The Parkinson’s Disease Foundation (PDF) hosted a symposia on Parkinson’s on July 18, 2008. The overall topic is “Mind, Mood and Body: Understanding Nonmotor Symptoms of PD.” Here’s a link to the archived recording of the symposia:
event.netbriefings.com/event/pdf/Archives/nonmotor/register.html
The first speaker, Dr. Ron Pfeiffer, gave a wonderful presentation on the topic of “When Parkinson’s Interferes with Gastrointestinal, Urological, Sexual and Other Functions.”
Even though this presentation was focused on PD, lots of references are made to MSA. And, of course, GI, urological, and other symptoms appear in all of the atypical parkinsonism disorders.
I’d heard Dr. Pfeiffer speak twice previously. There was one new item from him: To treat irritative urinary symptoms, he prefers the newer anticholinergics (Sanctura, Enablex, Vesicare — the first two are unlikely to cross the blood-brain barrier) compared to the older ones (Ditropan, Detrol, Levsin, Urispas, Pro-Banthine). Tricyclics such as Tofranil can be used.
Also, he mentioned an important difference between MSA and PD: “In PD, there can be sympathetic enervation to the heart is impaired. (36:48) In fact, it’s almost gone. This doesn’t affect the functioning of the heart. This may be useful in distinguishing PD from MSA because in MSA and in vascular parkinsonism the heart is normal. (38:10) This can be useful but it’s not sensitive enough.”
And I will relay his warning about Reglan: “Don’t ever let an MD put you on Reglan, which works well but is terrible for those with PD.” I think this caution would apply to those dealing with atypical parkinsonism disorder as well because the problem with Reglan is that it depletes dopamine.
These are my notes from his presentation and his answers to the questions directed to him. Of course it’s much better to watch the video yourself.
Robin
Robin’s notes from:
When Parkinson’s Interferes with Gastrointestinal, Urological, Sexual and Other Functions (he starts speaking at 1:48)
Ron Pfeiffer, M.D., Neurology, University of Tennessee Health Science Center
Non-motor features of PD:
* abnormalities of sensation
* behavioral changes
* sleep disturbances
* abnormalities of respiratory function
* autonomic dysfunction –> the focus of his presentation
* fatigue
The autonomic nervous system might be called the automatic nervous system. It handles functions we don’t have to think about including:
* gastrointestinal –> he’ll spend most of his time here
* cardiovascular
* urological
* sexual
* thermoregulatory
* respiratory
In PD, things go wrong with the autonomic nervous system.
Gastrointestinal (starts at 5:00) dysfunction was described by James Parkinson. GI symptoms include:
* salivary excess
* dysphagia
* nausea
* decreased frequency of bowel movements
* defecatory dysfunction
* weight loss
It had been thought that GI dysfunction was due to problems in the substantia nigra (midbrain). Braak proposes that PD changes start in two other areas of the brain: the olfactory center and the medulla (brain stem). The medulla affects the vagus nerve, which controls a lot of the autonomic system.
Within the GI system, there’s another nervous system that controls the gut. This is called the enteric nervous system. Braak found alpha-synuclein deposition in the stomach. So maybe PD originates not in the brain but in the stomach! Maybe PD is transported from the stomach to the brain via the vagus nerve. Dopamine deficiency can also be found in the enteric nervous system.
Weight loss in PD occurs in 52%. (11:10) May precede diagnosis. Average weight loss is 7.2 lbs. (but 22% lose > 28 lbs!). Reason is unclear: reduced energy intake (but calorie intake is similar) or increased energy expenditure?
Excess saliva is experienced by 70-78% of PDers. Saliva production is actually decreased. Reasons saliva accumulates: decreased swallowing frequency and efficiency, tendency for mouth to be open, stooped posture.
Treatment of excess saliva:
* anticholinergics: but these can make saliva more tenacious and viscous; systemic administration probably best avoided; sublingual atropine ophthalmic solution; can cause urinary retention and memory problems; [his slide says this but he didn’t discuss it: glycopyrrolate avoids CNS but not peripheral AEs]
* intraparotid botox: but there’s risk of pharyngeal muscle weakness
* antiparkinson medication: to improve swallowing efficiency
* gum and hard candy: very useful in a social situation
* tympanic neurectomy: he doesn’t recommend this (dubious benefit)
Dysphagia in PD occurs in 30-82%, according to questionnaires. MBS (modified barium swallow) shows *some* abnormality in 75-97% though patients may be clinically asymptomatic. In MBS, a barium-laced liquid, pudding, and cookie are swallowed. MBS views mouth and throat, not esophagus. Any phase of swallowing may be affected.
