People with Parkinson's disease (PD) frequently struggle to identify drug therapies that can address bothersome symptoms such as sleep dysfunction, bladder urgency, drooling and tremor. Many of the drug therapies such as Benadryl (diphenhydramine), Advil PM, Alleve PM, common antihistamines, and others pills are readily available over the counter and do not require a prescription. These medications block a cholinergic receptor in the brain, and can improve many Parkinson’s disease symptoms. However, the price of taking these drugs may be steep (thinking problems, confusion, unsteadiness and even falling). An older French study of hospitalized Parkinson’s disease patients revealed that though 46% of all demented patients were confused, 93% on anticholinergic therapy had delirium and confusion when in the hospital (Agid et. al.). Deficiencies of the chemical acetylcholine have been reported to underpin thinking issues and shortages of the chemical have been observed in the brainstem, hippocampus, and cortex of Parkinson’s disease patients. Though anticholinergic use can result in drowsiness, dry mouth, urinary retention, memory problems as well as constipation, many patients find these therapies useful. In this month’s What’s Hot column we will address the short and long-term potential side effects of using of anticholinergic medications in Parkinson’s disease.

Cooper and colleagues in 1992 addressed thinking ability in a group of 82 freshly diagnosed and untreated Parkinson’s disease patients. The patients in this study were all randomized to receive levodopa (Sinemet), bromocriptine (a dopamine agonist) or an anticholinergic drug. Though all three treatments improved motor performance, the anticholinergic drugs produced memory impairments. Many subsequent studies including the Parkinson's Foundation QII prospective study have confirmed these findings.

Perry and colleagues in 2003 investigated the idea that blocking brain acetylcholine receptors could lead to more “Alzheimer’s changes” in the Parkinson’s disease brain. Interestingly, the researchers reported that an important marker of Alzheimer's disease, the amyloid plaque density, was present in more than double the concentration in Parkinson’s disease patients treated with long-term anticholinergic therapy. Another marker of Alzheimer’s disease, the neurofibrillary tangle, was also more prominent in the brains of those taking anticholinergic drugs.

The most recent worrisome evidence surrounding anticholinergic therapy is drawn from an article in a recent issue of JAMA Internal Medicine written by pharmacist Shelly Gray. The authors utilized data from the Adult Changes in Thought Study. The investigation was based in Washington state and had an impressive 3,434 people enrolled who were 65 years or older. All study participants were screened at inclusion to be sure there was no evidence for dementia. The authors cleverly used computerized pharmacy data to assess each participant’s exposure to anticholinergic drugs. The most common anticholinergic drugs were old-fashioned tricyclic antidepressants (TCA’s), antihistamines, and also drugs used for bladder and sleep. The patients were followed for 7 years and the data revealed that over 20% were shown to develop dementia. Participants who took anticholinergic drugs for three years or more had a greater than 50% higher dementia risk. Also, a higher cumulative dose of anticholinergic drugs increased the risk for dementia when compared to those taking anticholinergic drugs for 90 days or less.

The bottom line for people with Parkinson’s is that there should be a greater awareness of the short and the long-term potential side effects of anticholinergic therapy. Short-term, Parkinson’s patients should be aware that anticholinergics may precipitate drowsiness, dry mouth, urinary retention, memory problems, blurry vision, and constipation as well as a host of other side effects. Long-term, there is an increased risk of dementia. It is important for people with PD to routinely review medication lists with both a doctor and a pharmacist and to try to identify other medication alternatives.

Some practical suggestions include:

• Identify alternative antidepressants with less anticholinergic effects
• Watch out for over the counter drugs like Benadryl (diphenhydramine) and antihistamines
• Dopamine agonists, levodopa, and deep brain stimulation can all potentially be used for difficult to control tremor instead of anticholinergics
• Botulinum toxin injections can be employed for drooling and for some cases of bladder dysfunction
• Sometimes atropine drops under the tongue or chewing gum can be employed for drooling issues
• A type of physical therapy referred to as pelvic floor rehabilitation can be helpful for bladder retraining in those with urinary frequency
• If hospitalized be sure the doctors do not use anticholinergics for sleep or bladder dysfunction
• Parkinson’s disease patients and their interdisciplinary care teams can usually work together to reduce or to eliminate anticholinergic drug use

Selected References:

Cooper JA, Sagar HJ, Doherty SM, Jordan N, Tidswell P, Sullivan EV. Different effects of dopaminergic and anticholinergic therapies on cognitive and motor function in Parkinson's disease. A follow-up study of untreated patients. Brain. 1992 Dec;115 ( Pt 6):1701-25. PubMed PMID: 1486457.

