Episode 21: What Other Conditions Are Related to Parkinson’s?

Dan Keller 00:08

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 conditions that occur along with another disease. People with Parkinson's may face a variety of comorbidities. These can be the result of Parkinson's or its treatments, or they may just be conditions that are common among the general public. Also, as Parkinson's progresses, you're likely to be taking multiple types of medications several times a day. When you add in drugs to treat comorbidities, you increase the chance that the medications will interact with each other. It all gets pretty complicated. To help sort it out and get suggestions on how to deal with comorbidities, I spoke with Dr. Connie Marras, a movement disorders neurologist at the University of Toronto in Canada. She sees comorbidities as falling into two main categories.

Dr. Connie Marras 01:35

You can divide comorbidities in Parkinson's disease into things that happen because of the Parkinson's disease, and then things that happen not related specifically to Parkinson's disease, or for which we don't understand the relationship. At least those that are related to Parkinson's disease, I would say one of the most common comorbidities is infections, in particular pneumonia. And this can occur because people with Parkinson's disease have difficulties controlling the swallowing of liquids and foods, and some of them will go down the windpipe occasionally and lead to infections like pneumonia, and that's commonly called aspiration pneumonia, and that can be a particularly dangerous complication of Parkinson's disease, often leading to hospital admission. Urinary tract infections can happen also in Parkinson's disease. And the other big one that I would always think about is falls. Because of the balance difficulties that people with Parkinson's disease have, they're more prone to falls, particularly as the disease progresses. And obviously the big danger is fractures, like hip fractures, for example, which are also a major cause of hospital admission in people with Parkinson's disease. So those I put under the category of things that are related directly to the Parkinson's disease. There are also associations with other diseases that we don't really understand, and so a number of observational studies in Parkinson's disease have identified associations with other conditions, and one of them that's emerging and is of significant interest is, for example, diabetes, which has been found to be a risk factor for Parkinson's disease, actually, and there is emerging evidence that people with diabetes and Parkinson's disease have a risk of more aggressive progression of Parkinson's symptoms. That would be the way I think about comorbidities in Parkinson's disease.

Dan Keller 03:35

Cardiovascular disease also often goes along with diabetes. So does that also complicate things?

Dr. Connie Marras 03:42

Yes, in fact, there's been a number of studies looking at the relationship between cardiovascular disease and Parkinson's disease, and there does seem to be an increased incidence of cardiovascular disease, maybe because of the diabetes association. Also, there's an association between levodopa treatment, which you may well know is a cornerstone of Parkinson's disease therapy, and metabolic changes that may predispose to cardiovascular disease. And while that's not something we can particularly avoid, because levodopa is, as I said, a cornerstone of therapy, it is something that needs to raise our awareness of the need to monitor for cardiovascular disease in this population.

Dan Keller 04:25

People with chronic disease often have some depression. Does depression also occur here? And does treatment of depression, especially with drugs, have the potential to interfere with treatment of the Parkinson's disease?

Dr. Connie Marras 04:39

For sure, depression is a part of Parkinson's disease. I didn't mention it as a comorbidity so much because I think of it as an integral symptom of Parkinson's disease and not something that arises sort of as a secondary event or sort of an unrelated, coexisting event. So we're more and more aware of non-motor symptoms in Parkinson's disease, like depression, anxiety as well, constipation, and blood pressure issues, particularly low blood pressure, for example. So these things all go along as part and parcel of Parkinson's disease, and I wouldn't label them as comorbidities so much, but maybe that's a semantic issue. And depression is a major non-motor symptom of Parkinson's disease, and I do think that it has implications for Parkinson's disease health above and beyond the depression itself. Because it seems that in people who are depressed, all the symptoms get worse, all of the other symptoms that we're treating in Parkinson's disease are exacerbated and also are often more resistant to treatment themselves. So the treatment of the underlying depression often gives people benefits even beyond their mood.

Dan Keller 05:56

Are all these conditions in the realm of the neurologist, or do other kinds of physicians have to come in to deal with some of these comorbidities?

