5. Treatment for Parkinson’s disease

A multidisciplinary team that includes a neurologist and therapists who specialise in movement disorders is recommended for the management of the complex PD symptoms.

The appropriate multidisciplinary team members should be seen from the time the diagnosis of PD is received.

The advancement in the treatment options for PD over the last few decades has meant the progression of disabilities can be slowed and a good quality of life maintained. The following is an overview of current treatments that have good evidence to support their effectiveness.

Medical treatment

A neurologist specialised in movement disorders can advise on medical treatments to treat the presenting symptoms.

Medication

PD medications are used to control symptoms and do not reverse the disorder. The type of medication, the dosage and timing is determined by the doctor after consultation with the person with PD and their caregiver or family and is tailored to the individual. It is important that the person with PD adhere to the schedule recommended by their doctor in order to gain the greatest benefit from the medications.

Side effects can occur with all PD medications and the treating doctor should discuss them with the person with PD and their carer before any new medication is introduced.

The doctor, in particular a PD specialist neurologist, is the best person to determine if the PD medications are causing any adverse responses and make the necessary adjustments to reverse or minimise side effects.

Other medications, such as herbal supplements and other remedies, may interact with PD medications.  The person’s doctor and pharmacist are the best people to talk to regarding potential drug interactions.

Levodopa preparations

Levodopa is usually the first-line drug prescribed for PD. Levodopa preparations replace the dopamine that is no longer produced naturally by the brain. Levodopa is converted into dopamine in the brain and is taken to improve motor symptoms, such as stiffness and slowness of movement and tremor.

The common brands available include Sinemet, Madopar and Kinson which come in various preparations and strengths. They are available in immediate release, long acting (Sinemet CR, Madopar HBS) and rapid acting (when dissolved in water (Madopar rapid)). Levodopa preparations are available in combination with other drugs (Stalevo) and in gel form, Duodopa.

Examples of possible side effects: involuntary movements (dyskinesia), changes in mood or behaviour, confusion, nausea, light headedness, lowered blood pressure.

Dopamine agonist preparations

Dopamine agonists work by stimulating the dopamine receptors of the brain. They are considered not to be as powerful as levodopa drugs however they can be very effective at controlling involuntary movements (dyskinesia) associated with taking levodopa and motor fluctuations(‘off’ times when symptoms re-emerge). They can be taken either alone or in combination with levodopa drugs across the stages of PD.

Dopamine agonists available in Australia include Pramipexole (Sifrol), Cabergoline (Cabaser), Rotigotine (NeuproPatan), Apomormorphine (Movapo).

Examples of possible side effects: impulse control disorders (e.g. gambling), hallucinations and confusion, daytime sleepiness, swelling in legs.

COMT Inhibitors

COMT inhibitors work by blocking an enzyme present in the body which converts the levodopa into a form that cannot be used by the body.  By blocking this process the amount of dopamine available in the brain increases. They are often commenced when ‘wearing off’ or motor fluctuations develop. COMT inhibitors available are Entacapone (Comtan) and Tolcapone (Tasmar).

Examples of possible side effects: diarrhoea, increase side effects of levodopa medications e.g. dyskinesia, confusion and hallucinations.

MAO-B Inhibitors

MAO-B inhibitors block an enzyme present in the brain that breaks down dopamine so that more dopamine is available for treating motor symptoms. The inhibitors also have some effect in controlling the motor symptoms and as such may be the first drug of use in the early stages. MAO-B inhibitors may be used initially on their own or in combination with other PD medications.

Selegiline (Elderpryl) and Rasagiline (Azilect) are the common MAO-B inhibitors used.

Examples of possible side effects: dry mouth, light headedness, constipation, confusion and hallucinations in the elderly.

Amantadine

This drug is used along with levodopa to treat dyskinesias.

Anticholinergic drugs

These drugs are used to treat tremor and dystonia or muscle cramps due to PD. The common ones available include Artane and Cogentin, however as they both may cause confusion and hallucinations, they are usually avoided in older adults.

Examples of possible side effects: Confusion and hallucinations, decreased short term memory, dry mouth, blurred vision, urinary retention.

Advanced medical treatment options

There are several medical approaches used to improve the symptoms of PD in the mid to advanced stages, including:

  • Deep brain stimulation, the most commonly used surgical approach
  • Intestinal infusion pump for continuous delivery of Duodopa
  • Infusion of apomorphine

The use of other forms of brain surgery including thalamotomy, pallidotomy and subthalamotomy are less common and have largely been replaced by DBS surgery.

