Asked us anything about
treatments. I'm Scott Gilbert.
Approximately 1 million Americans
currently live with Parkinson's disease
an illness for which there is no cure.
In fact there's really no way to even
slow the progression of symptoms. But
there are many ways to treat those
symptoms as they come up and we're going
to be talking about some of those ways
today, with Dr. Sol De Jesus. She's a
neurologist who specializes in movement
disorders here at Penn State Health.
Dr. De Jesus, thanks for being here. Thank you
for having me today! Let's talk about
some of those symptoms, especially the
early stage versus late stage symptoms
of Parkinson's disease. We all think
about tremor as being a main symptom but
it's about more than that isn't it. It is,
there are both non-motor and motor
symptoms in parkinson's disease. What we
concentrate on in terms of the clinical
diagnosis are four cardinal features or
motor features. Patients may have one or
maybe they may have all of them. The main
one that we think about is a slowness
and movement a slowness and that
automated type of movement that you can
have and that can be disabling for
patients. At one period they can be
moving regularly and at another time
they can slow down. Another feature that
we think about is tremor about seventy
percent of patients with Parkinsons can
have what's called a rest tremor of
involving a hand or a leg when it
initially starts. Over time, it starts to
move to the other side of the body so
initially can start on one side and
eventually involve the other side over
time as the disease progresses in terms
of tremors and other symptoms. Another
third feature is stiffness or a
tightness in the muscles and the last
one has to do with balance and postural
instability and again patients may have
one or more of those features over time
and they can have non-motor features
that include speech problems with memory
and recalling words issues with mood
changes depression and anxiety. Later on
in the disease of some individuals can have
hallucinations or psychosis with their
disorder but not everyone has the same
symptoms. It's variable between patients.
When it comes to diagnosis early on is
it based solely on symptoms or
other additional tests you can run scans
that type of thing. So the diagnosis is a
clinical diagnosis so you will see your
neurologist or your movement disorder
neurologist and they'll have you do a
couple of things in the clinic to
examine and find these features that
we've talked about. There are studies
that can be supportive of your diagnosis
but they're not definitive and so that
would be like a DAT spec scan which
looks for changes in the level of
dopamine in the brain which is the
substance that is reduced in Parkinson's
disease but not everyone needs to get
that scan to make the diagnosis. Usually
the neurologist can make it in the
clinic in an appointment visit. You're
watching ask us anything about
Parkinson's treatments from Penn State
Health I'm Scott Gilbert along with
Dr. Sol De Jesus, we welcome your questions
whether you're watching this video now
or after the fact on playback, feel free
to add those questions to the comment
field and will pose them here to
Dr. De Jesus, so let us know what your
questions are feel free to share this
post too if you find the information
helpful we can get it out to more people
that way . What do we know Dr. De Jesus
about the causes of Parkinson's disease
and what don't we know. The majority of
cases are what we call idiopathic so
there's not a clear cause that we can
pinpoint to that leads to the disease.
There are some genetic forms of
Parkinson's where there's been a gene
identified that's been mutated but that
tends to be a very small number of cases
of Parkinson's disease so most cases are
they spontaneously occur based on your
own unique body genetics or a body
system and with potential interactions
with your environment and environmental
exposures but there's, at this time we
don't have a clear cause for
Parkinson's. And there's no cure and it's
as we said earlier not even a way to
really slow the progression of symptoms,
right? So there is a, you're correct,
there's no cure right now for
Parkinson's it is a disease that slowly
progresses over time but there are
medications that we can use that we have
available for patients that can maintain
a good
quality of life and maintain high
functioning
early on in the disease. Does the disease
progress at the same rate in every
patient or is there some variability?
No, there it's very variable and
what we recommend is that you don't
compare yourself with other individuals
that have the diagnosis of Parkinson's
each individual has a very unique
journey with the disorder and the way
that they progress is based on how their
symptoms have been changing over time
and they would be their own marker of
the progression of the disease and so it
will be a very individual journey for
each patient. Similar to other
neurological disorders actually to? It is.
You're watching ask us anything about
Parkinson's treatments from Penn State
Health feel free to add your questions
in the comment field and will pose them
here to Dr. De Jesus. So on the topic of
treatments it seems like a lot of them
pretty much all of them are about
improving the quality of life for people
with Parkinson's disease. Let's start
with medications, what kind of medical
options are out there and what do those
medicines do. So there are many different
classes of medications out there for
Parkinson's disease. The gold standard is
levodopa this is us providing the brain
with the substance that is deficient in
Parkinson's disease. It gets converted to
dopamine in the brain and that's one of
the ways that we can get patients to be
more mobile. There are many other
medications that will stop the breakdown
of dopamine in the brain and then
there's another group of medications
that have an effect on the receptors of
the brain that interact with Parkinson's
to allow it to use the Parkinson's more
effectively. So it really works the
medications work on chemicals in the
brain really, on that chemical balance. They
do as a main issue with Parkinson's is a
loss of the cells that produce dopamine.
