Transcription:
Treatment Options for Parkinson's Disease

Melanie Cole (Host): Parkinson's Disease affects millions of patients worldwide, but potential new treatments being examined by UVA neurologists and neurosurgeons may give patients more options. My guest is Dr. Binit Shah. He's a neurologist at UVA Health System specializing in treatments for Parkinson's disease and other movement disorders. Welcome to the show, Dr. Shah. Let's speak a little bit about Parkinson's disease. People don't often really know what it is or what causes it. Are there certain risk factors?

Dr. Binit Shah (Guest): Well, what it is, at least from our understanding, is we know that it's what's called a neurodegenerative disorder. In other words, that means parts of the brain start to degenerate and die off, leading to abnormal neurologic symptoms. The exact cause of that, we don't know, at least on a molecular level. But how it tends to present is that patients can have any constellation of slowing of movement, either on one side of the body or notice slowing of walking, stiffness, particularly stiffness on one side of the body as well, but really can affect both sides even early, or a typical tremor that we see. So unlike other types of tremor where it's usually seen with action or intentional movement, oftentimes, this tremor tends to happen more when people are sitting quietly and resting or particularly stressed or anxious. As far as what the risk factors are, I think that's a hot area of research. We've known for a long time that age is the biggest risk factor. In other words, the incidence of Parkinson's disease goes up after the age of 60, but younger patients can be affected as well. Understanding what those risks are are important. Some things that we know about repetitive head trauma increases the risk of developing Parkinson's, but we don't exactly know what. Also, a family history of Parkinson's disease can increase somebody's risk of developing Parkinson's, so that overall amplitude effect is fairly low. So just because there's a first degree relative affected, while that increases another person's chance of developing Parkinson's, it still remains well below one percent of a chance. And then there's some other studies looking at various sorts of environmental exposures, things like pesticides, and particularly other things associated with farming or rural communities, that have been shown to potentially be associated with Parkinson's. But again, we still don't know exactly why that's the case.

Melanie: Now, people often see that tremor in people, which can happen for so many reasons, really. Right away, they think Parkinson's, but there are other more telling symptoms, aren't there, that, Dr. Shah, would signal really getting to a neurologist pretty quickly because you want to catch this as early as possible?

Dr. Shah: Exactly. Tremor, as you mentioned, is very common, and it happens to, really, the majority of people at some point in their lives. And it may not be related to anything that's leading to degeneration of neurologic functions. So when we're thinking about Parkinson's, it's not only a tremor that we're looking for. There are really other features that can be subtle, especially early on. But if they're recognized, and certainly people who specialize in Parkinson's or see a lot of Parkinson's patients, whether that be a Parkinson's specialist, a general neurologist, or even a family physician, can pick up on subtle cues like slowing of movements, deterioration of writing in particular patterns, that can help us make the diagnosis.

Melanie: So once you've made this diagnosis -- and is it a tough diagnosis to make?

Dr. Shah: It is, to a certain degree. Unlike many other diseases that we think of, there's no single lab test or imaging, MRI or CAT scan or anything like that that really makes the diagnosis. So it's truly what's called a clinical diagnosis made in the room with the patient between the physician and the patient. So there can always be some uncertainty with that. I think that a lot of the evidence has shown that the more experienced somebody is in seeing patients with Parkinson's, the better they are at accurately diagnosing it or ruling it out. But in the absence of what we call a marker of the disease, it can be challenging at times, absolutely.

Melanie: Now, when we talk about treatments, medication being what, the first line of treatment? And we will talk about some lifestyle things as well, but what is the first thing you do when you've discovered that someone has this diagnosis?

Dr. Shah: Well, it goes to what our treatments are. Ideally, we would have treatments that both help the symptoms as well as slow or stop the disease progression. Unfortunately, where we are now is we have very good symptomatic treatment but not necessarily anything proven to slow or stop the disease. Of course, the ultimate goal is to reverse and turn the disease, but unfortunately, we're not there yet.

Melanie: So it's really symptom management at that point.

Dr. Shah: Exactly. It's really treating symptoms. When we talk about symptom control, especially early in Parkinson's, we can do that very well. And our goals then turn into well, what are the symptoms, how are the symptoms bothersome or problematic for patients, and what can we do to sort of treat those particular symptoms. So, it's a sort of multi-directional approach. If we're talking about things like the tremor and slowness and stiffness that we're looking at replacing a particular neurotransmitter in the brain, something called dopamine, which we can do fairly effectively with a number of different medications to help with, the most effective one being something called Levodopa that's available in a combination pill called Cinemet But there are many other options of other classes, including Dopamine agonists and another group called MAO inhibitors. But when we also talk about Parkinson's, we know that it's not simply a disease of motor neurologic features. There can be other things involved, including sleep disturbances, depression, or anxiety, and it's important to treat those things appropriately as well, particularly where they interfere with people's quality of life.

Melanie: Now, what about surgical procedures, deep brain stimulation and such? What's being examined at UVA that can give some hope to people with Parkinson's?

Dr. Shah: Well, I think it's an important thing to mention. When we talk about surgical treatments, our goal -- again, it's still symptomatic treatment, so we're still in the same phase where we're trying to improve patient symptoms. What we look for with surgery is to mimic the best effect of the medications. But when there may be limitations to the medication, either if they are wearing off too early or they don't last or they don't kick in early enough or there may be side effects due to the medications, we can use surgery to provide a baseline level of support, above which additional medication may be necessary, but hopefully, we can reduce that and provide sort of a smoother benefit throughout the day. The theory behind surgical treatments is there are abnormal neurologic circuits in the brain. Essentially, the brain can be thought of as clusters of cells where there are connections between them. In Parkinson's, we know that due to the degeneration, abnormal signals are being sent through these pathways. If we interrupt these abnormal pathways in particular areas, we could treat the slowness, stiffness, and tremor in combination or the tremor itself. We're targeting just another particular area. The FDA-approved treatments we have for doing this are deep brain stimulation, which involves going in through the skull and implanting an electrode into a deep part of the brain and running that down under the skin to a pacemaker-like device in the chest, and then we can program that stimulator. So we can kind of tailor effect to treat the symptoms that are really bothering patients. The other way is to go in and actually make a burn lesion rather than leaving in a stimulator. That's traditionally also involved making a borehole or making a small drill hole through the skull going in with the electrode, heating up the tip of that electrode, and then removing it when we know we're at the right spot.

Melanie: Dr. Shah, in just the last 30 or 40 seconds, please wrap up Parkinson's for us. Give some hope to people listening for that symptom management and the work being done at UVA.

Dr. Shah: Absolutely. Going back to the surgical treatment with focused ultrasound, we're experimenting with taking those burn lesions in the brain without needing to make any incisions in the scalp. We're going through the skull, and we hope that that will be a safer surgical treatment that will have just as good effectiveness for patients with Parkinson's and all their features. But that's not all we're doing, and that's not all that's being done in Parkinson's research. Really, finding what the underlying cause is is really what's going to help us find a cure for this.

Melanie: And working on balanced and lifestyle management is all of what they do at UVA Health System. You're listening to UVA Health System Radio. For more information, you can go to uvahealth.com. This is Melanie Cole. Thanks for listening.