PATIENT CONTENT

Parkinson’s Disease
Parkinson's disease is a progressive disorder that is caused by degeneration of nerve cells in
the part of the brain called

by AANS

APRIL 30, 2024 PRINT

OVERVIEW

Parkinson’s disease is a progressive disorder that is caused by degeneration of nerve cells in the part
of the brain called the substantia nigra, which controls movement. These nerve cells die or become
impaired, losing the ability to produce an important chemical called dopamine. Studies have shown
that symptoms of Parkinson’s develop in patients with an 80 percent or greater loss of dopamine-
producing cells in the substantia nigra.

Normally, dopamine operates in a delicate balance with other neurotransmitters to help coordinate
the millions of nerve and muscle cells involved in movement. Without enough dopamine, this balance
is disrupted, resulting in tremor (trembling in the hands, arms, legs and jaw); rigidity (stiffness of the
limbs); slowness of movement; and impaired balance and coordination – the hallmark symptoms of
Parkinson’s.
The cause of Parkinson’s essentially remains unknown. However, theories involving oxidative
damage, environmental toxins, genetic factors and accelerated aging have been discussed as
potential causes for the disease. In 2005, researchers discovered a single mutation in a Parkinson’s
disease gene (first identified in 1997), which is believed responsible for five percent of inherited
cases.

Prevalence and Incidence

It is estimated that 60,000 new cases of Parkinson’s disease are diagnosed each year, adding to the
estimated one to 1.5 million Americans who currently have the disease. There were nearly 18,000
Parkinson’s disease-related deaths in the United States in 2003. While the condition usually develops
after the age of 55, the disease may affect people in their 30s and 40s, such as actor Michael J. Fox,
who was diagnosed at age 30.

A partial list of famous people with Parkinson’s:

Muhammad Ali, boxer (boxing-induced)

Johnny Cash, singer

Michael J. Fox, actor

Estelle Getty, actress

Billy Graham, evangelist

Pauline Kael, film critic

Deborah Kerr, actress

Janet Reno, former U.S. Attorney General

George Roy Hill, 81, director

Michael Redgrave, 77, actor

Pope John Paul II, 84, pope

Terry-Thomas, 79, actor

SYMPTOMS OF PARKINSON’S DISEASE

Tremor or the involuntary and rhythmic movements of the hands, arms, legs and jaw

Muscle rigidity or stiffness of the limbs – most common in the arms, shoulders or neck

Gradual loss of spontaneous movement, which often leads to decreased mental skill or reaction
time, voice changes, decreased facial expression, etc.

Gradual loss of automatic movement, which may lead to decreased blinking, decreased frequency
of swallowing and drooling

A stooped, flexed posture with bending at the elbows, knees and hips

Unsteady walk or balance

Depression or dementia

DIAGNOSIS OF PARKINSON’S DISEASE

Presently, the diagnosis of Parkinson’s is primarily based on the common symptoms outlined above.
There is no X-ray or blood test that can confirm the disease. However, noninvasive diagnostic
imaging, such as positron emission tomography (PET) can support a doctor’s diagnosis.
Conventional methods for diagnosis include:

The presence of two of the three primary symptoms

The absence of other neurological signs upon examination

No history of other possible causes of parkinsonism, such as the use of tranquilizer medications,
head trauma or stroke

Responsiveness to Parkinson’s medications, such as levodopa

TREATMENT OF PARKINSON’S DISEASE

The majority of Parkinson’s patients are treated with medications to relieve the symptoms of the
disease. These medications work by stimulating the remaining cells in the substantia nigra to
produce more dopamine (levodopa medications) or by inhibiting some of the acetylcholine that is
produced (anticholinergic medications), therefore restoring the balance between the chemicals in the
brain. It is very important to work closely with the doctor to devise an individualized treatment plan.
Side effects vary greatly by class of medication and patient.

Levodopa
Developed more than 30 years ago, levodopa is often regarded as the gold standard of Parkinson’s
therapy. Levodopa works by crossing the blood-brain barrier, the elaborate meshwork of fine blood
vessels and cells that filter blood reaching the brain, where it is converted into dopamine. Since blood
enzymes (called AADCs) break down most of the levodopa before it reaches the brain, levodopa is
now combined with an enzyme inhibitor called carbidopa. The addition of carbidopa prevents
levodopa from being metabolized in the gastroinstenal tract, liver and other tissues, allowing more of
it to reach the brain. Therefore, a smaller dose of levodopa is needed to treat symptoms. This
advance also helps reduce the severe nausea and vomiting often experienced as a side effect of
levodopa. For most patients, levodopa reduces the symptoms of slowness, stiffness and tremor. It is
especially effective for patients that have a loss of spontaneous movement and muscle rigidity. This
medication, however, does not stop or slow the progression of the disease.

