There are many factors to consider when a trip to the hospital is necessary during the COVID-19 pandemic. One important suggestion we have heard from our Parkinson’s disease (PD) community is to make sure to update your Advanced Directives if you have not already. This includes your health care power of attorney (or health care surrogate).

Even though it can be daunting, it is still important to go to the hospital if you do have a serious fall, a heart attack or another incident that warrants care. If you come prepared and advocate for yourself, you can have a successful hospitalization.

About Advanced Directives

Advanced Directives consist of two components:

1. Designation of Healthcare Surrogate (or Proxy)

A document where you name someone as a healthcare surrogate to make healthcare decisions on your behalf should you become incapacitated or unable to communicate. This could apply to a simple procedure where you receive anesthesia, like dental surgery, to more serious medical emergencies or hospitalizations, such as a coma.

2. Living Will

Document that provides directives, or your official instructions, relating to end of life decisions. While this can differ from state to state, a living will can only come into effect in the event that you are terminally ill or in a persistent vegetative state (showing no signs of higher brain function and only alive with medical intervention), and two doctors determine no reasonable medical probability of recovery.

Steps to Update Your Advanced Directives

1. Find the printable advanced directives here for your state (provided by AARP). Every state has its own paperwork.
    
2. Print and complete your state’s form. Some states require a notary public, a professional appointed by the state government to be an impartial witness for official documents, to notarize your advanced directives. If this is the case, you can usually find a free notary public at a local bank. All states require witnesses present to sign the form.
    
3. Keep several copies in your Aware in Care kit. Make sure your loved ones and/or next of kin has a copy. If you live alone, you can choose a trusted person to be your health care agent to ensure access to your directives. If you do not have someone to entrust with your directives, you should still fill out the form and keep several physical and digital copies with you.

Steps to Further Ensure Your Safety in The Hospital

• Now more than ever, it is important to bring all your Parkinson’s medications in their original bottle when going to the hospital, as a loved one may not be able to bring them to you if your medications are not in the hospital pharmacy (on formulary).
• Update your Medication Form and print copies to include in your kit.
• If possible, obtain your doctor’s signature for the Hospitalization During COVID-19 Letter, which should also be kept in your kit.
• Every hospital has a different policy around visitors during COVID-19, which includes care partners. Ask your local hospital ahead of time if you will be able to have an in-person advocate with you. Check multiple hospitals in your area — they might each have different policies.

Advice for Care Partners

Hospital staff may or may not take the initiative to contact your family while you are hospitalized, so immediately advocate for ongoing communication.

• Using the phone of the hospitalized person with Parkinson’s for video calls like Facetime, Skype or Zoom is HIPAA compliant, but requires the person with Parkinson’s to be conscious and coherent, which may or may not be the case.
• In addition to phone calls from the hospital, Zoom is typically HIPAA compliant from within the hospital, so a care partner can request updates via zoom video call.
• It is appropriate to contact the hospital to check in on your loved one. Some health professionals recommend calling in once a shift to have up-to-date information.

Learn More

Learn more about Parkinson’s, COVID-19 and hospitalization in the following Parkinson’s Foundation resources or by calling our free Helpline at 1-800-4PD-INFO (473-4636):

• Getting Organized
• Parkinson.org/COVID-19

Visit Parkinson.org/AwareinCare to order your Aware in Care kit and download essential hospitalization resources.  

Palliative care is a holistic, team-based approach to managing chronic health conditions, such as Parkinson’s disease (PD). Palliative care specialists champion quality of life and can be central to navigating the challenges of PD from initial diagnosis, onward. Most insurance plans cover all or part of palliative care treatment costs.

The following article is based on a Parkinson’s Foundation Expert Briefings webinar exploring the role of palliative care in Advanced PD, hosted by Janis M. Miyasaki, MD, MEd, FRCPC, FAAN, Director of the Parkinson and Movement Disorders Program at University of Alberta. Regarded as the founder of PD palliative care, Dr. Miyasaki leads a movement disorders group comprising several neurologists, a neurosurgeon, neuropsychiatrist and geriatrician, and a dedicated interdisciplinary team.

What is Palliative Care?

It’s important to distinguish that palliative care is not hospice or end-of-life care. Palliative care practitioners help patients focus on living well now by actively treating all aspects of a disease.

