Transcription:
Latest Advances in Parkinson's Treatment

Melanie Cole (Host): According to the National Parkinson’s Foundation, an estimated one million people in the United States have Parkinson’s disease. My guest today is Dr. Jill Giordano Farmer. She’s a neurologist with Lourdes Health System as well as Drexel Neuroscience Institute where she’s Director of Drexel’s Movement Disorder and Parkinson’s Disease Program. Welcome to the show, Dr. Farmer. So, tell the listeners first, a working definition: what is Parkinson’s disease.

Dr. Jill Giordano Farmer (Guest): Hi. Thanks so much for having me. Parkinson’s disease is a disorder of movement primarily. You move slower. You may notice a tremor. You may notice balance problems and you may notice an increased stiffness but it’s not just that. There are also what we call non-motor symptoms of Parkinson’s disease and those can include things like constipation, sleep disturbances where you act out your dreams very vividly, depression and anxiety, and sometimes cramping. Sometimes you can also have the softening of your voice and you can notice that your writing changes where it gets much smaller the longer you write.

Melanie: Who is at risk for Parkinson’s? Is there a genetic component to it?

Dr. Farmer: There is a genetic component to it but it’s actually a very small component of patients with Parkinson’s disease. The vast majority of people have what’s known as “sporadic Parkinson’s disease”, meaning that we don’t know why but for whatever reason, usually it happens in people above the age of 65. They will just go on to develop this loss of dopamine which is this chemical in the brain that helps coordinate movements, thoughts, and emotional qualities. The genetic component usually is seen in patients that have Parkinson’s disease that presents much younger than 65 and also if they do have a strong family history, it can be considered. They have isolated a number of genes but this testing is not routinely done because it does not change the management. Whether you have a Parkinson’s disease diagnosis that does have a gene identified or whether you don’t, you’re still treated with the same medications and the same therapy recommendation.

Melanie: Do we know what causes the loss of those dopamine-producing neurons?

Dr. Farmer: We don’t. That’s the million-dollar question and that’s where a lot of the research right now is currently looking. We do know that there are some potential risk factors. As far as environmental risk factors go, the one that I always find important to mention is Agent Orange exposure. Because if patients have had exposure to this chemical through their military service, they may be able to get service connected through the Veterans’ Administration for their routine care medications and any other procedures associated with Parkinson’s disease. But, the vast majority of environmental factors are really just looked upon as potential risks, nothing that actually causes Parkinson’s disease.

Melanie: Are there some symptoms? What would send somebody to even be diagnosed with Parkinson’s? Are there some things they would notice--maybe tremors? Because a lot of people get those little shaking hands and right away that’s what they think of. But, are there some symptoms that you can identify that say, “Yes, you know this is a red flag”?

Dr. Farmer: Sure. I always, whenever I’m always evaluating a new patient who comes in with a concern of tremors, I say just that. Whenever someone has a tremor, the first thing they think of is, “Oh, no! Do I have Parkinson’s disease?” There are things to look at over the course of time. If you’ve had tremors your entire life and if they are in both hands instead of one hand and if you notice that they get really bad in social situations or if you drink alcohol that they sometimes get a little bit better and if you have a family history where other people in your family have these types of tremors in both hands or in their head where their head may bob up and down, this is more along the lines of another condition called “essential tremor”. If you’re an older person that notices a tremor intermittently when you’re at rest and I should state that for essential tremor, this mostly happens when you’re trying to do an action. So, if you’re reaching for an object or if you’re eating or if you’re applying makeup or something like that, you’ll notice the tremor more. If you’re an older patient that notices a tremor that starts on one side that happens primarily at rest and is able to go away when you are doing an activity, that is something that can be more consistent with a Parkinson’s tremor. But, it’s not just the tremor. If that comes along with a decreased arm swing and worsening feeling of balance, if it comes along with an increased stiffness on that same side, then you may have this tremor. If it comes in context with other things not related to a tremor such as sleep disturbances or constipation or things like that, then all of those reasons are good enough to bring up to your doctor and ask, “I have all of these symptoms. Could they be related to Parkinson’s disease?” And no one will fault you for getting an evaluation with a neurologist or movement disorder specialist because the best thing we can say is, “Nope, this is not Parkinson’s disease but it was good of you to take the time to find out.”

Melanie: If you do diagnose somebody, what is the first line of treatment? This can’t be cured, correct?

Dr. Farmer: Correct.

Melanie: So, what you are doing is managing the symptoms and some of these comorbidities that go along with it.

