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about daily management
Question : How much protien one should have in daily diet since i am having Parkinsons' desease since last 6 years , age of the person with PD is 49 years & date of DBS 9 Nov 2010
Answer : Patients with Parkinson’s disease need a normal protein intake just like other people. We usually recommend avoiding a high protein load around the time of L Dopa or dopaminergic drugs.
However that does not mean that the patient should take less protein. He or she should consume the bulk of the protein in the night at dinner time.

Additionally you have had a DBS. DBS reduces the unpredictability associated with response to drugs. Hence protein restrictions may not really be required in your case.
Question : The patient is around 80 years old and last few days has been talking non-stop, meaningless. Is there any remedy , how to handle this situation correctly?
Answer : It sounds like the patient is having a change in his behaviour which may suggest that there is some medical problem going on. The most common situation in patients with Parkinson’s disease is delirium.
DELIRIUM or acute confusional state is a situation where patients may lose orientation to where they are or what time or date it is. Most commonly this occurs due to either an infection (commonly respiratory or urinary), constipation or then sometimes due to drugs. Some of the Parkinson’s medications can induce it. However in these cases usually there is a history of change in the medication schedule.
We would suggest you to take an appointment with your doctor, go through the different factors and correct the same.
Question : Patient has Parkinson,wherein his left hand & left legs trembles, He used to go for walk in the morning for 1 hour, however last week he had a fall; due to which he is not able to walk till now, the ct scan & MRI,MRA report are clear please advise as he lives alone
Answer : Falls are a very common problem in patients with Parkinson’s disease. It is often the reason for institutionalizing patients abroad too. There are several reasons for a fall. Some include freezing of gait, dyskinesias, poor postural balance and cognitive decline. Some of these can be addressed with drugs or surgery. Please get a proper thorough clinical assessment from your doctor to try and find out what is the cause in his case. Maintaining a FALL DIARY can be of help to your doctor in trying to identify the cause. In such a diary the time of each fall is recorded with the time of day and the state of the Parkinson’s disease (was he ON drugs or OFF drugs or was he dyskinetic) and also recording the time of the last medication.
Question : The patient is the sole bread earner in the family and his work involves a high level of physical activity. Will the physical exertion worsen his condition and symptoms?
Answer : On the contrary, keeping active and busy is the key to keeping PD under control. Physical activity will not harm or worsen PD in any way. The only care to be taken is to avoid falls which can happen in PD.
Question : Do I need to take any precautions before starting Yoga?
Answer : One may take into consideration the following precautions before starting any form of Yoga.
-One should not perform yoga for at least 2 hours after eating.
-Avoid yoga alone until you’ve practiced it with a qualified teacher.
-Before beginning, always tell your teacher about any medical problems you have, including back and joint problems. Alternatively, you could consult your doctor as to the conduciveness of Yoga yourself.
One shouldn’t push oneself beyond their limits. If experiencing any pain during Yoga, you should tell your instructor, and don’t attempt to do an asana you have difficulty with.
about symptoms
Question : My father 55, was diagnosed with PD 5 years back. He is on Syndopa and Syndopa CR (before sleeping). Off late we have noticed that it is taking 1- 1.5 hours for syndopa to be effective in his body. Initially it used to take just half an hour. What could be the reason?
Answer : Firstly in the initial stages of Parkinson’s disease due to a higher indigenous production of dopamine the response to L Dopa (Syndopa) is more predictable. As the disease advances this response may become more unpredictable. At this stage either the dose may be increased or other drugs may be added to improve the efficacy of the treatment.

