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Options for Parkinson’s Patients Abundant, Says
Specialist
There are a lot of reasons to be optimistic, he says
Sept. 14, 2005 - Some people call it "the dark
time," the period between when a person is diagnosed with Parkinson's
disease, which is most common in senior citizens, and when treatment
with medication begins.
Julie Carter, R.N., knows it all too well. The
associate professor of neurology in the Oregon Health & Science
University School of Medicine hosts workshops to help newly diagnosed
Parkinson's patients and their families cope with the prospect of
fighting a chronic, degenerative, incurable neurological disease the
rest of their lives.
"Some people say it's like looking through a
picture window and someone comes along and shatters it," said Carter,
associate director of the OHSU Parkinson Center of Oregon, which runs
the workshops. "Patients are told they're not ready for medication and
to come back in six months. But in these early stages, what you're
really dealing with is a diagnosis. You're dealing with a fear of what
the future will hold."
And there is a lot that can be done to treat
Parkinson's patients, in the early months and beyond. So says an article
by John "Jay" G. Nutt, M.D., professor of neurology, and physiology and
pharmacology, OHSU School of Medicine, and director of the Parkinson
center.
The article appearing in the Thursday, Sept. 8,
edition of the New England Journal of Medicine outlines reliable,
evidence-based strategies for general practitioners to effectively and
confidently diagnose Parkinson's, and suggest ways patients and their
caregivers can initially manage the disease.
"These are things the general practitioner might
not be as aware of," said Nutt, who co-authored the paper with G.
Frederick Wooten Jr., M.D., of the University of Virginia Medical Center
in Charlottesville. "This is really looking at what is the clinical
evidence right now. It gives clinicians an unbiased view of what they
might do. It captures the essence of diagnosis and management, and
points out where issues exist."
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About Parkinson Disease |
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Journal of the American Medical Association
Parkinson
disease involves the nervous system, specifically, movement and
control of muscles. Parkinson disease affects more than 1
million individuals in the United States. Because it is more
common in older persons, the incidence (number of new cases) of
Parkinson disease is increasing as the population grows older.
Parkinson
disease was first described in 1817 and was originally called
"shaking palsy." Medical researchers later discovered that
parkinsonian symptoms were due to degeneration of nerve cells in
an area of the brain called the substantia nigra. These cells
supply dopamine, a chemical that modulates movement, to other
areas of the brain called the basal ganglia.
Parkinson
disease is progressive and leads to severe limitations in
activity and quality of life if the disorder is not treated.
Neurologists (doctors who specialize in treating diseases of the
nervous system) and neurosurgeons (doctors who specialize in
surgery of the nervous system) individualize each person's
treatment to manage the symptoms and slow the progress of
Parkinson disease. The January 21, 2004, issue of JAMA includes
an article about treatment of Parkinson disease.
SYMPTOMS
>
Rigidity—stiffness of
arms, legs, face, and posture
> Tremor—shaking of the head, face, arms, legs, and
hands; not everyone who has Parkinson disease has a tremor
> Slowness of movement—also called bradykinesia
> Instability—unstable gait, poor balance
MEDICAL
TREATMENT
>
Levodopa (a synthetic
medication) replaces dopamine for patients with Parkinson
disease, improving symptoms of tremor and rigidity.
> Carbidopa helps reduce adverse effects of levodopa
and increases the amount of dopamine in the brain (and not in
the rest of the body).
> Several other medications are available to decrease
symptoms or slow the progression of Parkinson disease.
> Antidepressants may be prescribed if depression
occurs.
SURGICAL
THERAPY
>
Pallidotomy—a probe
delivering electrical current is used to create a permanent
lesion (scar) in a specific area of the brain (the globus
pallidus) to lessen rigidity, tremor, and abnormal movements (dyskinesias).
> Thalamotomy—electrical current creates a small,
permanent lesion in the area of the brain called the thalamus.
This helps reduce tremor and rigidity.
> Deep brain stimulation—an electrode is placed into a
specific deep brain structure. Electrical current is delivered
continuously to control tremor, rigidity, or bradykinesia. This
requires a small generator (like a heart pacemaker) to be placed
under the collarbone.
An operation
may help persons with Parkinson disease, especially if medical
therapy has failed to slow the disease process or if intolerable
adverse effects occur from medications. Because these operations
involve the brain, there are significant risks involved. The
risks and benefits of surgical therapy should be discussed with
a neurologist and neurosurgeon. This type of surgery does not
replace medical therapy, but it may lessen the amount and types
of medications a patient takes.
FOR MORE
INFORMATION
>
National Institute of
Neurological Disorders and Stroke
http://www.ninds.nih.gov
> American Parkinson Disease Association
888/400-2732
http://www.apdaparkinson.org
> Parkinson's Disease Foundation
800/457-6676
http://www.pdf.org
> National Parkinson Foundation
http://www.parkinson.org
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Among these issues is a debate over dopamine
agonists. These drugs mimic the effects of dopamine by stimulating
dopamine receptors directly and are associated with a two- to three-fold
risk of developing dyskinesia and other motor function fluctuations are
generally in the first four to five years of therapy. However, they
frequently need to be used in combination with levodopa, the drug
converted to dopamine in the brain and considered the most common and
effective treatment for fighting Parkinson's symptoms.
"One of the biggest controversies now is whether a
doctor should start by putting patients on a dopamine agonist or start
them on levodopa," Nutt explained. "Starting them on a dopamine agonist
means they're less likely to develop dyskinesia," or the "on-off"
fluctuations in motor function experienced by many Parkinson's
sufferers.
But levodopa is generally more effective. "You get
more anti-Parkinson's effects from levodopa," Nutt added. Further, there
are fewer side effects, such as sleepiness, hallucinations or ankle
swelling, with levdodopa.
There are other drugs for treating motor symptoms,
such as anticholinergics, which are antispasmodic agents used to treat
trembling; amantadine, which are used to improve muscle control and
reduce stiffness; and selective MAO-B inhibitors, which increase the
potency of dopamine in the brain and serve as antioxidants to clean out
neurotoxins resulting from other treatments. But while they have fewer
side effects, they provide only modest relief from many symptoms.
Support and education are critical when informing
patients of a diagnosis of Parkinson's disease, the NEJM article points
out. Patients should understand that Parkinson's disease often has a
course over decades, the rate of progression varies greatly among
patients and there are many treatments available for reducing symptoms.
Patients also should be counseled about exercise, including stretching,
strengthening, cardiovascular fitness and balance.
"Exercise is thought, although not proven, to be
really important," Nutt said. "A person can do a lot for themselves to
keep many early-stage Parkinson's symptoms at bay."
And support groups, such as those organized by
Parkinson Resources of Oregon for newly diagnosed patients, offer
ongoing support.
"That dark period can be minimized or alleviated
with the right kind of care," Carter said. "The beauty of Parkinson's
disease is there are a lot of exciting pharmacological therapies, but
people really require the non-pharmacological therapies to live,
especially in the early period before drugs are needed. Exercise,
nutrition and emotional health are all things that are needed in
addition to pharmacological care."
Instilling hope in newly diagnosed patients is part
of the treatment process, Carter added. "They're looking for information
that can generate hope, and that it doesn't mean an end to a meaningful
life. There are a lot of reasons to be optimistic about the future."
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