Parkinson's Disease

What Is Parkinson’s Disease?

Parkinson’s disease (PD) is a slowly progressive condition resulting from a deficiency in the brain of a chemical called dopamine.

Dopamine is one of many chemical messengers (called neurotransmitters) in the brain that allow nerve cells to communicate with each other. Without it, messages from the brain to the muscles are disrupted. Over a period of time symptoms appear that include:

  • Tremor (shaking) when the body and limbs are at rest
  • Slowness and difficulty beginning a voluntary movement, such as standing up from a chair or turning around, and difficulty with fine precise movements such as doing up buttons. (called bradykinesia)
  • Muscle stiffness, also called rigidity, and
  • Difficulty with maintaining balance (called postural instability)

The amount of dopamine in the brain is reduced in Parkinson’s disease because some of the nerve cells that produce it are destroyed.

The small group of nerve cells affected in Parkinson’s disease nerve cells lies deep in the brain, in a region called the substantia nigra (black substance), a part of the brain involved in initiating movement. It is situated near the center of the brain and contains a clump of dark cells that manufacture dopamine.

Parkinson’s disease is named after the English physician Dr. James Parkinson, who described it in 1817. However there is a much earlier description of Parkinson’s disease among the writings of Leonardo da Vinci, in the Royal collection at Windsor Castle in England.

Facts About Parkinson’s Disease

  • The incidence of Parkinson’s disease is increasing at a rate that is faster than the population is aging.
  • Parkinson’s disease affects an estimated 1 in 1,000 people over age 55.
  • Parkinson’s disease affects about 1 in 100 people age 65 and older.
  • Some 20 percent of people with Parkinson’s disease may be diagnosed under the age of 50.
  • About 8 percent to 10 percent of people with Parkinson’s disease may be diagnosed under the age of 40. Well-known people who have had or have Parkinson’s disease include Pope John Paul II, Francisco Franco, Muhammad Ali, Yasir Arafat, Janet Reno, Sir Michael Redgrave, Adolf Hitler, Vincent Price, Morris Udall, Margaret Bourke White, Pierre Elliot Trudeau, and Michael J. Fox.
  • There has been excellent progress with research into the treatment of Parkinson’s disease. This includes stem cell technology in which very basic cells are grown in the laboratory, and can be easily cultivated into large populations. Researchers have succeeded in turning these stem cells, in the laboratory, into dopamine producing nerve cells, like those cells in the substantia nigra of the brain that produce dopamine.
  • Human trials have already begun and been published using retinal epithelial cells, and human trials using stem cells for the treatment of Parkinson’s disease should begin in the foreseeable future.


Parkinson’s Disease: What Causes It?

Deep inside the brain, in an area of the brain called the basal ganglia, are nerve cells that normally control a person’s voluntary movement and coordinate changes in person’s posture.

  • When the brain sets in motion an action that results in lifting an arm, for instance, the basal ganglia signals and transmits messages to the other parts of the brain.
  • Those messages are forwarded as electrical impulses along and between nerve pathways by the chemical messenger called dopamine, which is made in the area of the brain called the substantia nigra. The message passes on to the basal ganglia and down the spinal cord to the muscles used to lift the arm.

The basal ganglia are normally rich with this chemical called dopamine which has been delivered from a nearby area in the brain called the substantia nigra where the dopamine is manufactured.

In people with Parkinson’s, the nerve cells in the substantia nigra (where the dopamine is made) die, and the surviving cells do not produce enough dopamine.

The symptoms of Parkinson’s will begin when 80 percent of dopamine production from this area of the brain is lost.

We do not know why some previously normal nerve cells die causing dopamine levels to fall.

Parkinson’s is known to occur in some families, (10 percent to 15 percent of Parkinson’s disease may be inherited) and several genes have been identified in the last decade that appear to be associated with Parkinson’s and undoubtedly more will be discovered as research continues. However, not all familial Parkinson’s disease is inherited and in these cases it may occur as a result of a shared environment and a common susceptibility.

When Parkinson’s disease is inherited, it tends to occur in people under fifty years of age. (reference : Tanner and co-authors – Journal of American Medical Association. 1999 Jan 27;281(4):341-6). However, this does not mean that everyone who develops Parkinson’s under the age of fifty has inherited the disease.

The majority of people with Parkinson’s have what is called ‘sporadic’ disease, which means it occurs in the absence of a family history with no known cause.

Researchers feel that there may be more than one cause of Parkinson’s disease. (reference: ‘Parkinson’s is not one Disease’ by Dr D B Calne in ‘Parkinsonism and Related Disorders’ 7 (1): 3-7, 2000)

There is renewed interest in the possibility that a virus might be one cause of Parkinson’s. Parkinson’s was a complication of the influenza pandemic that occurred after World War 1. This virus disappeared in the early 1930s, before it could be identified. Animal studies support this, and two studies studies (reference: J. K. C. Tsui, and co-authors. Occupational risk factors in Parkinson’s Disease. Canadian Journal of Public Health 90 (5):334-335, 1999., and Tanner and co-authors) in humans showed that Parkinson’s is much more common in people who work and live in close contact with others.

The most recent study involved confirmed earlier findings that teachers and members of the medical profession carry twice the risk. The last study found no increase in Parkinson’s in welders.

A recent study described three statistically significant ‘clusters’ of people who worked together and who developed Parkinson’s within a similar time frame.One involved 4 members of a TV cast and crew (4 subjects out of 120) one a group of professors (4 subjects out of 30) and one a group of people in the office of a garment factory (3 out of 7). The authors do not speculate on the cause but each group worked in an environment with artificial ventilation.(reference: A Kumar and co-authors: Clustering of Parkinson’s Disease: Shared Cause or Co-incidence? Archives.Neurol.61 (7):pages 1057-1060, 2004)

There are still some scientists who think that “free radicals” may contribute to the damage to the nerve cells. These are toxic substances made in the body as a result of normal chemical reactions. Some people with Parkinson’s have increased levels of iron in the brain, which is part of the oxidation process. The implication of these findings is unclear. The use of vitamin E in Parkinson’s as a putative ‘free radical trapping’ agent is no longer recommended; indeed a recent study from the UK suggests that mega doses of vitamin E may be toxic.

In some cases, the cause is known.

  • Parkinsonism can be a consequence of some medications (used to treat psychiatric illness or control nausea ).
  • A small group of people developed Parkinsonism as a result of a known toxin called MPTP, found in an illegal synthetic opiate-derivative street drug and sold in California in the early 1980s.

How Is Parkinson’s Disease Treated?

A number of treatments have been shown to improve symptoms of PD, well being, and quality of life. But, at present, none has been found to cure or slow down the progression of the illness. Research continues throughout the world, however, in search for the cause, new treatments and, a way to slow down, cure or prevent the illness.

Most people will continue quite a normal life after the diagnosis has been made and treatment begun. Some may decide together with the doctor that they can manage a while longer without treatment. A good way of knowing when treatment should begin is if small everyday tasks are becoming frustrating and tiring or if one’s work is threatened.

Need To Know:

There is no medical benefit to be obtained by delaying the start of treatment and there is some evidence that delaying it for too long can actually have an adverse effect in the long term.

It’s a commonly held misconception that the drugs only work for five to seven years, and some patients conclude that they can choose which five-to-seven-year period of their illness this will be. They decide to delay treatment for as long as possible. But if they wait too long, a higher dose of medication will be needed sooner – to control symptoms that have been steadily worsening over the years. The side effects from the higher doses of medication will occur more quickly. In the meantime, the person and the family will have endured months (or years) of frustration and fatigue.

The drugs may appear to stop working but this is actually a result of the symptoms no longer being controlled by the dose. This calls for an adjustment of the medications or the addition of others.


