• Stage I involves only one side of the body.
• Stage II involves both sides of the body but does not impair walking.
• Stage III impairs balance or walking.
• Stage IV markedly impairs balance or walking.
• Stage V results in complete mobility.

Stages I-II are considered mild, III moderate, and Iv-V advanced.

An estimated 60 to 90 percent of people with Parkinson’s will develop some difficulty speaking.

Speech impairment is referred to as dysarthria, often characterized as weak, slow, or uncoordinated speaking.Dysarthia varies greatly among individuals and can affect speaking volume and/or pitch.The voice may sound hoarse, monotone, or come out in short bursts.Often, speech problems worsen over time.

At least half of Parkinson’s patients develop swallowing problems or dysphagia.Dysphagia may cause the person to spill food or liquid from the mouth or to send food to the back of the throat before it is ready to be swallowed.Individuals with dysphagia may be more prone to choking on food or drink-or even their own saliva.Dysphagia may allow food to enter the food passageway while eating.Parkinson’s patients and their caregivers should take care to watch for signs of choking, food stuck in the throat, or increased congestion after eating.Due to difficulty coughing and clearing the lungs, people with Parkinson’s also run an increased risk of developing pneumonia.

Studies have indicated that over half of people with Parkinson’s have mild intellectual challenges; about 20 percent have more substantial cognitive impairment.Memory problems in Parkinson’s are typically milder than in Alzheimer’s disease.In Parkinson’s disease, the person may have difficulty concentrating, acquiring new information and recalling names.All medications should be monitored since high doses of some drugs used for Parkinson’s can cause hallucinations or confusion.

Other Parkinson’s disease symptoms include depression, constipation, weight loss, sleep disturbances, “masked” facial expression, forced eyelid closure, drooling, urinary tract infections, excessive sweating, and problems with sexual performance.

Diagnosis
Although there are no specific tests for Parkinson’s disease, there are several ways of making a diagnosis.Usually a diagnosis is based on a neurological exam which covers evaluation of the symptoms and their severity.If symptoms are severe enough, a trial test of anti-Parkinson’s drugs may be indicated.Also, when indicated, brain scans may be made to rule out other diseases that resemble Parkinson’s disease.

Treatment
There is no cure for Parkinson’s disease at this time.If the disease progresses beyond minor symptoms, drug treatment may be indicated.The most commonly prescribed medication is L-DOPA (levodopa) which helps replenish some of the lost dopamine.Other drugs, designed to stimulate the dopamine system or mimic its controlling effect on other nerve cells, are used, such as bromocriptine, pergolide, slegilene and trihexyphenidyl.

Levodopa is considered the most effective drug at this time.Sinemet, a combination of levodopa and carbidopa, is usually the drug most doctors use to treat Parkinson’s disease patients.While side effects including large uncontrollable movements called “dyskinesias” and confusion may develop after about 8 years.Drug therapy for Parkinson’s typically provides relief for about 10 – 15 years or more.

Surgical Interventions
In recent years, surgical options have also become more popular.These surgical options are available to individuals for whom more conventional drug therapies have proven inadequate.To ensure the best results, surgical candidates must fit certain criteria before surgery can be considered.Candidates must have specific symptoms treatable by the procedure.They should be otherwise healthy and should be relatively young-e.g., under age 65 or 70.Candidates should always be evaluated by a Parkinson’s specialist: a neurologist with special “movement disorder” training.All procedures can harm inappropriately selected patients.

Thalamotomy surgically destroys cells in the brain’s thalamus to correct a disabling tremor in the hands or arms for persons with few other symptoms.Risks are considered low.Immediate improvement is seen in 80-90 percent of all patients after the operation; full recuperation generally takes six weeks.

Pallidotomy surgically destroys certain cells in the globus pallidus, the part of the brain controlling movement. The operation may correct problems in slow movement, tremor, and imbalance is performed with the patient conscious.Generally, the most dramatic result is the decrease in dyskinesia.Post-surgical recuperation is similar to that of thalamotomy.

Fetal tissue implantation is an experimental technique used to restore the brain’s ability to produce dopamine.Political and ethical controversy over this procedure may lead to the future development and use of genetically engineered cells for this type of surgery.To date, long term studies are not available on the effects of fetal implant surgery.Preliminary findings indicate that the surgery can dramatically decrease the need for medication, although this improvement may not begin until six months after the surgery and may not peak for 12 to 24 months.

Physical and Speech Therapy
Care for Parkinson’s patients includes a well-balanced diet and regular exercise.Physical, occupational or speech therapy may also be indicated for some patients.

Physical therapy and muscle strengthening exercises can be a key part of managing Parkinson’s disease.A physical therapist can help develop and monitor a home exercise program.A good exercise routine should include strengthening and flexing all limbs, stretching legs and feet, walking, facial and breathing exercises, and specific exercises to gain better control in swallowing.An occupational therapist can help the person with walking and accomplishing everyday activities.

A speech therapist can help the person with Parkinson’s improve voice volume, quality and articulation.Therapeutic exercises, including verbalizations and tongue movements, can often make a difference.Where speech is severely impaired, a machine or computer-generated voice can be used in some cases.It may also be important for families to learn new strategies for families to learn new strategies to help the person communicate.If the person is confused for example, it may be necessary to use verbal cuing to understand or assist.The inability to articulate may be very frustrating for the individual.Offer reassurance and support.This may alleviate some of the person’s anxiety over not being able to express a thought or need.(See RECOMMENDED READINGS for publications on home exercises for Parkinson’s.)

