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PORTSMOUTH

Portsmouth Herald - 2/4/2018

PORTSMOUTH

Approximately 60,000 Americans are diagnosed with Parkinson's disease each year. It's a chronic disease and there is no cure. But, advances are being made in diagnosing and treating the disease.

Most recently Parkinson's was in the news when Grammy-winning singer-songwriter Neil Diamond, 77, was diagnosed with Parkinson's and announced his immediate retirement from touring.

The cause remains largely unknown. Although there is no cure, treatment options vary and include medications and surgery. While Parkinson's itself is not fatal, disease complications can be serious.

The Centers for Disease Control and Prevention rated complications from Parkinson's as the 14th cause of death in the United States, according to the Parkinson's Foundation.

"In and of itself, Parkinson's is not life ending, such as something like a brain tumor could be," said Dr. Gareth Davies, a neurosurgeon with Coastal New Hampshire Neurosurgeons who practices at Portsmouth Regional Hospital. "But people can die from complications from the symptoms like difficulty with balance and falling or trouble swallowing."

Davies said his group is reaching out to primary care practices in the area to update them on the latest treatments for Parkinson's and to raise awareness of noticing early symptoms such as the classic hand tremor, a shuffling gait, slowness of movement (bradykinesia) and rigidity or stiffness of the limbs and trunk.

However, in some individuals, the diagnosis is more challenging. Patients who present only with a tremor may have Parkinson's or may have essential tremor, a completely different disorder.

Dr. Robert Donnell of Core Neurology in Exeter said Parkinson's disease falls under the overall umbrella of what is called parkinsonism.

"Eighty-five percent of patients with parkinsonism have idiopathic Parkinson's," Donnell said. "The other 15 percent have atypical parkinsonism that can include medication-induced symptoms or vascular issues."

Donnell said a collection of other neurodegenerative illnesses including cortical basal degeneration, dementia with Lewy bodies, multiple system atrophy or progressive supranuclear palsy can also fall under the umbrella of parkinsonism.

"There is a fairly new study that can be done," Davies said. "It's called a DaTscan that looks at the level of dopamine in the brain."

In Parkinson's disease, certain nerve cells (neurons) in the brain gradually break down or die. Many of the symptoms are due to a loss of neurons that produce a chemical messenger in the brain called dopamine.

As the disease progresses, the amount of dopamine produced in the brain decreases, leading to decreased activity on the brain scan. Dopamine is a chemical that sends messages to the part of the brain that controls movement and coordination.

A DaTscan is able to detect this decreased activity early in the course of Parkinson's when the diagnosis may still be uncertain.

Medication is the usual course of treatment to replace the dopamine that is being lost. The most common medication is a combination of carbidopa/levodopa called by the brand name Sinemet.

"The problem is that over time, the dose has to be increased and there are more side effects," Davies said.

"We're now able to offer deep brain stimulation surgery, or DBS, that can help limit the amount of medication needed, and give the patient better symptom control."

Portsmouth Regional Hospital is the only facility on the Seacoast to offer this surgery for patients with tremor and motion disorders that meet required criteria.

During DBS surgery, a neurostimulator (a battery operated device similar to a pacemaker and about the size of a stopwatch) is surgically implanted to deliver electrical stimulation to the areas of the brain that control movement, blocking the abnormal nerve signals that cause tremors.

Patients have a pre-surgical visit for imaging to identify exact locations within the brain where electrical nerve signals trigger the symptoms. They then have an overnight stay after surgery to place the electrodes deep into the brain, and another visit to program the neurostimulator device once it's implanted under the skin near the collarbone.

The patient is able to control the neurostimulator with a wand that can be programmed by their neurologist.

"Most patients prefer to have their neurologist program the neurostimulator," Davies said. "If the patient really wants more control, the neurologist can set the wand up to be programmed by the patient. For instance if they are going to be sitting and want more control of their tremor, that could be program A. If they will be walking more, they could choose program B for balance."

Davies has done seven DBS cases including new implementations and battery replacements since Portsmouth Regional Hospital began offering the surgery a year and a half ago. He has done well over 100 DBS cases in training.

"It's exciting to be able to offer this option," Davies said. For more information on DBS at Portsmouth Regional Hospital, visit portsmouthhospital.com/service/deep-brain-stimulation-dbs.

Donnell said the average age of Parkinson's disease onset is 70, and that it has a male predominance. The ratio is 1.5 males to 1 female. There is also a young-onset Parkinson's as was seen in the diagnosis of actor Michael J. Fox.

Depression is another component to Parkinson's. It is an early response to the disease, as the patient progressively becomes less mobile.

"There is a high prevalence of depression in Parkinson's patients," Donnell said. "It occurs in about 20 to 50 percent of patients, and it exhibits as more of a loss in interest in doing activities that they once found pleasure in."

About 30 to 40 percent of Parkinson's patients progress to dementia later on in the illness.

"The risk factors for this are an older age of onset or how long they've had the disease," Donnell said.

Davies said patients who stay engaged in activity generally have the best outcomes.

A study done by the Parkinson's Foundation beginning in 2009 with 10,000 participants in five countries, called the "Parkinson's Outcome Project" confirms this.

One of the findings of the research project, released in January, was that interventions providing neuroprotective benefits, such as exercise, could change the course of the disease and that increasing physical activity to at least 2.5 hours a week can slow decline in quality of life.

The study followed those newly diagnosed to people who have lived with Parkinson's for 20 years or more, providing a comprehensive view of the disease and its overall impact on people's lives.

Other research highlights found that people with Parkinson's who receive different medicines and treatment plans, depending on where they receive care, showed vastly different results.

It also found that regular neurologist care can save the lives of thousands of people each year and that depression and anxiety are the number one factors impacting the overall health of people with Parkinson's.