Causes, Symptoms, and Treatment of Parkinson's Disease
Robert Cranston, MD, discusses the causes, symptoms, and treatment of Parkinson's Disease.
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Learn more about Robert Cranston, MD
Robert Cranston, MD
Robert E. Cranston, MD, MA, FAAN, is an Attending Physician, and Medical Director for Medical Subspecialties at Carle Clinic and Carle Foundation Hospital in Urbana, Illinois. Prior to his current position, he served as chair of the Neurology Department at Carle for ten years. He is a Clinical Associate Professor at The University of Illinois at Urbana-Champaign.Learn more about Robert Cranston, MD
Transcription:
Melanie Cole (Host): Expert Insights is an ongoing medical education podcast. The Carle Division of Continuing Education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA category one credit. To collect credit, please click on the link and complete the episodes posttest.
Welcome, our topic today is Parkinson disease and my guest is Dr. Robert Cranston. He’s a neurologist at the Carle Foundation Hospital. Dr. Cranston, let’s start with a little bit about Parkinson’s disease. What are some of the hallmarks of this disease process?
Dr. Robert Cranston (Guest): Thank you for having me. I guess I’d say a number of things. You will often see patients with tremor although the tremor itself may be absent in the beginning. It’s usually a rest related tremor. There is also a slowness of general movement and a paucity of general movement. So if you sit and watch somebody with Parkinson’s they frequently will not blink as frequently as other people. They also may have a masked face and probably a hallmark of Parkinson’s is the gait along with balance difficulty. The gait is really slower with a little bit of a shuffle, difficulty getting out of the chair, often an asymmetric arm swing and as the patient turns to come back to you, instead of gracefully pivoting on their lead foot, they will often take three smaller steps or even more as they turn around slowly to come back to you. Many patients with Parkinson’s have a softer voice as well.
Melanie: Do we know what causes Parkinson’s doctor? Do we know what causes this loss of dopamine producing neurons? What’s going on in the brain with Parkinson’s?
Dr. Cranston: Well that’s a good question, and in fact we may discover down the road that Parkinson’s is not a discreet entity but there are several things that give the same clinical picture. For example, some Parkinson’s seems to be genetically indicated or caused. Some has definitely been linked to certain toxin exposures, but for many people it just appears to be a gradual failing of a specific system, the substantia nigra, just like a lot of our other systems wear down over time like our joints and our heart, and our general cognition.
Melanie: Now tell us a little bit about the risk factors. Is there a really strong genetic component to Parkinson’s disease?
Dr. Cranston: I think in general you – we may discover that everything that happens to us has a genetic component, but right now as far as separating things out, there are strong familiar trends only about 5% or 10% of the time. The rest of the time it seems to arrive on the person de novo, essentially out of the blue. There has been some epidemiological evidence over the years about exposure, for instance country well water as opposed to city water and certainly some inhaled toxins in industrial settings.
Melanie: How important is early diagnosis as being crucial to improve outcome prediction. We know there’s no cure and it’s about symptom management for Parkinson’s, but what are some of the valuable prognostic tools to aid in early diagnosis? How is it diagnosed?
Dr. Cranston: Typically it’s diagnosed clinically based on the signs and the symptoms that I’ve mentioned to you. However, there is a dopamine type CAT scan basically that can be used in some patients. It’s not widely used because usually the diagnosis is self-evident, but in difficult cases where you’re really having trouble pinning it down, sometimes that can be helpful. As far as the importance of early detection versus much later, we used to think it didn’t matter too much and that all the medications were only symptomatic, but in the last few years there’s been some evidence that shows that it actually does matter and if you get people on the medications sooner, the long term outlook is better for them. I am currently following some patients who have been taking care of for 18 or 20 years and many of them are still ambulatory. I don’t know if that’s because we got them on treatment early or if they were just the lucky ones, but my approach to patients with Parkinson’s is to be fairly confident of the diagnosis but then go ahead and start some treatment early on.
Melanie: Then let’s speak about treatment and managing those symptoms and some of the comorbidities that you mentioned earlier in the segment that go along with it as gait and balance and the masking and speech, so speak about treatment modalities, doctor, if you would.
