Two years ago, my father began displaying an occasional slight tremor on his right side. Now, at age 90, his tremor is on both sides and noticeably worse, he has a slow, shuffling walk, and as a result he refuses to leave the house or climb stairs.
I believe that my father is suffering from Parkinson's disease, and from what I've read, he has only a few years left. Might L-dopa therapy make a difference? — Marietta, Ga.
I would first recommend that your father see a doctor for a thorough neurological examination. While his symptoms are consistent with Parkinson's disease, they are nonspecific, especially at his age. They could come from a variety of causes.
If the diagnosis is Parkinson's, then levodopa (commonly called L-dopa) would likely alleviate his tremors and improve his walking.
Since its introduction in the 1960s, levodopa has been the gold-standard drug therapy for Parkinson's disease. By partially correcting the dopamine deficiency in the brain that causes muscle rigidity and problems with balance and coordination, the drug extends the time that patients can lead reasonably normal lives.
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But after five or so years on levodopa, complications often begin. Patients can experience dyskinesias (involuntary twitching or jerking movements of the arms or legs) and motor fluctuations when the drug's effectiveness waxes and wanes, forcing the patient to take doses more frequently and to endure lapses until the latest dose kicks in.
Neurologists express some disagreement about whether such problems are caused by levodopa or by the disease itself. These complications occur less frequently in the elderly, but some physicians are reluctant to prescribe the drug early on to younger patients, preferring to try other medications first.
Alternative drugs have their own side effects, however. So-called dopamine agonists, such as pramipexole and ropinirole (which do not produce dopamine but mimic its effects), can cause fatigue, blood pressure drop and hallucinations. And the anti-cholinergics such as trihexyphenidyl and benztro- pine may produce memory loss, confusion, severe constipation and difficulty urinating — especially in men with enlarged prostate glands. While these drugs may still offer a considerable net benefit to a younger person, for an older patient they could be intolerable.
Two nondrug options also should be mentioned. The first is surgery — specifically, deep brain stimulation. A pacemakerlike unit is implanted in the chest wall, and it transmits electrical impulses to tiny electrodes placed in a structure deep within the brain that controls many aspects of motor function. Deep brain stimulation is generally most helpful for advanced cases in which drug-related complications already have begun to occur. It can smooth out motor fluctuations, for example, and improve dyskinesias. But because your father is at an early stage of the disease, deep brain stimulation wouldn't be appropriate for him now, even if he were younger.
The second option consists of self-help activities such as physical therapy and exercise, which are extremely important for all ages and at virtually any stage of Parkinson's. As long as they are practiced steadily, these activities keep the muscles and other tissues as healthy and viable as possible. Otherwise, Parkinson's patients find themselves spiraling downward. Inactivity causes secondary effects such as bursitis, tendonitis and cramps, which reduce activity even further.
Parkinson's disease is not fatal, like cancer, though it can reduce the life span slightly because of a patient's handicapped condition. Treatment's main purpose is to avoid or postpone such handicaps — to make the individual's remaining years as healthy, functional and enjoyable as possible.
Because the decision to use levodopa or other therapies is complex, it is essential for you and your father to consult with his doctor so that the most judicious course of treatment is pursued.
— Dr. James H. Bower, neurology, Mayo Clinic, Rochester, Minn.