Scott Webb (Host): Though there's no cure for Parkinson's disease yet, early diagnosis of the disease can improve the lives of patients. And joining me today to tell us more about Parkinson's, early signs and symptoms, and the latest treatment options is Dr. Nima Beheshti. He's a neurologist with Salinas Valley Health.

 This is Ask the Experts, the podcast from Salinas Valley Health. I'm Scott Webb. Doctor, it's nice to have you here today. We're going to talk about Parkinson's disease and the symptoms or signs and symptoms that perhaps, you know, some of us, all of us, might want to be on the lookout for. So, let's start there. Like, what are the earliest symptoms of Parkinson's disease and which ones are most commonly missed or misattributed?

Dr. Nima Beheshti: That's a very great question. So when looking back in patients who get diagnosed with Parkinson's, some of the most common presenting symptoms years before their first tremor or their first fall, one is constipation. And it's usually a pretty severe constipation that keeps on getting worse. Other ones include acting out your dreams at night, so punching or kicking while you're asleep. These are usually accompanied with pretty vivid dreams or intense dreams.

Another one is loss of sense of smell. So, that may be slowly over the last few years, but just a worsening sense of smell is also commonly seen before the first motor symptoms of Parkinson's. So, those are some of the ones that we ask about to see, you know, are we seeing these before the tremors? And is that really helping us get the diagnosis of Parkinson's?

Host: Well, it sure is a good thing, Doctor, that we have experts because none of those, in my mind, as a lay person who doesn't know really anything about Parkinson's, to associate them, you know, constipation and Parkinson's, it's hard to get my mind around.

Dr. Nima Beheshti: Yeah, absolutely. And, you know, it shocked us as well, even as experts. And so, there was a whole bunch of research, maybe about a decade ago, that was showing that some of the plaques that caused Parkinson's in the brain, we're starting to see them in the stomach, maybe even before someone has their symptoms. And so, there was a theory, does Parkinson's start in the stomach? We've been looking at this. We haven't made any big breakthroughs about this yet. But, you know, stay tuned. We have some smart people looking at this, and it may change how we look at Parkinson's in the future.

Host: And how it's diagnosed or when it's diagnosed. All good things, obviously, for patients and families. Let's talk about motor symptoms, tremor, rigidity, bradykinesia, like how do they typically progress over time?

Dr. Nima Beheshti: The tremors are seen in about two-thirds of patients, which is to say about one-third never get tremors. It tends to start on one side over the other. So, maybe it's only on your right side or only on your left side. But after a few years, the other side will catch up. And, you know, by the five or seven-year mark, it's usually they're more or less the same.

The rigidity and the bradykinesia that you mentioned also tend to start more on one side than the other. But over time, they do kind of catch up with each other. There are some more aggressive versions of Parkinson's that can break these patterns, and that's what we're checking for early on in the first few years of symptoms.

But generally speaking, the symptoms start on one side, tend to linger there for, you know, maybe a year, maybe two or three years if you're lucky, and then start to involve the other side as well.

Host: Yeah, and it sounds like Parkinson's can present without tremors. And if that's true, then, you know, how often is that? Like what percentage, if you can put a percentage on it?

Dr. Nima Beheshti: Yeah. We know about a third of patients never get a tremor in the course of their Parkinson's. And so, it's on us, the neurologist, to look for other symptoms of Parkinson's. So, we look for the rigidity, we look for the slowness, we look for the falls or the balance difficulties. And then, there's a whole host of what we call non-motor symptoms that we ask about to try to get to the bottom of, you know, is this Parkinson's or not.

Host: Yeah. Let's stay there. Let's talk about the non-motor symptoms, because I think for most of us, we associate-- whether it's because of Michael J. Fox and others, family members we've known-- is those, you know, the classic motor symptoms, tremors, rigidity, those kinds of things. What are some of the non-motor symptoms?

Dr. Nima Beheshti: In no particular order, some of the symptoms we see with patients that can develop over the first few years of Parkinson's include memory issues, especially kind of at the five to seven-year mark. There can be some short-term memory loss. Depression, anxiety and apathy are very common. More than half of patients will experience those. Other symptoms include hallucinations. Sometimes there are kind of mild things like small pets or small children, even shadows. But later in the disease, they could be more distressing.

Some patients will get blood pressure fluctuations, especially when they stand up, so they'll get very lightheaded when they stand up and could even pass out, which is dangerous. I mentioned constipation. There could also be difficulty with urination, either too frequent or not enough. Choking on foods is alarmingly common and is the number one cause of death in patients with Parkinson's. And so, swallowing difficulties is something we often ask about.

Other symptoms can include drooling, you know, like a very severe uncontrollable drooling. And like I mentioned also the vivid dreams and acting out of dreams. You know, there are many more, but those are just some of the symptoms that we see. Those are what we call the non-motor symptoms, so in addition to, you know, the tremor, rigidity, slowness, and balance issues.

Host: It sounds, Doctor, like there's a range of symptoms from person to person. It makes me wonder if that's true, then do we have any sense of like what the influence is on that variability? Is it age, height, weight, family history, diet? Like, take us through that. Do you have any sense of why it varies so much?

Dr. Nima Beheshti: That's a very great question. There are a number of things that can affect the progression, and we're learning more about this every day. So, you listed a few of them. So, age is a big one. Patients who tend to get Parkinson's at a younger age, we say under the age of 50, they tend to have less of a tremor component and more of a stiffness component, like they're just very rigid and have difficulty moving.

You mentioned family history. So, we suspect at this time that maybe 15% of Parkinson's patients have a genetic component associated with it. You know, we're learning more genes all the time. Just a few years ago, we used to say 5%, but we found more genes and now we think it's 15%. People with a genetic component tend to have earlier presentation than their counterparts. And then, some other components.

