What is Parkinson’s disease?
Parkinson’s disease is a brain condition that affects movement. It happens when brain cells that make dopamine slowly stop working. Dopamine is a chemical messenger that helps your body move smoothly.
Parkinson’s disease usually starts slowly and changes over years. It is different for every person. Some people notice a tremor first. Others notice that they move more slowly or feel stiff.
Parkinson’s disease is a long-term condition. Many treatments can help with symptoms, and your care plan can change as your needs change.
Common symptoms
Movement symptoms
- Tremor at rest. Shaking of a hand, arm, or leg while it is relaxed. It often lessens when you use that hand.
- Slowness. Everyday tasks, like buttoning a shirt, take longer. Handwriting may get smaller.
- Stiffness. Arms, legs, or the neck may feel tight or achy.
- Balance changes. Steps may get shorter or shuffling. Some people feel unsteady when they turn.
Symptoms that are not about movement (pre-motor symptoms)
Many people also have symptoms that have nothing to do with movement (non-motor symptoms). Some of these can show up before the tremor or slowness.
- Loss of the sense of smell
- Constipation
- Acting out dreams during sleep (REM sleep behavior disorder)
- Changes in mood, such as depression or anxiety
Non-motor symptoms that begin after motor symptoms occur
Non-motor symptoms can often be more disabling and decrease quality of life more than the motor symptoms (tremor, slowness of movement, rigidity, and shuffling).
Daytime drooling (sialorrhea)
Daytime drooling, when it is more than mild, is an early sign of swallowing dysfunction. It is treated with oral medications and/or botulinum toxin injections.
Depression and anxiety
Depression and anxiety can occur before or after the movement (motor) symptoms. They are treated with a holistic therapy program, antidepressants, and anti-anxiety medications.
Delayed gastric emptying (gastroparesis)
Gastroparesis is a form of autonomic nervous system failure and is a later sign of Parkinson’s disease, in which the stomach takes much longer than normal to empty. Symptoms can include:
- Feeling completely full after eating only a small amount of food
- Reflux (heartburn)
- Abdominal gas and bloating
- Weight loss
- Nausea or vomiting
Many people have no symptoms but have a poor response to immediate-release medications.
Psychosis (hallucinations or delusions)
Psychosis is a symptom of more advanced Parkinson’s disease and usually occurs with dementia. Symptoms include:
- Visual hallucinations
- Auditory hallucinations (hearing sounds, music, or voices)
- A false sense of presence: seeing a shadow or figure of a person or animal in your peripheral vision that goes away once you try to look at it
- False beliefs (delusions)
What can be mistaken for psychosis
Visual hallucinations can be confused with vivid dreams and nightmares.
They can also be confused with sleep hallucinations when waking up (hypnopompic hallucinations) or when falling asleep (hypnagogic hallucinations). These can cause a false perception of objects, sounds, smells, or touch. Sleep hallucinations seem real, but they are not. They are common and usually not a cause for concern. Up to 70% of people experience them at least once. Sleep hallucinations are not psychosis, because true psychosis occurs at any time of the day, not just at night.
REM sleep behavior disorder (RBD)
RBD can occur 20 years before or after motor symptoms begin. It can occur only once and disappear years before motor symptoms. About 60% to 80% of people who have RBD will develop Parkinson’s disease, Lewy body dementia (LBD), or multiple system atrophy (MSA).
RBD is frequently mistaken for visual hallucinations or nightmares, because people can have conversations or make purposeful movements in their sleep as if they were awake, such as hitting, kicking, or even rolling out of bed. People can injure themselves or their bed partners and are almost always completely unaware of moving in their sleep. RBD can usually be treated very effectively by your movement disorder specialist.
Neurogenic orthostatic hypotension (NOH)
Neurogenic orthostatic hypotension is a form of autonomic nervous system failure. It can start in mid to late Parkinson’s disease, or early in atypical Parkinson disorders. Many people have no symptoms at all for up to 1 to 2 years, while others have symptoms when it starts. The most common symptoms, which occur minutes after standing, include:
- Lightheadedness when you stand up
- Knee buckling or sudden leg weakness
- Blurry vision
- Passing out, with or without involuntary movements that can be mistaken for seizures
We screen for neurogenic orthostatic hypotension. It is one of the symptoms of autonomic nervous system dysfunction, in which the body loses its ability to regulate blood pressure. It is important to recognize because neurogenic orthostatic hypotension does not follow the same blood pressure parameters that usually signal the need to treat.
Screening for NOH is important not only because of the risk of falls and passing out, which can cause injury. Many people take medication for hypertension to lower their blood pressure, and their doctors are unaware they are developing NOH. Since there can be large drops, sometimes of 40 to 80 points or more, this can cause dangerously low blood pressure when standing, leading to frequent passing out, falls, and emergency room visits. Use the BPMedTracker app to screen for NOH and print a detailed report for your doctor.
Sleep apnea
Sleep apnea occurs in about 60% to 80% of people with Parkinson disorders, and they are usually unaware of it. People will say they sleep just fine because they are unconscious all night or do not snore. But this does not mean they are getting into deep sleep (restorative sleep, when neurological repair happens) or that they do not have sleep apnea. A board-certified sleep specialist can diagnose and treat sleep apnea, which can in turn improve symptoms of Parkinson’s disease.
Consequences of sleep apnea
- It can affect insulin levels, leading to high blood sugar (hyperglycemia) and possibly diabetes.
- It increases the risk of stroke and heart attack by increasing the formation of atherosclerotic plaque.
