Sarasota Neurology

Parkinson’s disease is the second most common neurodegenerative disorder, just behind Alzheimer’s disease. Parkinson’s disease is characterized by specific clinical symptoms including rigidity (stiffness), slowness of movement, unsteadiness (gait imbalance) and tremor. For the accurate diagnosis of Parkinson’s disease to be made, a patient needs to have 3 of the 4 major symptoms of the disorder. Each patient with Parkinson’s disease is different and may have differing degrees of each component of Parkinsonism. Not all patients with Parkinson’s disease have tremor. Some may have more instability of gait, shuffling or slowness of movement. There are several medications available that neurologists can use to treat Parkinson patients to alleviate their Parkinson symptoms and improve their overall quality of life. Unfortunately, there is a down side to this treatment. Patients who have been on Sinemet for a few years tend to develop motor fluctuations. Motor fluctuations include end-of-dose wearing off, where their functional abilities deteriorate before the next dose of medication is due. Other motor fluctuations include freezing and off time.
Parkinson freezing is simply when a patient becomes “stuck” meaning they cannot move. This occurs more frequently when going through doorways, stepping up onto a curb or stair or when getting up to start walking. Freezing can also occur first thing in the morning, just when getting up out of bed. Freezing episodes can last for a second up to a few minutes. It is the goal of every Parkinson’s disease neurologist to minimize a patient’s amount of freezing, through various medications and dosing schedule changes. Off time can occur in two settings: one is predictable, usually at the end of the dosing interval but the other occurs randomly, without warning. These sudden off time events are more problematic as they tend not to respond as well to medication changes. Off time is troublesome for the patient and caregiver. Affected patients become virtually immobile, essentially frozen in place. There are different degrees of off time, but in all cases, the patient’s mobility and ability to function are severely impaired. Off time may last minutes to hours. For those patients with short duration off time, additional medication or shorter dosing intervals usually will help. Off time may also occur first thing in the morning when waking up. Even if Parkinson patients take their medications, it may be an hour or more before they are functioning normally. For patients with prolonged off times, usually greater than 45 minutes, there is treatment.
Apokyn (apomorphine) is a self administered injectable medication that rapidly relieves off time. Its duration of action is generally less than 2 hours. This is an ideal medication for patients with one or multiple daily freezing episodes. For those affected patients, Apokyn can literally give them their lives back, particularly when more waking hours are spent in the “off time” than in “on time.” For a patient or caregiver to administer Apokyn, some training is required. This is covered by the drug manufacturer and by Medicare. Side effects can include a drop in blood pressure, lightheadedness, nausea or vomiting. When initially starting a patient on Apokyn, medication to prevent nausea is given first. After being on the Apokyn for a few weeks, patients frequently can stop the antinausea medication.
If you are a patient or caregiver and feel that Apokyn may be of benefit, contact your neurologist or Parkinson disease specialist for more information. An excellent information package, with DVD, is available at no cost. The first step is to make the call to improve your quality of life.  For more information, visit the website for Dr. Kassicieh at: www.DrKassicieh.com.

There are many studies that have shown excellent health benefits from taking omega 3 type fish oil. Omega 3 oils are found in fish oils, flax seed and several vegetable oils including canola, soybean and olive oils. There are different components to these oils that provide health benefits. The DHA and EPA oils in fish oil have been linked to reducing hardening of the arteries and lowering triglycerides. They also have the benefit of lowering blood pressure and heart rate to a mild degree. This all results in an overall reduction in risk for coronary artery disease, heart attack, sudden death, irregular heart beat and stroke. Fish oil can also have a blood thinning effect to reduce abnormal blood clotting, similar to that of aspirin. This latter effect is a two edge sword because too much fish oil can increase the risk for serious bleeding. Generally three grams (3000 mg) daily or less is considered safe. Daily intake of Omega 3 should come from dietary sources with no more than 2000 mg (2 grams) coming from supplements.

Omega-3 is derived from high fat containing fish such as albacore tuna, salmon, flounder, pompano, anchovies, sardines and mackerel. Fish in the equatorial regions around South America have a higher content of Omega 3 than do those caught in the more northern areas around Scandinavia and Iceland. Interestingly flax seed, flax oil and kiwi fruit contain higher amounts of Omega 3 oils than do that of fish. Flax seed can be added to cereal, baked goods or eaten alone. Fish oil capsules are available in 1000 mg and 1200 mg sizes. It is important to not confuse Omega-3 oils with Omega-6 oils. Omega-6 oils do not confer the health benefits that Omega-3 fish oils do. Omega-6 is found in high concentrations in various types of vegetable oils derived from the following: corn, safflower, sesame, soybean, sunflower and walnuts. It is important to reduce the consumption of Omega-6 oils as they compete with Omega-3 oils, thereby decreasing the benefit from Omega-3 fish oils. Eating fish twice a week is the standard recommendation, in addition to taking any supplements.