Perry EK, Kilford L, Lees AJ, Burn DJ, Perry RH. Increased Alzheimer pathology in Parkinson's disease related to antimuscarinic drugs. Ann Neurol. 2003 Aug;54(2):235-8. PubMed PMID: 12891676.

Bédard MA, Pillon B, Dubois B, Duchesne N, Masson H, Agid Y. Acute and long-term administration of anticholinergics in Parkinson's disease: specific effects on the subcortico-frontal syndrome. Brain Cogn. 1999 Jul;40(2):289-313. PubMed PMID: 10413563.

Gray SL, Anderson ML, Dublin S, Hanlon JT, Hubbard R, Walker R, Yu O, Crane PK, Larson EB. Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study. JAMA Intern Med. 2015 Mar;175(3):401-7. doi: 10.1001/jamainternmed.2014.7663. PubMed PMID: 25621434; PubMed Central PMCID: PMC4358759.

Faulkner MA. Safety overview of FDA-approved medications for the treatment of the motor symptoms of Parkinson's disease. Expert Opin Drug Saf. 2014 Aug;13(8):1055-69. doi: 10.1517/14740338.2014.931369. Epub 2014 Jun 24. Review. PubMed PMID: 24962891.

Sakakibara R. [Cognitive adverse effects of anticholinergic medication for overactive bladder in PD/DLB]. Rinsho Shinkeigaku. 2013;53(11):1389-92. Review. Japanese. PubMed PMID: 24292000.

Campbell NL, Boustani MA. Adverse cognitive effects of medications: turning attention to reversibility. JAMA Intern Med. 2015 Mar;175(3):408-9. doi: 10.1001/jamainternmed.2014.7667. PubMed PMID: 25622111; PubMed Central PMCID: PMC4346513.

Mate KE, Kerr KP, Pond D, Williams EJ, Marley J, Disler P, Brodaty H, Magin PJ. Impact of multiple low-level anticholinergic medications on anticholinergic load of community-dwelling elderly with and without dementia. Drugs Aging. 2015 Feb;32(2):159-67. doi: 10.1007/s40266-014-0230-0. PubMed PMID: 25566958.

Kalisch Ellett LM, Pratt NL, Ramsay EN, Barratt JD, Roughead EE. Multiple anticholinergic medication use and risk of hospital admission for confusion or dementia. J Am Geriatr Soc. 2014 Oct;62(10):1916-22. doi: 10.1111/jgs.13054. Epub 2014 Oct 3. PubMed PMID: 25284144.

Kidd AC, Musonda P, Soiza RL, Butchart C, Lunt CJ, Pai Y, Hameed Y, Fox C, Potter JF, Myint PK. The relationship between total anticholinergic burden (ACB) and early in-patient hospital mortality and length of stay in the oldest old aged 90 years and over admitted with an acute illness. Arch Gerontol Geriatr. 2014

Jul-Aug;59(1):155-61. doi: 10.1016/j.archger.2014.01.006. Epub 2014 Feb 5. PubMed PMID: 24582945.

Dubois B, Pilon B, Lhermitte F, Agid Y. Cholinergic deficiency and frontal dysfunction in Parkinson's disease. Ann Neurol. 1990 Aug;28(2):117-21. PubMed PMID: 2221841.

Dubois B, Danzé F, Pillon B, Cusimano G, Lhermitte F, Agid Y. Cholinergic-dependent cognitive deficits in Parkinson's disease. Ann Neurol. 1987 Jul;22(1):26-30. PubMed PMID: 3631918.

Dubois B, Ruberg M, Javoy-Agid F, Ploska A, Agid Y. A subcortico-cortical cholinergic system is affected in Parkinson's disease. Brain Res. 1983 Dec 12;288(1-2):213-8. PubMed PMID: 6661617.

You can find out more about our National Medical Director, Dr. Michael S. Okun, by also visiting the Center of Excellence, University of Florida Health Center for Movement Disorders and Neurorestoration. Dr. Okun is also the author of the Amazon #1 Parkinson's Best Seller 10 Secrets to a Happier Life and 10 Breakthrough Therapies for Parkinson's Disease.

April is Parkinson’s disease awareness month and we thought it would be fitting to discuss how we are approaching the measurement of quality, and how best to measure depression at the bedside in Parkinson’s disease.