So, we know that there is no cure for Parkinson's, and that the only treatment that slows it down is exercise. So generally speaking, my patients who have led very physically active lives, or athletes, they're runners, they tend to have a slower progression of their Parkinson's. And so, that tends to be a very helpful factor.

And then, somewhat uniquely in the Salinas area, we have some up and coming evidence that exposure to pesticides may be linked with an increased rate of Parkinson's disease. And so, we are looking into this. The risk is highest for our farm worker community and the workers in the field themselves. And in my personal experience, the patients who have gotten Parkinson's while working in the field or after working in the field, they tend to get a slower progressing version of Parkinson's. But again, we're still working on the data for that one.

Host: How do we tell doctor the Parkinson's symptoms, like how do we differentiate, in other words, between just normal aging, the stuff we all go, "Oh, well, you know, I am getting older," right, and other perhaps neurological conditions?

Dr. Nima Beheshti: Parkinson's is a tough diagnosis to make at the best of times. And you're right, it tends to fall in our older patients who may already have issues with memory loss, balance, maintaining blood pressure. So, part of it is, you know, we look to see is this part of a bigger Parkinson's picture? And that kind of helps us link it together.

Some of the treatments for some of these conditions are Parkinson's-specific. And so if someone is having difficulty walking and it's due to Parkinson's, you know, we try the medicine for Parkinson's and see if it gets better. And if it doesn't, that makes us think maybe this is unrelated. And so, part of it is trial and error on our part of just seeing-- You know, let's try different treatments that are unique to one condition or another, and seeing if you respond. For other things like memory difficulties with Parkinson's, it's really hard to tell is this memory loss due to Parkinson's, due to dementia, like Alzheimer's, or is it both? And in most cases, it's both.

And so, you're right. It's a challenge to tell. For better or for worse, there isn't too much of a difference in treatment. Normally, we treat them the same whether they're from Parkinson's or other causes. So functionally, it's not that different for us. But you're right, it is a challenge for us diagnostically.

Host: Wondering, you mentioned what a big risk choking is for Parkinson's patients. It's like the number one cause of death, right? So, it makes me wonder then, which symptoms have the greatest impact on just the quality of life of Parkinson's patients?

Dr. Nima Beheshti: We've studied this extensively. And interestingly enough, the symptoms that affect quality of life change depending on when you ask someone in their Parkinson's story. So in the early years of Parkinson's, people will cite tremor and balance issues as being some of the most difficult symptoms to deal with.

But at the five or seven-year mark, the data starts to change. Patients will complain more of apathy, which is where they just don't want to do anything, and depression. And then, the other one is the constant pill burden of having to take more and more pills more frequently. It gives them a constant up and down in their symptoms where they're feeling on and very active and then, an hour later, will feel very slow and very off is what we call it.

So, that constant fluctuating between the on and the off times, later on that gets cited as the most difficult part of their Parkinson's. And so, it really depends on when you ask someone, but those are the kind of things that we ask about, because we do have ways to manage all of these symptoms, but I always ask all my patients, you know, what is most bothersome to them? And that's what we try to focus on.

Host: Yeah. And just learning from you today and, as I'm sure listeners are as well, I heard you say depression is a thing, is a real thing for Parkinson's patients. And I'm getting a better sense of that, of just what they go through physically, emotionally. As you say, they're up, they're down, they're hot, they're cold, they feel great, and then they feel horrible. I just wanted to have you touch on that a little bit, just sort of the mental side of it or the psychological side of it.

Dr. Nima Beheshti: Absolutely. I tell my patients all the time that Parkinson's itself is a devastating illness and it affects all parts of your life. And so, that alone is enough reason to have depression, anxiety, and apathy. But we also do know that the chemical changes, the up and down of the dopamine, and the constant fluctuation make you more susceptible to depression and anxiety. And so, it's why we see them as some of the most common symptoms in Parkinson's. In fact, we suspect more than 90% of patients with Parkinson's will have anxiety at some point. So, this is much more common than the tremor, for example. We just don't see it as much.

Host: Right. Yeah. Again, that maybe that's an entirely separate podcast. But for today, let's finish up here and just talk about which symptoms or when the respective symptoms should, in your opinion, prompt referral. Like, when do we need to, you know, move forward, to speak with someone like yourself, to be properly diagnosed and start having conversations?

Dr. Nima Beheshti: In my experience, the most common referral reason that I see is for tremor. So, to make sure a tremor is Parkinson's or not. But like I mentioned, that's going to miss about a third of patients who never have a tremor. So, in my opinion, the most important symptom that should warrant further evaluation by a neurologist should be falling that we can't otherwise explain. So if balance is getting worse, there's frequent falls, we're now having to use a walker or maybe even a wheelchair. And if we don't have a clear reason for why they should be evaluated by a neurologist, because that could be one of the symptoms of Parkinson's, and it's one of the most dangerous symptoms of Parkinson's.

Host: Yeah. This is anecdotal at best, but I remember watching something on Michael J. Fox and just the frequent falls and the fall risk and in just how often Parkinson's patients end up hurting themselves because of the falls, as you say. It's at the top of the list. And if it can't be explained otherwise, that's a good time to reach out, to be referred. Really appreciate your time today. There's so many more questions I want to ask you and I want to keep you on for longer, but for today, thanks so much.

Dr. Nima Beheshti: Thank you. I really appreciate it.

Host: And to listen to more of our podcasts, please visit salinasvalleyhealth.com/podcasts. And if you found this podcast to be helpful, please be sure to tell a friend, neighbor, or family member. And subscribe, rate and review this podcast, and check out the entire podcast library for additional topics of interest. This is Ask the Experts from Salinas Valley Health. I'm Scott Webb. Stay well, and we'll talk again next time.