Smart Patients Blog Series 1 of 5: Dr. Gilbert Discusses Early Symptoms of Parkinson’s
Some early symptoms of Parkinson’s disease (PD) can begin many years before the classic motor symptoms (slowness, stiffness, tremor) ever appear. Symptoms such as sleep disturbances, loss of smell, constipation, and mood changes can emerge years before a formal PD diagnosis. Researchers are even exploring ways to detect Parkinson’s before symptoms ever appear.
This post is the first in a five-part series recapping APDA’s recent “Ask the Expert” event on Smart Patients, where APDA’s Dr. Rebecca Gilbert answered questions from the Parkinson’s community about diagnosis, symptoms, and treatment. Below are her answers to participant questions about recognizing these early warning signs and what to do if you suspect you may be at increased risk. (Scroll to the bottom to learn more about APDA’s partnership with Smart Patients, a supportive online community.)
Question and Answers for Early Warning Signs of Parkinson’s and Prevention
Q: In your video session at the 50-minute mark, you talked about prodromal (pre-Parkinson’s) symptoms – ones that show up before motor symptoms start to give a clear indication of a Parkinsonism. You mentioned REM sleep disorder, loss of smell, constipation, and depression and anxiety as frequently preceding a diagnosis of Parkinson’s. Obviously, it’s easier to connect these symptoms to Parkinson’s after Parkinson’s is actually diagnosed. Do you have any sense of how frequently “potentially pre-Parkinson’s” symptoms actually turn into Parkinson’s?
A: This is an active area of research, and REM behavior sleep disorder (RBD) has the most data on this question. That data suggests that over half of people with REM behavior sleep disorder may develop PD or a related disorder within a decade of diagnosis of RBD, and this number increases more with time. So, there is a very strong connection between the two.
Q: Other than report these symptoms to their primary care provider, are there things people can or should do if they notice prodromal symptoms? Can they perhaps get monitoring to see where they are?
A: If you think you may have REM behavior sleep disorder, you can speak with your primary care physician about having a sleep study to formally diagnose it. If you are diagnosed with it, there are observational clinical trials that you can join that can connect you to researchers who are studying RBD and Parkinson’s. You can learn about one such study here: NAPS Consortium for REM Sleep Behavior Disorder. The purpose of the NAPS Consortium is to support clinical care and advance discovery in order to improve the quality of life and long-term care for people living with RBD.
Q: Would APDA’s suggested exercises be helpful for these patients as well? Can you tell us anything about that? Any or all exercise is helpful as we age, of course – but is there anything specific or particularly helpful for people who may be noticing these pre-Parkinson’s symptoms?
A: APDA has a free exercise resource guide specifically for people with PD called Be Active & Beyond and it is a fantastic starting point for people who should be exercising. In general, there aren’t specific research studies on people at increased risk of PD and which specific exercises they should be doing, but it makes sense that this group would benefit from a similar exercise regimen as people with PD. During the Dr. Gilbert Hosts broadcast, I discussed the exercise guidelines of the CDC that are meant for all older adults. Aerobic activity is the core of the exercise program. People with PD and those at increased risk of PD should also incorporate balance, strengthening, and stretching exercises.
Q: Does sleep apnea play a role in causing Parkinson’s or making it worse? Does treating it help with Parkinson’s symptoms? And if so – does that mean supplemental oxygen might help all Parkinson’s patients?
A: There are many types of sleep disorders that are associated with Parkinson’s disease, and sleep apnea is one of them. It is considered a non-motor symptom of PD. In addition, there was a recent study that concluded that having untreated sleep apnea can increase the risk of developing PD, and that treating with a CPAP mask lowers that risk! Sleep apnea causes dips in oxygen levels throughout the night. In anyone with this problem (whether they have PD or not), sleep apnea can cause morning headaches, cognitive fog, excessive sleepiness, and other symptoms. A person with PD can’t afford to have these additional or worsened problems, so treating sleep apnea by wearing a CPAP mask at night (that pushes oxygen into the lungs) is important. This does not mean that supplemental oxygen would help everyone with PD – just those who experience dips in their oxygen levels.
Q: What is the magnitude of risk that pesticide exposure has on developing PD? (Husband with PD used lots of pesticides in gardening.)