What Are The Signs And Symptoms Of Parkinson’s Disease?

Parkinson’s disease has classic signs and symptoms, but they do not all appear at the same time or to the same degree. Some people are more troubled by one than another. The condition can vary significantly between individuals, for example how the disease progresses, and how well someone responds to the drugs, etc. Therefore, people with PD should never compare themselves with others who have PD.

These Are The Four Major Signs Of PD:

  • Tremor. In about 70 percent of people with PD, this is the earliest symptom to appear. It is a tremor that occurs in a limb when it is at rest. The tremor starts in one arm or leg on one side of the body and can progress to include the other side of the body. It usually remains more pronounced on one side of the body. Although socially distressing, the tremor does not usually interfere with activities of daily life, and it tends to disappear with voluntary movement (picking up a cup, for example). Often, medications do not completely control tremor. Fatigue, emotional stress, and worrying about the tremor can make it worse in the short term.
  • Rigidity. This describes increased tone or stiffness in the muscles when they are at rest. Joints may sometimes feel locked. The lack of mobility often causes muscle fatigue and ache. Rigidity usually responds well to treatment.
  • Slowness of movement. This condition is called bradykinesia. Fine movements become clumsy, for example, doing up buttons. Typically, it is often hard to begin a movement, for example, getting up from a chair, or there may be an abrupt stopping of ongoing movement such as when turning corners or going through doorways. This symptom is the most disabling, but it responds well to treatment.
  • Impaired balance. Normally, reflexes allow us to make rapid adjustments to changes in the body’s center of gravity when standing or walking. These reflexes become impaired in people with PD who may eventually be at risk for falls. Medication may help, but rehabilitation therapy is most valuable.


There are also a number of symptoms associated with PD. Not all people will experience them to the same degree. They include:

  • A changed facial expression. Because the facial muscles that normally create expression don’t move as well, people with PD sometimes appear to look uninterested or sad when they are not. This is known as hypomimia.
  • A soft voice. This is known as hypophonia. People with PD may have difficulty being heard, particularly on the phone. In addition, the rhythm of the voice can be affected, and words may be spoken in a monotone.
  • Small, cramped handwriting. Writing may be normal size for the first few words and then will trail off and get smaller. This is known as micrographia.
  • Pain. Painful stiffness, for example affecting the shoulder or calves, is a common early feature of PD. Painful cramps can also affect some people, sometimes as a result of too much medication and sometimes too little. The physician will want to know when the cramps occur in relationship to the timing of the drugs. Successful treatment of PD symptoms can lead to improved mobility, but can sometimes aggravate existing arthritis.
  • Fatigue. Everyday tasks take longer to complete when one has PD. It is hard to do two things at once. Sleep may also be disturbed. When combined, these problems often contribute to the tiredness experienced by many. It also takes a while for people with PD to learn to pace themselves to avoid reaching the end of a day without feeling exhausted. Some people experience a noticable benefit in their symptoms after a good nap or a sleep.
  • Depression. Research indicates that up to 50 percent of patients with PD can experience a period of depression during their illness. Depression in PD is caused by disturbed brain chemistry, and it can be triggered or made worse by stressful situations in life. Depression may occur at any time during the illness. But if depression is present when the person is first diagnosed with PD, it sometimes gets better on its own when PD symptoms start to improve with treatment.

    Depression may, however, need some treatment itself. The most important first step is for the person with PD to be able to admit to being depressed and seek appropriate help. Today’s antidepressants are safe and well tolerated, and most can be taken very successfully with antiparkinson drug therapy. There may be mild side effects early in treatment (dry mouth, dizziness, drowsiness), but these usually disappear with time. Full benefit from treatment for depression can take from four to six weeks. Patience, determination, and family support are needed while the right dose level is achieved.

  • Constipation. PD and the drugs used for its treatment contribute to constipation. Severe constipation can lead to a medical emergency. If constipation continues to be a problem, it is important to seek medical help.

Intellectually, people with PD usually remain normal. But because speech and everyday tasks take longer to execute, it may appear that they lack comprehension or understanding – when actually they know exactly what they want to do but are unable to process their thoughts or actions in a timely manner. Some 30 percent of patients with PD, however, do develop dementia – the loss of cognitive and intellectual functions without impairment of perception or consciousness. Dementia can also lead to disorientation, a flattened mood, impaired memory, judgment, and intellect.

Parkinson’s Disease: If You Have to Go into the Hospital

People ith Parkinson’s Disease may need to go into the hospital or have surgery. People with the condition and their caregivers should be well informed about how to ensure good management of Parkinson’s Disease while in the hospital.

While it is easier to plan in advance for pre-scheduled admissions to hospital for elective surgery’ (for e.g. hip replacement, heart, prostate or bladder surgery, emergency hospital admissions pose greater challenges (for e.g. hip surgery after a fall/fracture, pneumonia, infection, bowel impaction or stroke). Be aware that trips to emergency rooms for the management of increased dyskinesia or prolonged off periods are best avoided. These episodes will eventually resolve spontaneously and it is better to stay at home in a calm, safe environment.

We recommend you keep this fact sheet where you or a family member can find it should it be needed.


Day surgery is generally not a problem for a person with Parkinson’s Disease. However, some procedures during which you would normally be awake, such as cataract surgery or some dental procedures, may pose a problem if your tremor or dyskinesia create too much movement. You should bring this to the attention of the surgeon before the date of the procedure is set. It is important to ensure that you know how your GP, surgeon and neurologist (if you see one) will coordinate the care of your Parkinson’s Disease with your procedure.

If surgery is recommended, discuss with the surgeon:

  • Benefits & risks of the procedure
  • Tests & procedures involved
  • Expected outcomes and odds of success
  • Potential complications
  • Length of hospital stay
  • Alternatives to surgery. Is there a more conservative approach?
  • Alternatives to general anaesthesia
  • Alternatives to admission

Then you can make an informed choice.

Pre-operative Medication

For surgery requiring a general anesthetic, your anti-Parkinson medication may be stopped the night before surgery. Alternatively you may be allowed to take an early morning dose of Sinemet with the least amount of water. Ask if it is possible to be first on a morning surgery list to avoid long periods without medication.

Parkinson’s Disease medication timing in hospital

  • Ask your doctor to send your drug regimen and schedule with your hospital admitting orders before hospital admission. Also, bring your medications with you in the original bottles. Bring several copies of your list of daily Parkinson’s Disease medications and schedule to hospital. If, for example, you take your medication three times daily, write the times taken. Otherwise it mat be interpreted as taken every 8 hours.
  • If you are on an experimental Parkinson’s Disease drug bring your own supply and a letter about the study.
  • Discuss with your doctor the possibility of getting authorization to administer your own medication if you have frequent doses or as needed doses.

Contraindicated drugs & side effects

  • Supply a list of all allergies to the hospital
  • For pain control, People with Parkinson’s Disease tend to tolerate morphine better than Demerol. Demerol, pre-medication, and drugs used for anesthesia can cause severe confusion, which may take a few days to a few weeks to resolve even in people who are not normally confused.
  • For post operative nausea, ask your physician and staff not to give you dopamine antagonist drugs such as Reglan or Maxeran (metoclopramide) or Compazine or Stemetil (prochlorperazine) for nausea. Gravol is a useful drug choice and can be given by mouth, suppository, and injection. (Domperidone only prevents the nausea associated with antiparkinson drugs).
  • If you become confused post-operatively it could be drug or anaesthesia induced or the result of dehydration, constipation or an infection. Avoid all conventional anti-psychotic drugs such as haloperidol, respiridone, and olanzapine. Quietapine (Seroquel) is the only safe antipsychotic drug for Parkinson’s patients.
  • For bladder or prostate problems, anti-cholinergic drugs often help relieve muscle spasms after surgery, but these can cause confusion, constipation and retention of urine.

