Everyone who is diagnosed with Parkinson’s should be aware that it is a progressive disease. We cannot restore that area of the brain. That would be called along the lines of stem cell therapy, which is ongoing. We would like to slow that progression. We also do not have any effective therapies for that – that’s called neuro-protection – although there are various drugs that have been trialled over the years.
So what we really have to offer is good effective dopamine replacement therapies, as doctors. I always emphasise that there are non-drug approaches to treatment, and one of those is keep healthy, exercise, all that basic stuff.
Non-pharmacological treatments for Parkinson’s disease
So when talking about treatment of Parkinson’s disease it’s important not to forget the non-drug approaches. This includes various forms of exercise or physical therapies. I generally refer patients to programs that are more evidence based, which there are numerous. But essentially it’s not as simple as going out and having a daily walk. There are focused physiotherapist or exercise physiologist-based programs that have been proven to improve patient symptoms, delay the need to start treatment, enhance the effects of medication and other treatments that they are on. So that’s one avenue for treatment.
Who is involved in treating Parkinson’s disease?
Most Parkinson’s services will have an allied health approach. So there’s the physiotherapy for mobility. There’s the speech therapist who will assist people with softness of speech and swallowing problems that may occur. There is occupational therapy for difficulty with day to day activities. There is a clinical psychologist and a neuro-psychiatrist to deal with the mood disorders and other psychiatric aspects.
So when we’re talking to a patient who is newly diagnosed or in the early stages, we emphasise that we are not going to focus on medication at this point, we’re going to focus on all these non-drug approaches. Often that’s all they need. Personally I will see someone a few times after diagnosis to reinforce that I will put them in touch with various support services, including the Parkinson’s nursing service which is critical.
I will say to them, “You won’t need me, you don’t need me for a few years. I will catch up with you every year or as needed.” We call that the honeymoon period, so even patients who have started on medication may only need to see me once a year, and that’s what we call early Parkinson’s disease.
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Medications for Parkinson’s disease
To talk about treatment, it depends on the level of disability. We would never start medication in someone who is not sufficiently disabled to warrant treatment. Treatments are targeting replacement of dopamine within the brain in various ways. There can be pills, there’s a patch, there’s injectable and pump therapies, but most patients will start on a once daily simple medication regimen and gradually build it up to minimise the chance of side effects. They will stay on that medication long term. It is a progressive disease, so they’ll be reviewed regularly or as the need arises and the medication will be adjusted upwards.
We tend to start with a long acting drug like the synthetic dopamine agonists and then introduce levodopa which has been around since the 60s. It’s taken up into the blood stream and into the brain. It’s taken up by the remaining dopaminergic cells, so it’s the same as the dopamine our body is making. The problem with that is that you need to take it three times a day. It’s a little more intensive and difficult to comply with. So there’s different treatment approaches for early Parkinson’s disease.
Motor fluctuations with medications
When the disease progresses, the phenomenon of motor fluctuations emerges. This is inevitable in everyone. People are often fearful of starting medication because of these motor fluctuations and we try to tell them that, “Look, it’s going to happen, whether or not you’re on treatment.” It’s a combination of having Parkinson’s and being on treatment. People are often fearful and will delay starting really effective medication. And what happens is that they miss out on that early honeymoon period, when the medication would have worked really well. It’s important to emphasise that.
Motor fluctuations come in various types but the two simplest ones are, you take your medication, it works for a period of time and then it wears off. That wearing off can be a gradual thing, that people notice and know to go and get their next dose of medication. It can be severe in some people where the medication cuts out. They’ll go from functioning, good mobility, less tremor, to suddenly being unable to walk and function. So that’s called wearing off. And we manage that by moving the medication closer together, taking them more often. That will alleviate that issue for a period of time.
The other problem, the other type of motor fluctuation, is when the dopamine levels are peaking, you’ll get your movement back, but because you have Parkinson’s disease and you don’t have a fully functioning dopamine system, there is an overshoot. You get involuntary movements and these are called dyskinesias. They look completely different from the symptoms of Parkinson’s disease. They are writhing movements. They can be subtle, non-intrusive and not important, ranging right up to severe movements where people are thrashing around, where they’re distressed with them, where they put people off balance. And you can fall out of a chair because you are thrashing around with these dyskinetic movements.
So there are two types of motor fluctuations. Taking more medication can make the dyskinesias worse.
Changing treatment as Parkinson’s progresses
At some point, in many patients you will have to look at alternatives. This is not in everyone. There are a lot of patients that will continue to do well on various combinations of short and long acting medications and other supplementary medications and non-drug treatments.
The general rule of thumb is don’t escalate therapy if people’s quality of life is reasonable. You can track people over time with various quality of life measures. It generally goes down a few points year by year with Parkinson’s. If people are losing their independence, threatening their occupation, clearly miserable, and we’ve excluded other causes such as pain and mood disorders, then we would consider moving on to one of the advanced therapies.
Video kindly featuring:
Dr Julian Rodrigues MBBS FRACP; Consultant Neurologist at Hollywood Medical Centre, and Editorial Advisory Board Member of the Virtual Neuro Centre.