A: There is increasing recognition that just like every chronic disease, the risk of getting Parkinson’s is due to both a person’s genetic makeup and their environmental exposures. It is typically not one specific thing that causes PD – it is a combination of lots of things. In addition, some environmental exposures are more problematic in people with certain genes. Having said that, certain pesticides such as paraquat and rotenone have been associated with developing Parkinson’s disease. There are likely other chemicals that can also increase the risk but have not been studied as much. So bottom line, while it is certainly possible that extensive pesticide exposure was instrumental in a particular person developing PD, another person with the same exposure may not have developed PD. APDA’s Public Policy & Advocacy Department is working hard to get paraquat banned at both the state and federal levels. You can learn more and get involved.
Q: Can heavy-metal toxicity be involved in causing Parkinson’s? Is heavy-metal testing recommended?
A: It is well established that exposure to one particular heavy metal, manganese, can cause movement problems that can resemble Parkinson’s disease. This has been described with occupational exposure to manganese and is not an established cause of PD in people without a source of exposure. The link between exposure to other heavy metals and PD are less well established. At this juncture, heavy metal testing is not standard of care for people with PD.
Q: Is Lexapro one of the drugs that can cause drug-induced Parkinson’s? What drugs are most likely to be involved in that? Does stopping the drug usually or always reverse it if it’s really drug-induced Parkinson’s?
A: Although there might be case reports associating Lexapro with drug-induced Parkinson’s, this is highly unusual. In fact, Lexapro is commonly used to treat depression in PD and works well. Drug-induced Parkinson’s is much more commonly caused by dopamine-blocking agents. APDA has a fact sheet that lists medications to avoid or to use with caution in someone with PD: Medications to avoid or use with caution in PD. If Parkinson’s symptoms are due to a drug, then the symptoms should stop with stopping the drug. It might take a while though – so give it three months off the medication before reassessing.
Q: Can rigidity come on gradually/progressively rather than rapidly?
A: The answer is yes! Parkinson’s symptoms, including the stiffness or rigidity that are characteristic of PD, tend to evolve slowly. When PD symptoms start rapidly, your doctor will be concerned that something else is going on – such as a urinary tract infection. Be wary of PD symptoms that don’t come on gradually, and be sure to bring all concerns to your doctor.
Conclusion
While researchers and clinicians continue to learn more about the earliest stages of PD, evidence suggests that recognizing potential warning signs may provide opportunities for monitoring, research participation, and healthy lifestyle changes. Currently, no single symptom or exposure guarantees a future PD diagnosis, but understanding risk factors and maintaining overall brain health remain important goals to optimize outcomes.
About APDA’s Partnership with Smart Patients
APDA collaborates with Smart Patients, an online discussion forum where people with PD and their care partners can connect, share advice, and get support from others who understand what they’re going through. Last month, we hosted a special “Ask the Expert” session on the Smart Patients platform, an outgrowth of our virtual broadcast Dr. Gilbert Hosts: Ask the Doctor Anything. For three days after that webinar, Dr. Gilbert answered a wide range of reader questions about Parkinson’s diagnosis, symptoms, and treatment, including several she didn’t have time to address live. We are compiling these questions and answers into a series of blog posts so everyone can benefit from the information.
We encourage you to join the Smart Patients community – it’s free and easy to participate, and you might find it to be a helpful addition to your PD toolkit.
Tips & Takeaways
- APDA partners with Smart Patients, an online discussion forum for people with PD and their loved ones. You can join for free today and start connecting with people who understand what you’re going through.
- REM sleep behavior disorder is one of the strongest known predictors of future PD
- Sleep studies can help confirm suspected REM sleep behavior disorder
- Regular exercise may benefit individuals at increased risk of PD
- Untreated sleep apnea may increase PD risk
- Environmental exposures such as certain pesticides have been associated with PD
- Bring all symptom concerns to the attention of your doctor
- Keep an eye out for additional Q&A blogs like this one as we summarize important questions asked during the Smart Patient “Ask the Expert” event.
This blog was written by Clark Jones, PhD, and was reviewed, edited, and approved by Dr. Rebecca Gilbert.