Re-starting anti-Parkinson medication after surgery

In most cases you can restart your anti-Parkinson drugs as soon as you are fully awake, and able to sit up and swallow.

Anti-Parkinson drugs cannot be given during surgery. After some surgical procedures (for e.g. abdominal surgery) you will not be able to take anything by mouth. If this is the case you should ask about having a nasogastric tube inserted before surgery even if the surgeon does not usually insert one for your procedure. You must be able to restart your anti-Parkinson drugs as soon as possible post-operatively to ensure optimal mobility. Post-surgery, crushed regular levodopa can be given with water through tube. Other tablets and the contents of capsules can be administered via nasogastric tube. However, Sinemet alone is preferred for the first few days to minimize the risk of psychosis and nausea.


  • Parkinson’s Disease is already creating stress, so your body may be less able to cope with additional problems and adapt to the hospital environment.
  • Stress reduces energy for healing and will make all Parkinson’s Disease symptoms worse. Use the stress management skills that work for you, such as breathing exercises, relaxing music on a walkman, and optimism
  • Different diet, inadequate fluid, and lack of mobility can lead to constipation, which can be severe. Bring a bowel management protocol with you
  • Do not be surprised if you aren’t always clear about what is going on. Different staff on different shifts and medical jargon can all create uncertainty. Ask questions and seek clarification.
  • Medication complications can disrupt mobility and mental status, and delay recovery. Family caregivers need both a support system and a key hospital contact person.

Communicating your needs

Staff may not have much Parkinson’s Disease experience, so discuss these issues with the nurse:

  • On/off fluctuations are not intentional
  • The importance of taking Parkinson’s medications on time. Most hospitals allow nurses a window of time in which they can deliver medications. Delayed drug delivery can disrupt your Parkinson’s Disease and delay your recovery.
  • Physical and mental slowness associated Parkinson’s Disease
  • Speech problems may affect intercom use
  • Hand dexterity may affect eating/hygiene
  • Bed turns, transfers, and walking assistance may be required
  • Hospital stays increase the risk of falling and fractures for those with Parkinson’s Disease.

Restoring Mobility and Rehabilitation during hospital recovery

  • People with Parkinson’s Disease need to restore their mobility as quickly as possible to avoid complications such as pneumonia, deep vein clots, urinary tract infections, and increased rigidity.
  • Physiotherapy should be ordered by your doctor following surgery for chest therapy to ease ribcage rigidity and risk of lung complications as well as body mobility exercises. There are inpatient and outpatient geriatric programs commonly used by patients needing assessment and rehabilitation services.

Discharge planning

If necessary:

  • Ensure that you and your family understand the medical team’s follow up plans.
  • Discuss the following with appropriate staff members: home nursing care, rehabilitation therapy and caregiver respite needs, and concerns arising about the need for ongoing facility care. The hospital social worker can provide links to community health resources.

Parkinson’s Disease: Making the Most Of Your Health Team

You need your partner, family and friends on your side. You may have to educate them yourself. Your family may find the adjustment to your diagnosis as difficult as you do.

It is a good idea to seek some professional help if you or anyone else cannot come to terms with the diagnosis. Inability to accept it can generate anxiety that can work against your symptoms and cause friction within the family.

A variety of professionals may comprise your care team:

  • Your primary care physician will continue to look after your general health and will liaise with your neurologist if you have one. Continue your annual check-ups, and don’t assume that every problem with your health is related to PD.
  • If you attend a specialty PD clinic, there may be a nurse available to provide education and counseling, as well as provide information about how best to manage the disease. Depending on the clinic, the nurse may be your most frequent contact for advice.
  • If you are depressed or are having difficulty adjusting to your diagnosis and have a high level of anxiety, you might benefit from the help of a psychiatrist. Depression, anxiety, and other disorders may occur in some, but not all, people with PD. They can be disturbances in feelings, thoughts, behaviors, and intellectual functions such as memory. Psychiatrists use several methods of treatment that include verbal therapies (psychotherapy), marital and family counseling, and the use of medications.
  • physical therapist can help you with your posture, walking, and balance (to prevent falls), as well as with safe completion of daily activities (getting in and out of bed).
  • Many people exercise alone, but community-based programs are better because they offer social support and a good reason to get out of the house on a regular basis.
  • An occupational therapist can offer advice and instruction on adapted equipment, safety promotion at work and at home, conserving energy, problem-solving, and improving mobility. Some offer help with stress management, as well. A consultation with an occupational therapist in your home can be valuable if it needs some adaptation to provide easy access for someone with limited mobility.
  • speech-language pathologist can design a program to improve communication – possibly with ways other than speech. If you have a problem with swallowing, either a speech-language pathologist or an occupational therapist may help.
  • nutritionist can help you plan a healthy diet, considering your need to either maintain or reduce your weight. A nutritionist can also offer advice about meal preparation, taking your PD symptoms into account. A nutritionist can be your best source of information about food values.
  • social worker might help you solve social, emotional and economic concerns.
  • pharmacist will dispense your prescription drugs. If you are taking multiple drugs for multiple problems prescribed by different physicians, you should seriously consider using one pharmacy. In this way, you are less likely to encounter problems with one drug being incompatible with another.

Nice To Know:

You might benefit from a consultation with a physical therapist even if you are newly diagnosed. This is important if you plan to begin an exercise program or want to know whether you can continue your current sports and exercise. Walking and swimming are excellent activities for people with PD.

However, in the months before diagnosis, you may have noticed some difficulty with exercise or sports, and you might have felt more tired than you once did. These problems often improve when you start medication and can return to your former level of activity. (For instance, one avid golfer only succeeded in scoring a hole-in-one after taking SinemetTM; and thereafter, his golfing friends wanted to take it too!)

Medications Used to Treat Parkinson’s Disease

Nice To Know:

A few important comments before describing the medications for Parkinson’s Disease

  • Drug therapy for Parkinson’s disease, and the choice of drugs used for the treatment of Parkinson’s disease, should be a joint decision between the person with Parkinson’s disease and the physician, based on the severity of symptoms and their impact on quality of life.
  • It is emphasized that treatment for Parkinson’s disease should always be individually tailored for each person.
  • Never compare your treatment schedules with those of other people with Parkinson’s Disease. You are all different.

Properly selected medications with the correctly tailored dose form the mainstay of treatment of Parkinson’s Disease.

Drugs currently used to treat Parkinson’s Disease make movement easier and can prolong function for many years. Medications aim to replace or mimic the missing chemical dopamine in the brain.

The following are the medications used in the treatment of Parkinson’s Disease. Each will be considered below.

  • Levodopa with carbidopa:SinemetTMSinemet CRTM
  • Levodopa with benserazideProlopaTMin Canada and MadoparTMin Europe
  • COMT inhibitors : entacapone(ComtanTM), TasmarTM)
  • Dopamine agonists:pramipexoleMirapexTM), ropinerole( RequipTM), bromocriptine( ParlodelTM), pergolide ( PermaxTM)
  • Other medications: amantadine(SymmetrelTM), benztropine (CogentinTM), trihexyphenydil(ArtaneTM), deprenyl (EldeprylTM)


Considered below is:

How it works

Levodopa preparations

Side effects

How It Works

Levodopa (L-dopa for short) has been used successfully in the treatment for Parkinson’s Disease for over 30 years. It remains the most effective treatment for Parkinson’s Disease.

L-dopa is a natural chemical found in animals and plants. When L-dopa is formulated for drug use, the generic name levodopa is used.

