Parkinson's disease
In Parkinson's disease the nerve cells in a small area of the brain that make dopamine gradually die off.
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Medicines commonly prescribed for Parkinson's disease
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: TABLET, 1 mgActive substance: rasagilineManufacturer: Kern Pharma S.L.Prescription requiredDosage form: MODIFIED-RELEASE TABLET, 100 mg levodopa; 27 mg carbidopa monohydrateActive substance: levodopa and decarboxylase inhibitorManufacturer: Organon Salud S.L.Prescription requiredDosage form: TABLET, 1 mgActive substance: rasagilineManufacturer: Teva B.V.Prescription required
In Parkinson's disease the nerve cells in a small area of the brain that make dopamine gradually die off. Movement becomes slow and stiff, and a tremor appears at rest. The illness develops over years; there is still no treatment that halts it, but there are medicines and therapies that keep people independent for a long time. It usually begins after sixty and is slightly more common in men than in women, though it also occurs earlier.
What happens in the brain
Deep in the brain lies a cluster of cells called the substantia nigra. It produces dopamine, the chemical through which different parts of the brain agree on movement: when to start, with how much force, when to stop. Dopamine gives movement its automatic quality, which is why we do not have to think about how to put one foot in front of the other.
In Parkinson's these cells die, and inside the surviving ones a protein called alpha-synuclein builds up in deposits known as Lewy bodies. The process is slow: by the time the first noticeable symptoms appear, a substantial share of the cells has already been lost. That is why the illness stays hidden for so long, and why medicines that top up dopamine work so well at the start. Why the cells die is not known for certain: an inherited susceptibility and outside influences appear to combine, and a link has been described with long exposure to pesticides and some industrial solvents.
How it first shows itself
The onset is nearly always one-sided — in one hand or one leg — and that asymmetry persists for years. It is worth remembering, because it separates Parkinson's from many similar conditions.
- Slowness. The cardinal sign. Movements become smaller and slower: handwriting shrinks along the line, buttons take minutes, steps shorten, and one arm stops swinging when walking.
- Tremor at rest. The fingers shake while the hand lies on the knee and settle the moment the person picks up a cup. It worsens with emotion and disappears during sleep.
- Stiffness. The muscles are permanently tense and the limb straightens in jerks. Hence the shoulder and neck pain that often takes people to a doctor first, under the label of a worn neck.
- What others notice. The face becomes less expressive, the voice quieter and flatter, the walk shuffling with small steps and the trunk leaning forward.
Later comes unsteadiness: the person is carried forward, finds it hard to turn and to stop, and starts to fall. Freezing may appear too, with the feet seeming to stick to the floor in a doorway.
Symptoms that have nothing to do with movement
These are often not connected with the illness at all, and yet some of them appear years before the tremor and stiffness.
Early ones. Loss of smell, usually blamed on a blocked nose. Persistent constipation. Low mood and anxiety with no outward reason. And separately, acting out dreams in sleep: the person shouts, flails, punches as though living out the dream, and sometimes falls out of bed or hits the partner beside them. This is REM sleep behaviour disorder, and it often runs years ahead of everything else. On its own it does not mean the illness will certainly follow, but it is worth raising with a doctor.
Ones that come with time.
- blood pressure dropping on standing — dizziness, greying vision, sometimes fainting;
- frequent need to pass urine at night, incontinence;
- drooling, caused not by extra saliva but by swallowing less often;
- difficulty swallowing and choking on food;
- pain in the limbs, sweating, reduced sex drive;
- sleeplessness at night and drowsiness during the day;
- slowed thinking and difficulty planning; in some people, over time, dementia;
- visual mistakes: a shadow taken for a figure, and later genuine hallucinations.
What else it could be
The word parkinsonism describes a set of signs — slowness, stiffness, tremor — and it has several causes. Telling them apart matters, because some are reversible.
- Essential tremor. The commonest confusion. Both hands shake, and they shake during action — writing, pouring tea, lifting a spoon — while settling at rest. The head or the voice often shakes too, relatives frequently have the same thing, and a small amount of alcohol often reduces it. There is no slowness.
- Drug-induced parkinsonism. Caused by medicines that block dopamine receptors: antipsychotics, the anti-sickness drugs metoclopramide and prochlorperazine, some medicines for dizziness and certain blood pressure tablets. The symptoms are usually on both sides and appear within weeks or months of starting; once the drug is stopped they generally settle.
- Vascular parkinsonism. Follows a series of small strokes, affects the legs more than the arms, and responds poorly to levodopa.
- Other degenerative conditions: multiple system atrophy, progressive supranuclear palsy, corticobasal degeneration, dementia with Lewy bodies. They give themselves away by rapid deterioration, early falls, restricted eye movements, early dementia and a weak response to levodopa.
- Normal pressure hydrocephalus. Disturbed walking, urinary incontinence and memory loss together; visible on a brain scan and treatable with surgery.
- Wilson's disease. A rare but crucial cause in younger people: a disorder of copper metabolism in which treating in time prevents irreversible damage. Parkinsonism below the age of forty is a reason to rule it out.
How the diagnosis is made
There is no blood test or scan that confirms Parkinson's disease. The diagnosis is clinical: a neurologist makes it from the whole picture of symptoms, history and examination. The key combination is slowness plus either resting tremor or stiffness, beginning on one side.
