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PARKINSON'S DISEASE
What Is Parkinsons Disease?
Parkinsons disease is a neurological disorder that affects movement, muscle control, and
balance. Parkinsons disease most commonly affects people 55 - 75 years old, but it can also develop
in younger people. The disease is usually progressive, with symptoms becoming more severe over
time.
Symptoms of Parkinsons Disease
Parkinsons disease may be difficult to diagnose in its early stages. The disease is diagnosed
mostly through symptoms, which may include:
Tremors (shaking) in the hands, arms, legs, and face
Slowness of movement, especially when initiating motion
Muscle rigidity
Difficulty with walking, balance, and coordination
Difficulty eating and swallowing
Digestive problems
Speech problems
Depression and difficulties with memory and thought processes
Medications.
Because Parkinsons disease symptoms are due to a deficiency of the brain chemical
dopamine, the main drug treatments help increase dopamine levels in the brain. Levadopa, usually
combined with carbidopa, is the standard drug treatment. For patients who do not respond to
levadopa, dopamine agonists (drugs that mimic the action of dopamine) may be prescribed. Other
types of medication may also be used. Unfortunately, many of these drugs can cause side effects and
lose effectiveness over time.
Physical Therapy.
Physical therapy is an important part of Parkinsons treatment. Rehabilitation can help
patients improve their balance, mobility, speech, and functional abilities.
Surgery.
In some cases of advanced-stage Parkinsons disease, surgery may help to control motor
problems. Deep brain stimulation is currently the preferred surgical method.
New Drug Approval
In 2012, the Food and Drug Administration (FDA) approved rotigotine (Neupro) for treatment
of early and advanced stage Parkinsons disease. The dopamine agonist drug is delivered through a
transdermal (skin) patch that is applied once a day.
Deep Brain Stimulation: Expert Consensus
In 2011, a panel of 50 international experts published a consensus statement on the use of
deep brain stimulation (DBS). The panel advised that: It is most appropriate to consider DBS for
younger patients with advanced Parkinsons disease who do not have significant cognitive or
psychiatric problems.
Deep brain stimulation of the subthalamic nucleus (STN) or globus pallidus pars interna (GPI) works
equally well in improving motor symptoms and STN treatment may help patients use less medication.
However, DBS of the STN can result in worsening of non-motor symptoms, including
depression, apathy, and falls. DBS is also effective in controlling tremors and dyskinesia.
This
procedure should be performed by an experienced neurosurgeon working as part of a
multidisciplinary team.
Tai Chi May Improve Balance
Tai chi, a Chinese martial art that emphasizes slow flowing motions and gentle movements,
may help patients with Parkinsons improve strength and balance and reduce the risk of falls,
according to a small study published in the New England Journal of Medicine. Other small studies
have suggested that dance styles such as the Argentinean tango may help with balance and mobility.
Introduction
Parkinson's disease (PD) is a slowly progressive neurological disorder that affects movement,
muscle control, and balance. Parkinsons disease is part of a group of conditions called motor system

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disorders, which are associated with the loss of dopamine-producing brain cells. These dopamineassociated motor disorders are referred to as parkinsonisms.
Parkinson's Disease and Dopamine Loss
Parkinson's disease occurs from the following process in the brain:
PD develops as cells are destroyed in certain parts of the brain stem, particularly the crescentshaped cell mass known as the substantia nigra.
Substantia nigra
Parkinson's disease is a slowly progressive disorder that affects movement, muscle
control, and balance. Part of the disease process develops as cells are destroyed in certain
parts of the brain stem, particularly the crescent-shaped cell mass known as the substantia
nigra. Nerve cells in the substantia nigra send out fibers to tissue located in both sides of the
brain. There the cells release essential neurotransmitters that help control movement and
coordination.
