Treatment Of Parkinson's Disease

Parkinson's disease: therapy

Treatment for Parkinson's disease consists of drug and non-drug therapies. The aim of all measures is to control and alleviate the symptoms and to delay the occurrence of late complications. This is intended to enable those affected to have a largely independent life in their family, work and society with a good quality of life for a long time.

In the early stages of the disease in particular, the symptoms of Parkinson's disease can usually be significantly alleviated. In advanced stages, treatment becomes increasingly difficult, and possible side effects of the therapies also increase over time. The treatments have to be continuously adapted to the individual.

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• How is the drug treatment of Parkinson's disease carried out?
• How does the non-drug treatment of Parkinson's disease take place?
• Whom can I ask?
• How are the costs going to be covered?

How is the drug treatment of Parkinson's disease carried out?

The drugs used in Parkinson's disease are designed to make up for the lack of dopamine in the brain. They can reduce the symptoms, but not reverse the damage that has caused the brain. It also cannot stop the progression of the disease. As a result, the drugs often no longer work properly after a few years.

The following classes of active substances are used in drug treatment:

L-dopa (levodopa)

L-Dopa is the most effective drug for treating Parkinson's disease and is used in all stages of the disease. L-Dopa is the precursor to dopamine and is converted to dopamine in the brain. Oral standard preparations are available as capsules or tablets with the usual, rapid or delayed effect.

L-Dopa is always administered in a fixed combination with a so-called dopa decarboxylase inhibitor. This slows down the breakdown of L-dopa into dopamine in the blood, ie it prevents L-dopa from being converted into dopamine before it even reaches the brain. On the one hand, it increases the availability of dopamine in the brain and, on the other hand, it reduces the undesirable effects of dopamine.

Note Protein-rich food can delay the absorption of L-Dopa, reduce its plasma level and its availability in the brain. L-Dopa should therefore be taken at least one hour before or after eating, if possible.

Possible side effects of L-Dopa include nausea and loss of appetite, drowsiness, dizziness as well as depression, hallucinations and confusion. In long-term therapy, motor complications can arise. This includes fluctuations in effectiveness (fluctuations) that arise because the effectiveness decreases over time, fluctuates or occurs with a delay. Excessive movements (involuntary movements, twitching, etc.) also belong to the so-called L-Dopa late syndrome. These are known as L-dopa induced dyskinesias.

Dopamine agonists

Dopamine agonists are drugs that are chemically very similar to dopamine and mimic its effects. They directly stimulate the dopamine receptors in the brain and can be used in all stages of the disease.

As the sole treatment, they are primarily used in younger patients, as they have a higher risk of motor complications as a result of long-term therapy. In addition, dopamine agonists are often combined with drugs from other drug classes.

Compared to L-Dopa, dopamine agonists are less well tolerated, possible side effects include edema, drowsiness, dizziness, drop in blood pressure when changing from sitting or lying down to an upright position ("turning black in front of the eyes"), constipation, nausea and hallucinations Confusion. Some preparations are also associated with an increased risk of heart valve disease.

The choices are:

• Oral substances (e.g. pramipexole, ropinirole) with rapid or delayed onset and long-lasting effects.
• Apomorphine: Due to its short duration of action, it is administered under the skin (subcutaneously) - either as rescue medication using an autoinjector ("pen") or as a continuous pump application.
• Rotigotine: as a skin patch.

MAO-B inhibitors

Active ingredients from the group of MAO inhibitors (monoamine oxidase B inhibitors) reduce the breakdown of L-dopa and thus increase the dopamine concentration in the brain. The substances rasagiline and selegiline can increase the therapeutic effect of L-Dopa or the dopamine agonists. They are used particularly in the early stages of the disease.

COMT inhibitors

So-called COMT inhibitors slow down the breakdown of L-dopa in the blood by the enzyme COMT (catechol-O-methyltransferase) and thereby increase the constant availability of L-dopa in the nervous system. COMT inhibitors (entecapone, tolcapone) are always administered in combination with L-dopa, without simultaneous administration of L-dopa they have no effect of their own. They are mainly used for patients with fluctuations in effectiveness.

NMDA (N-methyl-D-aspartate) receptor antagonists (e.g. amantadine)

On the one hand, the active ingredient amantadine promotes the release of dopamine in the brain, which increases its concentration. In addition, it slows down the excessive activity of the messenger substance glutamate, which is partly responsible for the disturbances in movement processes in Parkinson's disease. Amantadine can be used in the early stages of the disease. However, it is particularly helpful for patients in advanced stages of the disease, as it can alleviate the L-dopa-induced dyskinesias.