Palliative care:

• Improves life
• Provides pain and symptom relief
• Integrates psychological and spiritual aspects of patient care
• Supports patients and families; when caregivers do well, so do people with PD
• Addresses needs through multiple disciplines
• Begins early in the course of illness
• Affirms life and regards dying as a normal process
• Neither hastens or postpones death

The best palliative care emphasizes well-being. It also acknowledges difficult feelings, such as anger and despair, that can come with a Parkinson’s diagnosis. Addressing these emotions can help people with PD cope with the often-challenging job of managing day-to-day physical symptoms.

The Care Team Role

A person’s Parkinson’s disease journey often begins in a doctor or neurologist’s office. But addressing Parkinson’s changing needs, whether physical, emotional, social or spiritual, takes a team. Specialists can include doctors, nurses, social workers, chaplains, pharmacists, nutritionists and counselors.

People with PD can also struggle with existential distress. Different from depression, these hopeless feelings stem from trying to make sense of overwhelming events, such as a Parkinson’s disease diagnosis. It’s important to address these emotions. A psychologist or an experienced spiritual care practitioner can help.

Managing Pain

As Parkinson’s advances, coping with pain can pose another challenge. Always consult your physician for pain management advice. One of the first lines of PD pain treatment is levodopa, a dopamine agonist. It treats motor symptoms, including rigidity and dystonia (sustained or repetitive muscle twisting, spasms or cramps), associated with PD pain. Range-of-motion exercises, alone or with assistance, also offer relief. A doctor or experienced licensed physical therapist can recommend appropriate exercises.

If levodopa and exercise aren’t adequately addressing pain, talk to your doctor about injectable botulinum toxin A (BOTOX) treatment. It can alleviate dystonia by targeting and weakening overactive muscles.

When all else fails, ask your physician about prescription pain medication. Due to drowsiness, confusion and other side effects, pain medication is often considered last.

Reducing Side Effects       

It’s important to take any medications as prescribed. Skipping doses or waiting until the pain is unbearable can require larger doses of medication to treat symptoms, resulting in increased side effects.

Constipation, another unpleasant pain medication side effect, can lead to more problems, including stomach and back pain, difficulty absorbing medication and hemorrhoids.

Diet can help curtail constipation. It is important to:

• Drink 64 ounces of water each day
• Eat a well-balanced, high-fiber diet including fruit, vegetables and whole grains
• Include dried fruit such as figs, dates
• Consume more beans and less meat
• Avoid white bread, rice or pasta    

Consult your doctor about constipation treatment, which can include daily exercise, abdominal massage and/or over-the-counter and prescription therapies. Read the Parkinson’s Foundation publication Constipation and Other Gastrointestinal Problems in PD for constipation solutions to discuss with your doctor.

Planning Advance Care

Palliative care includes planning for the future; a step that requires careful, thoughtful decisions. Because forms can be complicated and confusing, it is important to start the planning process early.

Aging With Dignity’s Five Wishes document can help express:

1. Who makes future care decisions
2. Desired medical care
3. Comfort level
4. Preferred treatment
5. Information to share with loved ones

Conclusion

Palliative care fosters comprehensive Parkinson’s disease management. Initial pain management approaches include non-medication therapies and range-of-motion exercises to alleviate PD symptoms. Medication used as prescribed can also minimize pain. Identifying values and consulting a psychologist or spiritual care advisor can lessen existential distress. And advance care plans can guide future healthcare in accordance with your wishes.

Have questions about Parkinson’s disease or anything you read here? Call our Helpline at 1-800-4PD-INFO (473-4636) or email us at Helpline@Parkinson.org.

Marijuana and Parkinson’s disease (PD) is a hot topic. Watch our newest video, Neuro Talks, where James Beck, PhD, Parkinson’s Foundation Chief Scientific Officer, explains what the PD community should know about marijuana.

What are the risks of marijuana for a person with PD? Can it help with symptoms? What is the Parkinson’s Foundation doing to learn more? Find out in this four-minute video:

For more information, call the Parkinson’s Foundation Helpline today at 1-800-4PD-INFO (473-4636) or email us at Helpline@Parkinson.org with your Parkinson’s questions in English or Spanish.