There have been many studies showing the beneficial effects of Omega-3 oils. The main benefit comes from reduction of hardening of the arteries (atherosclerosis), reduced coronary artery disease, decreased risk of heart attack and potentially fatal heart beat rhythms. Omega-3 oils have also been shown in some studies to have a brain cell protective effect in such conditions as Alzheimer’s and Parkinson’s disease. Fish oils can improve memory to a degree. Several studies have shown that 2000-3000 mg of Omega-3 oil intake daily, has a potent antiinflammatory action as that of high dose ibuprofen. Patients with arthritis or rheumatoid arthritis may benefit from Omega-3, without the risks associated with taking
antiinflammatory drugs for extended periods (such as bleeding stomach ulcers, kidney and liver damage.) It should be noted that the fish oil capsules have a more robust effect for reducing inflammation than that of flax seed oils.

Omega-3 oils can reduce total triglyceride levels and increase “good” cholesterol (HDL) levels. These oils also have an overall beneficial effect on the blood vessels, both in increasing blood flow and improving the health and stability of the vessel walls themselves. This effect is in part responsible for the risk reduction in having a stroke or heart attack as well as patients with problematic varicose veins and leg pains due to peripheral vascular disease. A word of caution: in patients with congestive heart failure, consultation with your cardiologist is first advised. As fish oil has a blood thinning effect, you should check with your doctor if you are taking prescription blood thinners. Additional benefits from Omega-3 fish oils have been shown in improving retinal (visual) function and possibly slowing down macular degeneration. Studies in psychiatric conditions have demonstrated Omega-3 beneficial effects in reducing depression, lessening memory loss and improving memory function.

Recent studies have suggested that qualifying Parkinson patients benefit from earlier treatment with deep brain stimulation, as reported in Clinical Neurology News. The study indicates that younger Parkinson disease patients are more likely to benefit from early brain stimulator treatment. There is information that may suggest that this therapy may have a protective effect in delaying the progression of Parkinson’s disease. Deep brain stimulation (DBS) was FDA approved in 2002 for treatment of Parkinson’s disease. Symptoms that are best controlled include tremor and dyskinesias although brain stimulation can also help reduce freezing and off time. Younger Parkinson patients develop motor complications such as dyskinesias, off time and freezing much earlier than older patients with Parkinson’s disease. As reported by Dr. David Charles, a Vanderbilt University Medical Center Parkinson neurologist, “No therapy…has bee shown to slow the progression of Parkinson’s.” The previous thinking was to wait until a patient had severe motor complications that could not be controlled with medications prior to considering DBS therapy. The new thinking, and research, is exploring benefits of DBS in earlier stages of Parkinson’s disease. In various reported cases, patients not only benefited from better control of their Parkinson motor symptoms but also had improved quality of life. Added advantages is that Parkinson patients treated earlier with DBS used less medications over an 18 month period, as shown in one small study. There are two studies currently looking at the benefits of early DBS therapy in Parkinson patients: EARLYSTIM is a French study and a smaller study at Vanderbilt University are in progress. It should be noted that Parkinson’s disease is a progressive neurodegenerative disorder. Even patients with DBS therapy do have progression of their symptoms. Memory loss can be a part of the Parkinson syndrome and is not helped by DBS therapy. DBS is not a substitute for optimal neurological and medication management of Parkinson symptoms. Dr. Kassicieh, at Sarasota Neurology, provides medical and neurological management for patients with Parkinson’s disease and brain stimulators. For more information click here.

Neupro patches were approved by the FDA for Parkinson’s disease treatment in September 2007. They proved to be very effective in the control of Parkinson symptoms, as compared to the effects of other dopamine agonists including Mirapex and Requip. Unfortunately, in March, the FDA recalled Neupro due to problem with the patch delivery of the medications. What they found posed no imminent danger to patients. Rather what was happening was that the active drug, rotigotine, was crystallizing in the patch therefore not delivering the full dosage of medication to the patient. What would happen is that affected patients’ Parkinson symptoms would not be as well controlled. It is not clear if Neupro patches will be brought back to market as reported on Emaxhealth.

Dopamine agonists remain one of the main Parkinson treatment medication groups available to control Parkinson symptoms. These can be used as first line medications for early Parkinson’s disease, showing as good as an effect as Sinemet - the gold standard for treatment of Parkinson’s disease. Many feel that it is beneficial and studies have shown that starting early treatment with dopamine agonists can limit the long term side effects of starting Sinemet early. This is particularly true for delaying development of dyskinesia, which are involuntary movements of arms, legs and head. Dopamine agonists can also help to suppress tremor associated with Parkinson disease.