The Parkinson's Foundation has been committed to improving the quality of care throughout its Centers of Excellence network and throughout the world by funding and promoting the Quality Improvement Initiative Study. The study was modeled after the Cystic Fibrosis Foundation’s successful registry, profiled by Atul Gawande. In the Cystic Fibrosis experience, their focus on identifying best practices yielded a 10 year increase in life expectancy. In Parkinson’s disease we are hoping for similar success.

The Parkinson's Foundation Quality Improvement Initiative was launched several years ago and the aim was to understand Parkinson’s disease and its care by annually completing a simple profile of the status of people with Parkinson’s and the treatments they receive: one patient assessed on one page, once a year. The study now has 5000 enrolled patients, and, by looking at how patients change each year, we are getting new insight into important issues like mobility, depression, and cognition in patients and their impacts on quality of life, caregiver stress, and hospitalization. 

A management guru named Peter Drucker described his philosophy as, “what’s measured improves.” Now, for the first time in a massive, multi-center study across all stages of the disease, we are measuring health and health care in people with Parkinson’s. I am really thrilled to be a part of this important initiative and I and my team are drawing insight from this project every day.

Another of the leaders on our Quality Improvement Initiative is Laura Marsh, MD, of the Houston VA. She specializes in mental health and Parkinson’s and has focused on the evaluation of depression in Parkinson’s disease. This month she published the long-awaited Methods of Optimal Depression Detection in Parkinson's Disease (MOOD-PD) study. This study compared 9 depression scales and made recommendations for use in Parkinson’s disease.

The most important finding was that depression is more common than many thought. She recommends that doctors always screen for depression in Parkinson’s disease patients because it can be well managed, but when it’s not identified, it can affect everything in a patient’s life. Interestingly, the depression screening on the commonly used Unified Parkinson’s Disease Rating Scale performed the worst, and was not recommended for use in screening patients. All other scales performed well. The authors stressed that depression screening should be part of the routine evaluation in Parkinson’s disease patients.

In conclusion, as we strive for better quality of care, we will need to improve our ability to measure quality and to select bedside tests that can help us to better optimize the management of all Parkinson’s disease patients. The Parkinson's Foundation Quality Improvement Initiative Study and the MOOD-PD study are two important steps in this direction.

Selected References

1. Okun MS, Siderowf A, Nutt JG, O'Conner GT, Bloem BR, Olmstead EM, Guttman M, Simuni T, Cheng E, Cohen EV, Parashos S, Marsh L, Malaty IA, Giladi N, Schmidt P, Oberdorf J. Piloting the NPF data-driven quality improvement initiative. Parkinsonism Relat Disord. 2010 Sep;16(8):517-21. Epub 2010 Jul 6. PubMed PMID: 20609611.

2. Williams JR, Hirsch ES, Anderson K, Bush AL, Goldstein SR, Grill S, Lehmann S, Little JT, Margolis RL, Palanci J, Pontone G, Weiss H, Rabins P, Marsh L. A comparison of nine scales to detect depression in Parkinson disease: Which scale to use? Neurology. 2012 Mar 14. [Epub ahead of print] PubMed PMID: 22422897.

You can find out more about our National Medical Director, Dr. Michael S. Okun, by also visiting the Center of Excellence, University of Florida Health Center for Movement Disorders and Neurorestoration. Dr. Okun is also the author of the Amazon #1 Parkinson's Best Seller 10 Secrets to a Happier Life and 10 Breakthrough Therapies for Parkinson's Disease.

For more insights on this topic, listen to our podcast episode “Staging PD – UPDRS: What it Measures and What Your Score Means”.

Exercise is vital for improving balance, mobility and overall health in persons diagnosed with Parkinson's Disease (PD). PD is the second most common neurological disease in the world(1). It is characterized by a deficit in dopamine resulting from a progressive loss of neurons in areas of the brain responsible for movement and coordination(2).

Recently, literature has demonstrated that participating in strength training regularly can improve symptoms, make dopamine use more efficient and possibly even slow the progression of PD! In this article, we will look at why strength training has benefits specific to PD, and discuss ways to make it safe and fun.

Why Exercise?

Exercise is amazing because it changes the way our brain functions. Studies have shown that in people who regularly exercise, brain cells use dopamine more efficiently. This occurs because areas of the brain responsible for receiving dopamine signals – the substantia nigra and basal ganglia, are modified. Exercise also increases the number of D2 receptors in the brain, meaning dopamine has more places to go. Additionally, researchers at the University of Pittsburgh were able to demonstrate that in animal models, exercise increased the amount of a neurotrophic factor called GDNF, which helps protect dopamine neurons from damage(3).