A person with Parkinson’s disease (PD) may experience visual, cognitive and mobility challenges as symptoms progress or as side effects from certain medications. Compromised vision can make it difficult to distinguish objects, perceive depth and safely maneuver a space while cognitive changes may make previously automated tasks (such as walking) more cumbersome.

Visual cues, however, can help a person with PD stay on track. See how members of our PD community have embraced color to train their brains:

Comfort in the Home

Our surroundings are important to us and contribute to our overall mood. Soft, warm colors are calming. Incorporate tranquil shades of orange, brown, red, yellow, orange and yellow-green to make large spaces feel cozier.

Flooring Around the Home

Carpet

A solid-color carpet is best. Solid colors emphasize boundaries between the wall and the floor and any changes in surface level. Large patterns or multiple colors can be distracting and make it more difficult to maneuver across a space. Be particularly cautious and try to avoid using patterned carpets and rugs on steps and stairways.

Stairs

Apply brightly colored tape on the top and bottom steps to signal the beginning and end of the steps.

Doorways and Hallways

Placing colored tape lines in a doorway can make it easier for people with Parkinson’s who have difficulty moving and experiencing freezing episodes. The tape provides a visual cue for where to place each foot when moving through the door. Taped lines can be placed down a hallway or in other places where freezing often occurs.

Bathroom Safety

Consider color contrast when installing grab bars and other safety items. For example, put a dark grab bar on a white wall. Also consider adequate lighting with few darkened or shadowy spaces.

Sitting

Changes in the brain can make it difficult for a person with Parkinson’s to determine proper body alignment when moving to sit down in a chair. This can result in the person attempting to sit down before his or her body is close enough or in proper position to sit safely. Marking the floor with a taped “x” provides the proper cue for where a person’s foot needs to be before sitting.

Maintaining Independence

Dressing

Choices allow a person to maintain their self-esteem and dignity.

Allow the person with Parkinson’s to provide as much help as he or she can with dressing. Even if physical or thinking changes prevent a person from accomplishing this on their own, it is important to offer choices. For example, asking whether they would prefer a red shirt or blue shirt can encourage participation.

Cognitive

Keep things simple to avoid confusion. Limiting options can help streamline an activity.

Remotes that only offer the “off”, “on”, “volume” and “channel” options can restore self-sufficiency when watching TV. Consider covering remote control buttons with tape to help minimize visual distractions and streamline productivity.

Overcoming Freezing

Use a mobile laser device that creates a colored line for you to step over. To combat freezing of gait, there are canes and walkers available that project a laser line to help cue steps.

Eating and Food

Utensils

Due to vision changes, contrast sensitivity in the eye makes it hard to discern objects that are similar in color.

People with Parkinson’s may have difficulty if the color of the food is the same color as the dish. Consider using dark dishes when serving light colored foods and light dishes when serving dark foods.

You can also use contrasting placemats under the person’s dish to outline the edges of his or her bowl or plate.

Nutrition

Incorporate foods high in antioxidants (which are important for overall brain health) into your diet. Eat brightly colored and dark fruits and vegetables. Cranberries, strawberries, oranges, beets, cherries, broccoli, blueberries and red kidney beans all deliver high concentrations of vitamins, minerals and antioxidants.

All Science News articles summarize a research study and are not an official opinion, endorsement or position of the Parkinson’s Foundation’s.

People with Parkinson’s disease (PD) commonly suffer from tremors and other movement symptoms, such as slowness and stiffness, caused by the loss of dopamine-producing nerve cells in an area of the brain called the substantia nigra. The cornerstone therapy for reducing these symptoms is the drug, levodopa. Often referred to as simply L-dopa, this drug works by helping to replenish the brain’s supply of dopamine. However, with long-term use of L-dopa, upwards of half of people with PD can develop levodopa-induced dyskinesia (LID) — a side effect that causes involuntary rapid jerking and twisting, or slow and extended muscle spasms. The severity of these side effects can range from bothersome to incapacitating.