Meals are one of the most common factors which delay the absorption of L dopa. Hence we usually advice that the dose should be given at least one hour before a meal and 2 hours after a meal to cause more rapid absorption of the drug. Even when giving meals we usually recommend avoiding a high protein load in the afternoon. However that does not mean that the patient should take less protein. He should consume the bulk of the protein in the night at dinner time.
Question : The patient has been diagnosed with parkinson's disease 5 yrs ago. The medication taken are pacetane, pramipex, syndopa cr and syncopa 50. Off late the patient is having breathng problem. is it bcause of some side effects of medicine?
Answer : It is not possible to comment on your problems without seeing you. However one possibility is that you may be having early dyskinesias. Dyskinesias are involuntary movements in patient with Parkinson’s disease usually occurring at the time when the dopamine levels peak due to medication. They are usually seen an hour or two after the L Dopa dose (Syndopa in your case). Chart the same and discuss it with your doctor. You may be asked to do tests to look for another cause like lung or heart problem.
Question : In the night when I feel pressure for urine, open my eyes I see black shedow as someone is standing. First I thgought that may be my wife there but she was sleeping. When I got up completely I found nothing. What does it indicate ?
Answer : This could indicate hallucinations or a dream, which ended just as you woke up. Though more details would be required to cpmpletely understand this experience, it is important to discuss this with your doctor. REM sleep behavior disorder occurs very commonly in Parkinson’s disease. It may manifest as dream enactment behavior, talking in sleep, shouting, and moving in bed while asleep. It is very easily treated in most cases by a small dose of Clonazepam. Hallucinations is seeing, hearing or feeling things that others do not perceive. This is commonly a side effect of the drugs used for Parkinson’s disease.
Question : I have Parkinson’s since 1994, under good control but I am get severely constipated. Is the constipation drug induced or disease induced?
Answer : Constipation is a troublesome complaint experienced by many Pd patients. It is due to the Pd itself and also to a great extent, aggravated by the use of anti PD drugs. Almost all PD drugs can worsen constipation, but the worst offender is anticholinergic medication (pacitane). As far as possible, it wouyld be better to reduce or stop this medication, especially in elderly patients. Taking plenty of water, fruits (papaya and figs) and vegetables would also help in constipation. Stool softeners (softovac), laxatives (dulcolax) and in some cases enema may also be needed.
Question : Is swelling in the feet a result of Parkinson’s disease or a side effect of medicines taken for PD?
Answer : Parkinson’s disease itself does not cause swelling of feet. Some anti PD like amantidine can cause swelling and redness around the ankles. A medication called amlodipine used in cases of high blood pressure can cause swelling of feet if a Pd patient is taking it for high BP. Swelling of feet per se is not something to be worried about but you must consult your physician to rule out any medical disorder. Often swelling of the feet subsides if the legs are elevated on the stool or in bed.
Question : Has high blood pressure got anything to do with Parkinson’s disease?
Answer : There is no correlation between high BP and typical Parkinson’s disease although both are seen more frequently in the elderly age group. Patients with long standing uncontrolled hypertension may develop a multi-infarct (many small areas of poor circulation in the brain) in which some features of Parkinsonism may occur.
about treatment
Question : How many days does it take for the symptoms to improve after starting the medication and are there any chances of pulmonary aspiration in PD patients who was not on medication
Answer : Most doctors give Parkinson’s disease medications starting with a low dose and gradually increasing the dose. This is done to reduce side effects and let the patient tolerate the drugs gradually. Till the maximal dose is reached it is not possible to feel completely better. But one does start feeling a bit better. Most doctors take a few weeks to a couple of months before reaching and deciding on the final dose of the medication.

The risk of pulmonary aspiration is present in those whose swallowing is affected. It is rare for patients with Parkinson’s disease in the early stages to have difficulty swallowing causing pulmonary aspiration
Question : Is there a centre which does DBS surgery /stem cell treatmenin Mumbai ?
Answer : Stem cell treatment is NOT APPROVED by any regulatory authority in the world for the treatment of Parkinson’s disease.

There are one ongoing research trial for stem cells going on in the city of Mumbai registered on the NIH website. This is being done in the interest of science with no commercial interest. If you were to participate in this study you would need to fit the criteria and also be willing to sign the consent form.

However there are other centers across the country, which are offering the same for commercial gains without adequate evidence for the same. Be careful of such centers.

