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People with a family history of Parkinson's disease may have an added susceptibility to the disease after pesticide exposure or head trauma In a recent case-control study of nearly 1,000 patients with Parkinson's disease or parkinsonism and almost 2,000 controls, high exposure to pesticides increased the risk of the disease by 41%. Pesticide exposure has been linked to neurological disorders and other diseases. It is not clear exactly which toxins are at fault, and what level of exposure is required to cause harm. Also, a history of traumatic head blows causing a loss of consciousness, a common occurrence in boxing and other sports, was associated with a 2.5-fold greater risk of developing Parkinsons, the authors reported. Even a single blow to the head causing loss of consciousness may increase the risk of Parkinson's disease and related disorders. Occup Environ Med, BMJ May 2007

Exposure to pesticides increases the risk of Parkinson's disease by 70%
A recent study strengthens the mounting evidence that certain pesticides used in agriculture and home insect control are associated with the development of Parkinson's disease. In a recent study from Harvard, 140,000 men and women were followed through 2001 as part of a cancer prevention study. Those who reported being exposed to pesticides or herbicides before 1982 had a 70% higher rate of Parkinson's disease 10 to 20 years after the initial exposure. The incidence was highest among people who had experienced occupational exposure to pesticides such as farmers and ranchers. Farmers not exposed to pesticides did not have a higher incidence of Parkinson's disease. There were no significant associations between Parkinson's disease and other occupational exposures to such toxins as asbestos, acids and solvents, coal, stone dust, or other materials.

Symptoms of pesticide exposure can include respiratory problems, gastrointestinal disease, headache, dizziness, confusion, skin problems, eye problems, and many other nonspecific conditions.
MedPage Today June 2006

About Parkinson's Disease
Parkinson's disease is a slowly progressive neurological disorder that results from degeneration of neurons in a region of the brain that controls movement, muscle control and balance. This degeneration creates a shortage of dopamine (a neurochemical) throughout the brain.  This decrease in dopamine results in the  movement impairments that characterize the disease.
Secondary Parkinsonism
This is a similar condition of nerve cell death.   The symptoms are similar to Parkinson's Disease but the etiology of the nerve cell death can be traced to a specific cause such as: antipsychotic drugs (i.e. Haldol), carbon monoxide poisoning, manganese poisoning, hydrocephalus, brain tumors, stroke, encephalitis, meningitis, IV drug abuse of N-MTP, and reserpine.
Symptoms of Parkinson's Disease

Frequently, the first symptom of Parkinson's disease is tremor (trembling or shaking) of a limb, especially when the body is at rest. The tremor often begins on one side of the body, frequently in one hand.

Other common symptoms include slow movement (bradykinesia), an inability to move (akinesia), rigid limbs, a shuffling gait, and a stooped posture. People with Parkinson's disease often show reduced facial expressions and speak in a soft voice.

Occasionally, the disease also causes depression, personality changes, dementia, sleep disturbances, speech impairments, or sexual difficulties.

The severity of Parkinson's symptoms tends to worsen over time.

Incidence of Parkinson's Disease
In the United States, more than 1.5 million people are believed to be affected by Parkinson's disease. These figures are expected to increase as the average age of the population increases. The disorder appears to be slightly more common in men than women. The average age of onset is about 60. Both prevalence and incidence increase with advancing age; the rates are very low in people under 40 and rise among people in their 70s and 80s. However, there is  an alarming increase of patients of younger age.  
Causes of Parkinson's Disease
The cause of Parkinson's Disease is unknown.  Although there are many theories, none have ever been proven.  Recent studies  have suggested that some people have an inherited susceptibility to the disease which is further influenced by environmental factors.
Diagnosis of Parkinson's Disease
There is no test that can clearly identify the disease. Parkinson's disease is usually diagnosed by a neurologist who can evaluate symptoms and their severity.  Sometimes people with suspected Parkinson's disease are given anti-Parkinson's drugs to see if they respond. Other tests, such as brain scans, can help doctors decide if a patient has true Parkinson's disease or some other disorder that resembles it. Microscopic brain structures called Lewy bodies, which can be seen only during an autopsy, are regarded as a hallmark of classical Parkinson's.
Treatment for Parkinson's Disease

There is no cure for Parkinson's disease. But, with proper treatment, people with Parkinson's can lead long and productive lives.  The progression of the disease varies from individual to individual, however, so treatment is  individualized. 

