Parkinson's Disease in the Elderly
Last Updated: April 4, 2013
Parkinson's disease (also known as Parkinson disease, or PD) is
a neurological disorder that occurs when certain neurons in the
brain die or become impaired. These nerve cells, located in a
midbrain structure that controls muscle movement, produce dopamine,
the chemical responsible for coordinated muscle function. Symptoms
of Parkinson's disease begin to appear when 80% of these neurons
According to the National Institute of Health (NIH), Parkinson's
affects 50% more men then women, but impacts people of all
ethnicity and socio-economic backgrounds. According to the National
Parkinson Foundation (NPF), approximately 60,000 new cases of PD
are diagnosed each year, joining the 1.5 million Americans who have
the disease. The condition usually affects those over age 65.
Approximately 1% of seniors have some form of the disease.
Persistent body tremor is the most common symptom of Parkinson's
disease in the elderly. Sluggish movement, stiffness and challenges
with balance are also indicators, as are hand cramps, shuffling,
frozen facial expressions, muffled speech patterns, and
Parkinson's disease in the elderly is not easily diagnosed, as
neither x-rays nor blood tests reveal the condition, though blood
tests and magnetic resonance imaging (MRI) can be used to eliminate
Usually the early symptoms are quite mild, affecting one side of
the body. These early symptoms often do not require medication.
Though tremors are often the first symptom and the least disabling,
they often cause the most embarrassment for the patient.
Like Alzheimer's disease, the most common neurodegenerative
condition in America, symptoms of Parkinson's patients progress and
worsen over time. Increased tremors affect dexterity, while
movement slows considerably (called bradykinesia). These physical
changes impact the most routine habits like getting dressed or
rising from a chair. Posture begins to stoop, as the head and
shoulders press forward to compensate for the apparent lack of
balance. Symptoms may occur on one or both sides of the body, but
typically begin on one side and eventually spread to the other side
as well. Some Parkinson's patients may also develop
dementia late in the process, although it's still unclear how
likely this symptom is.
Because there is so much variability among patients in how the
disease progresses, doctors are not able to accurately predict how
quickly symptoms will worsen, or even which specific symptoms will
develop for each patient. This makes Parkinson's disease in the
elderly a difficult disease to diagnose properly.
According to the NPF, profiles of Parkinson's disease patients
vary significantly. For example, even though, 5 to 10% of those
affected have a family history of PD, the remaining 90% of those
affected have no family history of the disease. Environmental
toxins are also potentially influential in the onset of PD, yet
only a small percentage of patients have been exposed to these
"How one person displays symptoms may be quite different from
another patient," explains Ruth Hagestuen, director of field
studies at the NPF. "However, the sooner a patient visits a
neurologist the better. That way, a treatment regimen can be
implemented, because this is a chronic illness, and will require
many modes of treatment over time to maintain life quality."
In order to properly diagnose Parkinson's disease in the
elderly, a neurologist or other qualified physician must make the
appropriate neurological examination and evaluate the patient's
complete medical history. During the visit the doctor may also be
able to personally observe some of the symptoms affecting the
To further complicate diagnosis, onset of PD symptoms does not
definitively mean the patient has the disease.Parkinsonism,the term
for displaying symptoms without actually having Parkinson's
disease, was found in 35% of those patients monitored in a recent
study. Parkinsonism is often the result of medication, blocked
blood vessels in the brain, and other chronic conditions like
Several conditions, calledatypical parkinsonism, mimic PD
symptoms. These diseases can obscure early diagnosis of PD, another
significant reason why a neurology appointment should be scheduled
early in the diagnosis process. According to the NPF, the
conditions that are most similar to PD display a wide range of
Progressive supranuclear palsyresults in imbalance,
falling, stiffening of the midsection, and difficulty with eye
movement. This condition, affecting people after the age of 50,
typically worsens more rapidly than PD.
