Up To Date On Parkinson’s

By Dr. Web Ross
Interviewed by Rasa Fournier
Wednesday - March 30, 2011
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Dr. Web Ross
Neurologist at the VA Pacific Islands Health Care system

Where did you receive your schooling and training?

I graduated from the University of Arkansas School of Medicine in 1981. I was in general practice for four years, and then I went to Tulane University in New Orleans and did my neurology residency. I finished my residency in 1989, and I did a fellowship in behavioral neurology at UCLA from ‘89 to ‘91. I came to Hawaii to work for the Department of Veterans Affairs in 1991.

How does someone get Parkinson’s disease and what are the symptoms?

Parkinson’s disease is in a class of neurological diseases that we call neuro-degenerative disorders, and that means that there is a cell loss that’s associated with the symptoms and signs of the disease. We don’t really know the cause of that cell loss, but the main symptoms are related to abnormalities of movement.

There are three cardinal features that help us to make the diagnosis.

No. 1 is bradykinesia, or slowness of movement. It’s not just slowness in execution of movement but in spontaneous movement and in initiation of movement.

Patients don’t blink as frequently, and they may have a diminished facial expression.

The second feature is rigidity. That rigidity usually starts on one side of the body. They are stiff, so they have difficulty turning in bed at night. They have difficulty walking; they may shuffle because of the stiffness, take little tiny steps and kind of scoot along the ground instead of taking normal steps.

Dr. Web Ross checks a patient’s biceps tendon reflex

The third feature is tremor. The tremor of Parkinson’s disease is present at rest, when the hands are resting in the lap. That tremor has been likened to a pill-rolling movement. The tremor goes away when patients try to do something with the hand. The combination of those three features contributes to a lot of other symptoms.

So their body isn’t receiving the correct signals from the brain?

That’s a good way of putting it, because we know that one of the cell groups that is most affected in Parkinson’s disease is a group of nerve cells in the brainstem called the substantia nigra.

These cells produce a neurochemical called dopamine, which is necessary for smooth movement. So when we lose those nerve cells, we lose that normal smooth movement.

Do people die of Parkinson’s?

We have really good treatments now for the symptoms of Parkinson’s disease, but unfortunately we don’t have anything that slows down the progression of that nerve cell loss.

Over time medicines that counter the symptoms help less and less, and the window in which they are effective becomes narrower and narrower until patients don’t respond as well.

They may get into trouble with falls, with choking on their food and with infections. Mortality, therefore, is more often related to complications - hip fracture or falling and having a hemorrhage in their brain, or having an infection - aspiration pneumonia or urinary tract infection.

With the treatments available

nowadays longevity approaches normal, but the quality of life is what is really affected. Patients develop difficulty feeding themselves, taking care of their normal hygiene - showering, dressing.

Eventually, they need assistance with those things no matter how good the treatment is. The average from the time of diagnosis to death is probably 15 to 18 years now.

At any given time there are 1,500 to 2,000 people in Hawaii with Parkinson’s disease and about 200 new cases every year. It takes about $25,000 a year to take care of the average person with Parkinson’s disease. It comes out to be about $50 million in the state alone.

When is onset most likely?

Age is the strongest risk factor, so the older a person gets, the more susceptible they are to getting Parkinson’s disease. The average age at onset is in the late 60s.

Can you talk about the latest research?

We don’t know the cause of Parkinson’s disease, so that’s a very active area of research.

Over the last 20 to 30 years there have been studies that identify exposure to pesticides and herbicides with a higher risk of developing Parkinson’s disease. In fact, data from the Honolulu Heart Program based at Kuakini Medical Center indicate that people who worked on a plantation for 20 years or more had about twice the risk of developing Parkinson’s as those who never worked on a plantation, suggesting that agricultural chemicals might be related to Parkinson’s disease.

Another important area is genetics. We’re looking for genes that may make people more susceptible to Parkinson’s because that would help us identify people who are at risk.

Another active area of research is trying to find strategies to slow down the progression of Parkinson’s disease.

Several medications have been identified that might counteract the process of nerve cell loss.

These have been tested in animal models of Parkinson’s disease and found to be effective for preventing cell loss. Honolulu is a site for a couple of clinical trials that are testing medications that might slow down the progression of the disease.

Participants with Parkinson’s disease take part in these clinical trials with the hope that new medications or treatment strategies may one day prevent or slow the progression of Parkinson’s disease.

My hat’s off to the people who participate in these trials and we have many here. The people of Hawaii are very good about participating and trying to advance the field.

Any final comments?

There’s a symposium April 16 that the Hawaii Parkinson Association sponsors every year (parkinsonhawaii.org).

This year the conference will focus on deep brain stimulation for Parkinson’s disease.

In addition, on April 9, the American Academy of Neurology is sponsoring the Brain Health Fair (brainhealthfair.com). This event will feature presentations and panel discussions by national and international experts on a variety of neurological conditions including Parkinson’s disease for patients, caregivers and interested people in the general public.

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