A recently published study, titled, “Safety and tolerability of IRL790 in Parkinson’s disease with levodopa-induced dyskinesia—a phase 1b trial” (Svenningsson et al., 2018), investigated an experimental small molecule compound called, IRL790, which blocks a dopamine receptor called D3. Why D3? Studies in both animals and people with PD have found that long-term treatment with levodopa results in higher levels of D3 in the brain, which is believed to be what’s causing the LID side effects. Conducted at three university hospital outpatient clinics in Sweden, this was a randomized, double‐blind, placebo‐controlled study.

Ranging in age from 50 to 85, a total of 15 study participants with PD (9 men, 6 women) swallowed one oral capsule twice a day for four weeks of either IRL790 (11 people) or a placebo (4 people). All PD medications, including levodopa, were unchanged for at least 30 days and throughout the study period. Five clinic visits were required, with a follow-up phone call on day 21. A final follow-up visit was conducted within 10 days after the last dose. The starting dose prescribed for all participants was 10 mg (twice a day), with individual dose adjustments allowed up to a maximum of 40 mg twice a day, as needed. Doses were adjusted up to day 14 of the study, after which the dose remained stable.

The primary objective of this study was to investigate the safety and tolerability of the new drug, IRL790, including measuring frequency, seriousness and intensity of adverse events, physical examination, electrocardiogram (ECG) recordings, vital signs and safety laboratory measurements. To record movement data, i.e., dyskinesia and bradykinesia (slowness of movement), participants wore a kinetigraph device attached to their right or left wrist (their parkinsonian dominant side) for seven days priors to the study to establish a baseline, and then wore the device again for the last seven days of the trial.

Results

• A total of 13 participants completed the study. Two of the participants were withdrawn from the study due to possible adverse events associated with drug (one due to difficulty breathing and dizziness, and the other due to edema and redness of the feet).
• A total of 62 adverse events was reported by 14 participants (93.3%) — none were reported as serious and most could be mitigated by dose adjustments. All participants treated with a placebo experienced at least one adverse event.
• The average stable IRL790 dose was 18 mg daily.
• Among participants treated with IRL790, 55.5% were assessed as having an improved global clinical condition.
• Participants were reported to be in a steady state for plasma drug concentration after taking IRL790 for 14 days.
• Participants receiving IRL790 experienced a reduction in dyskinesia, without a reduction in the positive effects of levodopa.

What Does This Mean?

In 1961, L-dopa was hailed for its "miraculous" effect in people with PD (Hornykiewicz, 2010). However, by 1971 there were already studies investigating whether levodopa  was causing dyskinesias (Mones, Elizan, & Siegel, 1971). Today, we know that dyskinesia is a side effect associated with long-term use of L-dopa. Long term treatment with L-dopa results in making too much of the dopamine receptor called D3. While one may think that having a lot of a dopamine receptors sounds like a good thing for PD, in this case, it’s not. D3 is believed to produce the unwanted side effect of LID. The Svenningsson et al (2018) study supports this by demonstrating that by specifically blocking the D3 with the novel drug, IRL790, the negative LID symptoms could be significantly reduced without compromising the positive effects of L-dopa.

More than half of the study participants experienced less dyskinesia — and with no serious side effects. That’s not just encouraging, that’s groundbreaking. IRL790 may have the potential to become a game-changer in the treatment of PD. Of course, more research still needs to be done, as this was a phase 1 trial conducted in a small group of people. Researchers are already actively recruiting study participants for a Phase 2 clinical trial to help establish optimal dosing and are hoping to recruit 74 people with PD to participate (ClinicalTrials.gov, 2018). 

Learn More

The Parkinson’s Foundation believes in empowering the Parkinson’s community through education. Learn more about dyskinesia and PD medication by vising the below Parkinson’s Foundation resources or by calling our free Helpline at 1-800-4PD-INFO (473-4636) for answers to all your Parkinson’s questions.

• Expert Briefings: PD Medications: What’s New?
• Dyskinesia
• Bradyknesia (Slowness of Movement) 

This Parkinson’s Awareness Month, we want to hear your #KeyToPD.

Here are the Foundation’s top five keys to living a better life with Parkinson’s:

• ​Find a neurologist. Regular neurologist care can save the lives of thousands of people each year. Neurologist care saves about 4,600 lives each year in the U.S. alone.
• ​Get Answers. Call our 1-800-4PD-INFO (473-4636) Helpline or visit Parkinson.org to get your Parkinson's questions answered — at any stage of PD.
• Put together a care team. People living with PD who seek expert care have better outcomes — complication risks are lower, they enjoy better quality and longer lives.
• Establish an exercise routine. Increasing physical activity to at least 2.5 hours a week can slow decline in quality of life for people with PD.
• Get moving and socialize. Meet others with PD and families living in your area at your nearest Moving Day, A Walk for Parkinson's. Register at MovingDayWalk.org.