Complications of dysphagia: (17:18)
* some degree of aspiration is present in 15-56% of those with PD. Not necessarily full scale aspiration. Aspiration = something getting past vocal cords.
* clinically silent aspiration present in 15-33%. Coughing or choking when eating may be a clue.
* any abnormality increases risk of pneumonia.
[his slide says this but he didn’t discuss it: * one particular abnormality (vallecular residue) present in 88% of patients without dysphagia.]
Oropharyngeal dysfunction diagnosed by:
* MBS
* pharyngeal manometry
* electromyography
* videomanofluroometry
Esophageal dysfunction diagnosed by:
* videofluoroscopy
* endoscopy
* esophageal manometry
Other problems that can affect the esophagus but may have nothing directly to do with PD: (18:20)
* Zenker’s diverticulum: food collects; bad breath is common; people cough up undigested food hours after eaten; can be treated surgically
* cricopharyngeal bar: muscle that doesn’t relax when swallowing; can be treated surgically
* anterior osteophytes: arthritic changes
* achalasia: enteric nervous system is damaged and constricts down
At 19:32 there’s a good slide and discussion of how to approach diagnosis of dysphagia.
GERD can also affect swallowing.
Nausea in PD occurs in 16% of unmedicated people with PD. (20:50)
Bloating occurs in 43% of unmedicated people
Gastroparesis (impaired emptying of stomach) may be responsible
Gastroparesis symptoms: early satiety, sense of bloating, nausea/vomiting, weight loss
If there’s gastroparesis, alternate medication delivery routes can be sought:
* subcutaneous: apomorphine, lisuride (used in Europe)
* enteral (jejunal): levodopa (used in Europe)
* sublingual: selegiline
* transdermal: rotigotine (only briefly available in US)
Prokinetic drugs can improve gastric emptying: (23:00)
* dopamine antagonists: domperidone works the best; this med is not available in the US; “your cagey neurologist” can probably get this medication for you from Canada. Don’t ever let an MD put you on Reglan, which works well but is terrible for those with PD.
* serotonin 5-HT4 agonists: Cisapride, Tegaserod, Mosapride, Prucalopride, Renzapride. None of these is available in the US currently because of potential cardiac injury.
A gastric pacemaker can be placed to treat severe gastroparesis. This has not been studied in those with PD.
The small intestine has not been studied in PD. The clinical consequences of small intestine dysfunction are unclear. Could this lead to abdominal bloating? Could this lead to altered nutrient absorption, thereby causing weight loss?
Constipation = colonic inertia. Decreased bowel movement frequency. (25:12)
Defecatory dysfunction is more common than constipation, though he’s not sure everyone has found that.
The Honolulu Asian Aging Study showed that people who had less than one BM per day had:
* twice the likelihood of getting PD as compared to someone who had one BM per day, and
* four times as likely to get PD as compared to someone who had two or more BMs per day.
Unclear if this means that the presence of PD was evident years before the symptoms or if decreased bowel frequency has something to do with the etiology of PD.
Colon transit time is prolonged in PD. Occurs in about 80% of PD patients. (27:20)
The first step to treating constipation should always be to increase the amount of fiber and fluid one consumes. (28:48) Americans almost universally have a fiber-deficient diet. If adding fiber to the diet doesn’t work, try a supplement. Eight glasses of fluid a day need to be consumed. Add a stool softener if that helps. Next step is Miralax, available OTC. Can be taken as needed or daily. Next step is another choice of osmotic laxative. If all else fails, enemas can be used. It’s wise to avoid irritating laxatives for fear of damaging the enteric nervous system with prolonged used.
Medications have been looked at to speed up colon transit time: Cisapride, NT3, Tegaserod, Prucalopride, and Lubiprostone (Amitiza). Of these, only Amitiza is available. The others have been withdrawn due to toxicity. A teacher of his recommends pyridostigmine for this problem. Surgical treatment is available: colectomy (removal of part of the colon).
Defecatory dysfunction occurs in 66% of PD patients. This includes increased straining, painful defecation, and incomplete emptying. Some muscles are supposed to relax and others contract when having a BM. In PD, this doesn’t always happen. There can be insufficient intra-abdominal pressure. Underlying mechanisms may be due to bradykinesia, rigidity, and dystonia of the sphincters (off-period phenomenon). You can be tested for this but the tests (including defecography and anorectal manometry) are somewhat exotic. There really isn’t any proven treatment for this problem.