In patients with Parkinson’s Disease the cells in the brain that produce dopamine die (for more details see what causes Parkinson’s Disease LINK). Levodopa works by being taken up by the surviving dopamine-producing cells in the brain, and is converted by these cells into dopamine.

People with Parkinson’s Disease can’t simply take dopamine tablets or vegetable products containing dopamine (e.g.fava beans) to replace the missing dopamine, because dopamine taken by mouth does not get into the brain. Levodopa on the other hand does get into the brain and, once there, it converts to dopamine.

Levodopa Preparations

Levodopa is combined with carbidopa (Sinemet CRTM, SinemetTM and is the main treatment for Parkinson’s Disease. (Another preparation, levodopa in combination with benserazide, is available in Canada, Europe and other parts of the world.) Combining carbidopa or benserazide with levodopa has several benefits:

  • Carbidopa or benzerazide prevent levodopa from being converted to dopamine outside the brain.
  • They allow more levodopa to enter the brain where it is needed.
  • They help to reduce or prevent the side effects of dizziness and nausea.

The combination is usually started with low, but increasing doses, until the best effect is achieved. Levodopa never loses its effectiveness, although with increasing disability the dose required to control symptoms is also enough to precipitate unwanted side effects.

Nice To Know:

Levodopa is considered the “gold standard” of Parkinson’s Disease therapy, and it is more effective when combined with carbidopa or benserazide. But despite that success, some of the levodopa in a given dose is converted to dopamine outside the brain, where it is not needed, rather than in the brain where it is needed, due to the action of an enzyme in the body called COMT.

There are now drugs that block the COMT enzyme. They are called COMT inhibitors because they inhibit the action of this enzyme.

These COMT inhibitors make levodopa more effective by increasing its availability in the brain. This makes each dose last longer.

Need To Know:

Levodopa/carbidopa preparations

Levodopa/carbidopa tablets are referred to by two numbers. The large number is the amount of levodopa, in milligrams, in each tablet. The small number is the amount of carbidopa in each tablet, also measured in milligrams.

Levodopa/carbidopa is available as:

  • Sinemet CRTM (controlled-release drug)

    200/50 peach oval scored

    100/25 pink oval

  • Sinemet CRTM is a controlled-release tablet of levodopa/carbidopa.
  • Tablets should not be chewed or crushed.
  • The 200/50 can be split, but not the 100/25.
  • The total daily dose of Sinemet CRTM may be significantly higher than standard SinemetTM,due to absorption differences.
  • For some patients, a “booster” dose of immediate-release SinemetTMmay be required in the morning or late afternoon.
  • Sinemet CRTMappears to cause less dizziness and nausea than immediate releaseSinemetTM.
  • Immediate Release (Standard) SinemetTM

    100/25 yellow oval scored

    100/10 pale blue oval scored

    250/25 darker blue oval scored

  • The blue immediate release tablets are increasingly less often used by neurologists

Physicians may use either the SinemetTM or Sinemet CRTM preparation for their patients as soon as therapy is needed. The slow, steady release of the drug into the brain by the controlled-release Sinemet CRTM preparation may be better for remaining dopamine cells than the abrupt delivery of the SinemetTM (similar to a soaker hose versus a fire hydrant).

  • The immediate-release and controlled-releaseSinemetTMpreparations are best started slowly, increasing by small amounts until the required dosage is reached.
  • A starting dose may be one-half of a tablet once a day increasing to three to four times a day
  • This dose can be increased every four to seven days as tolerated.
  • Both medications can sometimes cause nausea and dizziness when they are started.
  • At high doses, they may cause involuntary movements (dyskinesias) and confusion. All side effects are dose-dependent (disappear when the drug is reduced or stopped).
  • Physicians are somewhat divided as to whether anitparkinson drugs should be taken on an empty stomach or with food. Taking the tablet with food will reduce the likelihood of side effects. Sinemet CRTM should always be taken with food for proper absorbtion. Patients should follow the recommendations of their neurologist.

Side Effects of Levodopa:

Levodopa preparations are not without side effects. The most common include nausea, vomiting, low blood pressure, involuntary movements, and, at higher doses in the elderly and frail, confusion.

  • Nausea and vomiting can be a problem as the drug is being introduced. This is because the dose of carbidopa is not large enough to control these side effects. Ironically, the nausea and vomiting often get better as the levodopa/carbidopa dose is increased. The controlled-release preparation, Sinemet CRTM, is absorbed more slowly and far less likely to cause early side effects. Taking the drug with a light meal or snack can also help these side effects.
  • Involuntary movements (dyskinesias) writhing, jerking, or free flowing movements and nodding can occur. The rate at which dopamine “turns over” in a person’s brain cells may determine whether or not they will develop dyskinesia. Dyskinesia can only be controlled effectively by lowering the dose of levodopa or, in some severe cases, surgery.

    (Reference: R. Fuente-Fernandez, V. Sossi, Z. Huang, S. Furtado, J. Q. Lu, D. B. Calne, T. J. Ruth, and A. J.Stoessl. Levodopa-induced changes in synaptic dopamine levels increase with progression of Parkinson’s disease: implications for dyskinesias. Brain 127 (Pt 12):2747-2754, 2004).

Other drug side effects include:

  • “Wearing-off effect.” This happens when Parkinson’s symptoms begin to recur before the next scheduled dose of drug, due to progression of the disease. When this happens, it is easy to think that the drug is making your symptoms worse – for a while after you take the next dose, your symptoms can continue to worsen until the next dose ‘kicks in’. This happens because the drug takes a while to be absorbed and reach your brain.
  • These can be improved by the addition of a COMT inhibitor or a dopamine agonist
  • “On-off attacks.” TThese are unpredictable fluctuations in response to drug therapy that may last up to several hours. They are thought to be due to a combination of levodopa dosage and progression of symptoms. The dopamine storage cells may lose their capacity to retain the dopamine delivered by the medication.

(Reference: R. Fuente-Fernandez, and others Presynaptic mechanisms of motor fluctuations in Parkinson’s disease: a probabilistic model. Brain 127 (Pt 4):888-899, 2004).

These can usually be improved with lower, more frequent doses of the drug, the use of a controlled release drug or with the addition of a dopamine agonist.

COMT Inhibitors

COMT inhibitors are a new class of drug that allows even more levodopa to enter the brain, by blocking an enzyme in the body called COMT. COMT stands for Catechol-OMethyltransferase. This enzyme is responsible for most of the levodopa in a given dose being converted to dopamine outside the brain (where it is not needed).

Entacapone (ComtanTM) is able to inhibit one of the COMT enzymes responsible for the breakdown of dopamine in the body, resulting in greater and more sustained blood levels of dopamine when given together with carbidopa/levodopa.

Entacapone is administered together with each dose of carbidopa/levodopa. It prolongs the duration of levodopa benefit, is easy to use, and provides quick results. There is a possibility that a person will experience the side effects of too much levodopa, which can then be controlled by reducing the levodopa or entacapone dose or spacing out the dosing regimen. The primary indication for the use ofentacapone is for the treatment of the wearing-off effect.

(Tasmar TM), is another COMT inhibitor that has proved to be very useful as an add-on medication for the treatment of Parkinson’ Disease, but had the serious side effect of fatal liver damage in a few individuals. Although it has been officially withdrawn in Europe and Canada, is still used in some patients in the U.S. and a very few in Canada who continue to do well on the medication without evidence of liver damage.

STALEVO®TM Is a drug that contains a combination of Levodopa,/carbidopa (Sinement ®TM) and entacapone(COMTAN®TM)

STALEVO 50®TM, containing 12.5 mg carbidopa, 50 mg levodopa, and 200 mg entacapone

STALEVO® 100TM, containing 25 mg carbidopa, 100 mg levodopa, and 200 mg entacapone

STALEVO® 150TM, containing 37.5 mg carbidopa, 150 mg levodopa, and 200 mg entacapone

STALEVO®TM can be used instead of carbidopa/levodopa and COMTAN by patients taking those medicines as separate tablets.