Anticholinergics

In Parkinson's disease there is a relative excess of the messenger substance acetylcholine in the brain due to the dopamine deficiency. This is partly responsible for the typical movement disorders such as tremors, slowed movements etc. So-called anticholinergics inhibit the activity of acetylcholine and thus lead to an improvement in symptoms. They were the first Parkinson's drugs to be used, but due to their numerous side effects, they are rarely used in Parkinson's therapy today.

Effect fluctuations in the course of therapy (ON-OFF phases)

The first few years of therapy are usually very positive for those affected. The symptoms can be relieved for a long time. The medication works well and the patient can move around easily - this condition is called the “ ON phase ”.

After a certain period of illness, however, an increased occurrence of symptoms can be expected. One speaks of so-called " OFF phases ", ie phases in which the anti-Parkinsonian drug shows no effect. This is because as the disease progresses, less and less dopamine is produced in the brain. In addition, the brain is less and less able to store the supplied L-Dopa and gradually use it up.

In such OFF phases, motor complaints mainly occur, such as stiffness, slowing down of movement, tremors or excessive movements. The restriction of movement can increase to the point of complete freezing. In addition, non-motor complaints are also possible, such as digestive and circulatory problems or impaired concentration. Pre-existing complaints are sometimes made worse in an OFF phase.

The frequent change between good and bad mobility (ON-OFF fluctuations) can dominate the entire daily routine of those affected and significantly affect both everyday coping and quality of life. If the effect of the day wears off some time before the next dose of medication would have to be taken, one speaks of "wearing-off" (the effect of the medication is used up or comes to an end). This means that those affected have the impression that they need their next dose of medication earlier than usual.

In the event of fluctuations in the effect, an attempt is first made to achieve better symptom control by increasing the dose or a new combination of drugs. If this is no longer successful, especially in very advanced stages of the disease, or if serious side effects occur, L-dopa or apomorphine pump therapy or an operation - so-called deep brain stimulation - can be considered.

Pump therapy

For patients in advanced stages who can no longer be treated satisfactorily with tablets or capsules or who have severe fluctuations in effectiveness and motor complications, pump therapy may be an option. The dopamine agonist apomorphine can be administered continuously under the skin (subcutaneously) via a thin catheter connected to a small portable pump. In this way, a uniform level of effectiveness is achieved and the effectiveness of the drug is improved.

Another possibility is L-Dopa infusion therapy: A permanent probe is placed through the abdominal skin into the small intestine (PEG probe). A pump that can be worn on the outside of the body transports gel-like L-Dopa into the intestine in a freely programmable dose via this probe. This leads to an even level of L-dopa in the blood.

The apomorphine pump is more likely to be used in younger patients, the PEG tube more in older patients who need a feeding tube because of swallowing disorders. The implantation of the respective probe, the setting of the pump and the training of the patient or their relatives in handling the device take place in specially qualified hospital departments.

Deep brain stimulation

If during the course of the disease there are strong fluctuations in activity or motor complications that lead to a significant impairment of the quality of life, surgical treatment may be considered. In so-called deep brain stimulation, electrodes are inserted into certain brain regions that are affected by the disease as part of a surgical procedure. The electrodes are connected to a stimulator implanted under the collarbone ("brain pacemaker"). Weak electric shocks cause electrical irritation in the affected brain regions and thus positively influence their impaired activity.

In particular, the three core motor symptoms of sedentary lifestyle (akinesia), rigidity (rigidity) and tremors (tremor) of Parkinson's disease as well as OFF symptoms can be significantly improved in patients who are suitable for this procedure. The main advantage of this method is that the effect lasts continuously over 24 hours and drugs can be significantly reduced. Deep brain stimulation is usually used in patients under 70 years of age.

How does the non-drug treatment of Parkinson's disease take place?

In addition to drug treatment, physiotherapy, occupational therapy and speech therapy are important pillars of Parkinson's therapy. In addition, psychological and social support measures are used if necessary. The various therapies must be selected individually and symptom-oriented and serve the goal of maintaining the independence of those affected.

