Drug-induced parkinsonism

I’m so thankful to those of you who submit potential topics for my blog as it helps me understand what you would like to know more about. A frequent topic that I am asked about is symptoms of Parkinson’s disease (PD) that are caused by medications. So today, I will address drug-induced parkinsonism.
Common symptoms of drug-induced parkinsonism
The motor features of PD are often (but not always) very easy to see via a neurologic exam in a doctor’s office. Rest tremor (which is a tremor that goes away with movement, but often returns when the limb is at rest) for example, is seen in virtually no other illness and can therefore be very important in diagnosing PD. But there is one other common condition that induces the symptoms of PD, including a rest tremor, which must be considered every time PD is being considered as a diagnosis, and that is drug-induced parkinsonism.
Parkinsonism is not technically a diagnosis, but rather a set of symptoms including slowness, stiffness, rest tremor, and problems with walking and balance. This set of symptoms can be caused by PD, but also can occur as a side effect of certain prescription medications (that have nothing to do with PD).
A number of medications can cause parkinsonism because they block the dopamine receptor and thereby mimic the symptoms of PD that are caused by loss of dopamine neurons in the brain. Reviewing a patient’s medications is therefore a critical step for a neurologist when seeing someone with parkinsonism. Anti-psychotics and anti-nausea treatments make up the bulk of the problematic medications, although there are other medications that can also cause parkinsonism. The primary treatment for this type of parkinsonism is weaning off of the offending medication, if possible.
For some people, it is not possible to stop the problematic medication. For example, some people with bipolar disorder or schizophrenia have tried multiple medications to control their mental health issues and the one that works best also causes parkinsonism. In these difficult situations, some amount of parkinsonism might be tolerated in order to maximize the person’s mental health. This is a tricky clinical situation, and one that typically requires the psychiatrist and neurologist to work together to optimize the circumstances.
The connection between PD and drug-induced parkinsonism
In addition to potentially causing parkinsonism in the general population, these medications should definitely be avoided in people who have parkinsonism from other causes, such as PD. APDA has created a list of Medications to be Avoided or Used With Caution in Parkinson’s Disease. It is important to note that there are anti-psychotics and anti-nausea medications which do not cause parkinsonism and can be used safely by people with PD.
Sometimes, a person without a diagnosis of PD is prescribed a medication which leads to a side effect of drug-induced parkinsonism. The prescribing physician may stop the new medication, but the parkinsonism does not resolve. The patient remains off the medication with continuing symptoms, and eventually is given a diagnosis of PD. In this scenario, that person most likely had dopamine depletion in the brain (prior

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Want to Join A Virtual Support Group?

If you would like to attend a support group while staying safe at home, we can help! The Coffee Break Support Group is meeting every Wednesday at 10 a.m. Eastern via Zoom. If you would like to join the discussion, do some exercise with the group or just make some new acquaintances in the PD Community, email apdavirginia@apdaparkinson.org and let us know. We will set you up!
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Highlights From The Movement Disorders Society Virtual Congress 2020

Every year the International Parkinson and Movement Disorder Society (MDS) holds a conference and every year APDA is there, learning about the newest research and sharing our resources with the wider PD community. The MDS Congress is the preeminent gathering of medical professionals from around the world who are dedicated to Parkinson’s disease (PD) and other movement disorders.  So much fascinating information is shared at the Congress that each year we report back to our readers about what we have learned. You can read our recaps from 2018 and 2019 to learn more.
This year the world has been turned upside down due to the COVID-19 pandemic, and an international conference that typically brings together thousands of people from dozens of countries around the world, was not possible. And much like many other in-person gatherings, this one went virtual.  It was a great accomplishment to conduct such a massive meeting on a virtual platform, and it was very exciting to be a participant in that inaugural event.
The event consisted of scientific talks as well as abstracts, or brief reports of new research.
Highlights from the Research Presented
Here are my highlights from the research abstracts presented at the first-ever MDS Virtual Congress 2020 along with a comment about why each project is important. It was interesting to see several COVID-19-related research projects presented.
Neurological manifestations of COVID-19 in Parkinson’s disease (Agarwal, P. et al)
The abstract reported neurologic manifestations in seven patients with Parkinson’s disease (PD) and COVID-19. Among this cohort, it was common to present with neurologic symptoms such as increased confusion. One patient presented with falls and worsening of tremor, which was initially attributed to progression of PD. Two of the patients died and five recovered to their baseline.
Take home message: It is important to recognize neurological manifestations of COVID-19 in PD patients in order to correctly identify and treat COVID-19 in this population. (Learn more about research related to the intersection of PD and COVID-19.)
Utility of deep brain stimulation remote programming for Parkinson’s disease during the COVID-19 outbreak (Zhang C. et al)
SceneRay, a medical device company based in China developed a deep brain stimulation (DBS) system that enables remote programming. The system allows the physician to change the DBS parameters of an individual’s device from a remote location. This technology is not available yet in the US. This abstract described the experience of practitioners using this technology in six centers in China both before and during the COVID-19 pandemic.
Take home message: Physician adjustment of DBS parameters remotely is available in some parts of the world (and hopefully will be available in the US in the future). Because of its convenience, it can be very helpful for patients who might have trouble getting to the doctor in person, especially during the COVID-19 pandemic.
UCB0599 transition to the clinic: An orally available brain-penetrant inhibitor of alpha-synuclein misfolding in Phase I development for Parkinson’s disease (Smit JW at al)
As explained in a recent blog, targeting of misfolded alpha-synuclein is one of the prime targets for

