. Next, a patient will have to undergo neuropsychological evaluations, psychiatric evaluations and MRI testing to map the coordinates of the lead placement. Finally, a neurosurgeon will implant the therapy.
To learn more about DBS and see if you qualify, please talk with your doctor and/or make an appointment with a movement disorders specialist.
Over time, Parkinson's disease symptoms will change, and medications will need to be adjusted. For this reason, I express to my patients the importance of staying in regular communication with your doctor. Your medical team is here to help you achieve the best quality of life possible.

Best Hospitals for Neurology & Neurosurgery

RankHospital NameLocation
Mayo ClinicRochester, MN
Johns Hopkins HospitalBaltimore, MD
Massachusetts General HospitalBoston, MA
New York-Presbyterian Hospital-Columbia and CornellNew York, NY
UCSF Medical CenterSan Francisco, CA
Cleveland ClinicCleveland, OH
Barnes-Jewish HospitalSaint Louis, MO
University of Michigan Hospitals and Health CentersAnn Arbor, MI
Northwestern Memorial HospitalChicago, IL
NYU Langone Medical CenterNew York, NY
Hospitals Ranking information as of April 5th, 2018

Dr. Raminder Parihar is a Movement Disorders Neurologist in the Montefiore Health System. She is an Assistant Professor of the Saul R. Korey, Department of Neu... full bio »

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