Without dopamine, the body can't run so
the way that I like to describe it is
your car. If the car doesn't have gas it
it won't move, it will move as
effectively and so that the dopamine is
like gas in the car. So because of how
Parkinson's progresses we know
that the symptoms do get worse over time,
there are some patients who I would
imagine have to take a prohibitive
amount of medication, so there are other
options out there one in particulars
deep brain stimulation. Can you talk a
little bit about that?
Early on patients have a great response
to medicine and they require more amounts
When that happens, individuals may feel a
fluctuation in their medicine where they
have really great times what we call the
on time and that the medicine starts to
wear off and the dopamine levels drop
they can have some off time and so we
call that motor fluctuations and so
individuals that have to take
medications more frequently or have side
effects with the medication, there are
alternative options that we can use as
an adjunct to the medication called deep
brain stimulation. So we have some of
those tools here used in deep brain
stimulation I'll bring them over here.
First of all can you kind of walk us
through what we're seeing in this kit
here looks like a wire and those are
batteries right? They're batteries. So the deep brain
stimulator is a brain surgery that's
done where there's a lead that has a
little metal contacts at the end of it
that get implanted in very specific
brain structures that help the symptoms
of Parkinson's disease. And then that
gets place and tunneled under the skin
and it's sort of similar to a pacemaker
it sits under the skin you can use a
battery that gets placed by the
neurosurgeon during the surgery and this
battery provides the energy to allow to
send electrical impulses to the brain
and these very specific brain targets to
reset or adjust the abnormal brain
signal that occurs. Now, this battery is
under the skin and after the surgery is
done your neurologist or programming
neurologist can do every all the
programming over the skin and over the
clothes and so it gets adjusted in the
outpatient clinic setting. How long does
that battery last how often does it have
to be replaced. It's variable for the
individuals and the type of battery.
Depending on how much energy the patient
needs to address the symptoms of their
Parkinson's, it can last between three
and seven years but there's no set
number for each patient what happens
after the battery, if they're the battery
is gets drained is a simple procedure to
just remove the battery from the skin
pocket underneath it doesn't require
another brain surgery. Okay, well this is
the lead that goes into the brain right
here so this is the part right here in
the end
and that that delivers the electricity
to the brain. Correct. So how do physician such
as yourself determine exactly where that
gets placed? So there's a lot of
individuals within in the operating room
the neurosurgeon is the physician that
does the actual surgery. I am a movement
disorder that's trained in
neurophysiology so we learn to read
brain signals within the brain and there
is a neurophysiologist as well and in
the room that works alongside and so
it's a sort of map that you get to see
as you're going through the different
brain structures you're looking at the
sounds from individual cells as you go
through and you can map out where you
are particularly in the brain and you
can find the specific target that you
want to look for based on the recordings
that we get with a very tiny electrical
recording device. You're watching ask us
anything about Parkinson's treatments
from Penn State Health I'm Scott Gilbert
along with dr. sold the hey Zeus we
welcome your questions and your comments
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that you catch future editions have
asked us anything about. We're talking
right now about deep brain stimulation
which as we're discussing, it's all
about this cable right here and
then these electrodes it get planted
deep inside the brain.
This is a month long process of fine-tuning
that equipment right? So there's various
stages one of the things that you want
to start with is getting an initial evaluation
by what we have here at Penn
State is a multidisciplinary team. So you
would see your movement disorder
neurologists you would see your neurosurgeon a
neuropsychologist and your physical
therapists and we would assess your
symptoms and assess your candidacy for
the surgery the second step is to
actually go through the brain surgery to
have the placement of these components
or devices and then after you have your
deep brain stimulation placed you work
with your neurologists and programming
specialists to adjust and find the
optimal setting for your symptoms. And so
after the stimulation is placed, we use
this is my patient programmer and I can
connect this towards the patient's
battery device over the skin and this
allows me to change where I apply the
stimulation how much energy i'm applying
to that battery into that
patient to address the symptoms. And then
the patient also has their own little
programming controller that will allow
their them to turn it off and on if they
have to and can also be allowed to
change programs if I give them more than
one to take home. The process takes about
six months to have an optimal program
but you do get benefit from the time
that the device gets turned on for your
first visit and it's trying to fine-tune
and find the correct program setting for
you. And you mentioned that there could
be a couple different programs (there can be) and switch
between them depending on what
they're experiencing at the moment? Correct. And it'll
depend on how comfortable they are to
use it and there are some people that
don't want to change the programs or
touch anything but we do teach them how
to turn it off and on in case they have
to get a certain procedures done or for
other reasons that there's any concern
that they they can do that themselves. So
that we gauge based on how comfortable
the patients feel and how much they want
to be involved in changing or changing
groups are changing the program's. I've
seen the process firsthand I was present
for when a patient had one program,
fascinating process and it's interesting
how the small changes you make can
really make a difference for the
symptoms they're experiencing.