More information on the use of stem cells in PD can be found in the recent newsletter ‘MOVEMENT’.
Click here to view details : http://www.parkinsonssocietyindia.com/Admin/News/Journal/17_Journal_Journal-12%20FINAL.pdf
Question : Once PD has been diagonised as being moderate and treatment (Syndopa and Amantrel) is given, will there be chances of the disease becoming worse?
Answer : Parkinson’s disease is a gradually progressive disease with loss of dopaminergic neurons (brain cells) in the substantia nigra. It can been controlled with drugs. However it is not curable.
It is not possible to prevent the progression of Parkinson’s disease till date. There has been a recent study with Rasagiline where 1mg showed some benefit in preventing progression of the disease. However 2mg per day did not. This makes the study very hard to believe and at present the results of the study are inconclusive. Till date there is no drug which has been shown to reduce the progression of the disease.
Question : My wife is sufferring from PD for last two years Inspite of taking madicines she is not improving . Is it cureable at all?
Answer : In addition to being on the right medications (either L Dopa or a dopamine agonist), the dose should also be adequate. Many patients are on very small doses of drugs which are not enough to cover the shortfall of dopamine due to the Parkinson’s disease and hence experience no benefit at all.
Parkinson’s disease is a gradually progressive disease with loss of dopaminergic neurons (brain cells) in the substantia nigra. It can been controlled with drugs. However it is not curable.
Question : What are the side effects of drug Rasalect 1 mg and prolonged administration of pramipex-1 , and syndopa plus along with entacom?
Answer : Pramipexole (Pramipex, Pramirol) specifically and dopamine agonists in general commonly cause nausea, leg edema (swelling) and excessive daytime sleepiness. More concerning are the behavioral changes seen with these drugs. Many cause a group of side effects called impulse control disorders including compulsive gambling, compulsive shopping, compulsive eating, hypersexuality and punding. In some there can be an elevation of mood and mania. Punding is an interesting side effect where people can spend hours on end doing the same tasks repetitively. Some can be sorting files again and again without any purpose while others can spend hours cleaning and re-cleaning the house etc.

L Dopa (Syndopa, Tidomet, LCD) in the short term is associated with nausea, lightheadedness and hallucination. In the long term a cause of concern is involuntary movements called dyskinesias. These movements is usually associated with a progression of the disease as well (usually a combination of the two). Entacapone (Entacom, Adcapone) per say only increases the duration of action of L Dopa. Hence the side effect profile is similar. Only one difference is that entacapone causes the urine to be discolored yellow. This has no long term consequence.

Rasalect (Rasagiline) is a new drug in the Indian Market. It is relatively well tolerated. It may add to the side effect of L Dopa, as like Entacapone, it too increases the duration of action of L Dopa.
Question : Though there are a number of Anti-Parkinson’s drug groups available in the market, for e.g. Levodopa, dopamine agonists and anticholinergics, I am confused as to which is most appropriate for patients at different stages of progression of Parkinson’s disease.
Answer : Unlike treatment of many diseases, treatment for Parkinson’s disease is tailor-made for each patient. From a therapeutic standpoint, Parkinson’s disease can be divided in to three stages-Early, Non- Fluctuating and Fluctuating. All though the same drugs , namely carbidopa-levodopa preparations, dopamine agonists and anticholinergic preparations, are usually prescribed, their pattern of use, including frequency and dosage varies depending on the nature of the dominant symptoms and stage of the disease. Management of Parkinson’s disease requires familiarity with both; the disease-rlated and drug-related components. Optimal functional efficiency for the patient is gained through striking a delicate balance between the drug regime and the disease related components.
Question : Please give me some practical guidelines about the use of the new drug Pramipex.
Answer : Pramipexole is a dopamine receptor agonist. Being a Non ergot drug it does not have many of the side effects of the older dopamine agonists like bromocryptine. It is useful in improving the motor symptoms of PD, both in the initial stages and in the more advanced cases. It is especially useful in young PD patients where we want to delay the use of levodopa as long as possible. As an added benefit, Pramipexole also has anti depressant properties and can improve the mood of patients. In some patients, it can cause excessive sleepiness
Question : I have read an article that Nicotine patches reduce tremors. Please let us have your views.
Answer : To the best of our knowledge, Nicotine patches do not reduce the tremors of PD. The tremors which occur as part of a withdrawal state when smoking is stopped maybe helped by Nicotine patches, not PD tremors.
Question : For dyskinesias which drug is used- Amantrel or Pacitane?
Answer : Dyskinesias are involuntary movements which occur with progression of Parkinson’s disease and are due to PD medications, mainly levodopa. Pacitane does not help dyskinesias, but Amantadine (Amantrel) has been found to be useful in reducing dyskinesias in long standing PD cases.
Question : My age is 60 and I have PD for the last 10 years. What is your opinion on surgery?
Answer : surgery, particularly Subthalamic Nucleus Deep Brain Stimulation, does significantly improve the motor symptoms of Pd in advanced cases. It, however, should be considered only in those cases in whom PD medications no longer give relief either due to lack of efficacy or due to disabling dyskinesias (on-off).
Click here to view details : http://parkinsonssocietyindia.com.w2kin2.onlyfordemo.com/index.aspx
Related concerns
Question : Patient is suffering from Parkinson’s for the past 17 yrs. He has been treated with Syndopa CR+ Ropark combination. He has lost his memory and is not able to recognize anyone. Is there any way that we can bring back his memory?
Answer : Parkinson’s disease is a neurodegenerative disease of which memory dysfunction is common.