Stalevo®TM is available in the USA and other parts of the world. It is expected to be available in Canada within the next 12-18 months.

Dopamine Agonists

Dopamine agonists are medications that imitate the action of dopamine in the brain and cause nerve cells to react as if dopamine were present. Unlike levodopa, they do not require conversion to dopamine to work.

Currently there are four dopamine agonists available:

  • Pramipexole (Mirapex TM)
  • Ropinirole (RequipTM)
  • Bromocriptine (ParlodelTM)
  • Pergolide (PermaxTM)

Pramipexole dihydrochloride and Ropinirole Hydrochloride are non-ergot dopamine agonists. Bromocriptine and pergolide are ergot-derived dopamine agonists. Ergot is a fungus that grows on grasses, and rye in particular. It produces alkaloids that are used in a wide range of drugs.

  • Pramipexole (Mirapex ®) TM or Ropinirole TM(Requip®) may be used as a “first line” treatment, that is, as the main treatment, particularly for people with young onset (under 50) Parkinson’s Disease.

Dopamine agonists are now frequently added to levodopa early in treatment, before levodopa side effects first occur, to extend the duration of benefit between each dose.

  • These drugs may also be used to replace some levodopa if its side effects have become unmanageable.
  • When given together with levodopa, symptom control between doses lasts longer, and wearing-off reactions, on-off effects , anddyskinesias can be reduced.
  • Side effects: Dopamine agonists can cause stomach upset, nausea and vomiting, and dizziness from lowered blood pressure when first started and, at high doses, confusion or hallucinations. These side effects are dose-dependent and reversible.

The best results are achieved when the agonist is started in a low dose, increasing by half a tablet until the required dose is reached. These drugs should be taken with food to minimize side effects and can be taken at the same time as other antiparkinson drugs.

Pergolide has recently been associated with cardiac valve disease in patients taking the drug for a long time. If you are on this drug discuss whether you should switch to another with your physician

(Reference: J. Horvath and others Severe multivalvular heart disease: a new complication of the ergot derivative dopamine agonists. Mov Disord. 19 (6):656-662, 2004).

Bromocriptine and pergolide can both cause fibrotic changes in the lungs after prolonged use but these symptoms are reversible if the drug is stopped. They also can cause a condition in the lower legs that makes them red, hot, and painful (erythromelalgia).

At the time ropinerole and pramipexole were first marketed there were reports of patients falling asleep while driving when taking one of these drugs. Some countries banned people taking the drugs from driving. Two major published studies have since shown that in certain people any drug used to treat Parkinson’s disease can produced daytime sleepiness and so everyone should be aware of this possibility whatever treatment they are on.

(Reference: C. C. Sanjiv, and others Daytime somnolence in patients with Parkinson’s disease. Parkinsonism and Related Disorders 7 (4):283-287, 2001.

D. E. Hobson, and others. Excessive daytime sleepiness and sudden-onset sleep in Parkinson disease: a survey by the Canadian Movement Disorders Group. J American Medical Association 287 (4):455-463, 2002).

  • The antibiotic CIPRO ®TM should be used with caution by patients taking ropinerol.

Need To Know:

Dopamine Agonists

While patients in whom Parkinson’s Disease began under age 50 (“young onset”) may benefit from starting treatment with one of the dopamine agonists, it is difficult to achieve a therapeutic effect similar to that possible with a comparable dose of levodopa. Dopamine agonists are also much more likely to cause nausea and vomiting than levodopa and must be started very slowly. In an older less robust person levodopa will most likely be the first line treatment of choice.

Other Medications Useful In Parkinson’s Disease

Other medications that are useful in treating Parkinson’s Disease include the following:

  • Amantadine (Symmetrel TMis available as a 100 mg soft red gelatin capsule or a syrup. This drug can be used as early treatment for rigidity. For many years, the action ofamantadinewas not understood. It has recently been shown to be a glutamate antagonist and to be effective at reducing dyskinesias. This is now its major role in the treatment of Parkinson’s Disease

    (Reference: P. J. Blanchet, L. V. Metman, and T. N. Chase. Renaissance of amantadine in the treatment of Parkinson’s disease. Adv.Neurol. 91:251-257, 2003).

    Side effects:Amantadine can cause lightheadedness and confusion and a red “spider’s web” mottling on the legs (lividoreticularis). It should be used with caution in the elderly and those with urinary problems. It should not be stopped abruptly after prolonged use.

  • Anticholinergic drugs (such asbenztropineCogentinorTMtrihexyphenidyl Artane TM) or antihistamines used in the treatment of allergy symptoms (such as diphenhydramine) may be used alone in the early stages of treatment, if tremor is the major problem. These medications are more useful in treating tremor than the slowness and stiffness.

    Side effects: In older, frail individuals, side effects that include confusion, blurred vision, and urinary retention often limit the usefulness of these drugs.

  • Selegiline (EldeprylTMThe use of this drug has declined in the last five years. This drug has a modest action. It works by slowing the breakdown of dopamine in the brain by inhibiting one of the enzymes responsible for the breakdown of dopamine (called monoamine oxidase B). It comes in 5 mg tablets and the daily dose must not exceed 10 mg. If used as initial treatment, selegiline may delay use of levodopa by about a year but should be stopped when more treatment is needed. There are reports suggesting that it should not be used in conjunction with levodopa. It can have a mild antidepressant effect.

    Side effects: The major side effect is insomnia (because it converts to amphetamine in the brain), and lack of sleep is extremely detrimental to a person with Parkinson’s Disease. Even though selegiline has few side effects, it has the potential to enhance side effects associated with levodopa if they are taken together.

Many of the drugs described above are now available in generic forms.

Now please read the important section “Parkinson’s Disease – getting the most out of your medications”.


Getting the Most out of Parkinson’s Disease Medications

To get the most out of the medications:

  • You should never compare your treatment schedule with those of other people suffering with Parkinson’s Disease. You are all different. Take the medication as prescribed by your doctor. While this advice sounds obvious, it is important since the medication has been individually adjusted for your symptoms. Remember that your doctor probably has more clinical experience in treating people with Parkinson’s disease than anyone else who is likely to give you advice.
  • Make sure you understand the expected benefit and potential early side effects of a drug before you leave the physician’s office.
  • Side effects of anti-Parkinson drugs are reversible by lowering the dosage or discontinuing the treatment.
  • Do not increase or abruptly stop any of your drugs without consulting your physician.
  • Taking medications on an empty stomach often leads to increased side effects.

Need To Know:

Is it safe to take other drugs while on PD medication?

Most drugs are safe to take with antiparkinson drugs. However,

  • One group known as dopamine antagonists (for example haloperidol (HaldolTM), rispiridone (RisperdalTM), olanzapine (ZyprexaTM), chlorpromazine ( LargactylTMand metoclopromide ( MaxeranTM, prochlorperazine ( StemetilTM), should be avoided because they can worsen the symptoms of PD by blocking the action of dopamine in the brain. They are generally prescribed for psychiatric conditions or nausea . Check with your doctor or pharmacist if you are not sure whether you have been prescribed one of these.
  • Demerol, frequently used to control postoperative pain, can cause confusion and hallucinations in people with PD and should be avoided.
  • Discuss any concerns about drug interactions with your doctor.

Two of the major side effects of anti-parkinson medication can be managed.