Dr. Farmer: Correct. It really all depends on the severity of the patient’s symptoms and as far as neurologic conditions go, Parkinson’s patients do have a number of effective treatment strategies available to them. It can be pharmacologic with medication and I explain it to patients to think of it like diabetes. If a diabetic person is deficient in insulin, you give them insulin and they’re able to function fairly normally and able to have their regular diet as best they can. For someone who is deficient in dopamine, if they have Parkinson’s disease, if I’m able to replace or mimic your dopamine, then you can function fairly normally in the beginning of the disease. Depending on how severe their motor symptoms are, it will determine the type of medicine we use. The strongest medicine we have is carbidopa-levodopa also known as Sinemet and it’s been around since the late 1960s. It was the medication that was discovered in the movie, Awakenings, if anybody has ever seen that movie. And, that essentially replaces the dopamine that your body is lacking. Then, there are other medications that are a little less potent but can still be equally effective in helping the motor symptoms. These medicines are called dopamine agonists or a medication that’s called “MAO-B” inhibitor which helps recycle the dopamine that your brain is still making and the levodopa that your body takes through medication by preventing its breakdown. So, if they don’t have a very significant tremor or they are not terribly stiff or rigid or slow, then we might use one of the less potent medicines. If they do have a significant motor problem where they have a very significant tremor that’s impacting them significantly or they’re very stiff and slow, then we might start with the Sinemet or the carbidopa-levodopa. In addition to the medicine, regardless of how severe or not severe your symptoms are, there is always a role for therapy-- physical therapy, occupational therapy, and speech therapy. There are specific programs for patients with Parkinson’s disease called the “LSVT” or the Lee Silverman Voice Therapy program which is a regimented one-hour-a-day/four-day-a-week program for speech therapy and a one-hour-a-day/four-day-a-week program for physical therapy that essentially retrains the Parkinson’s patient’s brain to function and move more normally. It is never an unconscious thing; it’s something that the Parkinson’s patient will always have to think about doing. But if they do do it and if they do it routinely and through cueing, then it becomes a more natural movement or a more natural speech pattern for them. There is a newer variation of this therapy called “Parkinson’s Wellness Recovery” or “PWR” and that is also very effective in helping patients maintain their fluidity, their balance, and their walking in a more natural cadence and pattern. Also, there is the concern for depression and anxiety and if that is something that goes along with the Parkinson’s disease diagnosis because it is a chronic diagnosis or if it’s part of the disease process itself, that also needs to be addressed and managed as needed, whether it’s through support groups or through counseling or through pharmacologic therapy with antidepressants and anti-anxiety medications.

Melanie: I’m so glad you spoke about all the various therapies because that was going to be my next question. What about staying well and living with Parkinson’s, what advice do you have Dr. Farmer for families and for the loved ones about exercise, nutrition, things they should do around the home for their Parkinson’s patient?

Dr. Farmer: Sure. So, when I sit down and discuss the diagnosis with the patient and their families, again, I try to lay it out in a landscape. Think of this while it’s a degenerative condition; think of it more like a chronic condition because we do have very effective therapies and strategies. The caveat is it takes work. I can’t give you a pill and have everything go away without any effort on the patient or family’s part. So, there does need to be active enrollment in those therapy programs and, like I said, it can be for anybody on the spectrum--from someone who is not very impacted by their symptoms yet to people who are significantly impacted by their symptoms. But, the sooner you sort of modify your behavior and change your process in being able to participate in some of the behavioral modification strategies of exercise and therapy and changing your diet and nutrition and sleeping well and things like that, this only helps down the road as the disease and the symptoms change and progress. So, I do try to tell patients that if, while they are getting a diagnosis that no one ever wants to hear, they do have a lot of tools available to them to be able to maintain a good quality of life and a high level of function for a fairly long period of time. I also try and stress more for the families and the caregivers don’t nitpick. There are going to be times where they just don’t want to participate in therapy or they just don’t want to do the things that you want them to do because apathy can become a part of Parkinson’s disease. And, to maintain everybody’s level of sanity, people do need in a sense to sort of pick their battles. They should be encouraging. They should be thoughtful in trying to help patients maintain a good quality of life but if there are some times when doing that is becoming more stressful than allowing the patient to do what they want to do, then you sort of need to have a conversation and a dynamic to figure out the best way to proceed and keep everybody happy.

Melanie: And, what are the most promising areas of current research?

Dr. Farmer: So, the most promising areas of current research really are looking into disease modification and something called “neuroprotection”. So, they’re looking at borrowing medications from other subspecialties whether it’s blood pressure or patients that have gout that may have some sort of protective benefit on those nerves in the brain that are making the dopamine and that you’re losing in Parkinson’s disease. They’re also looking into other therapies that are used for other conditions such as cancer or infectious disease to see if modifying your immune system or using lower doses of chemotherapy agents could also improve some of the loss of the dopamine neurons through different mechanisms. All of these things could potentially have the benefit to slow progression or reverse the symptoms of the disease but these are all in the very early stages of research. And, we tell patients, because Parkinson’s patients are extremely well educated and they teach me things all the time that they read on the internet and that they’ll bring in to talk about in the office, that we don’t know the long term effects of borrowing these other therapies that are already out there for different things. And, we don’t know the appropriate doses to use in patients with Parkinson’s disease. So, while they’re exciting potential developments, they’re not really safe to start to use just yet in patients with Parkinson’s.

Melanie: So, wrap it up for us in the last minute or so here, Dr. Farmer, with your best advice for loved ones, people with Parkinson’s, what you tell them every day about living with Parkinson’s disease.

Dr. Farmer: I tell them that they have a strong support system whether they know it or not and that’s through their family members that accompany them to the office visits and through me as their medical provider and my access to other specialties and therapists that are certified and familiar in dealing with patients with Parkinson’s disease. It’s important for them to take advantage of the resources that are out there. If they feel overwhelmed by their resources that are out there, then those are the questions they need to ask me so that I can help direct them. Like I said, there are very good and effective therapies. There are very good and effective medications and there are many support groups in the area for patients with Parkinson’s disease. They should use their movement disorder specialist as their resource to be able to help them navigate the things that are available. So, I often tell my patients that they’re already seeing a movement disorder specialist if they see me but if they do have friends with Parkinson’s disease or other family members that are not seeing a movement disorder specialist, it’s helpful for them to at least come and get evaluated. They don’t need to change their doctors if they’re happy with the doctor they’re seeing but a subspecialist in the area of Parkinson’s may have a little bit more access and a little bit more specific treatment strategies that they can share, that they can then take with them back to their family doctor or general neurologist.

Melanie: Thank you so much for being with us. It’s great information. You're listening to Lourdes Health Talk. For more information, you can go to www.lourdesnet.org. That's www.lourdesnet.org. This is Melanie Cole. Thanks so much for listening.