Nerve cells in the substantia nigra send out fibers to the corpus stratia, gray and white bands
of tissue located in both sides of the brain. There the cells release dopamine, an essential
neurotransmitter (a chemical messenger in the brain). Loss of dopamine in the corpus stratia is the
primary defect in Parkinson's disease. Dopamine deficiency is the hallmark feature in PD. Dopamine
is one of three major neurotransmitters known as catecholamines, which help the body respond to
stress and prepare it for the fight-or-flight response. Loss of dopamine negatively affects the nerves
and muscles controlling movement and coordination, resulting in the major symptoms characteristic
of Parkinson's disease. Dopamine also appears to be important for efficient information processing,
and deficiencies may also be responsible for the problems in memory and concentration that occur in
many patients.
Risk Factors
Age
The average age of onset of Parkinson's disease is 55. About 10% of Parkinson's cases are in
people younger than 40 years old. Older adults are at higher risk for both parkinsonism and
Parkinson's disease.
Gender
Parkinsons disease is more common in men than in women.
Family History
People with siblings or parents who developed Parkinson's at a younger age face an increased
risk for the condition. However, relatives of patients who developed Parkinsons at an older age
appear to have an average risk.
Race and Ethnicity
African-Americans and Asian Americans appear to have a lower risk than caucasians.
Possible Protective Factors
Both smoking and coffee drinking are associated with a lower risk for PD. Smoking and
Nicotine. Cigarette smokers appear to have a lower risk for Parkinson's disease, indicating possible
protection by nicotine. This finding is, of course, no excuse to smoke. The few studies on nicotine
replacement as a treatment for Parkinsons have not provided any strong evidence that nicotine
therapy provides benefits.
Coffee Consumption. Some studies suggest that the risk for PD in coffee drinkers is lower
than for non-coffee drinkers. In a 30-year study of Japanese-American men, coffee consumption was
associated with a lower risk for Parkinson's disease, and the more coffee they drank, the lower their
risk became.
Complications
Parkinson's disease (PD) is not fatal, but it can reduce longevity. The disease progresses more
quickly in older patients, and may lead to severe incapacity within 10 - 20 years. Older patients also
tend to have muscle freezing and greater declines in mental function and daily functioning than
younger people. If PD starts without signs of tremor, it is likely to be more severe than if tremor had
been present.

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Parkinson's disease can seriously impair the quality of life in any age group. In addition to
motor symptoms (motion difficulties, tremors) Parkinsons can cause various non-motor problems
that have physical and emotional impacts on patients and their families.
Swallowing Problems
Swallowing problems (dysphagia) are sometimes associated with shorter survival time. Loss
of muscle control in the throat not only impairs chewing and swallowing, which can lead to
malnourishment, but also poses a risk for aspiration pneumonia.
Emotional and Behavioral Problems
Depression is very common in patients with Parkinson's. The disease process itself causes
changes in chemicals in the brain that affect mood and well-being. Anxiety is also very common and
may present along with depression.
Cognitive and Memory Problems
Impaired Thinking (Cognitive Impairment). Defects in thinking, language, and problem
solving skills may occur early on or later in the course of the disease. These problems can occur from
the disease process or from side effects of medications used to treat Parkinsons. Patients with PD are
slower in detecting associations, although (unlike in Alzheimer's disease) once they discover them
they are able to apply this knowledge to other concepts.
Dementia.
Dementia occurs in about two-thirds of patients with Parkinsons, especially in those who
developed Parkinsons after age 60. Dementia is significant loss of cognitive functions such as
memory, judgment, attention, and abstract thinking. It is most likely to occur in older patients who
have had major depression. PD marked by muscle rigidity (akinesia), rather than tremor, and early
hallucinations also increase the risk for dementia. (Visual hallucinations can also occur as a side effect
of dopamine medication.) Unlike Alzheimer's, language is not usually affected in Parkinson's-related
dementia.
Sleep Disorder
Excessive daytime sleepiness, insomnia, and other sleep disorders are common in PD, both
from the disease itself and the drugs that treat it. Bladder problems can also contribute to sleep
disturbances. Many patients also suffer from nighttime leg cramps and restless legs syndrome. Some
of the medications used for Parkinson's may cause vivid dreams as well as waking hallucinations.