If you are still using Neupro patches, you should contact your treating neurologist or Parkinson specialist to get the weaning patches and titrate off this drug. Many other excellent treatments for Parkinson’s disease are available. For more information visit: Parkinson Doctor.

The FDA has recently approved the dementia fighting drug Exelon in a patch form. The new formulation, Transdermal Exelon, offers patients a new and unique way to get medication which can help with improving cognitive function and slow down memory loss in patients suffering from Alzheimer’s disease. The new patch is also FDA approved for patients with Parkinson associated dementia. This is the second patch approved for use in treatment of Parkinson disease. The other is Neupro, a transdermal patch containing the dopamine agonist rotigotine.

Transdermal Exelon joins the group of other medications used to treat Alzheimer’s disease, such as Aricept, Razadyne and Namenda. The patch for of Exelon offers the advantage of not having to take a pill twice daily, continuous medication administration through the skin and less stomach upset. Another advantage is that the patch demonstrated beneficial effects equivalent to the maximum oral dosing of this medication. The problem with the oral medication was intolerance due to nausea and vomiting. While much less, there were some reports of stomach upset with Transdermal Exelon. Another side effect, common to most patch medications, was that of skin irritation. The patch needs to be changed daily and administration sites should be rotated, not using the same site more than once every two weeks. While Exelon, Aricept and Razadyne are in the same chemical family of memory disorder drugs - the acetylcholine esterase inhibitors - Namenda is in a class by itself. For this reason, it can be used in combination with any of the other three. Studies have shown that there is a beneficial effect in improving cognitive function with combining these two different types of medication. Studies are looking into the use of these medications for patients with mild cognitive impairment. These are individuals who have some memory loss but do not fit the criteria to be diagnosed with dementia. Depression, manifesting as dementia, also needs to be excluded.

Alzheimer’s disease is a chronic debilitating illness that slowly robs patients of their memory, cognitive abilities and ability to function independently. They become more and more dependent on others to provide care and transportation for them. Even dressing, eating and bathing become impossible for them to perform without assistance. With the availability of these new memory drugs, the progression of the debilitating symptoms of Alzheimer’s disease and Parkinson disease associated dementia can be slowed down. Some patients actually show functional improvement. Unfortunately, none of these medications halt the progression of the disease. Eventually their quality of life deteriorates and others will need to assist with care giving. The benefit of these medications is that they significantly slow the progression of the disease, possibly keeping loved ones at home, instead of a nursing home, for anywhere from 6-18 months. If you have a loved one with memory loss, early diagnosis and treatment is important. Studies are ongoing to show that with earlier treatment, patients do better over extended periods of time. Bring your family member with memory loss to a neurologist for a complete evaluation.

The FDA has approved a new medication therapy for the treatment of Parkinson’s disease. The new drug is rotigotine (Neupro), which is in the family of dopamine agonists. Dopamine agonists mimic the effects of levodopa (Sinemet) without having to go through chemical transformation. Other dopamine agonists include Mirapex and Requip. Neupro is different in that it comes in the form of a patch. This has the advantage that the medication is delivered continuously through the skin, while you are wearing the patch. Theoretically, this would provide a more even blood concentration of medication throughout the day. Patients using Neupro should not be taking one of the other dopamine agonists. This patch can be used alone or in combination with other Parkinson medications, to help improve the daily function of patients affected with Parkinson’s disease. Side effects include low blood pressure, foot swelling, hallucinations and stomach upset - just like the other dopamine agonists. Neupro can also cause contact dermatitis (rash) from the patch adhesive. This is similar to what some patients experience with bandages and medical tape. The dopamine agonists help Parkinson patients in many ways including use of less Sinemet and decreasing dykinesias. Dykinesia is an involuntary movement that can affect the head, shoulders, arms and legs. The development of dyskinesia is related to the amount and duration of use of Sinemet.

Another new medication that was approved by the FDA is a drug called Azilect (Rasagiline.) This is in the class of medications known as the MAO-B inhibitors. MAO is a an enzyme in the body that breaks down dopamine. By inhibiting MAO-B, Azilect allows more dopamine to enter the brain. It also theoretically slows the breakdown of dopamine. Dopamine is the main brain chemical transmitter that is lacking in Parkinson patients. This drug can be used by itself or in combination with other Parkinson medications, particularly levodopa (Sinemet.) Unfortunately, like other Parkinson drugs, Azilect does not work for everyone.

