DAVID MARKS, MD: Hi and welcome to our webcast. I'm Dr. David Marks.
Parkinson's disease poses tremendous challenges to both patients and their caregivers. Fortunately, doctors have a number of effective treatments available to them. Now, these treatments can help alleviate symptoms and improve a patient's quality of life. One way to improve that is by open and consistent communication between patients, caregivers and their doctors.
Here to talk about the latest treatment options and the importance of dialogue between doctors and patients are four experts. First is Dr. Michele Tagliati, a neurologist from Beth Israel Medical Center in New York City. Welcome. And next to him is Dr. Ron Alterman. He's a neurosurgeon and he's also from Beth Israel. Thank you for being here.
We're also fortunate enough to have a Parkinson's patient, Carol Polenberg. Welcome. And Odus Lynd, he is the caregiver of a Parkinson's patient named Richard, who can't be here. But Odus is going to give us his expertise on the subject. Welcome.
Dr. Tagliati, what is Parkinson's?
MICHELE TAGLIATI, MD: Well, Parkinson's disease is caused by the premature death of a small area in the brain which produce a chemical that is called dopamine. And the brain needs dopamine to coordinate the movements of the body. And when dopamine is decreased because of the premature death of this small area, the symptoms of Parkinson's disease occur.
DAVID MARKS, MD: But how can you tell if someone actually has the disease? You're not necessarily looking in the brain always.
MICHELE TAGLIATI, MD: There are three fundamental symptoms that the patient can feel. One is tremor, the second one is unusual slowness or lack of dexterity in their movement or lack of coordination. And the third is a stiffness of the muscle that we call rigidity. There is a fourth symptom that usually occurs later on; that is a gait instability. A lack of balance while walking.
DAVID MARKS, MD: And they have to have all of these symptoms to be diagnosed with Parkinson's?
MICHELE TAGLIATI, MD: No, they don't. The definition of the disease is the presence of at least two of these four major symptoms. And there is a corollary of small other symptoms like a lack of expression of your face, a difficulty in writing -- the letters come out very small and very effortful -- and problems with sleeping or anxiety.
DAVID MARKS, MD: Dr. Alterman, as a neurosurgeon, it must be very exciting to you, because this is a time when we have an increasing number of treatments for Parkinson's. Tell us about them.
RON ALTERMAN, MD: Yes, it is a very exciting time. Because of advances in various technologies and in our understanding of the physiology, we've seen a renewal of the interest in surgery for Parkinson's disease. Nevertheless, the front-line treatment for Parkinson's continues to be medications.
The most successful of those medications is something called levodopa, which is taken up by the brain and literally replaces the dopamine that is being lost.
DAVID MARKS, MD: Now that's L-dopa.
RON ALTERMAN, MD: Yes L-dopa. Over time, however, we know that the levodopa will lose its effectiveness. That may be as short as five years for some people, but it could be as long as fifteen or twenty years for others. In addition to losing its effectiveness, many patients develop side effects from the medication. What we call levodopa-induced dyskinesias, which are abnormal, almost wriggly snakelike movements, which the patients experience when they have those medications. In addition, the patients may experience what are called on-off fluctuations where they quickly switch from the on state when the medications are effective to the off state when they are not.
As the patient's quality of life deteriorates because of these on-off fluctuations and the complications in medical therapy, those patients may benefit from surgery. And surgery is currently reserved only for those instances where the medications are no longer effectively giving people a good quality of life.
DAVID MARKS, MD: Now when you say "surgery," what exactly do you mean?
RON ALTERMAN, MD: Predominantly today, the surgery that we perform is deep brain stimulation, where we implant very small electrodes into another structure in the brain -- called the subthalamic nucleus. Alternatively, one can implant the electrodes into a structure called the globus pallidus. In both cases, to treat advancing Parkinson's disease.
DAVID MARKS, MD: Those are just parts of the brain.
RON ALTERMAN, MD: Parts of the brain, yes, they are.