Choose Strength Training

The benefits of strength training include increasing muscular strength, endurance, dynamic balance and cognitive functioning. Recent studies have demonstrated that there are decreases in gross muscular strength in people diagnosed with PD, most notably in the back and hip extensors4. Researchers have speculated that this occurs secondary to postures developed throughout the course of the disease. As people begin to hunch their shoulders and lean forward instead of standing upright, postural muscles become weaker. When postural muscles become weaker, it is more difficult to balance, or recover from perturbations. This increases the likelihood of falling. Strength training is an excellent, safe way to increase strength, stability and confidence for those with PD.

Where to Start

Beginning a new exercise program can be intimidating at first. My suggestion is to find a fitness buddy – a friend or family member to start with, and help you stick to your program. Then, do your research. Build a strong program, and execute it with good form. A great resource for learning to perform exercises correctly is Exrx.net. You can also consult a local fitness expert, or ACSM guidelines for strength training. When exercising, be sure to focus on all 5 major muscle groups – chest, back, legs, arms and core (abdominals).

Tips for Exercising Safely

1. Check with your doctor before beginning any new exercise program, and continue to take all medications prescribed by doctors. Strength training is not an alternative to medication.
2. Make sure you hydrate! Drink water before, after and during your exercise to feel better and stay safe.
3. Bring a copy of your workout with you, so you don't forget any exercises!
4. Progress slowly. Make goals, and work towards them by perfecting your form and starting with light weights first. Remember, all good things take time. Have patience and enjoy the ride!

Danielle Leshinsky is a Certified Strength and Conditioning Specialist (CSCS) and a doctoral candidate at Emory University School of Medicine's DPT program. She is currently researching with Dr. Madeleine Hackney and the Atlanta VA Center for Visual and Neurocognitive Rehabilitation , looking at the effects of Tango on Parkinson's Disease. She is also working in the INSPIRE laboratory at the Emory Rehabilitation Hospital. Danielle chose to pursue a career in physical therapy because she finds it both challenging and rewarding. She plans to obtain a Specialist Certification in Neurology upon graduation in May 2016.

A new study finds that traumatic brain injury from a blow to the head, with loss of consciousness, may increase a person’s risk of developing Parkinson’s disease (PD) later in life. The results appear in the July 11 online edition of JAMA Neurology. The researchers did not find an association between head injury and Alzheimer's disease.

The neurological effects of head injuries are much in the news, with worry over repeated, relatively mild, concussions among athletes, and with the recent death of boxing great Muhammad Ali, who lived with Parkinson's disease. This new study, however, focused narrowly on the long-term effects of even one instance of trauma to the head — especially injuries involving loss of consciousness — among older people more representative of the general population.

Researchers led by Paul K. Crane, M.D., M.P.H., at the University of Washington in Seattle, analyzed self-reported data, collected between 1994 and 2014, from 7,130 people who had enrolled in other studies that gathered data on memory, cognition and aging. On average, study participants were 80 years old at the time of this report, and did not have dementia, PD, or Alzheimer’s disease when they enrolled in the original studies. Forty percent were men. Brain tissue was examined on autopsy for 1,589 participants, to search for signs of PD and Alzheimer’s disease.

Results

• Eight hundred sixty-five study participants reported having had a traumatic brain injury with loss of consciousness at some time in their lives.
• During the time study participants’ health was followed, 117 new cases of PD were diagnosed among the total of 7,130 participants.
• A past traumatic brain injury with loss of consciousness longer than an hour was associated with three and a half times increased risk of developing PD.
• History of traumatic brain injury was also associated with the accumulation of Lewy bodies in brain cells, the toxic clumps of alpha-synuclein protein that are the hallmark of PD.
• Traumatic brain injury was not associated with mild cognitive impairment (MCI)|, dementia, Alzheimer’s or brain changes associated with Alzheimer’s.
• Microinfarcts — microscopic strokes in the brain that may be a cause of dementia — were found more often in the brains of people who had traumatic brain injury that lost consciousness for more than one hour.

What Does It Mean?

Head injuries are common, even among non-athletes. Earlier studies have suggested that they might be related to developing Alzheimer’s.

But the new research found instead that just one traumatic brain injury with loss of consciousness of more than one hour was associated with Parkinson’s, and not Alzheimer’s. Although most people recover to normal functioning after a traumatic brain injury, this study suggests that the consequences from even a single head injury may take decades to develop.