Initially, many patients are only mildly affected and need no symptomatic treatment for several years.   Many patients’ symptoms begin with tremor. As a rule, resting tremor is rarely disabling for most patients. Patients should try not to force the doctor to treat tremor early on just to avoid some perceived embarrassment unless there is accompanying functional disability from the tremor.  The reason for this is that although the initial response to symptomatic treatment can be dramatic, over time  the effectiveness of drugs frequently decline and their side effects can worsen.    Because of these eventual problems, conservative lifestyle changes are initially recommended to control symptoms reserving the use of medications for later in the disease.  Physical therapy, as well as a healthy diet and regular exercise can provide significant relief of symptoms early in the disease.

Physical therapy can help improve mobility, range of motion, muscle strength, endurance and balance.  Exercise can make a significant difference in the persons general well being and quality of life. Also, for many people, working with a speech pathologist can help improve problems with speaking and swallowing.

A major question that faces patients and physicians is when to start treatment and with what drug in a patient newly-diagnosed with PD. Most PD experts agree that treatment should not be started until a patient is experiencing some “functional disability” from the disease.

The following is a list of the categories of drugs used in treating the symptoms of Parkinson's.  Some new drugs have recently been approved offering a wider choice of medications, while others are under investigation in this country and overseas in an effort to obtain better therapeutic results with fewer side effects.

Levodopa is a natural substance found in plants and animals and is the most important and most effective drug to treat the symptoms of PD.    Levodopa helps all the major signs and symptoms in the majority of patients. In fact, if a patient is not helped by levodopa, this is often evidence that the patient may be suffering from one of the other forms of parkinsonism described earlier. Nausea is the most common side-effect experienced by patients who take levodopa. With persistence, most patients can overcome this problem (see below). The simultaneous administration with levodopa with an additional drug  allows a higher concentration of levodopa to reach the brain and also considerably decreases the side effects of levodopa.

Levodopa/carbidopa (Sinemet) Because of the nausea many patients experience when taking levodopa alone, it is usually taken in combination with carbidopa (Sinemet). Carbidopa markedly reduces the incidence of nausea and vomiting from levodopa. It also ensures that more levodopa goes into the brain Patients taking the combination  require less levodopa per dose than if they take levodopa alone. For these reasons it is the most common form in which patients take levodopa.

Levodopa/carbidopa comes in two forms, standard and controlled-release(CR). The standard form is absorbed quickly while the CR form is absorbed over several hours. Many patients who develop end-of-dose wearing-off symptoms are helped by switching from the regular to the CR form of levodopa.

Levodopa/carbidopa/entacapone (Stalevo) A new levodopa product that contains entacapone, Stalevo has a unique ingredient that helps levodopa work better for longer periods of time. People who take Stalevo may have better symptom control for longer periods of time between doses of levodopa, which improves activities of daily living. Just as carbidopa blocks the conversion of levodopa to dopamine in the blood and intestine, entacapone inhibits an enzyme that blocks levodopa breakdown in the blood. A more consistent level of levodopa in the blood may result in better and reliable control of symptoms.

Selegiline (Deprenyl, Eldepryl) By interfering with one of the enzymes that break down dopamine (monoamine oxidase), selegiline can enhance and prolong the effect of each dopamine molecule. It was once hoped that selegiline might slow the progression of PD, but few physicians still believe this to be the case. It is used frequently as a first drug for the treatment of early PD and seems to be of moderate help to about 60% of such patients. This benefit is sufficient to satisfy most patients for approximately one year, after which they may elect to start levodopa treatment, either by adding levodopa to selegiline or by switching to levodopa preparation. Some patients encounter difficulty sleeping when they take selegiline. Therefore, it is usually given at breakfast and lunch but not bedtime. In patients with more advanced disease, adding selegiline to levodopa may help those experiencing end-of dose failure using levodopa alone. In these patients, adding selegiline may worsen or bring on high dopa or peak-dose dyskinesias (see previous sections for definitions).