Research Outlook
New drugs under development include chemicals known as “agonists” which mimic dopamine in the brain and may delay the progress of Parkinson’s.In addition, research in Glial Derived Neurotrophic Factors (GDNF) has shown exciting results in testing on primates and may open up a new avenue of treatment.Other drugs, called COMT inhibitors (e.g., entecapone and tolcapone) look promising in terms of enhancing the Sinemet response. Moreover, existing surgical procedures are being refined.Fetal tissue implant researchers are exploring the addition of “nerve growth factor,’ a protein from the patient’s own body used to enhance cell growth, and pig fetal tissue may become a viable option for transplantation to humans.Finally, electronic stimulators, implanted in pallidotomy and thalamotomy target areas on an experimental basis may enable the patient to activate the benefit themselves.

Recommended Readings
Introduction to Speech and Swallowing Problems Associated with Parkinson’s Disease, Kathryn Pengilly, 1995, National Parkinson Foundation.

Exercises for the Parkinson Patient With Hints for Daily Living, Lucien Cote, MD, and Gerorgia Riedel, RPT Parkinson’s Disease Foundation, WilliamBlackMedicalResearchBuilding, 650 West 168th Street, New York, NY10032.(212) 923-4700.

Living Well with Parkinson’s Disease, Glenna Wotton Atwood, 1991, J. Wiley and Sons Inc., 605 Third Avenue, New York, NY10158-0012.

The Parkinson’s Handbook, Dwight C. McGoon, M.D.,1990, W.W. Norton & Co., 800 Keystone Industrial Park, Scranton, PA 18512.(800) 233-4830.

The National Parkinson Foundation, American Parkinson'’ Association and the United Parkinson'’ Foundation each put out informative publications on Parkinson'’ Disease.Additionally, the Parkinson'’ Report, a quarterly newspaper from NPF also provides information and research updates for families and medical professionals.

Credits
Green J., 1994, Memory Changes in Parkinson’s Disease, American Parkinson’s Disease Association Newsletter, Fall 1994.

American Parkinson’s Disease Association, 1995, Evaluating Disease Severity, Johns Hopkins Medical Institutions, 1995, Parkinson’s Disease: When to Consider Surgery, Health After 50, December, Vol. 7, No. 10:6.

Koller, W.C., 1993, Epidemology of Parkinson’s Disease, American Parkinson’s Disease Newsletter, Fall 1993.

Weekly, N.J., 1995, Parkinsonism: An Overview, Geriatric Nursing 16(4):169-171.

Stern, M.B., and Mackenzie, C.A., 1991, The Challenge of Young Onset Parkinson'’ Disease, Parkinso Report 7(4), 4th Quarter, National Parkinson Foundation.

Resources
Inland Caregiver Resource Center
1420 E. Cooley Drive, Suite 100
Colton, CA 92324
(909) 514-1404 or (800) 675-6694
Fax (909) 514-1613

Inland Caregiver Resource Center (ICRC) is one of eleven Caregiver Resource centers statewide serving families, friends and professionals who care for adults with brain disorders.ICRC provides a comprehensive range of services including information and referral, family consultation, education and training to caregivers and professionals in San Bernardino, Riverside, Inyo and Mono counties.

ICRC maintains a complete list of support groups in the service area pertaining to Alzheimer’s disease, head injury, stroke, Parkinson’s, ALS, Huntington’s and caregiving.

CRC’s operate under contract grants from the California Department of Mental Health.The statewide system of Caregiver Resource Centers was established under special legislation signed into law in 1984.For more information or to request services, please call Inland Caregiver Resource Center, during office hours Monday through Friday 9:00 a.m. to 5:00 p.m.

Family Caregiver Alliance
690 Market Street, Suite 600
San Francisco, CA 94104
(415) 434-3388 or (800) 445-8106 (in CA)
Web Site: www.caregiver.org
E-mail: .(JavaScript must be enabled to view this email address)

FCA’s information Clearinghouse covers current medical, social, public policy and caregiving issues related to brain impairments.

Loma Linda Neurology Associates Medical Group
11370 Anderson Street, Suite 2400
Loma Linda, CA 92354
(909) 478-6128

Parkinson’s Center for Excellence
Eisenhower Medical Center
39000 Bob Hope Drive
Wright Bldg., Suite 108
Rancho Mirage, CA 92270 (760) 773-1480
Mary Willis, Coordinator

American Parkinson’s Disease Association
60 Bay Street, Suite 401
Staten Island, NY 10301
(718) 981-8001 or (800) 223-APDA

National Parkinson Foundation
1501 NW 9th Avenue
Miami, FL 33136
(305) 547-6666 or (800) 327-4545

National Parkinson Foundation
West Coast Office
15840 Ventura Blvd., Suite. 215
Encino, CA 91436
(800) 400-8448 (in CA only)

Parkinson’s Disease Foundation
William Black Medical Research Building
Columbia University Medical Center
650 West 168th Street
New York, NY 10032
(212) 923-4700

Parkinson’s Institute
1170 Morse Avenue
Sunnyvale, CA 94089
(408) 734-2800

United Parkinson Foundation
830 W. Washington Blvd.
Chicago, IL 60607
(312) 733-1893


Reviewed by Kim Seidman, West Coast Director, National Parkinson Foundation, and Paula Lewis, RN, Research Coordinator, Parkinson’s Institute.Prepared by Family Caregiver Alliance in cooperation with California’s Caregiver Resource Centers, a statewide system of resource centers serving families and caregivers of brain impaired adults.Funded by the California Department of Mental Health.Revised July 1996.ã All rights reserved.