Parkinson's disease - Treating Parkinson's disease

Supportive therapies

There are several therapies that can make living with Parkinson's disease easier and can help you deal with your symptoms on a day-to-day basis. There are efforts underway to try and increase the availability of these supportive therapies for Parkinson’s patients in the NHS.

Physiotherapy

A physiotherapist can work with you to relieve muscle stiffness and joint pain through movement (manipulation) and exercise. The physiotherapist aims to make moving easier and improve your walking and flexibility. They also try to improve your fitness levels and your ability to manage things for yourself.

Read more about physiotherapy.

Occupational therapy

An occupational therapist can identify areas of difficulty in your everyday life, for example dressing yourself or getting to the local shops. They can help you to work out practical solutions and ensure your home is safe and properly set up for you. This will help you maintain your independence for as long as possible.

Read more about occupational therapy.

Speech and language therapy

Many people with Parkinson's disease have swallowing difficulties (dysphagia) and problems their speech. A speech and language therapist can often help you improve these problems by teaching speaking and swallowing exercises, or by providing assistive technology.

Diet advice

For some people with Parkinson's disease, making dietary changes can help improve some symptoms, such as:

• increasing the amount of fibre in your diet and making sure you are drinking enough fluid to reduce constipation
• increasing the amount of salt in your diet and eating frequent, small meals to avoid problems with low blood pressure (such as dizziness when you stand up quickly)
• making changes to your diet to avoid unintentional weight loss

You may see a dietitian (a healthcare professional trained to give diet advice) if your care team thinks you may benefit from changing your diet.

Want to know more?

• Parkinson's UK: Therapies and Parkinson's management

Medication

Medication can be used to improve the main symptoms of Parkinson’s disease, such as tremors (uncontrollable shaking) and movement problems.

However, not all the medications available are useful for everyone, and the short and long-term effects of each are different.

Three main types of medication are commonly used. These are levodopa, dopamine agonists and monoamine oxidase-B inhibitors

Your specialist can explain your medication options, including the risks associated with each medication, and discuss which may be best for you. Regular reviews will be required as the condition progresses and your needs change.

Levodopa

Most people with Parkinson's disease will eventually need to have a medication called levodopa.

Levodopa is absorbed by the nerve cells in your brain and turned into the chemical dopamine, which is used to transmit messages between the parts of the brain and nerves that control movement. Increasing the levels of dopamine using levodopa usually improves movement problems.

Levodopa is usually taken as a tablet or liquid and is often combined with other medication, such as benserazide or carbidopa. These additional medications stop the levodopa being broken down in the bloodstream before it has a chance to get to the brain. They also reduce the side effects of levodopa, which include feeling sick (nausea), vomiting, tiredness and dizziness.

If you are prescribed levodopa, the initial dose will usually be very small and will be gradually increased until it takes effect.

At first, levodopa can cause a dramatic improvement in the symptoms. However, its effects can be less long-lasting over the following years because, as more nerve cells in the brain are lost, there are fewer of them to absorb the medicine. This means that the dose may need to be increased from time to time.

Long-term use of levodopa is also linked to problems such as uncontrollable, jerky muscle movements (dyskinesias) and 'on-off' effects – where the person suddenly switches between being able to move (on) and being immobile (off).

Duodopa

If you have severe on-off swings, a type of levodopa called duodopa may be used.

This medication comes as a gel that is continuously pumped into your gut through a tube inserted through your abdominal wall (tummy). There is a small external pump attached to the end of the tube, which you wear on your belt.

However, only a few centres in the UK offer this treatment. It needs the support of your local NHS clinical commissioning group (CCG) to finance it.

Dopamine agonists

Dopamine agonists act as a substitute for dopamine in the brain and have a similar but milder effect compared to levodopa. They are used to treat early Parkinson’s disease as they are less likely to cause involuntary movements (dyskinesias) than levodopa.

Dopamine agonists are often taken as a tablet, but a type called apomorphine can be injected under the skin (subcutaneously). Sometimes, dopamine agonists are taken at the same time as levodopa as this allows lower doses of levodopa to be used.

Possible side effects of dopamine agonists include nausea, vomiting, tiredness and dizziness. Dopamine agonists can also cause hallucinations and episodes of confusion, so they need to be used with caution, particularly in elderly patients who are more susceptible.