In PD, there can be sympathetic enervation to the heart is impaired. (36:48) In fact, it’s almost gone. This doesn’t affect the functioning of the heart. This may be useful in distinguishing PD from MSA because in MSA and in vascular parkinsonism the heart is normal. (38:10) This can be useful but it’s not sensitive enough.
Orthostatic hypotension (drop in BP when standing) occurs in 58% of people with PD — in 20% it produces symptoms, while in 38% it produces no symptoms. Antiparkinson meds can magnify this problem. Lightheadedness (progressing to fainting) is the typical sensation but there are many others that people don’t realize. (39:10) Other symptoms include: vision problems, impaired thinking, headache in a coathanger distribution, lower back or rear-end ache (because muscles deprived of blood), fatigue or lethargy.
Postprandial hypotension (BP drops after meals) can be triggered by carbohydrates (most likely culprit). Sitting or standing may exacerbate. Same symptoms as OH. May develop within 15 minutes of eating, and may persist up to 3 hours. In a normal person, eating a meal doesn’t cause BP to drop. Deal with this by eating smaller meals more frequently. Or rest/relax after eating until the problem passes.
Urinary dysfunction occurs in 27-39% of those with PD, according to newer studies. (41:10) Troublesome incontinence is in 15%. Symptoms correlate with stage of disease. Two types: irritative (most common; consists of overactive bladder contraction) and obstructive. Characteristics of irritative bladder are: frequent urination, nighttime urination, urination of small amounts, urgency, and “urge” type incontinence.
To treat irritative symptoms, he prefers the newer anticholinergics (Sanctura, Enablex, Vesicare — the first two are unlikely to cross the blood-brain barrier) compared to the older ones (Ditropan, Detrol, Levsin, Urispas, Pro-Banthine). Tricyclics such as Tofranil can be used.
Obstructive urinary symptoms include hesitancy and weak urinary stream. May develop overflow incontinence. Treatment is more difficult. Intermittent catheterization is probably going to be the most effective treatment. (44:05)
Bladder ultrasound can be a useful test to differentiate if this is an overactive or underactive bladder.
Question: Will a colectomy have an impact on PD symptoms? (45:45)
Answer: I don’t think so.
Question: Can drugs like Flomax be used in women with PD?
Answer: I don’t think so.
Question: Any relationship between ulcerative colitis and PD?
Answer: I’m not aware of any. Ulcerative colitis is an auto-immune disease. PD is not an immune-related disease.
Question: Is there any relationship between PD and sigmoid volvulus?
Answer: It’s very rare and has to be treated surgically.
Question: You mentioned injections in Europe to treat nausea and bloating. (48:22)
Answer: Apomorphine infusions can be used to deliver meds if there’s gastroparesis but this med does not to treat gastroparesis itself.
Question: What about diarrhea? (51:12)
Answer: Generally diarrhea isn’t a problem with PD per se. Although if a person has severe constipation and gets impacted, eventually stool will liquify and go around the impaction area, and cause diarrhea. Also, some meds can cause diarrhea.
Question: My voice is raspy. It feels tight around my throat. What is this from? (51:56)
Answer: The most common speech problem in PD is a soft, breathy voice because people are not pushing enough air past the vocal cords or the vocal cords may not be closing tightly. When you say “raspy,” this might be that the vocal cords are spasming. Lee Silverman Speech Therapy has been developed for those with PD.
Question: Should someone with PD who has frequent UTIs keep getting meds or does cranberry juice work?
Answer: If you get an infection, you need antibiotics. Cranberry juice may prevent UTIs. If someone continues to get infections, a urologist may put him/her on chronic antibiotic therapy as a preventive measure.
Question: What about sexual dysfunction?
Answer: This is common but doesn’t get talked about much. 70% of so men have ED. ED drugs can drop BP. 44% of men have decreased libido. Much higher percentage of women have decreased libido. Not much treatment for decreased libido.
Audience Member Comment: PDers who drool give good wet kisses.
Question: Is gall bladder inflammation related to PD?
Answer: Nothing written about this.
Question: Is there a portable electrical device to improve bowel function?
Answer: I’m not aware of anything.
Question: Bee stings caused my PD symptoms to dissipate. Twice. Can you speak to this? France has been studying this.
Answer: I’m not aware of anything in the literature about this. Presumably this is affecting the body’s immune system.
Question: How does Viagra affect PD or vice versa?
Answer: Drugs like Viagra can be effective in treating ED but there can be a tendency for these drugs to cause the BP to drop. It’s not cool to faint when you are trying to get other things done. If you already have OH, you should probably stay away from these drugs.