Dr. Cranston: Sure the most effective medication for most people with Parkinson’s is the carbidopa/levodopa, brand name is often use Sinemet but there are other brand names as well. It comes in multiple preparations, short term, long term, and different combinations of the two medications carbidopa and levodopa. Having said that, there are also dopamine agonists, pramipexol and ropinirole which are used early with a lot of people. Historically they also used amantadine which is an old drug used for flu but it seemed to help somewhat in some people. Down the road an important consideration that we’ve been using lately is the concept that there are certain brain interventions, brain surgical interventions that can be helpful, but they do require an invasion of the brain itself so usually they’re not seriously considered unless the patient has failed several reasonable medications and is otherwise a very good surgical risk and has very significant symptoms, so deep brain stimulation for instance, and there are several other surgeries that can be helpful for certain people, but like I say usually you have to have those three criteria in place before you seriously consider surgery for Parkinson’s.
Melanie: Dr. Cranston, for other providers, as they are dealing with their patients with Parkinson’s and their families, what do you want the other providers to know about the lifestyle and the at home care that Parkinson’s patients sometimes and quite often require. As far as care giving, what things should they be doing at home, and how can providers help them and guide them with those lessons?
Dr. Cranston: Well it’s a multi-phased answer I guess in a way, because the disease process starts very subtly and then insidiously progresses. So what you would consider for someone early in the disease wouldn’t apply very much as the disease gets severe. The early patients, there really aren’t a lot of considerations, just that the family can know that the tremor is not just because of anxiety. The family can know that the balance issues are there, but over time, especially as balance becomes more of an issue, family really has to think about making the home safe so that if the patient falls they’re not going to seriously injure themselves and there are certainly ways to make homes safer. We often get an occupational therapy home evaluation for patients like this in order to protect them but also just to – and understanding that even during the course of the day, the deficit brought on by the Parkinson’s can be highly variable so if they’re talking to their spouse early in the day, soon after they take in their medicine, they may seem fairly fluid and verbal and thinking well and talking well, but at other points in the day they may be in an off phase where they can’t walk nearly as well or talk as well and they may have more tremor. In the long run, understanding on the part of the family does make a really big difference and physical therapy for the balance is an intervention that has been proven to be helpful. Recently, two other types of intervention that are nonmedicinal have been touted. One is bicycle riding and you might say how can you ride a bicycle if you have bad balance? Well you can either ride a fancy trike, they are coming up with some really nice tricycles or a stationary bike and both would do the same thing. It somehow is affecting the spinal cord and the brain itself to keep your balance better longer. Also there is something in the boxing realm. There’s a program in town for instance called Rock Steady, and they don’t pay me anything for mentioning their name and they’re not the only program like this, but it’s a physical therapy program that focuses on boxing maneuvers, balance maneuvers, and strengthening maneuvers and if you can get a patient with some early balance deficits into a program like this it can be very helpful. The one in town for instance is pretty inexpensive. So like $5 a visit. I don’t know how it will be in the long run at different places, but that’s certainly an option that can be helpful.
Melanie: As a wrap up Dr. Cranston, tell other providers what you’d like them to know about Parkinson’s disease and the interventions and what you see on the horizon for research and Parkinson’s.
Dr. Cranston: I think the main thing I’d say is have your antennae up and be aware that a patient with Parkinson’s may not have any tremor at all. That’s unfortunately often used to exclude it saying they can’t have Parkinson’s because they have no tremor. So remember that 30% to 40% of Parkinson’s patients may present without any tremor. Second thing I’d say is to be aware of how the disease changes the deficits of the patient over time and part of that is, is that eventually some of the patients begin hallucinating or having cognitive deficits due to the disease or the medications used for it. As far as future treatments, there are new formulations of current medications. There are also other medications that are being studied. The research and development for major pharmaceutical companies can certainly find this as a rich area to work in as there are so many patients with Parkinson’s as we age. I think patience with the person with Parkinson’s and also kind of a steady source of encouragement to help them continue to keep the person with Parkinson’s active. This is proven to be beneficial in keeping them more capable for a longer period of time.