Bowel and Bladder Complications
Constipation is a common complication of Parkinsons disease. It is often caused by muscle
weakness that can slow down the action of the digestive system. Weakness in pelvic floor muscles can
also make it difficult to defecate. Patients with Parkinsons disease frequently experience urinary
incontinence, including increased urge and frequency. Parkinsons can also cause urinary retention
(incomplete emptying of the bladder).
Sensory Problems
- Decreased Sense of Smell. Many patients experience an impaired sense of smell.
- Vision Problems. Vision may be affected, including impaired color perception and contrast
sensitivity.
- Pain. Painful symptoms associated with Parkinsons disease include muscle numbness,
tingling, and aching. Pain in Parkinsons is often a result of dystonia, involuntary muscle
contractions and spasms that can cause twisting and jerking.
Symptoms
Tremors
Parkinson's disease (PD) symptoms often start with tremor. It may be only occasional at first,
starting in one finger and spreading over time to involve the whole arm. The tremor is often rhythmic,
4 - 5 cycles per second, and frequently causes an action of the thumb and fingers known as pill
rolling.
Tremors can occur when the limb is at rest or when it is held up in a stiff unsupported position. They
usually disappear briefly during movement and do not occur during sleep. Tremors can also
eventually occur in the head, lips, tongue, and feet. Symptoms can occur on one or both sides of the
body.
About a quarter of patients with Parkinsons do not develop tremor.

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Motion and Motor Impairment
Many PD symptoms involve motor impairment caused by problems in the brain nerves that
regulate movement:
- Slowness of motion, particularly when initiating any movement (a condition called akinesia
or bradykinesia), is one of the classic symptoms of Parkinson's disease. Patients may
eventually develop a stooped posture and a slow, shuffling walk. The gait can be erratic and
unsteady. After several years, muscles may freeze up or stall, usually when a patient is
making a turn or passing through narrow spaces, such as a doorway. Patients' posture can be
unstable, and they have an increased risk for falls.
- Intestinal motility (the ability to swallow, digest, and eliminate) may slow down, causing
eating problems and constipation.
- Muscles may become rigid. This symptom often begins in the legs and neck. Muscle rigidity
in the face can produce a mask-like, staring appearance.
- Motor abnormalities that limit action in the hand may develop in late stages. Handwriting, for
instance, often becomes small.
- Normally spontaneous muscle movements, such as blinking, may need to be done
consciously.
- Patients may develop speech problems, including soft voice or slurred speech.
Other Symptoms of Parkinson's Disease
Parkinsons disease also causes non-motor symptoms, including sleep problems,
gastrointestinal and urinary disorders, sexual dysfunction, decreased sense of smell, and depression
and anxiety.
Sialorrhea (drooling) is a common and bothersome symptom for those with Parkinson's
disease. It can cause chapped skin and lips around the mouth, dehydration, an unpleasant odor, and
social embarrassment.
NUTRITION AND PARKINSON'S DISEASE: WHAT MATTERS MOST?
Eat a balanced diet
It is difficult for a person to feel well and maintain energy when he or she is not eating
properly. Eating properly involves eating regularly (no meal skipping), eating a variety of foods from
all of the food groups (grains, vegetables, fruit, milk/ dairy, meat/beans) and eating prudently to
maintain a healthy weight. Although this sounds like simple advice, implementing it can be a
challenge, particularly if you have a hectic lifestyle or if the symptoms of Parkinson's are affecting
your ability to shop, prepare food and eat.
Maintain bone health
People with Parkinson's are prone to osteoporosis, a disease caused by low bone-mineral
density. Risk factors for osteoporosis include older age, low body weight, smoking, excessive alcohol
intake, limited exposure to sunlight, inadequate intake of vitamin D and calcium and lack of weightbearing exercise. Osteoporosis can be especially worrisome to a person with Parkinson's who faces an
increased risk of falling. The inevitable result is an increased risk of fractures, which are dangerous
and painful and tend to be detrimental to one's quality of life. Ask your doctor about having your
bone-mineral density checked. If it turns out to be low, medical treatments may be available.
To maintain bone health, make sure your diet includes plenty of calcium and vitamin D.
