Episode 132: Managing Comorbidities with Parkinson’s Disease

Dan Keller 0:02 Welcome to this episode of Substantial Matters: Life and Science of Parkinson's. I'm your host, Dan Keller. At the Parkinson's Foundation, we want all people with Parkinson's and their families to get the care and support they need. Better care starts with better research and leads to better lives. In this podcast series, we highlight the fruits of that research—the treatments and techniques that can help you live a better life now, as well as research that can bring a better tomorrow.

Comorbidities are those conditions or diseases that a person experiences simultaneously with a particular disease. For example, a person with Parkinson's disease may also have arthritis, asthma, elevated cholesterol, kidney problems, or psychiatric or emotional problems. This raises questions of who is the best healthcare provider to treat the comorbidity. What other conditions would a movement disorder specialist feel comfortable treating? And how can care best be coordinated among the various treating physicians? I spoke with movement disorders neurologist Dr. Ashley Rawls of the University of Florida about how she approaches the issues arising with comorbidities in her patients with Parkinson's.

Dr. Ashley Rawls 1:33 Many of my patients will have additional health problems along with their Parkinson's disease, and many times I will evaluate their health problems as well, and make sure that they have the appropriate specialist that's helping to also care for those problems. I think it's important that when you see your movement disorder specialist, that your focus of the majority of your visit is going to be with the movement disorder itself. I want to have the best person for the best job, and that also means with certain other comorbidities or diseases, having a care team that can also address different parts of that as well, based on their experience.

Dan Keller 2:17 Do patients sometimes ask you to handle other conditions outside of your area of practice, and what do you tell them at that point? How do you advise them?

Dr. Ashley Rawls 2:26 Yes, patients have asked me to handle other conditions or comorbidities outside of my area of practice. My general advice is that if it is not part of the movement disorder for which they've come to see me, it is best addressed by either their primary care provider or a specialist in that field. I'm always happy to refer a patient to a specialist that is outside of my area of expertise. You would want to have the provider with the most expertise in that field to treat the ailment that falls underneath their purview. So, I feel like that is a better approach to make sure that we're focusing on the movement disorder while the patient is there.

Dan Keller 3:02 What comorbidities can you, or should you, handle as a movement disorder specialist? You had talked about some that you would refer out to the appropriate practitioner.

Dr. Ashley Rawls 3:14 This depends on the comfort level of the movement disorder specialist. Your movement disorder specialist is there to address your problems associated with your Parkinson's disease, and I believe that should be the focus of your visit now. If your movement disorder specialist feels confident addressing other neurologic issues, such as neuropathy or headaches, then I would leave it up to their discretion to do so. Some movement disorder specialists feel confident in treating mild anxiety and depression with medications. Other comorbidities are likely better handled by specialists that are trained in that area, particularly if there's several comorbidities involved, or if they are moderate to severe in nature. I think this is going to be a discussion between the patient, patient's family members, and the movement disorder specialist as a part of the care team, to see what they feel comfortable with treating.

Dan Keller 4:05 Who coordinates care, or how do you get it done? I assume you have many people to call upon, but how do you coordinate who's doing what?

Dr. Ashley Rawls 4:15 Excellent question for the person that really helps us coordinate care. I usually will involve the primary care provider, the general practitioner. Most of the time, that is the practitioner or the provider that has referred the patient to the tertiary care center for their Parkinson's disease care. So that is the person that I usually send back my note, and also recommendations to as well. Usually the primary care provider is going to be one of the center of the person's care team, mainly because the primary care provider is the one that sees the patient most often and helps coordinate their care, helping to make sure that the specialists are on the same page. So working closely with the primary care provider is a must.

Dan Keller 5:02 What kind of conditions do you see in your Parkinson's patients? Are they just the normal things of aging and what we all run into, or are there any conditions that affect Parkinson's patients more than others?

Dr. Ashley Rawls 5:17 Many of the patients that I see, a vast majority of them usually tell me that they have been healthy for majority of their lives and have not had to seek continued medical care for other significant issues besides the run of the mill cough and cold, which is interesting when they come in with Parkinson's disease, that becomes some of their main complaint. However, I've seen many comorbidities. The most that I've seen with the Parkinson's disease is going to be arthritis, cardiovascular disease, high blood pressure, strokes, and the like, diabetes, anxiety, depression, and sometimes thinking problems or cognitive impairment, but everyone differs when they present.

Dan Keller 5:58 Is there any connection between developing diabetes and Parkinson's?

Dr. Ashley Rawls 6:03 So there is some emerging evidence that suggests there could be a relationship between Parkinson's disease and diabetes. So, both of these disease states deal with abnormal protein accumulation, dysfunction of some of the powerhouse of the cell, the mitochondria, and kind of systemic inflammation across the body. There have been many studies out there. Systematic reviews and meta-analysis have explored the relationship between diabetes and the risk of Parkinson's disease, but the results can somewhat be conflicting. Some studies have shown that people with type two diabetes have a greater risk of developing Parkinson's disease, and they've been repurposing a diabetic drug, Exenatide, a GLP-1 analog, to see if they could reduce the severity of Parkinson's disease. Would I say that there's an actual direct correlation between the two? I think that remains to be seen, but there is research out here that is currently investigating this.