Levodopa is available as a standard (or immediate) release formula or a long-acting or “controlled-

release” formula. Controlled release may provide a longer duration of action by increasing the time it
takes for the gastrointestinal tract to absorb the medication.

Side effects may include nausea, vomiting, dry mouth and dizziness. Dyskinesias (abnormal
movements) may occur as the dose is increased. In some patients, levodopa may cause confusion,
hallucinations or psychosis.

Dopamine Agonists
Bromocriptine, pergolide, pramipexole and ropinirole are medications that mimic the role of chemical
messengers in the brain, causing the neurons to react as they would to dopamine. They can be
prescribed alone or with levodopa and may be used in the early stages of the disease or administered
to lengthen the duration of effectiveness of levodopa. These medications generally have more side
effects than levodopa, so that is taken into consideration before doctors prescribe dopamine
agonists to patients.
Side effects may include drowsiness, nausea, vomiting, dry mouth, dizziness and feeling faint upon
standing. While these symptoms are common when starting a dopamine agonist, they usually resolve
over several days. In some patients, dopamine agonists may cause confusion, hallucinations or
psychosis.

COMT Inhibitors
Entacapone and tolcapone are medications that are used to treat fluctuations in response to
levodopa. COMT is an enzyme that metabolizes levodopa in the bloodstream. By blocking COMT,
more levodopa can penetrate the brain and, in doing so, increase the effectiveness of treatment.
Tolcapone is indicated only for patients whose symptoms are not adequately controlled by other
medications, because of potentially serious toxic effects on the liver. Patients taking tolcapone must
have their blood drawn periodically to monitor liver function.

Side effects may include diarrhea and dyskinesias.

Selegiline
This medication slows down the activity of the enzyme monoamine oxidase B (MAO-B), the enzyme
that metabolizes dopamine in the brain, delaying the breakdown of naturally occurring dopamine and
dopamine formed from levodopa. When taken in conjunction with levodopa, selegiline may enhance
and prolong the effectiveness of levodopa.

Side effects may include heartburn, nausea, dry mouth and dizziness. Confusion, nightmares,
hallucinations and headache occur less often and should be reported to the doctor.

Anticholinergic medications
Trihexyphenidyl, benztropine mesylate, biperiden HCL and procyclidine work by blocking
acetylcholine, a chemical in the brain whose effects become more pronounced when dopamine levels
drop. These medications are most useful in the treatment of tremor and muscle rigidity, as well as in
reducing medication-induced parkinsonism. They are generally not recommended for extended use in
older patients because of complications and serious side effects.

Side effects may include dry mouth, blurred vision, sedation, delirium, hallucinations, constipation and
urinary retention. Confusion and hallucinations may also occur.

Amantadine
This is an antiviral medication that also helps reduce symptoms of Parkinson’s (unrelated to its
antiviral components) and is often used in the early stages of the disease. It is sometimes used with
an anticholinergic medication or levodopa. It may be effective in treating the jerky motions associated
with Parkinson’s.

Side effects may include difficulty in concentrating, confusion, insomnia, nightmares, agitation and
hallucinations. Amantadine may cause leg swelling as well as mottled skin, often on the legs.

Surgery
For many patients with Parkinson’s, medications are effective for maintaining a good quality of life.
As the disorder progresses, however, some patients develop variability in their response to treatment,
known as “motor fluctuations. During “on” periods, a patient may move with relative ease, often with
reduced tremor and stiffness. During “off” periods, patients may have more difficulty controlling
movements. Off periods may occur just prior to a patient taking their next dose of medication, and
these episodes are called “wearing off.” Uncontrolled writhing movements, called dyskinesias, may
result. These problems can usually be managed with changes in medications. Based upon the type
and severity of symptoms, the deterioration of a patient’s quality of life and a patient’s overall health,
surgery may be the next step. The benefits of surgery should always be weighed carefully against its
risks, taking into consideration the patient’s symptoms and overall health.

Neurosurgeons relieve the involuntary movements of conditions like Parkinson’s by operating on the
deep brain structures involved in motion control – the thalamus, globus pallidus and subthalamic
nucleus. To target these clusters, neurosurgeons use a technique called stereotactic surgery. This
type of surgery requires the neurosurgeon to fix a metal frame to the skull under local anesthesia.
Using diagnostic imaging, the surgeon precisely locates the desired area in the brain and drills a small
hole, about the size of a nickel. The surgeon may then create small lesions using high frequency radio
waves within these structures or may implant a deep brain stimulating electrode, thereby helping to
relieve the symptoms associated with Parkinson’s.