The finding underscores the importance of preventing head injuries. It also suggests that additional research to understand the relationship between brain injury and Parkinson's, and why they are linked, might provide ideas for possible interventions for reducing risk of PD.

Beth Vernaleo Ph.D., Associate Director of Research Programs, PDF added, “While previous research has linked head injuries to neurodegenerative disease, this study illustrates a more specific finding — that a single blow to the head causing a loss of consciousness for more than an hour, even in one’s 20s, may lead to a three-fold increased risk of Parkinson’s decades later. Although the vast majority of people who experience head injury will not develop Parkinson’s, this study may provide clinicians with an additional diagnostic tool. For example, asking patients about history of head injury, amongst other symptoms and risk factors, may prove a valuable means of ascertaining the likelihood of a PD diagnosis.”

A new study finds that the number of new cases per year of Parkinson’s disease (PD), and related diseases known as parkinsonisms, may have increased over a 30-year period. A possible explanation lies in the dramatic decline in cigarette smoking in recent decades. The research appears in the June 20 online edition of JAMA Neurology.

Smoking reached its peak in the 1940s and 1950s in the United States. Between then and 2009, the smoking rate among American men went down from 67 percent to 23.5 percent. An earlier study suggested that smokers may have a reduced risk of PD, and speculated that the decrease in smoking could lead to a higher incidence of PD decades later.

Researchers led by Walter A. Rocca, M.D., M.P.H., set out to test the idea. They analyzed medical records of people living in Olmsted County, MN, a set of data that is exceptionally complete and available electronically. In records between 1976 and 2005, the researchers identified 906 people with parkinsonisms (diseases such as Lewy body dementia and progressive supranuclear palsy, which share some symptoms with PD) and 464 people with PD.

Results

• Incidence rates of parkinsonism in men increased from 38.9 per 100,000 person-years between 1976 and 1985 to 55.9 between 1996 and 2005.
• Rates of PD in men increased from 18.2 between 1976 and 1985 to 30.4 between 1996 and 2005. The increase was greater for men over age 70.
• No similar trends were seen for women.
• PD incidence was higher for people born between 1915 and 1925, suggesting that early-life exposure to influenza boosted PD risk.

What Does It Mean?

In the group studied, researchers found that parkinsonism and PD increased, especially among men over the age of 70. However, they caution that aspects of this population make it different from others — it is nearly all white, for example — and so it will be important to confirm the findings in other populations.

The decline in smoking provides a possible explanation, although other lifestyle or environmental changes also could increase PD risk or provide protection from PD.

Projected into the future, the rate of increase found in this study points to a much larger number of people with PD in the coming decades than indicated by earlier estimates. If this is indeed the trend, then effective planning throughout the health care system will be needed — and the requirement for new therapies and a cure is more urgent.

Investment in Parkinson's Prevalence
The foundation is taking a proactive role in understanding prevalence, by investing $250,000 in P4, the PDF Parkinson’s Prevalence Project. Read reactions from Dr. Beck and more about this project below.

“I believe this will be the first of several reports in the US to demonstrate what the Parkinson’s Disease Foundation has come to realize — that the number of people living with Parkinson’s is dramatically undercounted. However, because the population studied is not as ethnically diverse as the population of the US as a whole, it will be critical to see if the results hold true in other communities. It is for similar reasons that we view current estimates of Parkinson’s prevalence as likely inaccurate. This is why PDF is taking a proactive role in determining Parkinson’s prevalence in the US — using a diverse group of datasets to improve our estimates of how many people live with the disease and who they are. The answers will be the impetus to remind government, industry, and science of the urgency to better treat and end this disease."
-James Beck, Ph.D., Vice President, Scientific Affairs, Parkinson’s Disease Foundation

This blog is the fifth in a series detailing the roles of each member of a comprehensive care team, covering social work, occupational therapy, speech-language pathology and physical therapy. Learn more about the healthcare professionals that are part of a comprehensive care team and how you can put your care team together today.

What Is Dance/Movement Therapy?

Dance/movement therapy is a form of psychotherapy that uses movement, in all forms, as a means of observation, assessment and intervention in the therapeutic relationship. Unlike dance, dance/movement therapy does not focus on a stylized choreography, specific set of skills or technique. Instead, it allows individuals to move and find comfort in their bodies and to express what words might be too difficult to uncover.

Dance/movement therapy can help support people with Parkinson’s disease (PD) in the moment, even when it is hard to be present to physical sensation and symptoms.

What Do You Do During a Dance/Movement Therapy Session?

There is no one-size-fits-all session, though there are some common basic components. In an individual session, you will likely start with a warm-up where the therapist guides you through movements, from head to toe.