Deep brain stimulation (DBS) surgery

DBS surgery has been available for over 20 years and is used to treat troublesome tremor, to prevent ‘off’ times and to moderate excessive dyskinesia. Recently there is a shift to perform DBS in the early stages of PD in an effort to delay the onset of disabilities and to maintain good quality of life for longer.

DBS surgery involves inserting electrodes into targeted areas of the basal ganglia, usually the sub thalamic nucleus. The electrodes are connected to an impulse generator battery that is inserted under the collar bone. The generator provides impulses to the brain via the electrodes. Usually the PD medications can be reduced dramatically after surgery.

Intestinal infusion pump for delivery of Duodopa

Duodopa is a gel form of levodopa and is used to treat severe motor fluctuations with prolonged and disabling ‘off’ times and troublesome dyskinesia.

A PEG-J tube is inserted into the intestine via a stoma or hole in the stomach wall. A cassette containing the gel is inserted into a pump worn by the person that is programmed to deliver the gel at the required rate.

Apomorphine

Apomorphine is usually used for more advanced Parkinson’s, when a person’s symptoms no longer respond well to oral drug treatments.

Apomorphine is given by injection or continuous infusion, using a pump.

  • An APO-go PEN is pre-filled and disposable to be used as needed.
  • A portable, battery driven pump is used to delivery apomorphine from a pre-filled syringe (APO-go PFS) over a period of several hours.
  • For infusion over longer periods apomorphine, stored in glass vials called ampoules, is delivered using a portable battery-driven pump (a syringe driver).

For all three methods, the apomorphine is given through a fine needle inserted into the fatty layer under the skin (a subcutaneous injection).

Education regarding Parkinson’s disease and managing medications

A nurse with specialist training in PD can provide education and support to the person with PD and their caregiver. This may include:

  • monitoring the effects of changes to PD medications as recommended by the neurologist and liaising with the neurologist
  • providing education and support around the recommended PD medications and assist with the minimisation of side effects
  • providing individualised education for the person with PD and their caregivers to ensure optimal understanding and management of the various PD symptoms as the condition progresses
  • arranging referrals to other relevant health professionals within the specialist team

Treatments for walking difficulties, balance, falls and posture problems

Physical Exercise

Research shows that regular exercise can improve walking, balance, mood and cognition for people with PD. In addition, regular exercise can improve many of the secondary deficits of PD, such as loss of fitness and strength.

A physiotherapist specialised in Parkinson’s disease can tailor an exercise program that meets the needs of the person.

Participating in moderate level of exercise or physical activity on a regular basis has been shown to decrease the risk of developing PD, and in those who have PD, to slow down the development of disability and to maintain a good quality of life for longer.

Regular physical activity is essential for all people with PD, regardless of the stage they are at.

Exercises that have been shown to be effective in PD include movement strategy training, progressive strength training, balance training, treadmill training and flexibility exercises.

To date no one form of physical exercise has been shown to be better than another.

Movement strategy training uses attention to normalise movement.  Movement size is reduced in PD but attentional strategies return movement to its normal size by by-passing the basal ganglia. Walking speed can be normalised in PD if the person concentrates on taking long steps. Everyday activities, such as getting into bed, getting out of a chair, can be improved using strategy training.

A physiotherapist specialised in PD can assess the person’s movement problem and advise on the best strategies to use.

Attending a local gym may be adequate in the early stages of PD the focus on strength, fitness, balance and flexibility. A physiotherapist or exercise physiologist with knowledge about PD can provide advice on the type of exercises that are likely to be beneficial.

Research shows non-traditional forms of activity for people with PD, such as dance and Tai Chi can also be beneficial. Dance is a social activity and as well as improving movement, it also improves mood. Tai Chi has been found to decrease falls rate and improve balance.

In the mid stage of PD, a physiotherapist is best suited to manage the more complex motor symptoms and secondary effects of PD. The physiotherapist will assess the person with PD, determine the main problems and plan an exercise program that will benefit them most. Depending on factors such as safety and ability to exercise alone the exercise program may be based at home, in the clinic or a mixture of the two.

Equipment and home modifications

In the later stages of PD, walking frames, home modifications (such as installing ramps to replace steps and grab rails in the bathroom) are often needed due to balance and walking difficulties. A physiotherapist is the best person to advise on the type of walking frame and an occupational therapist can advise on home modifications.

An Occupational therapist can also provide tips on how to make dressing easier, how to be safe when showering, make eating easier using adaptive cutlery and correct seating, what you need to know about PD and driving, tips on how to continue traveling and strategies to remind you to take your medications on time.