The doctor will ask about every medicine you take: without that, drug-induced parkinsonism is easily mistaken for the disease. Investigations are used not to confirm it but to exclude other causes:
- an MRI scan of the brain, to look for the effects of strokes, hydrocephalus or other changes;
- blood tests, including copper studies in younger patients;
- a dopamine transporter scan. It is arranged in doubtful cases, most often to separate Parkinson's from essential tremor; it cannot distinguish it from the other degenerative conditions.
A clear improvement on levodopa is indirect supporting evidence. One more thing: in the early stage the diagnosis is always provisional. A year or two of follow-up shows how the illness behaves and sometimes forces a rethink. That is the normal course of events, not a mistake by the doctor.
The medicines and what to expect from them
Medicines make up for the missing dopamine. They do not stop the cells dying, but they give movement back its speed and smoothness, and people live ordinary lives on them for years. Doses are built up gradually and reviewed as the situation changes.
Levodopa. The main and most effective drug: in the brain it is converted into dopamine. It is always combined with carbidopa or benserazide, which stop it breaking down in the bloodstream on the way. Side effects include nausea, a drop in blood pressure and drowsiness. It is best not taken alongside protein-rich meals, which interfere with absorption.
Dopamine agonists. They act more gently but for longer, and come as tablets or a skin patch. They more often cause drowsiness, swollen ankles and hallucinations in older people, and in some patients impulse control problems: an irresistible pull towards gambling, shopping, food, or a sharp rise in sexual interest. The person rarely sees anything odd in it, so it falls to those around them to notice the change and tell the doctor straight away.
MAO-B and COMT inhibitors. They slow the breakdown of dopamine and lengthen the effect of levodopa. They are added to a regimen rather than used instead of it.
After some years the effect of each dose shortens: "on" and "off" periods appear, along with involuntary sweeping movements at the peak of a dose. This does not mean the drug has stopped working — the regimen is rebuilt. Doses are split, other drugs are added, and for severe fluctuations there is apomorphine under the skin, levodopa gel through a tube into the bowel, or deep brain stimulation.
What helps besides medicines
This is not an add-on to the tablets but the other half of the treatment, and for some problems it works better than any drug.
- Exercise. Regular activity is the only thing that, on the available evidence, slows the build-up of movement problems. Anything accessible counts: walking, a stationary bike, swimming, dancing. Balance work and exercises using large, sweeping movements are particularly worthwhile.
- Physiotherapy. A therapist teaches tricks that bypass the loss of automatic movement: stepping to a count or to music, stepping over an imaginary line when the feet freeze, standing up and turning safely.
- Occupational therapy. Adapting the home: grab rails, no loose rugs or thresholds, easy-to-hold crockery, clothes without fiddly fastenings, lighting along the night-time route to the toilet.
- Speech and language therapy. Helps restore the volume and clarity of speech and choose a safe food consistency when choking becomes a problem.
- Diet. Fibre and fluids against constipation, smaller frequent meals; if blood pressure drops, more fluid, with salt intake and compression stockings agreed with the doctor.
Safety rules worth knowing
A few things are best known in advance, because they prevent serious complications.
Never stop the medication abruptly. Suddenly withdrawing levodopa or missing several doses can cause severe immobility with a high temperature and muscle rigidity — a life-threatening state. If a person can no longer swallow their tablets, contact a doctor that same day.
Take doses strictly on time. The effect depends on the timing. If you are admitted to hospital for any reason, ask for your drugs to be given on your usual schedule, and take your own supply and written timings with you.
Know which medicines to avoid. Metoclopramide and prochlorperazine for sickness, and most antipsychotics, make the condition markedly worse; tell any doctor treating you. Safe alternatives exist and a specialist will choose them. St John's wort and some antidepressants do not mix with MAO-B inhibitors.
Allow for sudden sleepiness. On dopamine agonists a person may fall asleep without warning, so driving is out while the dose is being adjusted. Drivers must also notify the licensing authority and their insurer of the diagnosis: the rules differ from country to country.
When help is needed urgently
Call an ambulance — in Spain, Italy, Portugal, Poland and Ukraine the single number is 112 — if someone with Parkinson's disease has:
- a raised temperature with suddenly rigid muscles and confusion, especially after missing or stopping medication;
- choked and cannot cough it clear, and is struggling to breathe;
- breathlessness and fever after an episode of choking — this is how pneumonia from food entering the airway begins;
- fallen and hit their head, lost consciousness, or fallen while taking blood-thinning medicines;
- sudden slurred speech, a drooping face or a weak arm — signs of a stroke.
The same day, though not by ambulance, contact a doctor if the person can no longer swallow tablets, if confusion has worsened abruptly or hallucinations have appeared (an ordinary infection or a new medicine is often behind it), or if falls and blackouts have become more frequent.
Online consultation
A remote appointment achieves more here than people expect: much of the doctor's work is going through a symptom diary and fine-tuning the regimen, and that does not need an examination every time. Online you can weigh up whether the picture fits Parkinson's, essential tremor or drug-induced parkinsonism, and work through fluctuations in the effect, side effects, and questions about daily life and caring.
Have ready: a list of every medicine with doses and exact times; several days of notes on when the effect wears off and when extra movements appear; short videos of ordinary walking, standing up from a chair, and the hands held out at rest; reports of previous investigations; and the questions of whoever is caring for you.
The first diagnosis is made face to face: it cannot be established without a neurological examination. And the signs listed in the previous section are not for an online appointment — they need in-person care immediately.
This material is for information only and does not replace medical advice.
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