Parkinson’s disease (PD) is largely known for its motor symptoms, slow movement, tremor and stiffness, but other wide-ranging challenges, known as non-motor or non-movement symptoms — can often be most problematic. Treating these non-motor symptoms promotes optimal living.

The following article is part one of a two-part series based on a Parkinson’s Foundation Expert Briefings webinar exploring the latest research and treatments in PD-related non-motor symptoms, by Ronald Pfeiffer, MD, Oregon Health and Sciences University, a Parkinson’s Foundation Center of Excellence.

Early Parkinson’s Symptoms

Early signs of Parkinson’s can appear before a Parkinson’s diagnosis is ever made. Non-movement symptoms can begin decades before a diagnosis. Impaired sense of smell occurs in 70 to 90 percent of those living with PD, often precedes other PD symptoms. Licorice, coconut and banana are some smells people with PD have difficulty with, while scents like chocolate, strawberry and onion, are not impacted.

Another common early pre-movement symptom, constipation, can begin around age 40, sometimes preceding a PD diagnosis by 20 years. Erectile dysfunction, REM sleep behavior disorder, depression and anxiety are often also early non-motor PD symptoms. 

Vision Changes

About 14 percent of people with PD experience vision changes including tired eyes, blurred vision, intermittent double vision or difficulties reading and seeing in dim lighting. Optometrists who look closely may discover convergence insufficiency, impaired color perception, blinking irregularities or reduced contrast sensitivity (the capacity to pick out an object from its background). Playing video games may improve contrast sensitivity, but no PD-specific studies have been done. Fitting glasses with prisms can help PD-related double vision. Both blepharospasm (involuntary eye closure) or apraxia of lid opening (inability to open the eye) may benefit from botulinum toxin A (BOTOX®). At-home eye exercises called “pencil push-ups” may help with convergence insufficiency. Talk to your doctor or optometrist about how to perform these exercises, or to discuss vision treatments.

Pain

Pain related to PD is divided into five categories:

1. Musculoskeletal: pain that affects the bones, muscles, ligaments, tendons and nerves. It can occur suddenly and be short-lived or long lasting and can occur in one or several areas. Someone with PD may describe this as aching or burning in their muscles or skeleton.
2. Neuropathic/radicular: chronic pain condition where the body sends pain signals to the brain, not caused by an injury. This sharp pain comes from a nerve or nerve root.
3. Dystonic: sustained or repetitive muscle twisting, spasm or cramp that can occur at different times of day and in different stages of Parkinson’s. Can stem from rigidity and dystonia.
4. Akathisia: causes the feeling of restlessness or inability to be still. An example of this outside of Parkinson’s is Restless Leg Syndrome.
5. Central pain: neurological condition caused by a dysfunction that affects the central nervous system and is resistant to treatment. This pain is usually sharp and burning with no clear cause.

Though muscle relaxers are not usually effective, adjusting PD medications may help minimize “wearing off" episodes. Physical therapy or surgery can improve pinched nerve pain, while BOTOX® injections may improve dystonia.

Autonomic Dysfunctions

Non-motor problems include those with the autonomic nervous system, which controls bodily functions, such as heart rate, blood pressure, sweating, sexual function and both gastrointestinal and urinary function. These can be among the most serious problems for people with PD.

Oral Health Issues

Excess saliva: Experienced by up to 80 percent of people with Parkinson’s, it begins as nocturnal drooling and can progress to heavy saliva outpourings. Drooling isn’t caused by excess saliva; in PD it is due to decreased swallowing frequency and efficiency, as well as tendencies toward an open mouth and stooped posture. While surgery was used in treatment in the past, it is no longer advocated. Hard candy, medications, including sublingual atropine or glycopyrrolate, or BOTOX® injections have all been used in treatment. Discuss options with your doctor.