Corticobasal degenerationis uncommon but also progresses more
rapidly than PD. This condition affects speech, balance, and
posture, and also leads to slowness of movement. Limbs affected by
this condition often become severely or completely disabled as it
Multiple system atrophyis the most difficult disease to
distinguish from PD. Earlier onset (mid 50's) and rapid progression
are two characteristics of this neurodegenerative disease of
unknown cause. Other symptoms arise as this condition intensifies,
symptoms that suggest other compromised systems of the body.
Vascular parkinsonism is caused by a series of small
strokes, usually leading to mobility challenges and is located
more often in the legs than the arms. Though treatment is the same
for vascular parkinsonism as for PD, it is much less
Lewy body dementia(LBD). Lewy bodies are round protein
structures that develop among brain cells, displacing them and
disrupting their functioning. Patients with LBD will typically
exhibit parkinsonism in addition to cognitive impairment similar to
Alzheimer's disease and vivid hallucinations.
Parkinson's disease and Lewy body
dementia: Possible link?
LBD is a disease that is now recognized as the second leading
cause of dementia after Alzheimer's disease
(AD), accounting for anywhere from 20 to 35 percent of all dementia
cases, according to the Lewy Body Dementia Association. Most
people, and even many doctors, have never heard of it, but the
disease has garnered increasing public attention as recent research
continues to establish links between PD, LBD, and AD.
Lewy bodies, the round protein structures that are found in LBD,
are also present in the brains of PD patients. However, in PD, the
Lewy bodies form only in the midbrain, whereas in LBD the Lewy
bodies occur in both the brainstem and the cerebral cortex. And LBD
and AD have often been found to coexist in the same patient, which
can make proper diagnosis extremely difficult.
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While Parkinson's disease in the elderly remains an irreversible
and progressive disease, several
medications are now used to treat and control its symptoms.
These medications have been so effective at helping people live
with PD that surgery is usually only considered after medications
have been tried and given time to work. Because symptoms will vary
with each patient, the choice and dosage regimens of medications
needs to be customized and adjusted as the disease progresses.
Levodopain combination withcarbidopais usually tried first, and
its effectiveness revolutionized PD treatments when it was
introduced in the 1960s. Essentially a building block of dopamine,
levodopa is converted into dopamine in the brain. The resulting
increase in dopamine levels helps to relieve the slowness,
rigidity, and tremor symptoms caused by the destruction of
dopamine-producing brain cells in PD. Carbidopa aids in the
absorption of levodopa in the body and also helps to reduce some of
its side effects, which may include hallucinations, drops in blood
pressure, nausea, and involuntary muscle movements (called
dyskinesia). Brand names include Sinemet® and Atamet®.
Dopamine agonistsare a type of medications that mimic dopamine,
and unlike levodopa these drugs are not converted into dopamine. So
instead of replenishing the depleted dopamine, they are able to
induce the affected brain cells to behave "normally," as dopamine
would be able to do. Although dopamine agonists tend to have fewer
motor side effects than levodopa, they appear more likely to cause
hallucinations as well as compulsive behaviors. And, because the
various dopamine agonists all differ somewhat, doctors may need to
try different ones before finding one that works most effectively
with the fewest side effects. Brand names include Mirapex®,
Requip®, and Apokyn®.
In addition to the dopamine-producing and -mimicking drugs
described above, doctors may prescribe other drugs to be used in
conjunction or as alternatives in case they become less
effective.Selegilineworks by inhibiting the breakdown of dopamine
and is often used in conjunction with levodopa/carbidopa
therapy.Amantadineis an antiviral that has been found to alleviate
some of the symptoms of PD. Andanticholinergicsare an older class
of drugs that are now less frequently prescribed because of
potentially serious mental and cognitive problems they can
Levodopa and the other medications described above have been
very successful at controlling the symptoms of PD, but over time
these drugs become less effective as the disease progresses in a
patient. This can take many years, as patients experience more
frequent periods where there is an increase in symptoms as the
effects of the medications wear off. They may also increasingly
experience dyskinesia (involuntary muscle movements) as a side
effect. When medication adjustments can no longer control these
symptoms or episodes, doctors may consider surgery as an
Several surgical techniques have been developed for PD, although
it's important to emphasize that none of them offers a true cure,
and that there are risks:
Thalamotomyandpallidotomyare brain lesioning procedures that
destroy different regions of brain tissue involved in PD. This
permanent effect on the brain is not recommended for both sides of
the brain, and the improvements don't always last. Thalamotomy is
only effective at reducing tremor, while pallidotomy may also help
to reduce the dyskinesia side effects of drug therapy.