  • Nausea is much less common with controlled-release SinemetTM, which is absorbed more slowly than the regular SinemetTMDopamine agonists can cause nausea even in people who did not experience it with either kind of SinemetTM. Building up your dose very slowly can help, even though you may be impatient to feel the improvement in your Parkinson’s symptoms. In Canada and other parts of the world there is a drug called domperidone (MotiliumTM, which is used to prevent the nausea caused by anti-parkinson drugs.
  • Dizziness is due to the fact that the drugs can lower your blood pressure. It may occur in the early stages of treatment, but it usually resolves over time. If it does not, consult your doctor, particularly if you are already taking a medication for high blood pressure. .


The following suggestions may help to raise blood pressure without the addition of medications (Non Medical Management of Low Blood Pressure (Orthostatic Hypotension)

Orthostatic hypotension is defined as a fall in systolic blood pressure of at least 20 mm Hg and/or diastolic blood pressure of at least 10 mm Hg within 3 minutes of standing and may or may not cause symptoms of dizziness or fainting.

Parkinson’s Disease patients with a combination of postural hypotension and impairment of postural reflexes are candidates for dizziness, fainting and falls leading to fractures. Fractures have serious consequences for the long term health of patients with Parkinson’s long term health. A safety assessment from a rehabilitation specialist is strongly recommended.Lying and standing blood pressure recordings are essential as diagnostic measures.

These are the triggers that may cause dizziness and fainting:

  1. The addition of anti-Parkinson drugs if you are already taking tablets to lower your blood pressure, or drugs known to lower blood pressure (e.g. tricyclic anti-depressants- amitriptyline, nortryptiline, doxepine )
  2. Increasing the dose of anti-Parkinson drugs too quickly -particularly dopamine agonists bromocriptine, pergolide, ropinerole or pramipexole.
  3. Taking anti-Parkinson drugs on an empty stomach
  4. The hour following medications, or a meal
  5. Urinating standing up (men)
  6. A bowel movement
  7. Lying flat for too long
  8. Getting up too quickly from a bed, or chair, or after a bowel movement
  9. Warm weather, dehydration and hot baths

Prevention strategies include:

  1. Increase intake of fluids and salt.
  2. Have a 6-8-oz glass of orange juice before you get out of bed each morning. Sit on the side of the bed for a couple of minutes, get up, and walk about.
  3. Have 1-2 cups strong real coffee for breakfast. It will help to increase your blood pressure.
  4. Increase your clear fluids until about 4 p.m. (To limit trips to the bathroom during the night)
  5. Remain seated after a meal for about 20 minutes. Blood is drawn to the gastrointestinal tract to aid digestion, which is why we feel sleepy after a big meal. If you stand up quickly after a meal there will not be enough blood volume to supply sufficient to the brain.
  6. Sit down to towel off after a shower or a bath and then get up and walk about.
  7. Be careful standing up too quickly after a bowel movement or urinating. Men with low blood pressure should urinate sitting down.
  8. Stay out of hot sun; avoid hot tubs, saunas, and steam rooms.
  9. Never stand still (particularly after exercise) as blood pools in the legs.
  10. Always sit down after any exercise even walking about the house.

If postural hypotension persists despite these measures, a physician may suggest reducing, stopping or replacing drugs known to be lowering your blood pressure. If this isn’t possible the physician may recommend an anti-hypotensive such as fludrocortisone or midodrine, which will artificially raise your blood pressure.

If you have very low blood pressure you may be at risk for recumbent hypertension. This means that your blood pressure may go up too much when you lie down. We recommend that when you are in bed or lying on a couch, your head be 30 degrees higher than your feet. This can be done with lots of pillows or by raising the head of the bed by putting the feet on bricks/blocks or books.

Are There Any Clinical Trials To Participate In?

There are clinical trials taking place all the time and scientists/researchers are always eager for participants. However many studies have restrictions about how far away subjects can live from the center conducting the trial. Visit the Parkinson’s Disease Clinical Studies site at or speak to your physician or local Parkinson’s Society.

Parkinson’s Disease: Putting It All Together

Here is a summary of the important facts and information related to Parkinson’s disease.

  • Parkinson’s disease is a slowly progressive condition resulting from a deficiency in the brain of a chemical called dopamine. This deficiency interrupts messages from the brain to the muscles.
  • Parkinson’s disease produces shaking of the body and limbs, slowness and difficulty beginning a voluntary movement, muscle stiffness and difficulty with maintaining balance.
  • The exact cause of Parkinson’s disease is unknown. The condition is known to occur in some families, but not all Parkinson’s disease is inherited.
  • The four major signs of Parkinson’s disease are tremorrigidity, slowness of movement, and impaired balance. Some people also will experience a changed facial expression, a soft voice, cramped handwriting, pain, fatigue, depression, and constipation.
  • Parkinson’s disease may be treated with medication or surgery.
  • Medication for Parkinson’s disease aims to replace or mimic the missing chemical dopamine in the brain.
  • Surgery for Parkinson’s disease aims to destroy small portions of brain tissue or disable nerve cells.
  • Eating nutritious foods, getting enough exercise, managing stress, and remaining active are keys to living with Parkinson’s disease.
  • Great progress has been made in understanding and treating Parkinson’s disease, and research continues to uncover new clues about this condition.

Parkinson’s Disease: Frequently Asked Questions

Here are some frequently asked questions related to Parkinson’s disease.

Q: Should I stop my Parkinson’s disease medications before general surgery or an operation?

A: Some neurologists recommend that medications be stopped 12 hours prior to general anesthesia for surgery. If you are on a complicated drug regimen, ask your surgeon prior to surgery to contact the physician responsible for your Parkinson’s disease therapy so that your drugs can be given appropriately.

Q: Can I drink alcohol if I am being treated for PD?

A: A modest intake of alcohol is not a problem for people with Parkinson’s disease. However, medications should not be taken with alcohol, and you should avoid alcohol altogether while you are building up the dose of a new drug.

Q: Are there any vitamins or minerals that cure Parkinson’s disease?

A: Vitamins and minerals certainly contribute to a healthy lifestyle and supplement food intake. However, none have been found to halt the disease process or cure PD.

Q: I have read that I should avoid protein and dairy products in particular?

A: This is untrue for the majority of patients with PD. We all need adequate amounts of all the food groups to maintain health. A protein redistribution diet can be useful in a very, very small number of patients who have fluctuations in response to their standard SinemetTM. This diet should be developed with the cooperation of your dietician and neurologist. If it is not effective in one week, it should be abandoned. It is true that any extra-large meal can cause a delay in gastric emptying and this may make anyone feel sluggish and tired. Most people with PD do better eating more frequent smaller meals with high-energy, easily digestible snacks in-between.

Q: Do I have to stop my PD meds when I’m taking drugs for another illness?

A: Do not stop taking your Parkinson’s disease drugs if you have to take medications for another medical problem. You can take antibiotics, painkillers, etc. Bear in mind that if you do get a common viral infection such as a cold or flu, for example, or if you develop another illness that makes you feel unwell, your PD symptoms may be worse for a while because of the extra stress on your body as a result of the added illness. If you are taking ropinerole, and are prescribed CiproTM it is possible that your ropinerole dose may have to be adjusted while you are taking the antibotic as CiproTM can affect absorption.

Where To Get Further Help

Here are some reliable sources that can provide more information on Parkinson’s disease.

Living with Parkinson’s disease does not have to be a lonely marathon, and there are ample connections and resources for those with Parkinson’s disease who have special needs. All are dedicated to action and advocacy that help meet those needs and provide a strong, informed voice in public policy decision making while empowering those with Parkinson’s disease to make changes in their lives and the lives of others with the disease.

Persons with PD and their families are encouraged to become educated and informed about the disease and related treatments and scientific research.