Essential tremor is a common disorder than is characterized by involuntary shaking of the head, jaw, hands or legs. It is estimated that there are 5-10 million affected individuals in the United States. Unfortunately, many patients are incorrectly diagnosed as having Parkinson’s disease when they actually have a form of essential tremor (ET). ET tends to run in families and can have onset anywhere from 20-60. Parkinson’s disease most commonly starts after the age of 60 and is generally thought not to be hereditary. The characteristics of essential tremor and Parkinson related tremor are quite different. Typically the tremor seen in Parkinson’s disease occurs in the hands and is seen with the hand at rest. The tremor has a unique “pill-rolling” quality to it. The Parkinson tremor stops when the individual moves or uses their affected hand. Essential tremor is not present when the affected limb is at rest. When an individual moves their arm or tries to grasp or hold an object, then their tremor becomes apparent. This is most readily seen when trying to write, hold a beverage container or use eating utensils. Writing is affected in both conditions. In essential tremor, the writing becomes jerky with a zig-zag appearance to letters whereas with Parkinson patients, their writing becomes progressively smaller, trailing off into a non-legible line. It is uncommon for Parkinson patients to have head, jaw or leg tremor. These are much more commonly seen in the ET population. Patients with Parkinson’s disease have other clinical features that benign tremor patients do not have.

Treatment for patients with essential tremor (benign tremor, familial tremor) is readily available. Many patients have already discovered that small amounts of an alcoholic beverage will temporarily stop their tremor. Medications used to reduce tremor severity may include primidone, clonazepam, propanolol, mirtazepine or Topamax. All of these medications can be helpful but there is a potential for side effects, as with any treatment. For patients with severe, disabling tremor that is not responsive to medical treatment, surgical treatment with deep brain stimulation can be very effective. This procedure is highly effective in minimizing or completely controlling tremor. It has been approved for use since 1997. This procedure can dramatically improve a patient’s quality of life.
In summary, if you or one of your family is affected by obvious tremor, it is in their best interest to see a movement disorder specialist to get the correct diagnosis and treatment. The treatment and prognosis of essential tremor and Parkinson’s disease is quite different. The medications used for one will not help the other. Significant problems with unwanted side effects can develop if each condition is not treated properly.

Deep brain stimulation is an innovative way to control severe tremor or some of the motor symptoms of Parkinson’s disease. This medical device was approved by the FDA in 1997 for treatment of patients with severe tremor that was not controlled by medications. A few years later, it was approved for treatment of Parkinson tremor and dyskinesias (involuntary head, arm and leg movements.) The main deep brain stimulation unit, manufactured by Medtronic, is called Activa Soletra. This is a small pacemaker-like device that is placed under the skin, just under the collar bone. The small electrode wire is then run under the skin, behind the ear and through the skull. The electrode tip is placed in a specific area in the brain that is responsible for tremor and dyskinesia control. A patient may need one or both sides done with a stimulator unit, depending on the severity and nature of their movement disorder. The risk of brain stimulator therapy is low other than at the immediate time of surgery. Once healed, patients can expect fewer side effects from deep brain stimulator therapy than from the several medications they may have to take to control their Parkinson symptoms. It should be noted that the best possible result from brain stimulator therapy will not exceed that of a Parkinson patient’s best response to levodopa therapy. Essential tremor patient’s can generally expect to completely stop medications that they are on for tremor control. Brain stimulator therapy is a safe, scientifically proven method for control of disabling tremor or other limb movements. It does not substitute for Parkinson medication but may help in reducing the amount of medication a patient has to take.

The FDA recently approved a new Parkinson medication for use in patients that are having problems with off time and freezing. The new drug is called Zelapar. It is a rapidly dissolving tablet whose active ingredient is selegeline. Many of you may have tried selegiline in the past (marketed as Eldepryl.) The new formulation of selegiline allows the drug to be absorbed into the bloodstream through the mouth instead of the stomach. This has the advantage that the medication bypasses going through the liver. All medications absorbed through the stomach and intestines pass through the liver first, which results in clearing much of the medication before it has time to provide benefit. Zelapar allows the selegiline to “go around” the liver so that patients will experience a better therapeutic response to the medication. I have used this on a number of patients who had problems with freezing, increasing off time or just need for higher doses of Sinemet. The added benefit of Zelapar is that it avoids having to increase the total daily Sinemet dosing. More than 50% of the patients have had benefit. Like all medications, Zelapar does not work for everyone and like other anti-Parkinson medications, it has the potential for side effects. It is important that patients with Parkinson’s disease or other movement disorders to be treated by neurologists that have more specialized training in these complex conditions.