More than 6 million people around the globe have Parkinson disease you may have heard of some

Michael J fox, Ella, Ozzy Osbourne and many others. You may also have some misconceptions about
this disease. Both Parkinson and Alzheimer disease occurring older people and many people falsely
believe that Parkinson leads to Alzheimer's disease. It doesn't. Parkinson is a disease of motor
control, but it can be readily managed with exercise medications and in some cases- surgery

A patient information page was published in the April 14th, 2020 issue of Jama one of its authors
was Dr. Michael Oaken who is the executive director of the Norman fixable Institute for neurologic
disease and is also a professor and chairman of the Department of Neurology at the University of
Florida in Gainesville. In this podcast, Dr. Oaken explains Parkinson disease to patients from the
JAMA Network.

This is Jama clinical reviews interviews and ideas about Innovations in Medicine Science and clinical
practice. Here's your host at Livingston.

Are there diagnostic tests for Parkinson's Disease?

So at the moment the best test for Parkinson disease is still a clinical bedside examination following
the patient in the clinic to see how they do and administering dopamine replacement therapies, like
levadopa to see how the symptoms respond and to see which subtype of Parkinson that you're
dealing with. This is still the gold standard of diagnosis. There is scan called a dopamine transporter
scan that will measure this enzyme that DAT enzyme in an area in the brain called the putamen. And
there is an FDA approval for this scan.

But the approval only tell us the difference between Parkinson and essential tremor, it doesn't
differentiate Parkinson from other forms of Parkinson. So other things that might have problems
with other dopaminergic system that light up on the skin. So it's still a clinical diagnosis. And so if
you're a great clinician, these are the things that we say you got to you got to keep your eyes open
on this disorder.

What medications are used to treat Parkinson's disease and what do patients need to know about
those medications?

So there are over a dozen different medicines for Parkinson disease. The things that patients need to
know is first of all, there is this myth about levodopa phobia or dopamine phobia that if you take
dopamine it's going to kill cells in the brain and people try to not take dopamine replacement
because they think in some way there's going to be a long-term benefit and that there's a harm from
doing this the truth is that is that this has been studied quite extensively and that there should be no
fear of taking medications.

And in fact the data suggests that you'll do better with less disability if you take medications and
that it's not toxic to take dopamine. The data also shows that it's not protective either. So taking
dopamine doesn't protect cells from dying but it certainly doesn't kill them off. Now. There are a
number of different medicines and we always say start with exercise and start with a class of
medicines called monoamine oxidase inhibitors.

First, they're very mild. They may not affect your symptoms at all. But in some patients you may get
enough benefit to stay on that medicine and then we move to things like levodopa or dopamine
replacement therapy. There are medicines called dopamine agonists that have to be carefully
monitored for side effects like impulse control disorders and we have a number of other
combinations. So if you get dyskinesia, we can give you an old-fashioned drug called amantadine if
you're wearing off between dosages. We can give you what are called COMT or cattle Colo
methyltransferase Inhibitors. And so there's a whole bunch of different combinations of medicines.

And if over time you're taking the same medicine like one tablet of cinnamon, which is Carbidopa
levodopa three times a day for years on end, then you're probably not getting the best possible
therapy for your Parkinson.

What's the role of Rehabilitation therapy or exercise in Parkinson?

So the idea that Rehabilitation is useful in Parkinson goes all the way back to the time when we
actually didn't have levodopa or dopamine replacement therapy. So patients will go on rounds with
the doctors and the Parkinson patients were institutionalized and they would have them fold towels
and do exercises and guess what when they moved they had better symptoms and they did better
and so exercise therapy is actually been around even before medication therapy.

We now know fast-forwarding a few decades that when we pair exercise therapy, and we tell
patients right out of the gate. As soon as you're diagnosed. We know from animal experiments and
human experiments that there can be a powerful symptomatic effect to exercise. So we always
recommend exercise and we also have shifted to recommend multidisciplinary care with physical
occupational and speech and swallowing therapy early on and if you have access to a social worker
for things like caregiver strain And that's also useful for this process

How quickly does the disease progress?

So the progression of Parkinson's disease really depends on the subtype. And so we think about do
you have your symptoms at a young age? And are you responding well to the dopamine medications
and your symptoms are predominantly motor stiffness slowness and Tremor those patients do very
well. There's an intermediate subtype where patients have a good response to the medications.
Maybe a few more symptoms than that and they still do well for many years and then about ten
percent of patients have a more severe subtype where they may have cognitive problems or thinking
problems and other symptoms like depression and not as good of a response to the dopamine
replacement therapies, and that 10% of patients. Don't do well long-term.

Now the largest longitudinal real life study that's ever been attempted is being done by the
Parkinson foundation and it's called the Parkinson outcome project and they're actually tracking.
People over time and trying to understand why dosome people live 40 50 years after the diagnosis
and some people have a less robust course in come in 5 to 10 years. And so we're sorting that out
and we think the answer is what subtype you have. And so as a clinician you want to see your doctor
a few times every year and start to get a sense of how do I respond to medicines? What types of
symptoms do I have and what subtype may I be?

I've heard about surgery or deep brain stimulation for treating Parkinson's. Could you tell me about
that?