A number of Parkinson’s disease organizations, associations, and support groups are located throughout the country, all of which can benefit persons with Parkinson’s disease in their quest for a better quality of life. Check these out:

The National Institute of Neurological Disorders and Stroke (NINDS) is a segment of the National Institutes of Health (NIH) and is the foremost Federal sponsor of research involving brain and nervous system disorders. The Institute also subsidizes a public information program about Parkinson’s disease diagnosis, treatment, and research:

National Institutes of Health (NIH) Neurological Institute 
Phone: 800-352-9424
Phone: 301-496-5751

Following are private organizations providing information for persons with Parkinson’s disease and families about Parkinson’s diagnosis, treatment, and services. Some associations fund research, sponsor support groups, conferences, and information and referral centers. Many publish newsletters and educational materials; others support research, clinical services, and physical, occupational, speech and psychological therapies. Some groups serve in areas of lobbying, activism, and advocacy, while others sponsor press conferences and public policy forums, maintain libraries, and sponsor speakers’ bureaus:

American Parkinson Disease Association 
Phone: 800-223-2732 East Coast 
Email: East Coast 
Phone: 800-908-2732 West Coast
Email: West Coast

National Parkinson Foundation 
Phone: 800-327-4545
Phone: 800-433-7022 In Florida 
Phone: 305-547-6666

Parkinson’s Action Network This is now the Michael J. Fox Foundation 
Phone: 800-850-4726
Phone: 707-544-1994

Parkinson’s Disease Foundation 
Phone: 800-457-6676
Phone: 212-923-4700

Parkinson Support Groups of America 
Phone: 301-937-1545

The Parkinson Society of Canada 
Phone: 1800 565 3000 Toll Free (in Canada) 
Phone: 1 416 227 9700
Fax: 1 416 227 9600

Parkinson’s Disease Society of the United Kingdom 
Phone: 020 7931 8080

Additional Sources Of Information

Agencies and numbers

  • American Occupational Therapy Association (AOTA)


  • American Physical Therapy Association (APTA)


  • American Massage Therapy Association (AMTA)


More Web Sites For Persons With Parkinson’s Disease And Their Caregivers


  • Living with Parkinson’s disease: A 12-Part Series

    Available to Parkinson’s disease Support Groups Nationwide


  • The Educated Caregiver and The Comfort of Home

    LifeView Resources


  • The Parkinson Education Team

    From the Young-Onset & Care Partner Support Group


  • Tai Chi for Seniors


  • Gentle Fitness


  • Sit and Be Fit (Special edition for Parkinson’s disease)


Parkinson’s Medical Alert Card

A Parkinson’s Medical Alert card notifies emergency personnel and/or others offering assistance and provides contact numbers for family and physicians. The card also provides important medical information. To request a card, call 800-327-4545.

Living With Parkinson’s Disease

People with mild Parkinson’s disease who take medication often regain a relatively ordinary activity level. The following suggestions may be useful:

General advice

Good nutrition

Managing stress


General Advice

  • Continue regular daily activities. This is important to help maintain mobility. In the early stages of PD, such normal movement should be maintained to the fullest extent possible. Do all you can to remain mobile and active.
  • Lead as normal a life as possible; don’t restrict activities you’re able to do.
  • A regular exercise program that involves some stretching and weight bearing (short of becoming exhausted) is beneficial because, as motor function becomes more impaired, an exercise program or physical therapy may help maintain or reestablish physical conditioning.
  • Walking is excellent, and a 30-minute walk each day can be a realistic goal. Start with a 10-minute walk and build it up in 5-minute increments over the course of several days, according to your tolerance. You should walk when you feel your best and not put it off while you complete household chores, etc. In inclement weather, walk around the house with the radio or CD player on.
  • It is never too early to seek the advice of rehabilitation specialists for help determining a realistic exercise level, or if you have difficulty with activities of daily living (getting in and out of the tub). It also is helpful if you have problems with balance and safety, difficulties with speech, or for fatigue and stress management. The physical therapist, occupational therapist, and speech language pathologist can each help you maintain function and independence.
  • If balance is a problem, adaptive training and use of quad-canes or straight canes, and other mechanical aids, can help maintain independence.

Because constipation can result from the PD, or from drugs used to treat the illness , or from inactivity, you should consume adequate food and a high-fiber diet. Dietary supplements such as psyllium or stool softeners can help regulate bowel movements as well.

Need To Know:


It is important to embark on a program of prevention rather than crisis management.

  • Increase daily fluid intake, especially in hot weather. Families and caregivers may need to reinforce this. At least six cups of liquid should be drunk daily.
  • Older people may not be able to tolerate large amounts of raw fruit and vegetables, but can usually manage dried fruits, hot prune juice, canned fruits, and soft cooked vegetables, all of which may help to relieve constipation.
  • Introducing bran or high-fiber cereal into the diet is important, but they should be started slowly and in small amounts. Large amounts can cause stomach cramps and excess gas, particularly in people who cannot exercise. Bran should therefore be taken with caution and be accompanied by an increase in fluid intake.
  • Regular exercise is also important.
  • Stool softeners, bulk laxatives, and bowel stimulants are the main categories of laxatives available over-the-counter. Any of these may be used if a simple change in diet is not effective.

Good Nutrition

Good nutrition will help you maintain your best level of health if you have PD. A professional dietitian/nutritionist is your best source of reliable nutrition information.

  • There is no specific diet for people with PD. Recommended daily allowances of the various food groups can be obtained from a dietitian or from your local health unit.
  • Sometimes your symptoms can interfere with your eating well. If you are experiencing problems with appetite, chewing or swallowing, weight loss, or constipation, a consultation with a registered dietitian/nutritionist could be very helpful.

For people with difficulty chewing and swallowing:

  • Smaller frequent meals may be easier to manage than three full-sized meals a day.
  • Food should be hotter or colder than the inside temperature of the mouth.
  • Avoid crumbly fibrous food if swallowing is difficult.
  • Eat in a quiet and relaxed atmosphere in a high backed chair.

Sucking on ice for a few minutes before eating may make swallowing easier (it may also help speech). Iced sodas also promote swallowing. The icy bubbles on the back of the throat help to trigger the swallowing reflex. Sour or acid food may be easier to swallow.

  • Put a few ice cubes in a blender with a small amount water or juice and blend until the ice is in small fragments. Have some of this chipped ice available throughout the day
  • Add some liquid to food in your mouth to assist swallowing.

Managing Stress

Try to avoid unnecessary stress in your life:

  • Leading a healthy life, eating regularly, sleeping regularly, and exercising will help keep you fit both mentally and physically.
  • Many people continue to work although this can be a problem for those who face the public every day, particularly for those who need to speak in a large space (classroom) or are required to supervise in some situations. The executive with a personal secretary to provide protection from the public will find it easier than a schoolteacher.

All symptoms of PD get worse under stress. Therefore, talk to your physician and your employer about managing stress and/or early retirement or reduced working hours if necessary (and possible). Since most people need to continue working for financial reasons, talk to your doctor about regulating your treatment so that it works best while you are on the job – particularly if you work shifts or work either very short or long days. This information will help the doctor to plan the best dosing schedule.


Having PD does not mean you need to stay at home. Many people with PD travel frequently, and long distances, very successfully. You just need to plan a journey more carefully.

  • Rest the day before and after you travel, particularly if time changes are involved.
  • Take advantage of any service offered at airports, railroad stations, cruise ship terminals, etc. that allow you to board or exit in advance.
  • Don’t walk miles at airports if there is a moving walkway, motorized cart, or wheelchair service. Save your energy.
  • If you are traveling by car, stop frequently for some exercise, and don’t travel as many miles in a day as you once did. Don’t travel for long periods in very hot weather.
  • Always keep all your medication in their original bottles in your hand baggage. Checked-in baggage may be lost or delayed. Customs officials are suspicious of odd containers containing several unnamed pills.