You will be encouraged to move each body part, no matter how small. This allows you to become more aware of your body and experience your capacity for movement. Next, the therapist will coach you to use your body to express behaviors and thoughts or to explore movement patterns and preferences.

Group sessions might incorporate elements from a support group, a social dance or mindful movement class. For example:

When asked how she felt at the beginning of the dance/movement therapy group, Sally reported feeling isolated, standoff-ish and unsure of her ability to participate because of her tremor and poor balance. The therapist invited Sally to show what that looked like using her body. Sally slumped over in her chair, crossed her arms and lowered her gaze. Sally then lifted her chest, looked up to the ceiling and threw her arms up in the air. With a smile on her face, Sally said, “A weight has been lifted. Now, I feel free!”

Who Is a Dance/Movement Therapist?

Dance/movement therapists are registered or board-certified individuals with a master’s degree in dance/movement therapy. Depending on where they practice, dance/movement therapists may be clinical counselors, social workers, creative arts therapists or psychologists. Most have a background in psychology and dance, with a focus on dance as an outlet for mental health and expression. Dance/movement therapists are required to fulfill clinical internships in such settings as hospitals, treatment facilities, day programs, nursing homes, day schools or even private practice.

A dance/movement therapist is an integral part of the care team because he/she can mesh clinical counseling or social work with movement observation and assessment. The therapist’s keen ability to observe the relationship between movement and mental health helps foster a more holistic, mind-body approach to medicine.

Dance/movement therapists receive referrals from other care team members and often co-treat, co-facilitate and collaborate with them. As part of the team, your dance/movement therapist should communicate with other care team members about treatment plans, symptom management and disease progression.

What Symptoms Can Dance/Movement Therapy Help Treat?

Dance/movement therapy addresses motor and non-motor symptoms of Parkinson’s. It focuses on balance, coordination, gait and mobility, but also uses movement to address depression, digestive complications, anxiety and fatigue.

Furthermore, dance/movement therapy encourages individuals to prioritize their mental health. Embracing the arts as a mode of psychotherapeutic intervention and expression seems to help reduce stigma around mental health issues.

Research specifically on dance/movement therapy with PD is taking off. For example, Northwestern University in Illinois recently conducted a study on the effects of dance/movement therapy on fatigue in people with PD. More researchers are becoming interested in this topic, so expect to hear more about the impact of dance/movement therapy in the future. In the meantime, try it for yourself.

How Do I Find a Therapist or Program?

Dance/movement therapists and programs are all over the country. To find one nearest you, go to The American Dance Therapy Association’s website at www.adta.org. You can find a list of resources and a directory of therapists in your area. The toll-free Parkinson’s Foundation Helpline can also help connect you to information and resources: 1-800-4PD-INFO (473-4636).

Dance/movement therapy is often a wonderful complementary or adjunct therapy for individuals affected by movement disorders. Some dance/movement therapy sessions may be covered by private health insurance, which can make it an affordable and accessible option for treatment of symptoms and maintenance of quality of life. 

Erica Hornthal, LCPC, BC-DMT, is CEO of Chicago Dance Therapy. She is a clinical counselor and board-certified dance therapist who specializes in working with individuals living with movement and cognitive disorders. Additionally, Erica works with people of all ages and abilities to connect the mind and body to promote self-awareness, self-expression, healthy attachments, compassion and improved quality of life. 

For more insights on this topic, listen to our podcast episode “A Western Perspective on PD: Understanding Complementary Medicine”.

People with PD often tell us that when they get sick with cold and flu-like symptoms, their pharmacist and healthcare professionals warn them to stay away from the medication aisle of the pharmacy. They are told that any over-the-counter medication has the potential to worsen Parkinson’s symptoms. Unfortunately, many people interpret this potential worsening as a recommendation to never use these medications.

Also contributing to this issue is a series of reports that medications such as anticholinergics (like Benadryl) may cause acute confusion and even contribute to long-term cognitive changes. It is important to keep in mind when selecting a cough or flu medication that the intent is not to treat long-term issues.