Those electrodes are then connected to a pacemaker -- literally just like the heart pacemakers that people with heart disease have. Only the current goes up into the brain instead of down into the heart. And these pacemakers can be programmed as needed to relieve many of the symptoms of Parkinson's disease.
DAVID MARKS, MD: Dr. Tagliati, what are the barriers to Parkinson's patients receiving the latest treatments?
MICHELE TAGLIATI, MD: Well, there is really no barrier to medications. Medication for Parkinson's disease are widely available, usually provided as soon as the symptoms become affecting your quality of life.
As far as the surgery is concerned, brain surgery is still seen as something very dangerous and something that shouldn't be done unless you're desperate or at the end of the line. And this is the perception that, at least in our experience, should be in some way modified, because when Parkinson's disease advance to the point in which the medication are no longer effective, surgery is not only a important option, but is something that the patient should be offered and obviously advised properly, but without fears dictated by lack of knowledge, basically.
DAVID MARKS, MD: Well, let's ask a patient. When you hear the term "brain surgery," does that scare you?
CAROL POLENBERG: No. My experience with brain surgery was very wonderful. The only pain that I had was when they put the injection in your head to dull the pain. And that was just a quick second. But the surgery went very fast as far as I was concerned.
DAVID MARKS, MD: Did it scare you beforehand, when you first spoke to your doctor about it? I mean, brain surgery is a scary concept to many people.
CAROL POLENBERG: When my doctor spoke to me about it, I was at wit's end. I had no other option. And then when Dr. Alterman explained the procedure to me, it was like the best gift I could have ever gotten.
DAVID MARKS, MD: Odus is nodding his head.
ODUS LYND: Right. My partner Richard wasn't afraid of it one bit either. He was looking forward to it, and I guess the scariest part about it was how he looked when he had the grid attached to his head going into surgery. I mean, it's not painful or anything like that, but it just looks kind of scary. But he had no problem with it whatsoever and no pain, except for -- as was mentioned -- the little pinpricks in the skin to deaden the pain.
DAVID MARKS, MD: Now, two brave people, obviously. But what do you suggest to patients who may not be satisfied with their treatment?
RON ALTERMAN, MD: With their medical therapy?
DAVID MARKS, MD: With their medical therapy.
RON ALTERMAN, MD: Well, obviously I think they need to speak with their physician and explore various options. There are what are called unconventional options in terms of vitamin therapy and such and there are experts in those areas that people can speak with. If the patient is being treated by a general neurologist, someone who does not have particular expertise in movement disorders, they may ask for a referral to a movement-disorder neurologist. People such as my colleague Dr. Tagliati are expert at manipulating the medications and, in many instances, patients that are referred to us from surgery often can get another couple of years just with management of their medications by a true movement-disorder expert.
DAVID MARKS, MD: Carol, we have now vitamins, there's l-dopa, there's brain surgery. How did you go about deciding which treatments were right for you?
CAROL POLENBERG: Well, when I was first diagnosed, I didn't know which way to go. And then I started to do my own research. And I never really tried the vitamin therapy, but they constantly check your blood to see what you're lacking and what you're not lacking and I did need a lot of B-12 vitamin. So I got a lot of B-12 shots.
But I basically was on the dopamine? Yeah. And after a while, that wasn't working. I was on dopamine for fifteen years.
DAVID MARKS, MD: But it stopped working.
CAROL POLENBERG: Yeah.
DAVID MARKS, MD: Which caused you to look for other options.
CAROL POLENBERG: I was more off and on. And then I was at wit's end when I spoke to my neurologist and he told me about the surgery. And I went for it.
DAVID MARKS, MD: Now, Odus, there's a lot of information out there. How did you find out the latest information, the very latest in treatments?
ODUS LYND: We went to a Parkinson's support group. And there are quite a few support groups out there -- there are a few in Manhattan, and also around the country. I would recommend that people find out about support groups in their neighborhoods, in their communities.
DAVID MARKS, MD: Thank you for being here and I want to thank the doctors for being here. Thank you for joining our webcast. I'm Dr. David Marks, goodbye.