Treatment options for Parkinson’s
THERE are several treatment options for Parkinson’s Disease patients. The treatment for one person will differ from another because of the varying levels of the disease and according to how each person reacts to the treatment.
Neurologist Dr Sng Kim Hock explains that Parkinson’s has five levels and four main features. The features are:
- Shaking of the hands, and sometimes feet or chin. It is a rhythmic shaking; and
- As they get worse, their stability is affected.
There needs to be two out of four of those symptoms for PD to be diagnosed.
He explains that there are two groups of Parkinson’s patients. The ones who get it older and those who get it before they turn 60.
It can also present in children – in such cases, it is called juvenile Parkinson’s Disease. These are often genetic (a gene defect called the Parkin gene) or familial – meaning that out of a family of six, either two or three will have it.
According to Dr Sng, the main feature of Parkinson’s is that patients are not so mobile. Their posture becomes quite stiff. They don’t swing their arms and they can be quite stationary like a statue. They would also have a mask-like face because they don’t smile much and there is not much expresssion. In addition, there is less blinking of the eyes, so they look like they are staring. Their posture also tends to be stooped. When they walk, sometimes it seems to be very fast and in shuffling steps.
“Because of all this, they are conscious and become socially withdrawn. They don’t like to go out. That is one of the main problems with Parkinson’s. They generally do not get dementia. Only about 10% get dementia later, so dementia is not a feature of PD,” he explains.
First line of treatment
According to Dr Sng, the treatment needs to be tailor-made to the individual. However he cautions rushing into treatment because, while there are many varieties of medication, they typically come with side effects.
Dr Sng explains that the first thing that the neurologist would do when a patient presents symptoms that look like PD is to confirm that it is not a treatable form of PD. For example, certain drugs and those who are exposed to heavy metals can develop drug-induced PD.
One particular disease to rule out is Wilson’s Disease, which causes copper accumulation. This can be checked by testing the urine for copper and through the eyes to see if there are copper deposits.
“The first line of treatment, I would say, is to improve the general health, with an emphasis on exercise. There is now evidence showing that people who do exercises, such as cycling, can delay the progress of the sickness.”
According to Dr Sng, the basic problem in Parkinson’s is the cells’ lack dopamine. So, the gold standard of treatment is to replace the dopamine.
“Dopamine is a chemical that is necessary for movement. Without dopamine, movement will be slow and stiff. In PD, the dopamine in the cells is lacking. So, we replace the dopamine. The discovery of dopamine in the early 70s or late 60s, in the form of Levodopa, resulted in a great breakthrough in Parkinson’s.
“However, if you take it too early, you get side effects, which sets in within three to five years. Because of this and in line with our standard guidelines, which is the same as the international guidelines, we don’t use Levodopa until someone is more than 60 years old.
“There is also a common practice to use one of the mild antioxidants called selegiline, or Jumex, which has some effect on slowing down the disease for up to a period of a year at the most.
“We would also use the dopamine agonist before we use Levodopa. These drugs help to improve the dopamine function. They are not as effective as Levodopa but they can be used to improve the patient’s function. Patients improve a lot when we use drugs like pramipexole, ropinirole and piribedic.
“The problem with the treatment is that in the first to second stage, they do very well. But, at some point, when they go to the third stage, usually after about eight years, the effect of the drug reduces. Then, we need to use combinations to improve the drug effect. The side effect is the wearing down of the drug and this leads to the patient getting various attacks like freezing, where they can’t move. Shortly after two to three hours of taking the drug, the effect is gone.”
Role of antioxidants
He says that the basic treatment for PD is two-fold – to improve the function of the patient, such as motor function, and non-motor functions like sweat and constipation.
“The motor function is the main emphasis. We want the patient to be mobile, active and, if possible, to work again. That’s the main key – treating the mobility. We also want to focus on prevention, if we can. That means to slow down the disease. In medical terms we call it secondary prevention.”
To slow it down and for secondary prevention, antioxidants are important.
“We know that free radicals get deposited in the brain and we know from experiments that if people are exposed to certain toxins and there is damage to the brain, it can result in Parkinson’s Disease. In the experiments, antioxidants were used to slow down the accumulation of free radicals.”
He recommends fruits like blueberries and acai berries which contain a lot of antioxidants. Antioxidants are like scavengers – they come in to clear the free radicals so that it’s not a toxic environment for the brain, explains Dr Sng.
Although the their exact role has not been determined, sleep, rest, low stress and good exercise also play a part in prevention.
For those who can afford it, there is the option of surgery. In the past, it was called ablation therapy, which means to destroy part of the brain. This option is still effective for those who have bad shaking or tremors.
“But these days people don’t want to damage the brain, so they use a stimulator. We call it deep brain stimulation. If you go to a good medial centre, the success rate is very good, however, the cost is high – about RM200,000.
“You can also choose to have apomorphine administered to the spinal cord. It has very good results. The results are dramatic and much faster than taking medication orally, but it’s not easy to co-ordinate it and it is very expensive.”
In recent years, there has also been the introduction of stem cell treatment for Parkinson’s. “The evidence is a bit thin, in my opinion. Maybe it needs to be perfected, but certainly there may be a role in the future,” says Dr Sng. Some Malaysians have gone abroad for such treatment as it is not yet available here.
Dr Sng also says there have been anedotal stories about how qigong, taichi and even massage have helped PD patients. According to him, because the body is an engine, any stimulation will generate feedback to the brain, which would be helpful.
In addition to mobility, Parkinson’s Disease also affects the patient’s speech. A PD patient’s speech usually becomes monotonous and you can’t hear the inflections.
“Malaysians in particular already start off speaking flat, so it can be worse when they get Parkinson’s. Certainly speech therapy plays an important role, and one of the things I advise a lot of my patients to do is to read aloud, so that they get better with time.
“Their speech can improve and it also improves the mind to read aloud, as it is an exercise for the brain. By reading aloud, you use your eyes, mind, tongue, lips and it stimulates the brain.”
At the end of the day, being positive and remaining active helps. Dr Sng says it is important for senior citizens to socialise, get out of the house and be active.
“The worst thing that can happen to a PD patient is that it cripples his emotional life. So, you’ve got to be active and go out. You’ve got to fight it.
“The progression of the disease is slow – about 15-30 years, so there’s always hope for a Parkinson’s patient if he is freshly diagnosed. He can hope to have a good quality of life for 10-15 years. After that, there’s still hope that newer drugs come into the picture.”
His best advice is to look after the body – eat well, get good nutrition and vitamins, take supplements, reduce stress, exercise regularly, get enough sleep and rest, and take antioxidants like CoQ10.
“I think, we shouldn’t wait until we are immobile. We have to push and mobilise, in the sense that if you have improved your physical ability to a very high level, and you drop one or two points you are still okay. But, if you are functioning at the minimal, then you drop one or two points, you’re in bad shape.”