If the person is confined to bed or a wheelchair in the advanced stage, an occupational therapist and physiotherapist can advise on equipment which helps position them to avoid skin lesions (pressure injuries), provide comfort and supports the body.  This will also help the person to eat and communicate more effectively.

There are various funding bodies that can fully or partially cover the cost of some home modifications and adaptive equipment such the State Wide Equipment Program (SWEP). An occupational therapist can advise you on how to apply for funds to assist with the costs if required.

Treatments for speech and swallowing difficulties

Speech and swallowing problems for people with PD also respond to exercise or strategies.  A speech pathologist specialised in movement disorders such as PD can assess the person’s speech and teach strategies to improve it.

Speech can be improved through particular exercises and programs such as the Lee Silverman Voice Therapy, Parkinson Voice Project SPEAK OUT!

Often identifying strategies to improve the communication environment or method can lead to more successful speech. Strategies and communication partner training can become invaluable to family and friends if a person with Parkinson’s is experiencing cognitive changes which impact on communication such as word finding difficulties.   Communication Devices such as amplifiers can help to increase volume and other devices or apps can be used when an alternative to speech is needed.  Speech Pathologists can help guide you through what is available and potential avenues to help fund these aids.

Swallowing difficulties (dysphagia) are more common in the later stages of PD and need to be investigated by a speech pathologist. Assessment may involve observing a meal or snack and completing an x-ray study call a videofluoroscopy.  Once the reason for the dysphagia is identified the speech pathologist will advise on how to manage the difficulty. This may involve strengthening exercises for muscles involved in swallowing, modification to the diet and adaptive behavioural strategies such as improving head and neck posture.

A speech pathologist may work with an occupational therapist and physiotherapist to decide on equipment or adaptive seating that helps the person achieve the best possible posture to facilitate swallowing.

When swallowing is difficult your speech pathologist and dietitian will work together to ensure you get sufficient nutritional intake. Your drinks may need to be thickened to make them easier to swallow and lessen the risk of aspirating. Your foods may need to be modified to a soft-moist, mashed or puree texture to make swallowing easier and safer. In some situations you may require a tube to be inserted directly into your stomach so you can receive most or all of your nutritional intake via the tube.

A speech pathologist can suggest ways to improve your drooling due to excessive saliva, such as being conscious to swallow often, using gum to remind you to swallow and upright posture. Oral hygiene is important if you experience a build-up of saliva in your mouth or a dry mouth.  A speech pathologist can advise on how to optimise your oral hygiene.

Management of nutrition

Adequate intake of nutritional food is essential with PD.

There are no special diets needed, but manipulation of what you eat and drink can help manage loss of appetite, loss of weight, constipation, chewing and swallowing difficulties, and reduce the impact that certain foods can have on the effectiveness and absorption of PD medications.

A dietician specialised in movement disorders such as PD can assess the person’s nutritional needs and make appropriate recommendations.

A dietitian is a person qualified in nutrition and dietetics who is trained to provide advice in health and disease by applying the science of nutrition.

A dietitian will assess your current dietary intake and provide advice on ways to manipulate it to help manage any nutrition related problems you may be experiencing. They can determine if your weight is suitable for you and plan short and long term goals to achieve your optimal weight taking into consideration causes that may be impacting. Loss of weight can occur due to loss of appetite, excessive dyskinesia, swallowing difficulties or constipation; weight gain (less common in PD) often occurs in people who have had deep brain stimulation.

Ensuring you consume enough protein for what your body needs is important for the growth and repair of your body, essential for your muscle and overall health and important to avoid weight loss. Protein can sometimes impact on the efficacy and action of your PD medications, causing you to go ‘off’ or slow down after meal times. It is essential not to avoid protein in your eating plan, and your dietitian can advise on ways of reducing the impact dietary protein has on your PD meds, without compromising your protein and nutrient needs.

Oral nutrition supplements may be suggested by your dietitian to help improve your overall nutritional intake. They may also be used if eating and swallowing problems are contributing to your poor food intake. Your dietitian will work with your speech pathologist to develop the best ways to improve this.

Managing the social and emotional impact

The effects of PD are broad and impact on the social and economic life of the person and their family from the time of diagnosis in a variety of ways.

Coping and adjusting to the diagnosis, facing increasing challenges at work and planning for the future can be a daunting undertaking.

Navigating this newfound uncertainty requires careful consideration and appropriate specialised support.