Melanie: Thank you so much Dr. Cranston for being with us today, sharing your expertise on Parkinson’s and explaining some of the treatments and comorbidities and lifestyle, help for the caregivers and what providers should know. Thank you again for joining us. You’re listening to Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities, please visit carleconnect.com, that’s carleconnect.com. We hope the information gained will be applicable to your work and life. This is Melanie Cole, thanks so much for listening.
Melanie Cole (Host): Expert Insights is an ongoing medical education podcast. The Carle Division of Continuing Education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA category one credit. To collect credit, please click on the link and complete the episodes posttest.
Welcome, our topic today is Parkinson disease and my guest is Dr. Robert Cranston. He’s a neurologist at the Carle Foundation Hospital. Dr. Cranston, let’s start with a little bit about Parkinson’s disease. What are some of the hallmarks of this disease process?
Dr. Robert Cranston (Guest): Thank you for having me. I guess I’d say a number of things. You will often see patients with tremor although the tremor itself may be absent in the beginning. It’s usually a rest related tremor. There is also a slowness of general movement and a paucity of general movement. So if you sit and watch somebody with Parkinson’s they frequently will not blink as frequently as other people. They also may have a masked face and probably a hallmark of Parkinson’s is the gait along with balance difficulty. The gait is really slower with a little bit of a shuffle, difficulty getting out of the chair, often an asymmetric arm swing and as the patient turns to come back to you, instead of gracefully pivoting on their lead foot, they will often take three smaller steps or even more as they turn around slowly to come back to you. Many patients with Parkinson’s have a softer voice as well.
Melanie: Do we know what causes Parkinson’s doctor? Do we know what causes this loss of dopamine producing neurons? What’s going on in the brain with Parkinson’s?
Dr. Cranston: Well that’s a good question, and in fact we may discover down the road that Parkinson’s is not a discreet entity but there are several things that give the same clinical picture. For example, some Parkinson’s seems to be genetically indicated or caused. Some has definitely been linked to certain toxin exposures, but for many people it just appears to be a gradual failing of a specific system, the substantia nigra, just like a lot of our other systems wear down over time like our joints and our heart, and our general cognition.
Melanie: Now tell us a little bit about the risk factors. Is there a really strong genetic component to Parkinson’s disease?
Dr. Cranston: I think in general you – we may discover that everything that happens to us has a genetic component, but right now as far as separating things out, there are strong familiar trends only about 5% or 10% of the time. The rest of the time it seems to arrive on the person de novo, essentially out of the blue. There has been some epidemiological evidence over the years about exposure, for instance country well water as opposed to city water and certainly some inhaled toxins in industrial settings.
Melanie: How important is early diagnosis as being crucial to improve outcome prediction. We know there’s no cure and it’s about symptom management for Parkinson’s, but what are some of the valuable prognostic tools to aid in early diagnosis? How is it diagnosed?
Dr. Cranston: Typically it’s diagnosed clinically based on the signs and the symptoms that I’ve mentioned to you. However, there is a dopamine type CAT scan basically that can be used in some patients. It’s not widely used because usually the diagnosis is self-evident, but in difficult cases where you’re really having trouble pinning it down, sometimes that can be helpful. As far as the importance of early detection versus much later, we used to think it didn’t matter too much and that all the medications were only symptomatic, but in the last few years there’s been some evidence that shows that it actually does matter and if you get people on the medications sooner, the long term outlook is better for them. I am currently following some patients who have been taking care of for 18 or 20 years and many of them are still ambulatory. I don’t know if that’s because we got them on treatment early or if they were just the lucky ones, but my approach to patients with Parkinson’s is to be fairly confident of the diagnosis but then go ahead and start some treatment early on.
Melanie: Then let’s speak about treatment and managing those symptoms and some of the comorbidities that you mentioned earlier in the segment that go along with it as gait and balance and the masking and speech, so speak about treatment modalities, doctor, if you would.
