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What is Parkinsonís disease?
Parkinsonís disease is a progressive disorder of the central nervous system resulting in a lack of dopamine in the brain, among other changes. Dopamine, a chemical produced by cells in the brain, is necessary for smooth, controlled movement of muscles. While researchers do no know what causes Parkinsonís disease at this time, the mission of The Parkinson's Institute is to: Enhance the Care, Find the Cause and Promote the Cure.

What is the usual course of Parkinsonís disease?

The most common initial symptom is tremor. Symptoms of tremor or slowness usually begin on one side of the body, often involving either an arm or leg. Over time, the other limb on the same side and/or limbs on the opposite side are usually affected. Mobility may become limited as the disease progresses. For most individuals on treatment, lifespan is not shortened by Parkinsonís disease.

In addition to the well-known symptoms of tremor, slowness and imbalance, other problems such as excessive saliva, a soft voice, as well as hand and foot cramps may occur. Depression, anxiety and a number of sleep disorders are quite common. Constipation, more frequent urination, increased sweating, and low blood pressure may develop. Some people with Parkinsonís disease will develop changes in memory and intellectual function.

A variety of treatments are available for many of the symptoms of PD. They include general health measures, physical and/or speech therapy as well as a number of medications. The treatment for Parkinsonís disease is individualized and is guided by a number of factors including the general health and symptoms of an affected individual.

The Neurologists at PI have specialized training in Movement Disorders and are extremely skilled in diagnosing and treating Parkinsonís disease, atypical parkinsonism and related conditions such as dystonia, blepharospasm, and hemifacial spasm. Call the New Patient Coordinator to become a patient at 800 655-2273

Who does Parkinsonís disease affect?
Parkinsonís disease affects approximately 1.5 million Americans. It strikes men slightly more often than women and is a condition usually affecting people in the over 60 age group. However, about 15% of patients with PD are diagnosed before the age of 40.

How does depression affect Parkinson's patients?

Over many years of taking care of people with Parkinson's disease, I have met with hundreds of patients, even more if you include the ones I have met at support groups and patient conferences. The vast majority of the patients I have met are optimistic, intelligent people intent on living life to the fullest, despite their diagnosis.

During an office visit, when I ask patients if they are depressed, most of them say no. I commonly hear "I get down once in a while, but I can snap myself out of it"

However, most studies have found that depression is extremely common in Parkinson's disease, present in up to 90% of patients depending on the type of depression scale that is used.

What accounts for this apparent discrepancy?

It is my belief that the problem arises in part from the terminology used. The word "depression" tends to imply a degree of sadness that is overwhelming, perhaps incapacitating, with overt displays of emotion, tears or even suicidal intentions.

Most PD patients do not report having anywhere near this degree of emotional upheaval, though of course there are exceptions. For example, people who have recently been diagnosed with PD or a related condition such as MSA(Multiple Systems Atrophy) may become quite depressed as they struggle to come to terms with the diagnosis and all of the potential implications on their life, work and loved ones. This is a perfectly natural response, though counseling and/or antidepressants may be helpful during this period. Typically, most patients get through this time with amazing strength and resolve as they learn to "fight back" against their PD with exercise, medications, and family support.

For the less acutely depressed group, we probably need a better term, something that means "not as happy as usual, a bit down" to describe the mood of many PD patients.

Family members, when asked, frequently tell me that the patient does have some degree of depression, even when the patient does not complain of a mood problem. Of course, this must be differentiated from the motor aspects of PD, which may cause the face to appear less animated even if the person is not actually depressed. Significantly, though, spouses and adult children may say that the patient no longer does things that he or she used to enjoy, avoids going out and no longer participates in previous activities (clubs, sports, volunteering).

The patient may blame this on the PD itself, even when the symptoms are quite mild, but it often turns out that depression is really to blame. Even when symptoms are more bothersome, some "quality time" with a good physical or occupational therapist can make many of these activities possible again, once the mood disorder is treated and interest returns.

As discussed in a previous issue, anxiety is a frequent companion to depression in PD and is sometimes a bigger problem. Treating both of these symptoms is an important step in improving quality of life for many reasons. In addition to effects on functions such as appetite and motivation to exercise, both depression and anxiety can cause insomnia and early morning waking. Sleep, vital to everyone for maintaining good health, is especially important in people with PD and other forms of parkinsonism. When patients who report having "good days and bad days" are questioned closely, they often note a strong relationship between a sleepless night and poor motor function the next day.