This flu season we wanted to provide the PD community with some tips to help you navigate Parkinson’s while simultaneously addressing cold and flu symptoms:

• If memory or thinking problems are present, take caution with drugs that may be sedating (such as Sudafed) or that contain an anticholinergic (for example, Trihexyphenidyl, Benadryl, Cogentin, Parsitan). Because of memory and thinking issues, anticholinergics are only rarely used to address cough and cold symptoms.
• Cough syrups with pain medication (such as codeine) could lead to memory issues, thinking problems or sedation. If you take one of these medications your memory and thinking should be monitored as confusion could lead to falls and other negative consequences.
• Pain medication (such as meperidine) can interact with other medications and can result in sedation.
• It may be useful to temporarily stop monoamine oxidase (MAO-B) inhibitor drugs (such as selegiline, rasagiline, safinamide) to avoid drug-drug interactions with cyclobenzaprine, dextromethorphan (often found in cough medicine), meperidine (also sold as Demerol), methadone, St. John's wort or the pain medicine tramadol. Talk to your doctor before making changes to your medications.
• Psuedoephedrine, phenylephrine and phenylpropanolamine can be found in any cold or flu medication and could increase blood pressure and possibly increase the risk of stroke, especially in those with high blood pressure.
• Aspirin, acetaminophen and other nonsteroidal anti-inflammatory drugs are usually safe, but can have side effects (particularly gastrointestinal).
• Antihistamines can sometimes cause drowsiness, but many people with PD can tolerate them for short courses.

In 2014, Kim Painter wrote a great article in the USA Today to help individuals and families stay safe in the cold and flu aisle.

Here are some of Kim’s tips:

• Treat only symptoms you have and be wary of multi-symptom products.
• Know your dose and don’t overdose.
• Know your health risks (for example, decongestants can cause blood pressure spikes, especially if you have hypertension; acetaminophen can lead to liver damage for heavy alcohol users).
• Don't double up and accidentally take two medicines with similar ingredients.
• Consider trying alternatives (rest, fluids, saline nasal sprays, salt-water gargles, honey for cough).

Where does this leave people with Parkinson’s when they find themselves in the medicine aisle? The most important take home is that it is possible to take over the counter medications if you have Parkinson’s disease. However, there are potential risks and benefits, as well as strategies and alternatives that may also address cold and flu concerns.

The commonly used strategy of telling a person with Parkinson’s to suffer through cold and flu symptoms may not always be the best strategy. Working through a solution with your healthcare team makes a lot of sense and can alleviate some of the discomfort associated with cold and flu-like illnesses.

You can find out more about our National Medical Director Dr. Michael S. Okun by visiting the Center of Excellence University of Florida Health Center for Movement Disorders and Neurorestoration. Dr. Okun is also the author of the Amazon #1 Parkinson's Best Seller 10 Secrets to a Happier Life.

One year after the Parkinson’s Foundation awarded $500,000 in research grants to address critical unmet needs in Parkinson’s disease (PD), we check in with one of three of the researchers making a difference right now. 

Researchers were tasked with jumpstarting practical solutions to ease difficulties related to cognition, fatigue and sleep, all debilitating yet under-recognized symptoms in Parkinson’s. They have each received a grant funded through the Parkinson’s Foundation Community Choice Research Awards, the first program to set research priorities based on the insights of people living with Parkinson’s.

Milton Biagioni, MD, received a research grant to study the "At-home Non-Invasive Brain Stimulation for Fatigue and Cognitive Slowing" at The Marlene and Paolo Fresco Institute for Parkinson’s and Movement Disorders at NYU Langone, a Parkinson’s Foundation Center of Excellence. 

Q: Can you explain your study in less than 100 words?

A: I am studying the likelihood and usefulness of a portable, non-invasive, brain stimulation device to alleviate fatigue and cognitive slowing in people with Parkinson’s. These are two of the most prevalent symptoms responsible for disability and for reducing quality of life in people with PD. To date there are no proven effective treatments available for either symptom. In this study we use a specially designed transcranial direct current stimulator (tDCS) device through a new method of remote supervision. The therapy is done in the participant’s home through video-conferencing.

To learn more about Parkinson’s research visit Parkinson.org/Research.

A recent study by Inga and colleagues at the Mount Sinai Beth Israel Parkinson’s Foundation Center of Excellence in New York examined the incidence of Parkinson’s disease in inflammatory bowel disease patients. The authors were also interested as to whether exposure to anti-tumor necrosis factor therapy (anti-TNF) could possibly reduce the risk of the later development of Parkinson’s disease. In this month’s What’s Hot in PD? blog we will discuss the links between inflammatory bowel disease and also examine the intriguing possibility that anti-TNF or related approaches may one day be used as Parkinson’s disease treatments.

