Parkinson Disease

Important Points to Consider: Parkinson Disease

• Nutrition Suggestions for People With Parkinson Disease

• Eat foods high in fiber to lessen constipation.

• Foods high in omega-3 fatty acids may be beneficial.

• Eat colorful fruits and vegetables for dietary sources of antioxidants.

• Vitamin B6 (Pyridoxine) Vitamin B6 can increase the peripheral conversion of levodopa to dopamine and should therefore be avoided in people taking carbidopa/levodopa. The decarboxylase inhibitor carbidopa should prevent this effect, but it may not at high doses of vitamin B6.

Prevention Prescription

For Parkinson disease, risk reduction rather than prevention is the goal.

• Engage in regular aerobic exercise.

• Drink three cups of tea per day, preferably green tea.

• Maintain a diet high in antioxidants and omega-3 fatty acids.

• Eat a handful (not a canful) of nuts daily (rich in vitamin E and in B vitamins).

• Reduce exposure to pesticides.

• Wash all fruits and vegetables carefully, including those that are grown organically.

• Reduce exposure to heavy metals.

• Test and filter well water as appropriate.

• Reduce exposure to industrial solvents and dry cleaning.

Therapeutic Review

Given here is a summary of the therapeutic options for Parkinson disease. Because Parkinson disease can have such a variety of manifestations and symptoms, the ladder approach will not always work. However, for mild motor symptoms, it may be useful to consider. Because this disease is chronic and progressive, most patients eventually will need to use strategies from multiple rungs of the ladder.

• Emphasis is placed on lifestyle and mind-body techniques and reduced reliance on medication.

Removal of Exacerbating Factors

• If other medical conditions allow, stop all medications that can induce parkinsonism. These medications include neuroleptics such as haloperidol, risperidone (Risperdal), and perphenazine, as well as metoclopramide and prochlorperazine. More rarely, lithium, valproate, amlodipine, and amiodarone lead to parkinsonism. Reduce exposures to pesticides. Have well water tested annually for heavy metals and pesticides. Remedy any abnormalities.

Mind-Body Therapy

• Facilitate optimism. The placebo effect is very strong in Parkinson disease.

Exercise

• Encourage regular aerobic exercise.

• Consider tai chi for stress management and improving balance.

Supplements and Herbals

• Melatonin: 6 to 10 mg nightly

• Valerian root: 100 to 300 mg nightly

Nutrition

• A high-fiber diet can help with constipation.

• Encourage foods rich in omega-3 fatty acids such as salmon, walnuts, pumpkin seeds, and flax seeds.

• Use turmeric when cooking. Drink three cups of tea per day, preferably green tea.

Neuroprotection

• Coenzyme Q10: 400 mg three times daily

• Creatine: 5 g twice daily

• N-acetylcysteine: 600 mg twice daily

• Rasagiline: 1 mg daily

Therapeutic Supplements

• CDP-choline: 500 to 1200 mg daily

• If the patient is taking carbidopa/levodopa, reduce its dose by 30% to 50% when CDP-choline is prescribed.

Acupuncture

• Acupuncture may help with the nonmotor and pain symptoms of Parkinson disease.

Pharmaceuticals

The general strategy is to start with a monoamine oxidase B inhibitor (as long as it is not contraindicated) and then try either amantadine or a dopamine agonist. In patients with mild cognitive impairment, consider starting with carbidopa/levodopa.

• Rasagiline: 1 mg daily

• Amantadine: 100 mg two to three times daily

• Dopamine agonists

  • Ropinirole: Start with 0.25 mg three times daily and titrate up to a maximum of
    24 mg per day.

  • Pramipexole: Start with 0.125 mg three times daily and titrate up to a maximum of 4.5 mg per day.

  • Carbidopa/levodopa IR: Slowly titrate up from 25/100 mg 1⁄2 tablet three times daily. Stop at lowest effective dose. May increase up to 1 g of levodopa (i.e., one 25/250 mg tablet four times daily) as necessary. May divide into more frequent but smaller doses.

• For tremor-predominant Parkinson disease, start with:

  • Zonisamide: 25 to 100 mg daily

  • Trihexyphenidyl: Titrate up from 1 mg once or twice daily and then three times daily (maximum of 15 mg per day).

• If carbidopa/levodopa wears off early, consider adding

  • Rasagiline: 1 mg daily (if not already being used)

  • Entacapone: 200 mg with each dose of carbidopa/levodopa up to eight doses per day

  • If dyskinesias develop and are causing the patient problems, try decreasing the dose of carbidopa/levodopa or divide it into smaller but more frequent doses. If these modifications are not possible, consider adding

  • Amantadine: 100 mg two to three times daily

Surgery

• Consider deep brain stimulation surgery targeting either the subthalamic nucleus or the globus
  pallidus internus for patients who respond to levodopa yet have severe motor fluctuations with rapid wearing off or dyskinesias.