Dopamine receptor agonists: pergolide (Permax®), bromocriptine (Parlodel®) , pramipexole (Mirapex®) and ropinirole (Requip®). These are synthetic compounds that mimic the action of dopamine in the basal ganglia. These agents are usually used in addition to levodopa for patients who experience end-of-dose failure on levodopa alone or might be used initially in early Parkinson's Disease, especially in younger adults.   The side effects of dopamine agonists are similar to those of levodopa, such as nausea, although they are less likely to cause involuntary movements and more likely to cause hallucinations and nightmares. Thus, major side effects include nausea, nightmares and hallucinations.  Patients who have already experienced hallucinations or confusion should avoid using this class of drugs.

COMT inhibitors (Stalevo) and Tolcapone (Tasmar)
These drugs prolong the effect of levodopa therapy by blocking an enzyme that breaks down dopamine in the liver and other organs. Tolcapone (Tasmar) is a potent COMT inhibitor that easily crosses the blood-brain barrier. But because Tasmar has been linked to liver damage and liver failure, the drug is normally used only in people who aren't responding to other therapies. Entacapone is a COMT inhibitor that shares some of the properties of tolcapone but doesn't cross into the brain. It may help manage fluctuations in the response to levodopa in people with Parkinson's disease. Entacapone doesn't cause liver problems and is now combined with carbidopa and levodopa in a medication called Stalevo.

Anticholinergics trihexyphenidyl (Artane) and benztropine (Cogentin), are available. The antihistamine diphenhydramine (Benadryl and antidepressants such as amitriptyline (Elavil) work much like anticholinergics and may be used in older adults who can't tolerate anticholinergics themselves. These drugs were the main treatment for Parkinson's disease before the introduction of levodopa. In general, they help control tremors in the early stages of the disease. Even so, they're only mildly beneficial and sometimes the benefits are offset by side effects such as dry mouth, nausea, urine retention — especially in men with an enlarged prostate — and severe constipation. Antcholinergics can also cause mental problems, including memory loss, confusion and hallucinations. 

Amantadine (Symmetrel, Symadine) This antiviral drug may be prescribed for people in the latter stages of Parkinson's disease, especially if they have problems with involuntary movements induced by levodopa (dyskinesia). Side effects include swollen ankles and a purple mottling of the skin.

Surgical Options

Depending upon the patient's specific condition, one of the following procedures may be considered:

  • Deep Brain Stimulation involves  implanting a brain stimulator, similar to a heart pacemaker, in certain areas of the brain. For some people, this may control symptoms so well that medications can be greatly reduced. Click here to read more about Deep Brain Stimulation at the website of The National Institute of Neurological Disorder and Stroke.

  • Pallidotomy  This  is a form of brain surgery that has been effective in reducing symptoms in patients who are severely affected.  This is done less frequently today, however, because of the risk of serious side effects and the availability of deep brain stimulation.

  • Thalamotomy It is thought that the abnormal brain activity that causes tremor is processed through the thalamus. Thalamotomy destroys part of the thalamus to block the abnormal brain activity from reaching the muscles and causing tremor

Although thalamotomy and pallidotomy surgeries are still done today, they are done less frequently because of the risk of serious side effects and the availability of deep brain stimulation, which is safer and has fewer complications.  

Support Groups in Pinellas County, Florida:

APDA Suncoast Parkinsonian Chapter/Support Group
St. Luke's United Methodist Church, 4444 Fifth Ave. N, St. Petersburg.  Call (727) 391-8214

Parkinson's Disease Support Group
Barrington, 901 Seminole Blvd., Largo  Call (727) 585-5900

Suncoast Parkinson's
Edward White Hospital auditorium, 2299 Ninth Ave N, St. Petersburg. 
Call 727-867-6719 or 727-321-0984

Parkinson's Disease Support Group for ages 60 and younger "Movers and Shakers"
Seminole Community Library, 9200 113th St. N, Seminole
Call Jackie (727) 397-2024

Parkinson's Disease Support Group
Healthsouth Rehabilitation Hospital, 901 Clearwater-Largo Rd, Largo, Call (727) 588-3405

Parkinson's Disease Support Group
Cypress Palms of Largo, 400 Lake Avenue, NE, Largo.  Call (727)-437-1600

Written by N Thompson, ARNP, MSN, in collaboration with M Thompson, MD, Internal Medicine, Last updated May 2007

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