Dr. Cranston: Sure the most effective medication for most people with Parkinson’s is the carbidopa/levodopa, brand name is often use Sinemet but there are other brand names as well. It comes in multiple preparations, short term, long term, and different combinations of the two medications carbidopa and levodopa. Having said that, there are also dopamine agonists, pramipexol and ropinirole which are used early with a lot of people. Historically they also used amantadine which is an old drug used for flu but it seemed to help somewhat in some people. Down the road an important consideration that we’ve been using lately is the concept that there are certain brain interventions, brain surgical interventions that can be helpful, but they do require an invasion of the brain itself so usually they’re not seriously considered unless the patient has failed several reasonable medications and is otherwise a very good surgical risk and has very significant symptoms, so deep brain stimulation for instance, and there are several other surgeries that can be helpful for certain people, but like I say usually you have to have those three criteria in place before you seriously consider surgery for Parkinson’s.
Melanie: Dr. Cranston, for other providers, as they are dealing with their patients with Parkinson’s and their families, what do you want the other providers to know about the lifestyle and the at home care that Parkinson’s patients sometimes and quite often require. As far as care giving, what things should they be doing at home, and how can providers help them and guide them with those lessons?
Dr. Cranston: Well it’s a multi-phased answer I guess in a way, because the disease process starts very subtly and then insidiously progresses. So what you would consider for someone early in the disease wouldn’t apply very much as the disease gets severe. The early patients, there really aren’t a lot of considerations, just that the family can know that the tremor is not just because of anxiety. The family can know that the balance issues are there, but over time, especially as balance becomes more of an issue, family really has to think about making the home safe so that if the patient falls they’re not going to seriously injure themselves and there are certainly ways to make homes safer. We often get an occupational therapy home evaluation for patients like this in order to protect them but also just to – and understanding that even during the course of the day, the deficit brought on by the Parkinson’s can be highly variable so if they’re talking to their spouse early in the day, soon after they take in their medicine, they may seem fairly fluid and verbal and thinking well and talking well, but at other points in the day they may be in an off phase where they can’t walk nearly as well or talk as well and they may have more tremor. In the long run, understanding on the part of the family does make a really big difference and physical therapy for the balance is an intervention that has been proven to be helpful. Recently, two other types of intervention that are nonmedicinal have been touted. One is bicycle riding and you might say how can you ride a bicycle if you have bad balance? Well you can either ride a fancy trike, they are coming up with some really nice tricycles or a stationary bike and both would do the same thing. It somehow is affecting the spinal cord and the brain itself to keep your balance better longer. Also there is something in the boxing realm. There’s a program in town for instance called Rock Steady, and they don’t pay me anything for mentioning their name and they’re not the only program like this, but it’s a physical therapy program that focuses on boxing maneuvers, balance maneuvers, and strengthening maneuvers and if you can get a patient with some early balance deficits into a program like this it can be very helpful. The one in town for instance is pretty inexpensive. So like $5 a visit. I don’t know how it will be in the long run at different places, but that’s certainly an option that can be helpful.
Melanie: As a wrap up Dr. Cranston, tell other providers what you’d like them to know about Parkinson’s disease and the interventions and what you see on the horizon for research and Parkinson’s.
Dr. Cranston: I think the main thing I’d say is have your antennae up and be aware that a patient with Parkinson’s may not have any tremor at all. That’s unfortunately often used to exclude it saying they can’t have Parkinson’s because they have no tremor. So remember that 30% to 40% of Parkinson’s patients may present without any tremor. Second thing I’d say is to be aware of how the disease changes the deficits of the patient over time and part of that is, is that eventually some of the patients begin hallucinating or having cognitive deficits due to the disease or the medications used for it. As far as future treatments, there are new formulations of current medications. There are also other medications that are being studied. The research and development for major pharmaceutical companies can certainly find this as a rich area to work in as there are so many patients with Parkinson’s as we age. I think patience with the person with Parkinson’s and also kind of a steady source of encouragement to help them continue to keep the person with Parkinson’s active. This is proven to be beneficial in keeping them more capable for a longer period of time.
Melanie: Thank you so much Dr. Cranston for being with us today, sharing your expertise on Parkinson’s and explaining some of the treatments and comorbidities and lifestyle, help for the caregivers and what providers should know. Thank you again for joining us. You’re listening to Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities, please visit carleconnect.com, that’s carleconnect.com. We hope the information gained will be applicable to your work and life. This is Melanie Cole, thanks so much for listening.