As the disorder progresses, caregiver burden also increases and quality of life can decrease.

A social worker specialised in movement disorders such as PD can assist the person with PD, their caregiver and family negotiate the challenges faced across the life time of the person’s PD.

Social workers are highly skilled professionals who can assist you and your loved ones by:

  • providing a range of different therapy’s like counselling
  • assistance with linking to other support services
  • directing you to financial support services
  • information provision of entitlements for care packages
  • help to facilitate suitable respite arrangements for the caregiver
  • assistance and support with navigating the pathway to permanent residential care if the need arises.

After receiving a diagnosis of PD it is normal to experience a change in mood. A social worker has the appropriate specialised skills to help you deal with the reaction to your diagnosis.

Depression and anxiety are common clinical symptoms of Parkinson’s disease. Depression and anxiety can benefit from a variety of interventions and approaches. It is important to talk openly with your doctor or neurologist if experiencing any of these to determine the best treatment plan for you.

Social workers are specifically trained to support you in understanding how best to manage such symptoms.

Cognition

PD causes changes to the person’s cognition. Cognition refers to our mental processes and includes the ability to learn, to reason and remember.

A neuropsychologist specialised in movement disorders such as PD can assess a person’s cognition and provide strategies to optimise independence.

Changes in cognition affect up to 40% of people at the time of diagnosis. They may present as slowness in thinking, problems with attention or concentration, difficulty making decisions, problem solving and planning difficulties. They can be so mild that they are not obvious to the person, family or work colleagues.

Cognitive changes may, however, interfere with work and the person’s daily activities which can cause frustration.

Levodopa medication, such as sinemet, can improve cognitive processes, such as speed of thought processes, in the early to mid stages. However in the later stages, PD medications may interfere with cognition.

There are specialists, such as a neuropsychologist, who can assess the severity of these changes.

A neuropsychologist can assess cognition when the person is experiencing problems that are interfering with their ability to work or live independently. The neuropsychologist will suggest strategies to use to address the underlying cognitive problems.

An occupational therapist specialised in PD also has the skills to train the person in the use of a range of strategies such as using attention, breaking activity into small parts before performing, use of cue cards, use of lists.

A speech pathologist can also help when communication is disrupted due to word finding difficulties.

Complementary therapies

Complimentary treatments are nonmainstream interventions used alongside conventional medicine. These may include dietary modifications, vitamins, herbs and botanicals, cannabis, iron and chelation therapy and mindfulness using meditation. Physical treatments include Tai Chi, yoga, dance therapy, music therapy, light therapy, whole body vibration and acupuncture.

Because most complimentary treatments for PD are not supported by good quality evidence, people with PD are advised to discuss treatments with their doctor before trying them. It is advisable to select a therapist who is qualified and registered with a professional body.

These are some of the complementary therapies you may read about. The evidence and risks are summarized here for you. This information has been accessed from a review article by Marcie L. Rabin,et al. in Movement Disorders Clinical Practice 2015, Vol 2(3) titled Complementary Therapies for Parkinson’s Disease: What’s Promoted, Rationale, Potential Risks and Benefits

Complimentary treatments, evidence and risks

  • Reduced protein diets for motor fluctuations – little evidence to support benefits or risk of malnutrition
  • Protein redistribution diet for motor fluctuations – some support for benefits. Risk of malnutrition & weight loss
  • Mediterranean diet – 13% reduction in incidence of PD. No evidence for benefits once PD is present
  • Coffee – some evidence reduces risk of PD. No evidence for benefits once PD is present
  • Antioxidants as nutritional supplements – all research remains inconclusive
  • Vitamins Bet-carotene, B3, B6, C, D, E – insufficient evidence to recommend their use in PD
  • Herbs and Botanicals – Flavanoids, Gastrodin, green tea phenols, Ginkgo biloba, Milk thistle – insufficient evidence to recommend their use in PD
  • Coenzyme Q10 – insufficient evidence to recommend their use in PD
  • Fish oil – no evidence that it is beneficial for PD
  • Iron and Chelation Therapy – no proven benefit in PD
  • Medical marijuana – more research needed to evaluate safety and benefits
  • Light therapy for seasonal depression and sleep disturbance – limited evidence showing improvement in PD symptoms and mood
  • Whole body vibration – cannot be recommended at moment due to lack of consistent evidence of benefits
  • Acupuncture – cannot be recommended at moment due to lack of consistent evidence of benefits; more rigorous studies are needed
  • Mindfulness using medication – no or little evidence published for PD
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