Dr. Connie Marras 06:07

So definitely not all in the realm of the neurologist. So when coming back to the comorbidities that I mentioned, for example, the falls, I would be seeking guidance from my physiotherapy colleagues, for example. Often, with respect to the multidimensional symptoms that we've already talked about, geriatricians are a very useful type of physician who can look at the problem more holistically than neurologists can. And so working alongside those other professionals is often very important. And obviously, you know, cardiovascular disease and diabetes are not the wheelhouse of the neurologist. And so if we identify a patient who has other risk factors for cardiovascular disease, like high blood pressure or diabetes, for example, we would then be referring on, and I think that it's important to facilitate that multidisciplinary care, for sure.

Dan Keller 07:08

Is there anything that people with Parkinson's disease can do to avoid some of these other conditions that either arise from the Parkinson's disease or are just common in people of older age? What can they do to help themselves before these things either develop or once they have them?

Dr. Connie Marras 07:27

We can take measures to try to prevent complications. So coming back to pneumonia, for example, because a major risk factor for pneumonia in people with Parkinson's disease is the swallowing difficulty, then the neurologist has a responsibility to ask about swallowing difficulties and to make people with Parkinson's disease aware that this is an issue. If people with Parkinson's disease are noticing coughing, for example, with swallowing of food and liquids, then it's very useful for us to give some bridging advice about swallowing, so avoiding things that are dry and crumbly that can go down the wrong way, taking things into the mouth in small amounts so that you're avoiding large amounts that have to be handled by the swallowing mechanism. And those pieces of advice can be helpful. And then we also need to engage our speech-language pathology colleagues to do swallowing studies, and they are really the experts in judging the risk associated with swallowing difficulty in Parkinson's disease. And they can do more advanced swallowing studies than could be done in an office, so video swallow studies, for example, that can actually document things going down the wrong way. And then sometimes they will recommend more advanced or significant interventions like thickening of liquids. And so they can help us a great deal in that regard. So vigilance regarding swallowing, coming back to being vigilant if you're coughing with your liquids or your solids, that should be an alarm bell to something happening. And then with respect to falls, you know, if people are feeling unsteady on their feet or having stumbles or near falls, then we want to try interventions like early consultation with physiotherapists. Or many communities have falls prevention programs that physicians can refer patients to in order to prevent those kinds of complications, like serious falls that lead to hip fractures, for example. And then things that are not related to Parkinson's disease, like cardiovascular disease or not directly causally related, let's say, we can be, again, vigilant for those risk factors in our patients, such as high blood pressure, smoking, high cholesterol, and blood sugar control that then would be taken on by the internal medicine physicians or the family doctor to help control. And that may help, making a patient with Parkinson's disease more robust in their general health is only going to help with respect to being able to combat these other aspects of the disease that are related to Parkinson's itself.

Dan Keller 10:06

A lot of people on chronic medication really have trouble with compliance or adherence, meaning taking the medication as prescribed often enough, in correct doses, things like that. Is that any more of a problem in people with Parkinson's, or do they just fall into the general category of trying to remember or afford their medication?

Dr. Connie Marras 10:28

I think it's particularly challenging for people with Parkinson's disease because often the medications are taken so many times per day. This is not so much an issue in the first years of the disease, but as the disease progresses, we can have patients taking medication every two to three hours, and that is very burdensome and difficult for people. So I do think that it's more challenging for people with Parkinson's disease.

Dan Keller 10:55

Is it recommended that people with Parkinson's either tell their pharmacist or tell other physicians about their complete medical history, because I would think there could be a lot of drug interactions when you have a lot of drugs?