Dan Keller 6:58 I've seen some talk about people with melanoma are at a higher risk for Parkinson's, and people with Parkinson's are at a higher risk for melanoma. Do you recommend that they get skin exams on a routine basis?

Dr. Ashley Rawls 7:13 Well, I'm currently based in Florida, and I recommend all of my patients, regardless of skin tone, to get skin exams, given the high amount of sun exposure that is here. I do recommend that my patients with Parkinson's disease be established with a dermatologist if they already have not been, because there can be a lot of skin issues that can occur with our patients that have Parkinson's disease—namely seborrheic keratosis or dermatitis that can happen with dry skin, particularly at the top of the head. This is something I feel can be with general overview of care as well, particularly in a very hot and sunny state like Florida. So, I do recommend that my patients seek out dermatologists, particularly if they have abnormally shaped moles or spots on their skin that may be concerning for cancer.

Dan Keller 8:03 Do comorbidities present more of a problem to people with PD? I'm thinking things as mundane or daily as being able to open the medicine container or things like that. Is that a problem, or are there other problems that would be particularly troublesome to people with Parkinson's that otherwise wouldn't?

Dr. Ashley Rawls 8:23 Yes, I would say that one big thing that can be difficult for this patient population is arthritis, in particular. My patients already have difficulty with stiffness and slowness of the body, and so compounding that with arthritis with deep bone pain or stiffness of the joints, this can make it difficult to fill out forms or turn pages on a book, cook, and also it can make it difficult for things like opening bottles. So that can definitely be an issue with my patients who are trying to just get over the problems of stiffness and slowness with Parkinson's disease and have compounded on top of it arthritis.

Dan Keller 9:03 Are there problems with medication interactions, especially for all these other conditions with levodopa?

Dr. Ashley Rawls 9:11 Yes, so some comorbidities can make management of Parkinson's disease more difficult and require careful consideration to avoid conflicting management. One main thing that I see is are my patients who are coming in who have a history of hypertension or high blood pressure, and they usually come in placed on blood pressure lowering agents. However, Parkinson's disease itself, and also the medications we use to treat Parkinson's disease, can actually lower our blood pressure, so then it comes in where some of my patients may present with lightheadedness and potentially fainting, usually upon standing, or almost fainting upon standing, and that can be precipitated by a low blood pressure state.

So the first thing that I do, the patient comes to me and says, "I am, you know, having this issue of lightheadedness that's pervasive, particularly upon standing," is I look at the person's medications and say, "Okay, is there something on here like an anti-blood pressure medication or a prostate medication that could be decreasing the blood pressure that needs to be adjusted or decreased or withdrawn to see if that will improve some of the symptoms that may come along with Parkinson's disease?" So that's one big example that I see in my clinic many times.

Dan Keller 10:28 And I take it some of those problems could probably be overcome by drinking more water or being a bit slower when you decide to stand up, things like that.

Dr. Ashley Rawls 10:37 Yes, so there are other behavioral changes that can be used to help combat low blood pressure, like using compression stockings while awake, making sure to exercise the feet before standing, trying to get in six to eight cups of water a day. Those are things that can be helpful sometimes. Salty foods, however, sometimes you could also be fighting a losing battle if you're on several blood pressure medications that are dropping your blood pressure, and you're trying to increase your blood pressure to make sure that you're having blood being able to get back to your brain or perfusing your brain. So, it is important to take a look at the medications to make sure there aren't any interactions between either the Parkinson's disease medication or the Parkinson's disease itself.

Dan Keller 11:22 Are people cognizant of over-the-counter medications, that these count too as medications, and that they should check with somebody before using them?

Dr. Ashley Rawls 11:33 So that can vary between person to person. Whenever I see my patients in clinic, I always ask about medications that have been prescribed, then also any over-the-counter medications as well, because some of the medications, unfortunately, that we think are for one indication can also have side effects like thinning out the blood or increasing the blood pressure that we may not be as aware if your providers aren't told about it. So I always make it a point to ask my patients, is there anything else they're taking that may not be on their medication list. One thing that can be helpful that all patients can do is to bring their medications in a bag in the original bottles. Then that can be helpful if there's an uncertainty about what a medication does, or if we're not sure how long they've been taking it, that can be helpful for us to see real time in clinic.

Dan Keller 12:25 What advice would you give to one of your patients who feels that their doctors aren't talking to each other? Or I guess the real question is, how much do people have to be their own advocate, and how strongly?