For some people, dopamine agonists, especially at high doses, have been linked to the development of compulsive behaviours, including addictive gambling and an excessively increased libido.

Talk to your healthcare specialist if you think you may be experiencing these problems. As the person themselves may not realise the problem, it is key that carers and family members also note any abnormal behaviour and discuss it with an appropriate professional at the earliest opportunity.

If you are prescribed a course of dopamine agonists, the initial dose will usually be very small to prevent nausea. The dosage is gradually increased over a few weeks. If nausea becomes a problem, your GP may prescribe anti-sickness medication. You may need blood tests and a chest X-ray before some types of dopamine agonist are prescribed.

Monoamine oxidase-B inhibitors

Monoamine oxidase-B (MAO-B) inhibitors, including selegiline and rasagiline, are another alternative to levodopa for treating early Parkinson's disease. They block the effects of a brain chemical that destroys dopamine (monoamine oxidase-B).

Both selegiline and rasagiline can improve the symptoms of Parkinson’s disease, although their effects are small compared with levodopa. They can be used alongside levodopa or dopamine agonists.

MAO-B inhibitors can cause a wide range of side effects, including nausea, headache and abdominal pain.

Catechol-O-methyltransferase inhibitors

Catechol-O-methyltransferase (COMT) inhibitors are prescribed for people in later stages of Parkinson’s disease. They prevent levodopa from being broken down by the enzyme COMT.

Side effects of COMT inhibitors include nausea, vomiting, diarrhoea and abdominal pain. If the COMT inhibitor tolcapone is used, you will need tests to check your liver health every two weeks.

Want to know more?

• Parkinson's UK: Drug treatments
• Parkinson's UK: Parkinson's drugs and compulsive behaviours

Surgery

Most people with Parkinson’s disease are treated with medication, although a type of surgery called deep brain stimulation is used in some cases.

This surgery is available in specialist centres around the UK, but it is not suitable for everyone. If surgery is being considered, your specialist will discuss the possible risks and benefits with you.

Deep brain stimulation

Deep brain stimulation involves surgically implanting a pulse generator (similar to a heart pacemaker) into your chest wall. This is connected to one or two fine wires placed under the skin and inserted precisely into specific areas in your brain. A tiny electric current is produced from the pulse generator, which runs through the wire and stimulates the part of your brain affected by Parkinson's disease.

Although surgery does not cure Parkinson's disease, it can ease the symptoms for some.

Want to know more?

• NICE: Deep brain stimulation for Parkinson’s disease (PDF, 37.5kb)
• Parkinson's UK: Surgery

Treating additional symptoms

As well the main symptoms of movement problems, people with Parkinson's disease can experience a wide range of additional symptoms that may need to be treated separately.

These include:

• Depression and anxiety, which can be treated with self-care measures (such as exercise), psychological therapy or medication. Read more about treating depression and treating anxiety.
• Problems sleeping (insomnia), which can be improved by making changes to your normal bedtime routine. Read more about treating insomnia.
• Erectile dysfunction, which can be treated with medication. Read more about treating erectile dysfunction.
• Excessive sweating (hyperhidrosis), which can be reduced using a prescription antiperspirant, or with surgery in severe cases. Read more about treating hyperhidrosis.
• Swallowing difficulties (dysphagia), which can be improved by eating softened food, or by using a feeding tube in more severe cases. Read more about treating dysphagia.
• Excessive drooling, which can be improved with swallowing exercises, or surgery or medication in severe cases.
• Urinary incontinence, which can be treated with exercises to strengthen the pelvic floor muscles, medication, or surgery in severe cases. Read more about treating urinary incontinence.
• Dementia, which can be treated with cognitive therapies and medication in some cases. Read more about treating dementia.

Clinical trials

Complementary and alternative therapies

Some people with Parkinson’s disease find that complementary therapies help them feel better. Many complementary treatments and therapies claim to ease the symptoms of Parkinson’s disease. However, there is no clinical evidence that they are effective in controlling the symptoms of Parkinson’s disease.

Most people think that complementary treatments have no harmful effects. However, some can be harmful, and they should not be used instead of the medicines prescribed by your doctor.

Some types of herbal remedies, such as St John’s wort, can interact unpredictably if taken with some types of medication used to treat Parkinson’s disease.

If you are considering using an alternative treatment along with your prescribed medicines, check with your care team first.

Want to know more?