Deep brain stimulation(DBS) is considered an alternative
treatment to lesioning surgery. A metal electrode is placed in the
targeted area of the brain and a pulse is generated to alter the
abnormal function of that region. No brain tissue is destroyed in
this procedure. The patient's general health often determines the
success of surgical treatment. DBS may be conducted in both sides
of the brain if symptoms warrant it and only if the patient is in
"Parkinson's disease will definitely impact every facet of a
person's life," Hagestuen explains. "But a closely monitored
treatment regimen including medication, exercise, and therapy
proves tremendously beneficial in most cases."
The patient with Parkinson's disease benefits from a
multidisciplinary approach to therapy, including physical,
occupational, and speech, as well as psychological counseling.
Creating an exercise plan, improving diet, and redesigning daily
routines usually improves one's wellbeing significantly.
Hagestuen recommends water exercise, Pilates, tai chi, even
dance therapy as ways to stay active and keep the muscles moving.
Walking is also essential. "Many people become much more physically
activeafterthey have received a Parkinson's diagnosis," she says.
"And many people live healthier lives and function quite well."
Hagestuen cites cooperative partners and family members as
instrumental in the patient's successful life with the disease.
"Those with Parkinson's disease must maintain good communication
with family members, who might also consider working with a
psychologist to cope with the day-to-day challenges of the
Patients with PD often feel a great deal of
anxiety, knowing that the progression of the disease is
irreversible. This fear often causes patients to turn inward and
avoid others with the disease, shielding themselves from what they
perceive to be their future state. This obstinacy can make it
difficult for family and supporters to persuade the patient to join
Parkinson's support groups and other activities with peers.
Various support groups are available for patients and care
partners alike. There are also several national organizations
available to provide Parkinson's disease information and suggest
strategies for coping with the disease. Establishing an "advisory
team" is essential as well, including a neurologist, family
physician, and also advanced practice nurses.
PD is a twenty-four hour condition, though days can vary
significantly. The same medicinal combination that worked fine
yesterday can appear ineffective today. Anger and
depression, the result of physical frustration, the loss of
independence, and hypersensitivity, surfaces for everybody.
The NPF suggests that a favorite physical hobby such as playing
a musical instrument be replaced with another, more cognitive
activity, like attending concerts. In addition, many patients
report that they have continued to work successfully in their jobs,
pursue their careers, and maintain their social and cultural
"It is easy to get discouraged," observes Hagestuen. "Seeing
oneself as a victim of a disease can be your own worst enemy.
Attitude makes a huge difference "
The first step a recently diagnosed patient should take,
according to Hagestuen, is to talk with someone who really
understands the disease. "Often people don't hear what they want to
hear and so continue onward in less than beneficial ways," she
explains. "Finding a care team that really listens and provides
good feedback will really help the patient maintain a good quality
"Quality of life" is a recurring theme to Hagestuen, who
originally joined the NPF because she was frustrated with the
institutional response to the disease. "My mother and
brother-in-law have advanced cases of the disease. As a nurse I was
always very concerned about our healthcare system, which is
designed for acute care and not chronic care."
Hagestuen became part of an interdisciplinary team, an approach
now strongly endorsed by the NPF. The team covers all facets of
treatment, and should include a psychologist as well. "It's not a
one-size-fits-all but it is important to find out what you can
really engage in," she says. "The benefits are enormous when people
who are diagnosed decide to maximize their health and lives."