Sports, exercise, physiotherapy

Parkinson's patients find it increasingly difficult to move around as the disease progresses, which also reduces muscle strength. In addition, there are progressive disorders of balance and coordination. This process can be slowed down somewhat by exercise and sport. In the early to middle stages of the disease, the main focus is on maintaining and promoting physical activity, later on falling prophylaxis and avoiding stiff joints. Furthermore, disease-specific disorders of the movement sequences as well as the postural reflexes should be compensated.

Positive effects can be achieved, for example, by stretching exercises, strength and endurance training, balance training, dancing, swimming, treadmill training, Qi Gong / Tai Chi, but also Parkinson's-specific training programs. These include the " Lee Silvermann Voice Treatment (LSVD) ", an internationally recognized treatment concept that was specially developed for Parkinson's patients. In addition to special training for voice and speech disorders (LSVD-LOUD®, see below), it also includes a form of exercise therapy, the so-called LSVT-BIG®Training. The aim of the training is to improve certain movement sequences and thus to make everyday life easier for those affected. The LSVT-BIG® training is always carried out as an intensive individual therapy in which you work specifically on individually selected everyday activities.

When choosing the respective therapeutic approach, it is helpful to include the personal interests and hobbies of the person affected in the design of the exercise programs. Good support from therapists is important. More on the topic: Recommended exercise for adults with chronic diseases

Occupational therapy

Occupational therapy should help you to look after yourself for as long as possible and to cope with everyday life on your own. Exercises to maintain mobility are carried out under the guidance of a specialist. In particular, fine motor skills and dexterity as well as everyday functions (e.g. dressing, toilet, etc.) are trained. Manual exercises (handicrafts, painting, etc.) or adapting the apartment to personal needs are also part of it.

Speech therapy

The increasing difficulty in speaking is very stressful for most of those affected. Speech therapy or speech therapy is important to strengthen the muscles in the face, tongue and larynx. Targeted exercises for breathing technique, articulation and swallowing sequences should help to speak clearer, louder and more clearly again. Swallowing disorders can also be improved with it. Conscious relearning of time sequences during language production and special attention to sharpness of articulation are further therapy goals.

A scientifically well-researched language training especially for Parkinson's patients is the so-called LSVD-LOUD® therapy. This method aims to improve the person's ability to speak simply through the volume. The goal is to train yourself to use a louder voice and thereby make yourself easier to understand in everyday life. The training is carried out as part of more intensive individual exercises.

Psychological care

The emotional confrontation with the illness can be supported by psychological individual or group discussions. Self-help groups are also useful for this. They offer those affected and their relatives the opportunity to exchange experiences about problems that arise in connection with Parkinson's disease and how to deal with them in the best possible way.

In addition, learning relaxation techniques (e.g. progressive muscle relaxation according to Jacobson) can be helpful. Courses are offered during rehabilitation, but can also be completed on an outpatient basis.

rehabilitation

In the context of temporary inpatient treatments in rehabilitation clinics specializing in Parkinson's disease, in addition to any necessary adjustment of medication, non-drug therapies such as physiotherapy, occupational therapy and speech therapy are carried out more frequently and more intensively than is possible on an outpatient basis. Psychological and social support are also offered.

Whom can I ask?

Parkinson's disease is treated by a neurologist in the ordination together with a general practitioner or under regular outpatient neurological treatment. In addition, temporary inpatient treatments in rehabilitation clinics specializing in Parkinson's disease are often useful. Important contact points are also:

• Physiotherapists
• Occupational therapists
• Logotherapists
• Psychologists

How are the costs going to be covered?

The e-card is your personal key to the benefits of the statutory health insurance. All necessary and appropriate diagnostic and therapeutic measures are taken over by your responsible social insurance agency. A deductible or contribution to costs may apply for certain services. You can obtain detailed information from your social security agency. Further information can also be found at:

• Right to treatment
• Visit to the doctor: costs and deductibles
• Prescription fee: This is how drug costs are covered
• Medical aids & aids
• Health Professions AZ

and via the online guide to reimbursement of social insurance costs.

When hospitalization is required

If a stay in hospital is necessary because of Parkinson's disease - for example to adapt a drug therapy or for surgical interventions - the hospital costs will be invoiced. The patient has to pay a daily contribution to the costs. Further information: What does the hospital stay cost?

rehabilitation

Rehabilitation costs during a stay in hospital are covered by social insurance. For further outpatient or inpatient rehabilitation measures, a doctor's prescription is required, which must be approved by the responsible social insurance agency. A deductible (income-dependent) is provided for inpatient stays in a rehabilitation center. Further information: Rehabilitation & Cure.