Dr. Ashley Rawls 12:40 So, if there is a concern that your providers do not appear to be on the same page with each other, the first step really is to speak with your providers and express your concern. It may not be apparent that there's a breakdown in communication between the providers, and sometimes simply bringing the issue to light is adequate to start the process of better communication. It goes without saying that if all of your providers are within the same system, it's likely easier for them to communicate and access clinic notes. However, many people are seeing multiple providers in different healthcare systems, so things that can be helpful are giving access to your outside notes, sending or even bringing updated notes with you to your appointments can be helpful.

I also want to caution that the provider that you have may not have the time during the appointment to read several notes from other physicians, but they should be able to review those notes at a later time. What I sometimes encourage my patients to do is to send the updated notes to the provider before the appointment, and then sending a message saying, "Hello, I have sent these notes to your facility, can you please review them, so we could potentially talk about what changes have occurred since we saw you last time." I will say that you and your loved ones are going to be the best advocates for your healthcare. If you feel that with your best efforts, that your needs are not being attended to by your current treatment team, you can always consider seeking out a new team that better fits your needs.

Dan Keller 14:08 You had mentioned that it's good to have your providers in the same system, because they can coordinate. I suppose the corollary to that may be you should keep using the same pharmacy or pharmacy chain, because they will know what medications you're on, and if a new one could possibly have interactions or things like that, they would have your whole history in front of them. Do you ever find a problem with people going to different pharmacies, or do you advise them to use the same one?

Dr. Ashley Rawls 14:36 Yes, so many of the patients that I see usually stay with the same pharmacy. It just makes it easier when all their medications are in the same place. Now, some of my patients do have specialty pharmacies that they have to order from as a part of their insurance to get the medications covered, but I usually recommend that they keep their medications with the same pharmacy. Unless they have one that's a mail order of a run of the mill medication, then sometimes I send it there, but usually before I prescribe a medication, I make sure that I have the appropriate pharmacy on file, because sometimes people can be moving around or on vacation, or they find the medication can be given cheaper, or they have an insurance change, but overall I do recommend that they stay with the same pharmacy, if possible.

Dan Keller 15:26 Do you ever have in your practice snowbirds? I mean, they're seeing somebody up north as well as in the winter down south.

Dr. Ashley Rawls 15:33 Yes, I do. I think that variety is the spice of life, and I welcome any person that comes to the door to see if I can help them with their Parkinson's disease. So I do have patients that spend six months out of the year in Florida, and then the rest of the time they're somewhere up north in Boston, New York, out west. So it is interesting having people come down for half the year and then go elsewhere. I do recommend that they have, if not a neurologist, at least a movement disorder specialist available to them when they are that far away or that amount of time, six months out of the year, so that they can make sure that they have someone who is checking on their Parkinson's disease.

And I pride myself on being collaborative, particularly with persons who are out of state, so if there are changes that are being made, I know about them, and then vice versa—the other outside hospital physician also knows about what they're doing while they're in Florida under my care. So it is important to create a bond in that way, not just with the patient who's the snowbird, but also their other treating physician.

Dan Keller 16:40 Very good, I appreciate it. This is very helpful advice, I'm sure, for people with Parkinson's and relating to their treating physicians. So, thank you.

As Dr. Rawls discussed, coordination of care among one's clinicians is important. Parkinson's education director and nurse, Lisa Mann of the Oregon Health and Science University, sheds more light on the topic in our podcast called Team Care for PD: Why it's important. She discusses who should be part of the core team, and how other therapists and healthcare professionals can be brought onto the team as needed. To learn more about comorbidities with PD, you may be interested in another past podcast of ours featuring Dr. Connie Marras of the University of Toronto, simply called Comorbidities in Parkinson's.

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At the Parkinson's Foundation, our mission is to help every person diagnosed with Parkinson's live the best possible life today. To that end, we'll be bringing you a new episode in this podcast series every other week. Till next time, for more information and resources, visit parkinson.org or call our toll-free helpline at 1-800-4PD-INFO, that's 1-800-473-4636. Thank you for listening.

Ashley Rawls, MD, MS is a clinical assistant professor at the University of Florida College of Medicine, specializing in Movement Disorders at the Fixel Institute for Neurological Diseases. After completing her undergraduate degree at Duke University and master’s degree in aging and neuroscience from the University of South Florida, Dr. Rawls received her medical degree from the University of Florida in 2014. After medical school, she completed her neurology residency at the Medical University of South Carolina. Then, she pursued a clinical movement disorders fellowship and post-doctoral research fellowship at Stanford University. Dr. Rawls is board-certified in neurology by the American Board of Psychiatry and Neurology, and she is currently licensed to practice medicine in both Florida and California. Dr. Rawls has also been recognized for her diversity and inclusion advocacy, such as serving as co-Chair on the University of Florida Department of Neurology Diversity and Inclusion Committee, and recently being elected to the Journal of America Medical Association (JAMA) Neurology as the Diversity, Equity, and Inclusion Editor.