Sure, so there are actually multiple ways in which we can address Parkinson's medicines and
multidisciplinary therapies, like physical occupational speech and swallow are certainly the Mainstay,
but when you get to symptoms like Tremor that doesn't respond to medicines were despite using
cocktail of medicines and moving dosages.
Every two or every three hours you're still wearing off between dosages and you're still getting these
dance like movements that we call dyskinesia and this, you know can wear people out throughout
the day there yo-yoing between being stiff and slow and tremulous and then when the medicines
kick in there quickly going to these dance like movements and or they have a Tremor that's not
responding to medications. This can be a very powerful therapy. It's called deep brain stimulation
and we Insert a lead into the brain. It can be done unilaterally on one side of the brain or bilaterally
on two sides of the brain and we can modulate the way that the different areas of the brain are
talking to each other I always tell patients. It's a very powerful for Tremor wearing off and on off
fluctuations. Those are the key things that deep brain stimulation really brings to the table for a
patient or family

Do people die from Parkinson.?

So this notion of death from Parkinson has been recently challenged and the the question really
comes down to how we record death and how we decide whether or not it's directly related to
Parkinson or indirectly related to Parkinson. And when we examine the question more closely
certainly Parkinson can contribute like any other comorbidities. So if you have arthritis or you have
lupus or you have diabetes certainly those things can contribute to the may or may not be the actual
cause of death, but we come down to the actual cause of death. Usually it's not the Parkinson
disease itself.

Now Parkinson disease patients can become disabled with less movement and probably the leading
cause of death among people with Parkinson and among the elderly population with Mobility
problems is aspiration, pneumonia and falls and fractures and then the comorbidities and the
morbidities that end up following that sequence and so it's kind of a tricky question.

So we are on the side of saying in general people don't die a Parkinson disease, but the Parkinson
can certainly contribute to the state or some of the other things that can happen to them
particularly with Mobility falling and aspirating and getting pneumonia i

What's the role of anticholinergic sand treating Parkinson's disease.

So historically anticholinergics have actually been a powerful treatment against some of the The
symptoms of Parkinson and particularly against Tremor and so it is really tempting to put a
Parkinson's patient on an anticholinergic and call it done and say great. I've got the charmer but it
turns out that the other treatments are so good that we rarely need to use anticholinergics and the
side effects particularly the cognitive side effects for these patients can be devastating. There's also
some long-term data suggesting that neuro pathologically, it may not be a good idea to be on
anticholinergic drugs long-term.

And so really for the practicing clinician, there isn't a need to treat with anticholinergics and when
there is it's very rare and should be monitored closely.

Could you tell us the names of some of those drugs?

So the common drugs that we see over the counter or things like Benadryl trihex fendaly, benxy
roping, but you have to be careful because anticholinergics can be part of cough syrups and they can
be part of cold remedies and so they can be hidden in a lot of the medicines that you see over the
counter and that's where it's useful. If you have Parkinson to check with your pharmacist, you know
to see do does this medicine have anticholinergics or something that might make me confused. Now
what is very interesting and very important for practitioners to understand Is that when it comes to
taking over-the-counter medications for whatever reason almost every single over-the-counter
medication is marked don't give it to somebody with Parkinson's disease and we know that this is a
myth and this is false and the things that you have to watch out for with Parkinson are cough syrups
with dextromethorphan. They can interact with drugs that are monoamine oxidase Inhibitors. So
your your pharmacist can help you with that

any medicine that raises your blood pressure if you have something in your medical history where if
you raise the blood pressure, this could be bad now in general Parkinson patients have low blood
pressure. So sometimes that's not such a bad thing and then cough syrups with opioids and other
pain medicines pain medicines constipate patients and constipation is one of the leading causes of
disability Parkinson disease. And so you definitely don't want to constipate patients, but the pain
medicines can also cause Them to be confused and so

We are sort of expand our discussion of anticholinergics because they're so easy to get to also all
over the counter drugs and to have patience think through it doesn't mean that you can't take it but
you just need to Monitor and understand what the potential side effects and benefits

Are there any GI effects of Parkinson disease itself, like especially on the colon?Is it constipating or
do they get motility problems?

So which really interesting is that when we look at the most common questions that come in about
Parkinson whether it's on the Parkinson Foundation website, whether it's on our own website at the
University of Florida or whether it's the clinic one of the leading. If not, the leading question is I have
constipation and sometimes this predates it could be prodromal. It can be starting to get constipated
many years before you actually end up with Parkinson's and then you start having this REM sleep
behavior disorder.

Constipation and Parkinson disease are really something that go together and practitioners need to
be aware of it so that you can put patients on good formulas keep their bowels moving and
sometimes even with your best efforts and I know some people who are really fabulous in treating
constipation some of the Parkinson patients. They just can't get their get their bowels to move

When we look pathologically. Guess what that alpha-synuclein protein is deposited all over the gut
and in fact, T' we have several research projects that are going throughout the world. Now looking at
the gut brain interactions between Parkinson disease proteins and deposits within the GI system
and the autonomic nervous system, which made predate what we see with the rest of Parkinson.
And so we believe there is a huge link between GI symptoms and Parkinson disease. We see it in the
clinic,

but there's also an unknown and we're now beginning understand changes in microbiota with it that
are within the gut we're understanding that when we modify the microbiota even in animal
experiments. We're now seeing that we can recapitulate Parkinson and then even make it better by
changing the microbiome back or two or sterilizing it and so there's this huge Frontier, you know of
nutrition and Parkinson disease and the GI symptoms, but if you're a practitioner keep your eye on
the constipation because nothing is worse for a patient than terrible constipation
I hope you found this podcast informative.