Well absolutely, as you select the
right candidate and you're addressing
the right symptoms you can get a lot of
benefit from the deep brain stimulator
it is not for everyone with Parkinson's
disease but if you do have a question it
is something worth exploring and talking
to with your physicians and getting
referred to the team. Who are the
best candidates for deep brain
stimulation? So that there are specific
symptoms that we know we can treat very
well. Patients with tremors, patients with
stiffness patients with slowness in their
movement the DBS device does very well
with that. There are certain things that
we could potentially worsen with having
the deep brain stimulation and that's
thinking speaking and walking and so
that's why there's the need to do this
comprehensive evaluation so that we can
assess the risk versus the benefit of
the procedure for individuals most of
most of all patients that have gone the
DBS device state that they are happy and
that they have had some benefit with the
DBS device long-term. This is ask us
anything about Parkinson's treatments
from Penn State Health I'm Scott Gilbert
along with Dr. Sol De Jesus and whether
you're watching this live or after the
fact on playback feel free to add your
questions to the comment field and we'll
get you some answers. We had talked
before as well about medical treatments
I want to jump back to that a second
because there is there's a rather
exciting development within just the
last week or so there's FDA approval of
a new medication. Can you talk a bit more
about what that does? That's right, this
is an exciting time for the field and
for Parkinson's disease there are many
medicines that are have been coming out
in the last two years or so the most
recently about a week ago the FDA
approved one medication called safinamide.
It's what we call an MAOB
inhibitor it's a monoamine oxidase inhibitor.
That's one of the enzymes in
the brain that breaks down dopamine and
so this medication was approved by the
FDA to be as an add-on therapy for
patients with motor fluctuations who are
on their levodopa. What it does is it
allows more of what we call the on time
feeling good on their medicine as
opposed to lower
and decreasing the off time with their
Parkinson's symptoms in the studies they
compared it with a placebo drug and it
was on patients who had levodopa already
on board and it increased on time by
about one hour. What's important to know
about this medicine is that there are
other classes there are other
medications within the same class of
drug that we have available in our
arsenal already that's saleduline and
azilect and some of the other of our
patients already on this type of class
of drug. And so at this point we don't
know exactly how it will compare with
those medications as there wasn't any
head-to-head comparisons and whether it
is when we're going to have to switch or
try this one versus the other types of
the mao inhibitors it's always exciting
when a new drug comes out if you're not
sure the drug is for you it's something
to discuss with your health care
provider. Laura has a question online
she's asking whether there'd be any
treatment advantage to having genetic
testing to flag an early genetic
predisposition to Parkinson. At this
point we don't recommend a genetic
testing for Parkinson's disease when
we're talking about idiopathic
parkinson's disease the regular form of
if it is in individuals that are younger
onset under 40 years of age and there's
a clear family history there may be some
benefit to obtaining the genetic testing
in the end it does not change what we do
in terms of the management of our
patients with Parkinsons. It must be an
exciting time to do what you do to see
so many promising treatments emerging
between DBS new medications as we're
just talking about and wondering what
the future holds. It is. It's a field that
continues to advance both from the
medication standpoint, we are doing very
well at treating again symptomatically
the field is moving towards more of the
neuro protection of the brain and trying
to reverse or stop the progression of
the disease so that's sort of where the
field is moving to from both the
medication standpoint and with the
imaging devices and our technological
advancements we're seeing changes within
the surgical options that we can offer
to our patients as well.
Okay, sounds good. We do have a question
from Jamey asking whether any link
between FTD and Parkinson's? So, there are
different forms of Parkinson's disease
and so there is genes that may be in
the same sort of genetic
linkage but there isn't a specific gene
that has been targeted to both. What is
FTD? A frontal temporal dementia so it's
a type of dementia that exists and can
some patients can have different forms
or presentations that can affect in
terms of their behaviors and their
speech patterns or language patterns
along with their movements. Sounds good.
Are we all set for questions? I think
that's all the questions for now right?
Good deal! Well, I want to say
thank you to those who ask questions and
thanks to everybody who's watched this
and thanks especially to Dr. Sol De Jesus.
She's a movement disorder
specialist and neurologists here at Penn
State Health thank you for your time
today. Thank you. Thank you for having me
and again I encourage you to keep asking
those questions online on this facebook
post even as you watch on playback we
can track her down and find some answers
for you and also feel free to share this
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editions of ask us anything about. Thank
you very much for watching
ask us anything about Parkinson's
disease from Penn State Health