Pallidotomy
This procedure may be recommended for patients with aggressive Parkinson’s or for those who do
not respond to medication. Pallidotomy is performed by inserting a wire probe into the globus
pallidus – a very small region of the brain, measuring about a quarter inch, involved in the control of
movement. Most experts believe that this region becomes hyperactive in Parkinson’s patients due to
the loss of dopamine. Applying lesions to the global pallidus can help restore the balance that normal
movement requires. This procedure may help eliminate medication-induced dyskinesias, tremor,
muscle rigidity and gradual loss of spontaneous movement.

Thalamotomy
Thalamotomy uses radiofrequency energy currents to destroy a small, but specific portion of the
thalamus. The relatively small number of patients who have disabling tremors in the hand or arm may
benefit from this procedure. Thalamotomy does not help the other symptoms of Parkinson’s and is
used more often and with greater benefit in patients with essential tremor, rather than Parkinson’s.

Deep Brain Stimulation (DBS)

DBS offers a safer alternative to pallidotomy and thalamotomy. It utilizes small electrodes which are
implanted to provide an electrical impulse to either the subthalamic nucleus of the thalamus or the
globus pallidus, deep parts of the brain involved in motor function. Implantation of the electrode is
guided through magnetic resonance imaging (MRI) and neurophysiological mapping, to pinpoint the
correct location. The electrode is connected to wires that lead to an impulse generator or IPG (similar
to a pacemaker) that is placed under the collarbone and beneath the skin. Patients have a controller,
which allows them to turn the device on or off. The electrodes are usually placed on one side of the
brain. An electrode implanted in the left side of the brain will control the symptoms on the right side
of the body and vice versa. Some patients may need to have stimulators implanted on both sides of
the brain.

This form of stimulation helps rebalance the control messages in the brain, thereby suppressing
tremor. DBS of the subthalamic nucleus or globus pallidus may be effective in treating all of the
primary motor features of Parkinson’s and may allow for significant decreases in medication doses.

Experimental Research
Embryonic stem cell research is a promising field that has created political and ethical controversy.
Scientists are currently developing a number of strategies for producing dopamine neurons from
human stem cells in the laboratory for transplantation into humans with Parkinson’s disease. The
successful generation of an unlimited supply of dopamine neurons may offer hope for Parkinson’s
patients at some point in the future.

Research currently being explored utilizes embryonic stem cells, which are undifferentiated cells
derived from several day-old embryos. Most of these embryos are the product of in vitro fertilization
efforts. Researchers believe that they may be able to prompt these cells, which can theoretically be
manipulated into a building block of any of the body’s tissues, to replace those lost during the
disease’s progression.

There is hope that adult stem cells, which are harvested from bone marrow, may be utilized in a
similar way to achieve results. Fewer ethical questions surround this sort of research, but some
experts believe that adult stem cells may be more difficult to work with than those from embryos.
Either way, the scientific community is nearly unanimous in arguing that research efforts and
potential breakthroughs will be negatively impacted if they are not allowed to work on both types of
stem cells.
Human studies of so-called neurotrophic factors are also being explored. In animal studies, this
family of proteins has revived dormant brain cells, caused them to produce dopamine, and prompted
dramatic improvement of symptoms.

Secondary Parkinsonism
This is a disorder with symptoms similar to Parkinson’s, but caused by medication side effects,
different neurodegenerative disorders, illness or brain damage. As in Parkinson’s, many common
symptoms may develop, including tremor; muscle rigidity or stiffness of the limbs; gradual loss of
spontaneous movement, often leading to decreased mental skill or reaction time, voice changes, or
decreased facial expression; gradual loss of automatic movement, often leading to decreased
blinking, decreased frequency of swallowing, and drooling; a stooped, flexed posture with bending at
the elbows, knees and hips; an unsteady walk or balance; and depression or dementia. Unlike
Parkinson’s, the risk of developing secondary parkinsonism may be minimized by careful medication
management, particularly limiting the usage of specific types of antipsychotic medications.

Many of the medications used to treat this condition have potential side effects, so it is very
important to work closely with the doctor on medication management. Unfortunately, secondary
parkinsonism does not seem to respond as effectively to medical therapy as Parkinson’s.

Note from AANS

The AANS does not endorse any treatments, procedures, products or physicians referenced in these
patient fact sheets. This information is provided as an educational service and is not intended to
serve as medical advice. Anyone seeking specific neurosurgical advice or assistance should consult
his or her neurosurgeon, or locate one in your area through the AANS’ Find a Board-certified
Neurosurgeon online tool.

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