People who are over the age of 50 should consume 1500 mg of calcium and 800 IU of vitamin D
daily. Milk and milk products are the richest dietary source of calcium. Three servings per day are
recommended (one serving is one cup of milk or yogurt, or one and one-half ounces of hard cheese).
Although there are other calcium-containing foods (e.g., tofu, calcium-fortified soy-based beverages,
orange juice and dark leafy greens), calcium from non-dairy sources may not be well-absorbed.
You can also obtain vitamin D by getting outdoors regularly and consuming foods rich in
vitamin D (e.g., vitamin D-fortified milk, yogurt or breakfast cereals and fatty fish). If you live in a
region with limited sunshine and/or do not consume many vitamin D-rich foods, use of a nutritional
supplement is recommended.
Maintain bowel regularity
Constipation is common in Parkinson's disease. Although the constipation observed in
Parkinson's is due in large part to the disease itself, lifestyle measures can be useful for managing it.

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These include eating foods high in fiber (whole grain bread, bran cereals or muffins, fruits and
vegetables, beans and legumes and prunes) and drinking plenty of fluid. Then there is exercise, which
helps maintain bone density as well as eases constipation. If you are not able to achieve bowel
regularity through lifestyle alone, laxatives and other bowel interventions may be required. Make sure
to see your doctor if constipation persists.
Balance medications and food
The medications used for Parkinson's can themselves cause nutrition-related side-effects, such
as nausea and poor appetite. Typically these side-effects are most severe when a medication is first
prescribed but some individuals have continuing problems with them. Taking a small snack (such as
ginger ale and a few crackers) along with medications may help to control these side-effects. If nausea
or poor appetite persist, contact your doctor, as these symptoms can lead to undesired weight loss.
Amino acids (from dietary protein) can interfere with the uptake of levodopa into the brain. If
you find (not everyone experiences this) that eating high-protein food (such as meat, fish, poultry and
dairy products) decreases the effectiveness of levodopa, keep the meat portion of your meal to about
the size of a deck of cards and take your Sinemet half an hour prior to a protein-containing meal.
WHAT CAUSES PARKINSON'S?
Parkinson's occurs when certain nerve cells (neurons) in a part of the brain called the
substantia nigra die or become impaired. Normally, these cells produce a vital chemical known as
dopamine. Dopamine allows smooth, coordinated function of the body's muscles and movement.
Although neurons are the longest living cells in the body, large numbers of them die during migration
and differentiation. The lives of some neurons can take abnormal turns. Some diseases of the brain are
the result of the unnatural deaths of neurons.
- In Parkinsons disease, neurons that produce the neurotransmitter dopamine die off in the basal
ganglia, an area of the brain that controls body movements. This causes difficulty initiating
movement.
- In Huntingtons disease, a genetic mutation causes over-production of a neurotransmitter called
glutamate, which kills neurons in the basal ganglia. As a result, people twist and writhe
uncontrollably.
- In Alzheimers disease, unusual proteins build up in and around neurons in the neocortex and
hippocampus, parts of the brain that control memory. When these neurons die, people lose their
capacity to remember and their ability to do everyday tasks. Physical damage to the brain and other
parts of the central nervous system can also kill or disable neurons.
- Spinal cord injury can disrupt communication between the brain and muscles when neurons lose
their connection to axons located below the site of injury. These neurons may still live, but they lose
their ability to communicate.
To date, despite decades of intensive study, the causes of Parkinsons remain unknown. Many
experts think that the disease is caused by a combination of genetic and environmental factors, which
may vary from person to person.
In some people, genetic factors may play a role; in others, illness, an environmental toxin or
other event may contribute to PD. Scientists have identified aging as an important risk factor; there is
a two to four percent risk for Parkinsons among people over age 60, compared with one to two
percent in the general population.
The chemical or genetic trigger that starts the cell death process in dopamine neurons is the
subject of intense scientific study. Many believe that by understanding the sequence of events that
leads to the loss of dopamine cells, scientists will be able to develop treatments to stop or reverse the
disease
Genetic Factors
The vast majority of Parkinson's cases are not directly inherited. About 15 to 25 percent of
people with Parkinsons report having a relative with the disease. In large population studies,
researchers have found that people with an affected first-degree relative, such as a parent or sibling,
have a four to nine percent higher chance of developing PD, as compared to the general population.