Usually when cognitive dysfunction occurs we change the treatment regimen to exclude drugs which may cause hallucinations and confusion as a side effect. This includes anti-cholinergic drugs, dopamine agonists, Amantadine and MAO-B inhibitors. This is done very gradually and step by step. At this time we may accept a little off time. I often also replace the Syndopa CR with an immediate release preparation.

Apart from this one also needs to look into other treatable causes of memory impairment. B12 deficiency, thyroid disorders often cause memory impairment and can be treated. Some patients of Parkinson’s disease may have falls and if these falls cause an injury to head some may develop a hematoma in the head which can cause impairment to the cognitive function. In this situations it may have to be surgically drained. A CT scan of the head would rule this out.

Lastly in patients with dementia a class of drugs called cholinesterase inhibitors are also helpful. Speak to your neurologist to plan your treatment.
Question : I am 70 yrs old. Its been 2yrs since I have been diagnosed with PD. I am taking Ropark 0.5mg & Bexol 2mg HS. If I take these medications in the morning, I feel very sleepy. After breakfast I feel very giddy & need to lie down. I also have tremors of Lt. limbs.
Answer : Drowsiness is a common feature of dopamine agonists like Ropinirole (Ropark). Many times the blood pressure falls (Orthostatic hypotension) when the tablet is taken causing dizziness and the need to lie down. This occurs because when we try to replace the shortage of dopamine in the brain using tablets the tablets have to pass through the stomach and cardiovascular system to reach the brain. In doing so, the extra dopamine in the cardiovascular system causing a fall in blood pressure.

To minimize this problem anti-dopamine drugs like Domperidone are used. Domperidone has a unique property by which it is unable to enter the brain thus allowing the benefit of the dopamine agonist on Parkinson’s symptoms to continue. Domperidone works best if it is take ½ hour before the time of medication (in this case Ropinirole). Please check with your doctor before trying any of these suggestions
Question : My wife 58,wt,68 kg,memory perfect, diagnosed PD in 2001 , is running with Tidomet 110 mg 1/2 Tab 6 x day,,Ropinrole 1mgTDS,Pacitane2mg 1/2 Tab BD,Amentrel 100mg OD.Rasagiline 0.5mg 1/2 OD,Syndopa CR 250 OD(at sleep time),Zolfresh 10mg OD,Depran Forte OD,Alprazolam 0.25 need based.Presently the she does not do anything simply crying through out the day. Always tells that she is unable to walk and that her body and limbs are stiff; getting jerks in body.Regular physiotherapy and massaging is being implemented.She has developed negative thinking.Complains and ,groaning through out the day. Has excessive craving for Tidomet. What are the ill effects of Tidomet.,dietary regulations. and ,also how to manage these symptoms.
Answer : Your problem relates to some drug induced behavioral side effects and also to disease related progression. Many times a stage comes in the disease where behavioral issues become a huge problem on the caregiver. They can occur either due to disease progressing to involve memory and cognition or it could be due to drug induced hallucinations. Many times in such a situation the neurologist may choose to withdraw the dopamine agonist (Ropinirole), Pacitane and Amantadine very gradually and increase the L Dopa and Carbidopa slowly to compensate. This is an extremely tricky situation as while you get the behavior better, often the Parkinson’s symptoms worsen with more slowness and stiffness than before. Dopamine antagonist drugs like Quetiapine to control the behavior and cognitive enhancing drugs like Donepezil or Rivastigmine are useful adjunctive drugs that are often employed in such patients.