Parkinson’s Disease: Glossary

Here are definitions of medical terms related to Parkinson’s disease.

Acetylcholine: A chemical which acts as a chemical messenger. An imbalance between dopamine and acetylcholine results in some symptoms of Parkinson’s disease.

Akinesia: Absence of movement

Allograft: Cells taken from one person to transplant into another person (such as using a human fetus for a human brain cell transplantation).

Amantadine (SymmetrelTM): An anti-Parkinson drug.

Amino Acid Decarboxylase (AADC): One of the two main enzymes (the other one being catechol-0-methyltransferase or COMT) that is responsible for the breakdown of levodopa in the bloodstream before it reaches the brain. AADC breaks down levodopa into dopamine before it can cross the blood brain barrier

Anticholinergics: Drugs that block the action of the chemical messenger acetylcholine. This means there’s less of acetylcholine, thus providing a better balance between it and dopamine This reduces rigidity and tremor; e.g., ArtaneCogentin.

Antihistamines: Drugs that are often used to relieve cold or allergy symptoms (for example Benadryl) but may also be effective in reducing tremor.

Ataxia: Loss of co-ordinated movement or balance.

Athetosis: Slow, involuntary movements of the hands and feet.

Basal ganglia: The part of the brain that coordinates movement.

Benserazide: The decarboxylase inhibitor that is co-administered with levodopa in MadoparTM or ProlopaTM

Biofeedback: Modifying behavior by teaching someone to partially control unconscious functions of the body, such as blood pressure or heart rate

Bradykinesia: Slowness of movement or difficulty initiating body movement.

Bromocriptine (ParlodelTM): A dopamine agonist, that is, a drug that mimics the action of dopamine

CabergolineTMA dopamine agonist.

carbidopa: A drug that allows more levodopa to get into the brain to be converted into dopamine. It prevents the enzyme AADC from normally breaking down levodopa in the blood. Levodopa therapy today is administered in a combination tablet with carbidopa.

Cogwheeling: A ratchet-like movement in a joint. It is characteristic of Parkinson’s disease.

COMT: Stands for catechol-O-methyltransferase. It is one of the two main enzymes responsible for the breakdown of levodopa before it reaches the brain

COMT inhibitor: A drug that inhibits the action of COMT, the enzyme responsible for the breakdown of levodopa in the bloodstream before it reaches the brain. COMT inhibitors improve delivery of levodopa to the brain.

Corpus striatum: Part of the basal ganglia in the brain. It is a relay station receiving information about the position and movement of the body from several different parts of the brain that transmits it to other parts of the brain.

Decarboxylase: An enzyme in the blood and brain that metabolizes levodopa to dopamine.

Decarboxylase inhibitors (DCI): Compounds that prevent the conversion of levodopa to dopamine by decarboxylase for example, carbidopa and benserazide. They increases the amount of levodopa reaching the brain resulting in a 70 percent reduction in the dose of levodopa required to control symptoms.

Dementia A loss of intellectual abilities.

Deprenyl (Eldepryl, selegiline, Jumex): A monoamine-inhibitor used to treat Parkinson’s disease. It blocks the enzyme monoamine oxidase B, which normally breaks down dopamine.

Dopamine: One of the many “chemical messengers” in the brain. It carries messages between the various nerves that control movement. Its deficiency in the brains of people with Parkinson’s disease is the underlying cause of the symptoms of the disease.

Dopamine agonists: Medications that attempt to mimic the role of dopamine in the brain.

Dopamine receptors: Sites on the nerve cells which are activated by dopamine and some of which are activated by dopamine agonist drugs.

Dyskinesia: abnormal involuntary movement usually seen in the arms and legs, trunk and head. It may result from taking levodopa over a long period of time or in high doses.

Dysphagia: Difficulty in swallowing.

Dystonia: Involuntary spasms of muscle contraction that cause abnormal movements and postures. The dystonia that occurs most frequently in Parkinson’s disease is in the foot and is a characteristic of Parkinson’s disease.

Entacapone: A COMT inhibitor.

Enzyme: a substance that speeds up a specific chemical reaction but that is not itself consumed in the reaction.

Erythromelalgia: red, warm painful and tender feet

Free radicals: toxic substances that are continuously produced by all cells of the human body.

Genes: The heredity factor that is passed from parents to children that determines the characteristics you inherit from your parents

Globus pallidus: A small part of the brain that regulates muscle tone needed for specific body movements. It is destroyed during the operation known as a pallidotomy

Hormone: a substance secreted by a gland that is transported in the bloodstream to various parts of the body to regulate or modify bodily functions.

Hypomimia: decreased facial expression.

Incontinence: inability to control voiding from the bladder (or bowel).

Levodopa: The main medication used to treat PD. It is converted to dopamine (the chemical messenger which is deficient in someone with Parkinson’s disease), when it reaches the brain.

MadoparTMA drug that combines levodopa and benserazide.

Microelectrode recording: The method of recording electrical activity from individual brain cells, using very fine wire electrodes, to improve precision during surgery for Parkinson’s disease.

Micrographia: A change in handwriting with the script becoming smaller and more cramped.

Motor fluctuation: Variations in one’s ability to control movement during the day, due to fluctuating levels of dopamine in the brain.

Myoclonus: Jerking, involuntary movements of the arms and legs. May occur normally during sleep.

Neuron: A nerve cell.

Neurotransmitter: A chemical messenger that carries messages or signals between the various nerves. Dopamine is a neurotransmitter

On-off effect: This describes the sometimes rapid changes in the ability of medication to control the symptoms of Parkinson’s disease.

Off-time: The period during which Parkinsons symptoms are not controlled by medication.

Orthostatic hypotension: A fall in blood pressure when standing; may result in fainting.

Oxidation: A chemical process in which a substance combines with oxygen

Pallidotomy: A surgical procedure in which a group of cells in the brain called, the globus pallidus is destroyed. It is a relay station from which information leaves the site of the basal ganglia (where dopamine is stored).

Pergolide (Permax): An antiparkinson drug.

‘Pill rolling’ movements: A rhythmical movement of the thumb upon the first two fingers of the hand. A classic and early sign of tremor in Parkinson’s disease.

Postural instability: Impaired balance and coordination, which often causes a person to lean forward or backward and to fall easily.

Pramipexole: A new dopamine agonist.

Resting tremor: A tremor of the arm or leg when it is at rest, that is, when it is not moving.

Rigidity: The muscles feel stiff and there is resistance to movement even when another person tries to move the joint.

Ropinirole: A new dopamine agonist

Selegiline: A drug that helps conserve levels of dopamine in the brain by blocking one of the enzymes responsible for dopamine degradation.

SinemetTMAn antiparkinson drug.

Spasm: A condition in which a muscle or group of muscles involuntarily contract.

Substantia Nigra: A part of the brain involved in initiating movement. It is situated near the center of the brain and contains a clump of dark cells that manufacture dopamine.

Stereotactic or stereotaxic surgery: A surgical technique in which surgeons use three dimensional coordinates to locate specific areas of the brain..

TASMARTM(tolcapone): The first in a new class of drugs called COMT inhibitors for the treatment of Parkinson’s disease.

Thalamotomy: A surgical operation in which surgeons destroy small areas of the thalamus in the brain in order to alleviate one-sided tremor.

Tremor: The shakiness or trembling, often in a hand (although it may affect the whole or any part of the body), that in Parkinson’s disease is usually most apparent when the affected part is at rest.

Wearing-off” effect: The tendency, as Parkinson’s disease progresses, for each dose of levodopa to be effective for shorter and shorter periods of time.

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