This means that if a persons parent has PD, his or her chances of developing the disease are slightly
higher than the risk among the general population. Researchers have discovered several gene
mutations that can cause the disease directly, but these affect only a small number of families. Some

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of these mutations involve genes that play a role in dopamine cell functions. Parkinsons has
developed at an early age in individuals with mutations in genes for parkin, PINK1, LRRK2, DJ-1,
and glucocerebrosidase, among others.
Environmental Factors
A synthetic neurotoxin agent called MPTP can also cause immediate and permanent
parkinsonism. The compound was discovered in the 1980s in individuals who injected themselves
with a synthetic form of heroin contaminated with MPTP. Cases of MPTP-induced Parkinsons in the
general population are exceedingly rare.
It is noted that a simple exposure to an environmental toxin is never enough to cause
Parkinsons. Most people exposed to a toxin do not develop the disease. In fact, there is no conclusive
evidence that any environmental factor, alone, can be considered a cause of the disease.
HOW IS PARKINSONS DISEASE TREATED?
Treatments are available only for the symptoms of Parkinsons disease. None of the currently
available treatments can halt or even slow the loss of neurons in Parkinsons disease.
One of the most effective and widely used treatments for the symptoms of PD is carbidopalevodopa. Levodopa, also called L-dopa, is a drug that is converted into dopamine in the brain.
Levodopa is often combined with carbidopa, which improves the action of levodopa and reduces
some of its side effects, particularly nausea.
The side effects of L-dopa, with or without carbidopa, are considerable and can include
Dyskinesia (muscle spasms), low blood pressure, arrhythmia (abnormal heart rhythms),
gastrointestinal problems, nausea, hair loss, sleep disorders, confusion, anxiety and hallucinations.
Within 4 6 years of treatment with L-dopa, the effects of the drug in many patients begin to
last for shorter periods of time after a dose (called the wearing off effect). The duration of the on
state becomes shorter and wearing off happens sooner. The wearing off state can result in a
tremor or slowness in movement, painful muscle spasms that can cause contortions in the neck, jaw,
midsection, eyes and feet. In some patients, the wearing off states are predicable, allowing the
patient to plan accordingly. For others it is unpredictable. Unfortunately, doctors have yet to
understand why these fluctuations are predictable in some patients and not in others. In response to
the wearing off effect, patients may choose to increase the dosage of levodopa, or frequency they
take it, but in doing so they face an increased risk of dyskinesia.
Other classes of drugs include:
Dopamine agonists.
Unlike levodopa, dopamine agonists dont change into dopamine, but mimic the effect of
dopamine in the brain. Theses drugs are not as effective as levodopa; however, they last longer in the
brain and dont wane over time. The side effects of dopamine agonists are similar to carbidopalevodopa, but may also include hallucinations, swelling, and sleepiness.
MAO B inhibitors.
Monoamine oxidase B (MAO B) is an enzyme in our brain that breaks down dopamine.
MAO B inhibitors block the breakdown of dopamine caused by the enzyme, slowing the loss of
dopamine and several of the side effects associated with PD. The side effects of MAO B inhibitors
alone are generally mild.
Amantadine.
Amantadine is often prescribed to provide short-term relief of symptoms of mild, early-stage
Parkinsons disease. It may also be added to carbidopa-levodopa therapy for people in the later stages
of Parkinsons disease, to help control the side effect of dyskinesia, caused by carbidopa-levodopa.
Amantadine can also have side effects, which may include a purple mottling of the skin, ankle
swelling or hallucinations.
SURGICAL PROCEDURES.
Deep brain stimulation. In deep brain stimulation (DBS), surgeons implant electrodes into a
specific part of the brain. The electrodes, which are connected to a generator implanted in the chest,
send electrical pulses to the brain, which can help improve many of the symptoms of PD and reduce
the need for levodopa. Deep brain stimulation is most often used in the late stages of the disease after
levodopa is no longer effective.