Dry mouth: Decreased saliva production in PD can cause dry mouth; medications can increase this dryness, raising the risks of cavities and periodontal disease. Artificial saliva products like Biotene®, which contains xylitol and glycerin, can help. Discuss treatments, including medications that increase saliva production, with your doctor or dentist.

Halitosis: Bad breath is common in PD, but rarely discussed. Many factors — dry mouth, inadequate brushing, gum disease, mouth bacteria and not drinking enough fluids — can contribute. Treatment includes adequate cleaning of teeth and mouth and alleviating dry mouth.

Recognizing and Addressing Symptoms

Non-motor PD features may also include sleep disorders, cognitive changes, hallucinations and delusions or weight changes. It’s important to stay abreast of all symptoms, and to discuss treatments with your doctor.

Read the second article in this series now: Non-motor Symptoms: What’s New? Part 2.

Understanding Medicare can be extremely frustrating for many seniors — there are so many parts involved, so many details that require research and potential changes to health care providers and their services, that some seniors become overwhelmed and find it hard to keep searching for the right coverage. As a caregiver, there are many things you can do to help the process along. From looking online for resources and information to helping your loved one make lifestyle changes that will prevent the need for medical attention, there are many simple ways you can assist in finding the right Medicare plan.

Of course, it is extremely helpful to become familiar with common terms and expressions used in Medicare plans as well as those used by doctors to describe various conditions. If your loved one has Parkinson’s disease (PD), it will be especially important to understand what the terminology is as well as what some of the treatments and medications will be. This will allow you to make sure your loved one has everything they need no matter what their health care requirements are.

Here are a few tips on how to help your loved one understand their Medicare options when you’re a caregiver.

Learn the terms

Understanding Medicare takes time, so do a little reading to learn more about the wording and what it all means. Fortunately, there are lots of resources online that explain what certain parts do and will help you sort out the various — and sometimes confusing — details. These will help you find everything from the dates of the open enrollment period to an explanation of a “coverage gap.”

Take specifics into consideration

Parkinson’s disease is considered an existing health condition that will affect coverage. People with PD may need to make sure a certain doctor accepts their plan. Look for an insurance plan that will meet their specific needs, keeping in mind budget. While some parts of Medicare come at no extra cost, medical insurance includes a copay and add-ons like vision coverage, dental care and prescription medication often require out-of-pocket payments.

Find out important dates

Keep track of important Medicare-related dates. There are specific times of the year for sign-ups and changes to existing plans and anyone who falls outside of those dates are subject to penalties. Take note of this crucial information and keep track of it for your loved one, as it can be confusing for many seniors to understand. It’s also a good idea to make sure your loved one has the type of coverage they need according to their current health status; an Advantage Plan will help cover health care needs that Part A and Part B don’t.. 

Talk to the doctor

Some changes in Medicare plans can affect a senior’s ability to have certain parts of care covered, and sometimes, those changes can cause issues with their chosen doctor. Talk to your loved one’s care provider to make sure they still accept the Medicare plan in question and that no changes need to be made to keep it current.

Helping your loved one understand Medicare is important not just for their present needs, but also for their future. In doing so, you’ll be ensuring that the senior in your life is able to get the care they require for years to come, giving them a great quality of life and keeping their health a priority. Talk to your loved one to get an idea of what their needs are, and keep detailed records related to their Medicare coverage.

Article written by Caroline James. Caroline created ElderAction.org, with her husband after becoming caregivers for their aging parents. Through her work with ElderAction, Caroline helps ensure that seniors are able to thrive throughout their golden years.

If you have detailed questions about Medicare or caring for a loved one with Parkinson’s, call our free Helpline at 1-800-4PD-INFO (473-4636).

Over the next three years the Parkinson’s Foundation will invest more than $50 million to Parkinson’s disease (PD) research and clinical care. At the heart of our research initiatives are scientists and researchers who have received Foundation awards to improve our understanding of Parkinson’s, which will ultimately lead us to a cure.

Gulcin Pekkurnaz, PhD, is a Stanley Fahn Junior Faculty Awardee who is working to understand how aging affects dopamine in Parkinson’s.

Parkinson’s disease develops when the cell’s energy factories, called mitochondria, start to fail in dopamine neurons or nerve cells. Dopamine is a brain chemical messenger that carries information between neurons and helps us to move smoothly. People with Parkinson’s have low levels of dopamine in the brain due to dopamine neurons dying.   