So how do we treat depression? In an ideal world, I would refer every patient to a well-rounded program that includes individual and family counseling, meditation, stress management, perhaps even a week at a spa, or a yoga retreat in a beautiful setting. The realities of life, insurance, time constraints, and often unwillingness on the part of patient makes most of this holistic approach hard to come by. Moreover, studies have shown that PD can cause changes in the levels of some brain chemicals related to mood, such as serotonin and norepinephrine. Therefore, drugs that restore the balance of these substances to a more normal balance, are often the most effective therapy. Patients are often reluctant to take these drugs, which include SSRIs such as Lexapro (escitalopram) and Paxil (paroxetine), because they have heard negative things about them, but when prescribed appropriately, they usually are safe and effective in people with PD.

Two troubling symptoms that may or may not respond to therapy for depression are fatigue and apathy (loss of motivation). In fact, fatigue is noted by most PD patients whether they have depression or not. Apathy may occur as part of a spectrum of depressive symptoms but may remain after depression has resolved. We work hard to treat these troubling symptoms in our patients. Drugs like Provigil (modafinil) or Ritalin (methylphenidate) help in some cases, but may cause side-effects in others. We have yet to find a solution that works for everyone.

As a patient, the best way to approach these issues is to work with people who know you well to identify mood issues that could be having a negative effect on your overall quality of life. Then, bring them to the attention of your doctor and prepare to be open-minded about possible solutions. Remember, a positive attitude is one of your most important assets in fighting PD!

Melanie M. Brandabur, MD
Clinic Director
The Parkinson's Institute

How can I handle the anxiety and stress of Parkinson's disease?

Patients with PD often ask whether stress affects their PD symptoms.

The answer is a definite "Yes!" While we don't know the exact mechanism for this, it does appear that many patients describe worsening of symptoms, including tremor, slowness and difficulty walking when in stressful situations.

Frequently patients describe stressful events that seemed to be associated with the initial onset of their PD symptoms. For example, many noted a tremor that appeared or was noticed following a major operation, a head injury or the diagnosis of another condition, such as thyroid disease. In other instances, symptoms were noted after a particularly stressful event, such as the death of a spouse or other family member.

Once the diagnosis of PD is established, stress remains a common cause of worsening symptoms. For example, having houseguests for the holiday may be a happy occasion but it may also be stressful, and patients frequently describe worsening of their symptoms during these times. Patients describe the stress of suddenly needing to go to the bathroom as another source of anxiety that can increase their symptoms and slow them down, making it difficult to get there in time. Even going to see the doctor may be a stressful event that can temporarily worsen symptoms.

Managing stress can be challenging but can often be done by keeping some simple ideas in mind: Plan ahead! Ask for help! Build in extra time!

During holidays, for example, it might be a good idea to enlist the help of family members to help with guests; perhaps they can house some of the visitors or help with food preparation and clean-up. Just because the person with PD has always been the main 'do-er' when it comes time to entertain doesn't mean that they can't begin to accept some help. Perhaps you can entertain one or two people at a time, instead of a whole houseful of visitors. Also, most guests are happy to help out when askedÖso ask!

With regard to bathroom visits, it is sometimes helpful to schedule them at regular intervals so that getting there does not become such an emergency. For instance, use the restroom every 2-3 hours whether you feel the urge or not.

Doctor visits can be less stressful if you plan to arrive early and bring and updated list of medications and a list of questions to ask the doctor. Think about changes made at your last visitÖ.did they help? Did they cause or lessen any side-effects?

Another good strategy for stress reduction is to practice a discipline such as yoga or meditation in which controlled breathing is taught. The breathing techniques learned in either program can be an excellent way to get stress under control in many situations.

Anxiety is another frequent symptom of PD and often goes hand-in-hand with stress. Anxiety or even panic attacks, often accompanied by depression, may occur because of changes in serotonin and norepinephrine in PD. Family members will say things like "She worries about everything!" Anxiety may also respond to some of the stress reduction ideas listed above. Finally, it is often helpful to treat anxiety with a low-dose SSRI (selective serotonin reuptake inhibitor) such as Lexapro or Paxil. While a benzodiazapine medication such as Xanax may be OK to take once in a while, frequent use may affect balance or thinking and are best avoided if possible.

In summary, stress and anxiety can be significant factors in PD and quality of life for some patients. Discuss these issues with your PD doctor and work together to find the best coping strategies for you.

Melanie M. Brandabur, MD†

675 Almanor Avenue | Sunnyvale, CA 94085
408.734.2800 main | 408.734.8455 fax (Main) | 408.734.9208 fax (Clinic Secure)