Please note the suggestions are general practice suggestions employed in patients. It may not be possible to withdraw drugs in all cases and in some cases it may not be advisable at all. Please discuss the case in detail with your doctor before making any changes. Sudden withdrawal of drugs has a risk of causing a critical condition (Neurolept Malignant Syndrome) requiring hospitalization in the ICU. Hence any change needs to be supervised.
Question : Patient is affected by PD at age 43. What are the chances of genetic transmission of PD to his son or does his son have more chances of developing PD then a normal person whose father is not affected by PD. No other person in family for last 3 generations have been diagnosed with PD
Answer : Most cases of Parkinson’s disease are not genetic in nature. Only 5% of cases have a genetic basis. Even in these 5% the penetrance of the gene is less than 30% indicating that even if the son got the gene (which itself is less than a 5% chance), the chance of him getting PD is less than 1/3rd. For all practical purposes this risk is miniscule hence the family should not be concerned.
Question : I am 60 years old parkinsons patient using medicine regularly. recently i have started experiencing difficulty having intercourse with my wife. is it the side effect of parkinsons disease or old age problem?
Answer : Erectile dysfunction is a common problem in Parkinson’s disease. This usually occurs a few years after the start of the disease. Patients who have this problem can take VIAGRA if they have no heart problems or other contraindications.

Just a note of caution, very early erectile dysfunction sometimes occurring even before the symptoms of Parkinson’s disease should raise the suspicion of atypical parkinsonisms like Multiple System Atrophy. Hence we urge all patients to discuss this matter with their doctor during their visit.

Lastly erectile dysfunction occurs in the absence of Parkinson’s disease or similar disorders in the population quite commonly esp. in this age group. Hence do not always assume the worst scenario if this occurs. DISCUSS this with your doctors……
Question : Is Parkinson's disease common?
Answer : Yes, Unfortunately Parkinson’s disease is very common. It is said to affect 1% of the population over 60 years.
Question : What is understood by the terms "advanced stage Parkinson's disease" AND "early stage PD" in India?
Answer : Usually early stage of Parkinson’s disease refers to the early part of the disease course before motor fluctuations set in. This is a ‘honey moon’ stage where the patient can have a good quality of life on the medications.

Advanced stages of Parkinson’s disease usually refers to patients of Parkinson’s disease with motor fluctuations while on medications, some may show non-motor features
Question : My father has Parkinson's. I am 21 years old male. What are the chances of me getting Parkinson's?
Answer : Parkinson's disease most commonly occurs sporadically from causes which we don't know.

Less than 5% of Parkinson's disease actually has a genetic origin. Among those who are more likely to have a genetic pattern are those whose onset of disease is very young (i.e. <40years of age); or those who have a strong family history of a disease (i.e more than 2-3 closely related family members). Even for those with an onset of 40 years or less the risk of genetic transmission is very low.Unless there is another affected member testing for genetic forms is not undertaken.

Lastly among the familial group too one may have the gene for parkinson's disease and never get it. There is no way to predict who will and who won't.

Due to some technical difficulties the FAQ form to post your questions to us is currently not available. If you wish to post your questions to us you may directly mail them to pdmds.india@gmail.com