- It increases weight gain by affecting the release of hormones that affect fat breakdown.
- Chronic headaches
- Short-term memory loss
How we make the diagnosis
There is no single blood test for Parkinson’s disease. The diagnosis is made mainly through a careful exam by a movement disorder specialist.
At your visit, we will:
- Ask about your symptoms, when they started, and how they have changed
- Review your medicines, since some can cause symptoms that look like Parkinson’s disease
- Watch how you walk, move, and use your hands
- Check your muscle tone, reflexes, and balance
When the diagnosis is not clear, we may order a DaTscan. This is a special brain scan that shows how the brain’s dopamine system is working. It can help tell Parkinson’s disease and related conditions apart from look-alikes such as essential tremor or drug-induced parkinsonism. It cannot, by itself, tell Parkinson’s disease apart from atypical Parkinson disorders.
Several conditions can look like Parkinson’s disease, especially early on:
- Essential tremor, a shaking that is usually worse when you use your hands
- Drug-induced parkinsonism, caused by certain medicines
- Atypical Parkinson disorders, such as multiple system atrophy or progressive supranuclear palsy
Getting the diagnosis right matters, because the treatment is different for each one.
Drug-induced parkinsonism
Some medicines that block dopamine can cause drug-induced parkinsonism. It looks like Parkinson’s disease, with slowness, stiffness, a tremor, or shuffling steps, but it is caused by the medicine, not by the loss of the brain cells that make dopamine. The most common causes are antipsychotic medicines and some anti-nausea medicines, such as metoclopramide and prochlorperazine.
It is crucial to bring a typed list of all antipsychotic medicines and anti-nausea medicines you received before your symptoms started. The list should include the name of each medicine, when it was started, and when it was stopped. You may have received as-needed medicines for nausea in the hospital or emergency room without being given their names.
Drug-induced parkinsonism often gets better after the medicine is lowered or stopped, but this can take months. Some people have both drug-induced parkinsonism and Parkinson’s disease. A DaTscan can help tell them apart. The same medicines can also cause tardive dyskinesia.
Treatment options
Treatment is built around your symptoms, your goals, and your daily life. It often changes over time.
Medications
Carbidopa/levodopa is the most common medicine for Parkinson’s disease. It helps movement by replacing the dopamine the brain is missing. Other types of medicine include:
- Dopamine agonists, which act like dopamine in the brain
- MAO-B inhibitors and COMT inhibitors, which help dopamine last longer
- Medicines for symptoms that do not involve movement such as loss of blood pressure regulation, drooling, acting out dreams, or constipation
Over time, some people notice their medicine “wears off” before the next dose is due or have involuntary movement called “dyskinesia” from levodopa, which can be improved with medication management.
Make sure you bring a typed list of medications used to treat Parkinson’s disease that failed or caused side effects. Use BPMedTracker to track your medications and print a list.
Exercise and therapy
Regular exercise is an important part of Parkinson’s disease care. We may refer you to:
- Physical therapy, for walking, balance, and strength
- Occupational therapy, for daily tasks at home
- Speech therapy, for a soft voice or trouble swallowing
Device-aided therapies
For people whose symptoms go up and down during the day, device-aided therapies give medicine steadily through a small pump. Vyalev and Onapgo are given under the skin. Duopa is a gel given through a tube placed into the small intestine during a minor procedure. We can help you decide whether one of these fits your needs.
Deep brain stimulation (DBS)
Deep brain stimulation (DBS) is a surgery that places thin wires in the brain to help control certain movement symptoms. We can evaluate whether DBS may be an option for you.
DBS may be worth considering if you:
- Still get good help from levodopa, but it wears off between doses
- Have involuntary movements (dyskinesia) that medicine changes no longer control
- Have a tremor that medicine does not control well
DBS helps most with symptoms that also improve with levodopa. It usually does not help symptoms that levodopa does not help, and it may not be a good choice for people with serious memory or thinking problems.
Before surgery, we do a careful pre-surgical screening. This includes a detailed movement exam on and off your medicine, a neuropsychological evaluation to rule out dementia, which is a contraindication for DBS, and a review of mood and overall health. When surgery is the right choice, we refer patients to experienced neurosurgeons in the Dallas–Fort Worth area and continue their care before and after surgery.
After surgery, we do the DBS programming in our office. Programming means adjusting the settings of the stimulator over several visits, often along with your medicines, to find what works best for you.
Botulinum toxin for select symptoms
Botulinum toxin injections may help with some Parkinson’s disease symptoms, such as drooling. Learn more about botulinum toxin injections.
When to see a specialist
Consider seeing a movement disorder specialist if you or a loved one has:
- A new tremor
- A diagnosis that isn’t clear, or symptoms that don’t seem to fit
- Medicines that wear off before the next dose
- Falls or trouble with balance
- Hallucinations, such as seeing things that aren’t there
- Trouble swallowing
You do not have to wait until symptoms are severe. Call 940-828-MOVE (6683) to schedule a visit.
Support and resources
Many people find it helpful to connect with others who understand. Dr. Lisk co-founded the Dallas Area Parkinson Society’s Parkinson’s disease support group at the Denton Senior Center. You can find more local support on our resources page.
Tracking your symptoms at home
A watch app can track your symptoms between visits and help us fine-tune your medicines.
NeuroRPM
NeuroRPM-Rx for Apple Watch
An Apple Watch app that tracks your Parkinson’s disease symptoms between visits.
Dr. Lisk is an advisor to NeuroRPM.