People with Parkinson’s do not develop disease symptoms until later in life. This indicates aging-associated changes are involved in the development of the disease. With aging, both mitochondrial function and cellular metabolism decline. We hope to gain a better understanding of why this happens.

Dr. Pekkurnaz at University of California San Diego received a research grant to study the mitochondria from dopamine nerve fibers in animals. Her goal is to identify what happens to dopamine neuron mitochondria before Parkinson’s symptoms start. To accomplish this, she will develop new technology that will allow us to analyze unique mitochondrial features from dopamine neurons as a function of age.

We hope to gain fundamental insights into how the dopamine neuron energy supply works and they start to fail. These findings can lead to potential drug targets for Parkinson’s.

The Parkinson’s Foundation Stanley Fahn Junior Faculty Award helps ensure promising early career scientists stay in the PD research field. This award provides junior investigators the support they need to develop their own independent funding source.

What’s Next: Reporting Our Findings

Parkinson’s Foundation research awards fund Parkinson’s studies than can span up to three years. Scientists submit yearly progress reports to the Parkinson’s Foundation, and we report findings once the studies have concluded. Stay up to date with our latest research findings at Parkinson.org/Blog.

Since its launch in the late 1960s, carbidopa/levodopa (brand name SINEMET®) is still the most effective Parkinson’s disease (PD) motor symptom treatment. However, it doesn’t address all facets of the disease. Medications to bolster its effectiveness and treat PD-related non-motor symptoms are newly available or just on the horizon.

This article is based on a Parkinson’s Foundation Expert Briefings webinar exploring innovative PD treatments by Rajesh Pahwa, MD, Director, Parkinson and Movement Disorder Division, University of Kansas Medical Center, a Parkinson’s Foundation Center of Excellence.

Pioneering Medicine

It’s an exciting time for PD drug advances. While gene therapy benefits are still being studied, many new medications are on the market or are soon to be. These new treatments are designed to tackle Parkinson’s disease challenges, including:

• Psychosis – hallucinations and delusions.
• Orthostatic hypotension – a blood pressure drop when rising or standing.
• “Off” time – when symptoms and movement difficulties increase.
• Dyskinesia – abnormal, involuntary muscle movement.
• Dementia – memory and thinking declines.
• Falls – PD can cause slowness of movements, increasing falling and other risks.

Current Treatments

Parkinson's Disease Psychosis

PD-associated psychosis can be caused by the disease itself or PD medications. Challenging for people with PD and caregivers, symptoms include confusion, delusions and hallucinations. Report any changes to your medical team.

Pimavanserin (Nuplazid®), newer to the market, is the only approved treatment for PD psychosis. It does not block dopamine or worsen motor symptoms. It can improve hallucinations, delusions, night-time sleep and daytime sleepiness. Side effects include nausea, confusion and hallucinations.

Orthosstatic Hypotension

From 20 to 50 percent of people living with PD experience a significant blood pressure drop upon standing, known as orthostatic hypotension; certain medications can worsen this. This drop can cause lightheadedness or fainting, and other symptoms.

Droxidopa (NORTHERA®) treats lightheadedness. It should not be taken within five hours of bedtime. Side effects include headache, dizziness, nausea, fatigue and high blood pressure when lying down.

"Off"-Time Advancements

Levodopa is synthesized in the brain into dopamine, making it key to PD symptom management. But several factors can interfere with steady, accurate dose delivery. When medication is not taken on time, or absorption is delayed, freezing and other sudden and debilitating motor symptoms can occur. These newer medications can help tackle “off” periods.

Carbidopa/Levodopa Enteral Suspension (Duopa™)

Duopa™ therapy, a newer carbidopa/levodopa treatment, can benefit people with advanced PD who respond well to levodopa and experience three or more “off” hours daily. It’s delivered in gel form (called enteral suspension). Duopa™ users must first have surgery to place a tube in their intestine that is later connected to a pump that delivers Duopa™.