Dr. Connie Marras 11:13

Always a good idea, for sure. And this is particularly not so much an issue perhaps with levodopa, which has relatively few drug interactions compared to others. But when we start to add on medications like antidepressants, for example, or medications for other non-motor symptoms, then these can definitely have interactions with other medications. And so that is an important aspect. And Parkinson's disease being such a multifaceted disease, people can get on quite a number of medications for the Parkinson's itself, and then you add on things for the comorbidities, and it really does add up. So it's very important for the patients to be talking with their pharmacists about interactions, and then for the pharmacist to be relaying this to doctors, and also for the patients to be telling their other doctors about their medication list. So I think one thing that often, as a movement disorder neurologist, I feel that I've sometimes done an incomplete job if my patient doesn't come with a full list of their medications, even beyond Parkinson's disease, so that I can't take a look and make sure that the combination seems safe. So my advice to people with Parkinson's disease is always carry a complete list of your medications to all your doctor's appointments and share that with your physicians.

Dan Keller 12:31

I suppose it's good to use just one pharmacy or one pharmacy chain so they know all your medications. If you go and get prescriptions filled at different places, they may not understand or know what else you're on?

Dr. Connie Marras 12:44

Absolutely yes, that's definitely a good idea, because otherwise they're not going to be able to flag those interactions.

Dan Keller 12:53

What kind of advice would you give to someone with Parkinson's disease, considering what we've been talking about, comorbidities? Are there any sort of nutshell pieces of advice that they should keep in mind?

Dr. Connie Marras 13:06

So I think we always want to try to prevent complications and these comorbid issues, like infections and falls, for example. So with respect to the infection issue, I'd say always be vigilant for coughing with your swallowing and tell your physicians about that, because there are things we can do then to reduce the risk of pneumonia. Another important point is that infection will often make all of the symptoms of Parkinson's disease worse. So if you have an infection of any kind, say a urinary tract infection, that can set off all the symptoms of Parkinson's disease and make it seem like your Parkinson's disease is progressing when what is happening is you have another illness that's making the problem worse. So if you're calling your neurologist saying, "My symptoms of Parkinson's disease have all of a sudden gotten quite a bit worse," the physician should be thinking about these other comorbid illnesses that might be playing a role. But also as a patient, you can help by mentioning any other issues with your health that are going on right now that might be playing a role. So keeping that in mind. And then the other nutshell, I think, is make sure that you talk to your physician about difficulties with balance and ask about referral to falls prevention or physiotherapy that can optimize your safety to prevent falls and fractures.

Dan Keller 14:36

Very good. I appreciate it.

Dan Keller 14:46

For more information on comorbidities in Parkinson's disease, you can call our toll-free helpline at 1-800-4PD-INFO. Our PD information specialists can provide you with information and resources, including movement disorders experts with experience in this area. They can also direct you to relevant past Parkinson's Foundation webinars. If you have any questions about the topics discussed today, or if you want to leave feedback on this podcast or any other subject, you can do it at parkinson.org/feedback. This episode of Substantial Matters was made possible through the generous donations of thousands of people affected by Parkinson's and a grant from Mylan 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. Our next two episodes will focus on hallucinations, a symptom not many people realize can be caused by Parkinson's. Psychosis can be a scary word, so our expert guests will help allay any fears you may have and help you understand this potential symptom. You can also tune into a Parkinson's Foundation expert briefing webinar on psychosis on February 27 at 1 PM Eastern Time. Go to parkinson.org/expertbriefings to register, see our schedule of upcoming webinars, and listen to all our past webinars. Until then, for more information and resources, visit parkinson.org or call our toll-free helpline at 1-800-473-4636. Thank you for listening.

Dr. Marras trained in neurology and movement disorders at the University of Toronto. She subsequently obtained a PhD in epidemiology at the University of Toronto and further trained in epidemiologic research methods at the Parkinson’s Institute in California. She is currently an Associate Professor of Neurology at the University of Toronto and a neurologist at the Toronto Western Hospital Movement Disorders Centre, a Parkinson’s Foundation Center of Excellence. She also serves as an Associate Editor for the Movement Disorders Journal, Executive Committee member of the Pan-American section of the Movement Disorders Society and vice-chair of the research ethics board of the University Health Network in Toronto. Areas of research focus include the epidemiology and clinical expression of Parkinson’s disease and evaluating clinical assessment tools in Parkinson’s disease.