The idea that inflammation is an important factor in the development of Parkinson’s disease is not new and systemic inflammatory diseases may provide an important clue to pathogenesis. There are almost two million people in the United States suffering from inflammatory bowel disease and there has been great interest in its potential links to neurodegeneration. The LRRK2 (leucine-rich repeat kinase 2) gene is a well-established risk factor for Parkinson’s disease. LRRK2 has also been strongly linked to Crohn’s disease, and this link has raised the question as to whether there is a relationship between inflammatory bowel and Parkinson’s disease. Ulcerative colitis is the other common inflammatory bowel disease, and although much less is known about its links to Parkinson’s disease there has been recent interest in exploring this area. Many inflammatory bowel disease studies include both Crohn’s disease and ulcerative colitis patients.

Inga and colleagues, in a recent issue of JAMA Neurology, examined administrative health insurance claims from approximately 170 million people (Truven Health MarketScan administrative claims database and the Medicare Supplemental Database) and observed that inflammatory bowel disease patients were 28% more likely to develop Parkinson’s disease. Even more intriguing was the observation that exposure to anti-TNF therapy was associated with a 78% reduction in Parkinson disease incidence.

Though the studies were observational and the results derived from analysis of data from health insurance claims, the idea that systemic inflammation plays a key role in Parkinson’s disease is intriguing. Anti-TNF or other anti-inflammatory therapies may be candidates for future clinical trials.

You can find out more about our National Medical Director Dr. Michael S. Okun by visiting the Center of Excellence University of Florida Health Center for Movement Disorders and Neurorestoration. Dr. Okun is also the author of the Amazon #1 Parkinson's Best Seller 10 Secrets to a Happier Life.

Every year, the top Parkinson’s experts from around the world who treat people with Parkinson’s at a Parkinson’s Foundation-designated Center of Excellence (a department or clinic within a hospital that specializes in PD) convene to discuss the latest Parkinson’s research and treatments. This article summarizes the 2018 Center Leadership Conference presentation on art therapy led by art therapist and consultant Kimberly Faulkner, ART-BC, LCAT. Read the articles covering some of the other topics discussed, such: intimacy issues, new therapies in trial, oral health and music therapy. 

Center coordinators play a critical role in the Parkinson’s Foundation Center of Excellence network. Not only do they support research activities, coordinate clinical trials and plan outreach services; they act as the liaison between the Parkinson’s Foundation, the center’s care team and patients. They advocate for a multidisciplinary approach to PD care, and work with all members of the care team to make Foundation resources available to patients and their families.

While center coordinators stay up-to-date on the latest PD treatments, they rarely get to experience them firsthand. That’s what made their session about the benefits of art therapy for people with PD so unique; after watching an educational presentation, coordinators from around the world picked up their paint brushes and became art therapy session participants.

Even if someone with PD has not picked up a paint brush since grade school, art therapy can help improve physical, psychological and social functioning.

Symptoms reported to improve with art therapy include:

• Tremor: About 70 percent of people with PD experience tremors at some point of the disease. Stress, as well as fatigue and intense emotions, can temporarily make tremors worse. Most people find art therapy relaxing, and therefore an effective way to reduce tremor in times of stress.
• Freezing: Some people with PD experience the temporary, involuntary ability to move, called freezing. Because art therapy introduces novel motions that are not part of everyday life, it conditions your body to operate less on autopilot, which decreases likelihood of freezing.
• Impaired speech: Art therapy is a powerful communication tool that creates avenues of self-expression that are invaluable to those struggling with speech problems. Even if participants do not have speech problems, it can sometimes be easier to express difficult thoughts and feelings visually instead of verbally.
• Isolation and depression: About half of people with PD can experience some form of depression during the course of the disease. Art therapy creates a sense of community and emotional support that can alleviate feelings of isolation that often make depression more likely.

After coordinators finished their art therapy session, they said they felt relaxed and reconnected with their past as their paintings reminded them of loved ones and allowed them to express themselves through color and shape. They learned that the joy found in art therapy is through the experience rather than the completed artwork. Many admitted that their final piece was far from what they had intended — a butterfly turned into a stingray; a fish evolved into an abstract masterpiece.

Kimberly Faulkner, the art therapist leading the session, encouraged her participants to share their paintings and experiences with their patients when they returned to their centers. “It may give someone else the opportunity to talk about their concerns, fears and anxieties because as adults, we want to make sure everything is so put together and organized,” Kimberly said. “But at some point, we’re all making a mess here and there and that’s okay.”

To find a Parkinson's wellness class near you, contact the Parkinson’s Foundation toll-free Helpline at 1-800-4PD-INFO (473-4636) or Helpline@Parkinson.org.