Safinamide (XADAGO®)

Safinamide tablets (XADAGO®) are an add-on treatment for people with Parkinson’s taking carbidopa/levodopa and experiencing “off” times. Safinamide is a monoamine oxidase B (MAO-B) inhibitor that can reduce “off” times up to 55 minutes a day, without dyskinesia. Interactions include other MAO-B class drugs, certain antidepressants and the cold medicine dextromethorphan. Anyone taking a PD medication should talk to their doctor and pharmacist about potential drug interactions.

On-Demand Therapy

Levodopa Inhalation (INBRIJA™)

The levodopa inhalation powder INBRIJA™ is an add-on drug for “off” periods in people taking carbidopa/levodopa. Administered via inhaler, it can be used up to five times a day, improving “off” symptoms as soon as 10 minutes and lasting up to 60 minutes. This can improve symptoms for people with decreased gut motility while waiting for oral carbidopa/levodopa to take effect.

Amantadine ER capsules (GOCOVRI®)

This is the only medication to treat dyskinesia and “off” time in people with PD taking carbidopa/levodopa. It must be taken before bedtime and provides control of dyskinesia upon awakening and throughout the day. It can cause hallucinations and lightheadedness. This medication is different from immediate-release amantadine and amantadine ER tablets (OSMOLEX ER™) which are not approved for dyskinesia or “off” time.

IncobotulinumtoxinA (XEOMIN)

More than 50 percent of people with PD can have excessive drooling, causing skin breakdown around the mouth, odors, embarrassment or choking. Two injections on the face, every 3-4 months of XEOMIN, can manage symptoms.

Future Therapies

Sublingual Apomorphine

Apomorphine is administered through injections under the skin. Sublingual apomorphine, dissolved under the tongue, can relieve “wearing off” episodes for people with Parkinson’s disease in 15 minutes and lasts up to 90 minutes. Side effects can include nausea, sleepiness, and dizziness.

Rimabotulinumtoxin B (MYOBLOC®)

Rimabotulinumtoxin B is currently approved for dystonia and used off-label for drooling. It is undergoing trials to treat drooling. Side effects include dry mouth, mild swallowing difficulty, mild chewing weakness and saliva thickness changes.

Adenosine A2 Antagonist: Istradefylline

A group of brain circuits called the basal ganglia play a role in causing PD symptoms. The basal ganglia have adenosine A2A receptors that are located next to dopamine receptors. Scientists believe that activating the dopamine receptor or blocking the adenosine A2 receptor can improve PD symptoms.

Istradefylline, an adenosine A2A receptor antagonist shows mild motor symptom fluctuation improvements. Approved for use in Japan, Istradefylline has also received U.S. FDA approval.

Subcutaneous Apomorphine Infusion

Available in Europe, subcutaneous apomorphine treatment offers a less invasive motor fluctuation treatment option. A small delivery tube placed under the skin is connected to an apomorphine-filled pumping device. It can reduce daily “off” time and possibly dyskinesia by reducing needed levodopa dose. Those with hallucinations and dementia might not be candidates.

Subcutaneous Carbidopa/Levodopa Pump

Two companies are currently developing pumps for continuous under-skin carbidopa/levodopa therapy to reduce “off” times and motor symptom fluctuations. The pumps can be used around the clock and don’t require surgery.

Carbidopa/levodopa extended release

New tests are underway for extended-release carbidopa/levodopa therapy to reduce “off” times and motor symptom fluctuations.

• Accordion Pill™, Carbidopa/Levodopa (AP-CD/LD) maker, will begin its Phase 3 clinical trial of new delivery technology. The Accordion Pill slowly releases treatment in the stomach for more steady absorption.
• IPX203, an investigational extended-release oral carbidopa/levodopa formulation that increases “on” time, is currently enrolling participants in its Phase 3 clinical study.

Opicapone

Experimental opicapone is a COMT (catechol-o-methyl transferase) inhibitor. This drug class can extend levodopa benefits. Available in Europe, opicapone reduces “off” time for people with PD experiencing levodopa effectiveness fluctuations.

If you have any questions about managing Parkinson’s, PD medications or caregiving, call our Helpline at 1-800-4PD-INFO (473-4636) on weekdays from 9 a.m. to 8 p.m. You can also check out these resources:

• Prescription Medications
• For Caregivers
• Episode 6: New Levodopa Delivery Methods for Parkinson’s
• Parkinson’s Treatment