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Ask the Doctor Q&A

Ask the Doctor Q&A
Q: I have PD. Now that the country is “opening up”, what should I do? Should I start to venture out or continue my current practices of staying at home and only going out for walks if I can safely stay six feet away from others?
A: Various states are creating plans to “reopen” as the rate of new cases of COVID-19 slows down. (It should be noted that in some places in the US, new cases are not slowing, yet reopening is taking place anyway.)  It is important to reiterate that the risk of a complicated course of COVID-19 is not the same for everyone. People who are over 65 and have underlying medical conditions will continue to need to be careful even if their city is opening up. Small studies from around the world are examining whether PD is an underlying medical condition that increases the risk factor for worsened COVID-19. For those with advanced symptoms, the answer seems to be yes. For those with mild symptoms, the jury is still out. The PD community will therefore have to be more careful than the general population as we ease back into “normal” life. If you must be in a situation in which there are other people around, wearing masks and staying more than six feet away are important, and don’t forget to wash your hands frequently. These measures reduce (but do not eliminate) the risk of transmission and should continue even if others around you are not complying.
Q: Since my diagnosis of PD in 2014, my eyesight has been affected in a number of ways. One thing I now have trouble with is following the ball when I play golf. I try to focus on the ball, but I can feel my eyes lose their focus. Is this related to PD? Is there anything I can do about it?
A: I wonder if the problem is what we call convergence insufficiency – you are able to see the ball at a distance, but not when the ball is closer to you, because your eyes don’t work together to see close objects. Ask your neurologist for a referral to a neuro-ophthalmologist who can test for this and other eye movement conditions. Sometimes prisms in your glasses can help with this problem.
Q: My husband has had PD for 14 years and recently started to have sudden falls, where he crumbles to the floor. They are very scary for me to watch, but he seems to quickly be OK once he is on the floor. What could be going on?
A: Sudden falling could be due to a number of issues and your husband definitely needs a complete medical evaluation to figure out what is going on. One possibility is that he is experiencing drops in blood pressure as he is walking, which is a common non-motor symptom of PD. Talk with his neurologist about what is going on because this problem needs to be solved quickly. Sudden falls can cause

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Share Your Parkinson’s Story

Share Your Parkinson’s Story
When it comes to Parkinson’s disease (PD) and the estimated 1 million people in the U.S. living with it, a story can make a world of difference. Your shared story helps raise awareness and can provide support to someone recently diagnosed who is perhaps unsure or afraid of what is to come. And it can provide hope and camaraderie to the care partner who is struggling to balance it all. One story can touch dozens, even hundreds of people.
You can make a difference
That’s why the American Parkinson Disease Association (APDA) has made it easier than ever for YOU to share your Parkinson’s story. Click here to view stories shared by others and use our new story-sharing tool to add yours. By adding your story of optimism, together, we can help people look closer at those affected by PD and see that there is so much more to a person than just their PD diagnosis.
Stories of hope
Here are just a few of the stories you’ll see in our Story Gallery.  Juanita, who praises the power of her support network, says, “Just knowing that my friends and family love and support me… every day… gives me a reason to fight every day.”
 Kermit, says, “Rather than withdrawing and feeling depressed, I made it a goal to engage life more – living each day to the fullest, embracing and savoring every moment, and surrounding myself with people who nourish me.” Allyssa, who started dancing at age 38, was inspired to get trained to teach classes for people with PD and states, “I have been so humbled at the drive and determination of my students.” She adds, “My students are truly the light of my life.” Brian is an avid cyclist and swimmer despite living with PD the majority of his life. His optimism is inspiring.
He states, “We can accomplish anything if we just try. Everybody’s journey with PD is individual. And what works today may not work tomorrow. We must keep looking for answers that work for us.”
People want to hear your story
Whether you’re living with PD or you’re a care partner, friend, family member, or even a medical partner, we hope you’ll let the world know what inspires your #PDOptimism.
Once your story is published, our new story-sharing tool makes it even easier for you to share your published story with your friends and community through Twitter and Facebook.
We hope you’ll join us in establishing a bold, optimistic, and authentic library of voices today. We know every story is powerful and we can’t wait to read yours.
Your shared story helps raise awareness and can provide support to someone recently diagnosed who is perhaps unsure or afraid of what is to come.
 
Create your own story
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A Message From Our CEO & President

A Message From Our CEO & President
Dear Friend,
For so many, this past year has been full of uncertainty and change. The COVID-19 pandemic has been disruptive in so many ways – but it’s thanks to your support that APDA has remained a constant resource for so many.
As you may already know, 60,000 people in the U.S. are diagnosed with PD each year, and this year, that diagnosis may have felt especially daunting since many have also been grappling with quarantining at home, concern about potential COVID-19 risks for people with PD, and/or trying to figure out how to see a doctor during a pandemic. But with your help, APDA has been providing the care and resources that help people with PD move forward and live life to the fullest. For that, I am so grateful.
In this issue of Insights, you will learn more about what APDA has done to ensure that people with PD can depend on us and will continue to receive the support, education, and research that will help them live their best life. Together, we have created a wealth of virtual programs and informational sessions to keep people with PD and their families informed, engaged, and supported. You will also learn about the inspiring stories of people with PD and how your story can make a difference.
As you read, please know that our work would not be possible without you. With your support, there is no limit to what we can accomplish.
Sincerely,
Leslie A. Chambers President & CEO American Parkinson Disease Association
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WHAT’S HAPPENING AT APDA

WHAT’S HAPPENING AT APDA
Optimism Walk Update
All 2020 Optimism Walks are being held virtually, and there’s one last chance for you to join us – no matter where you live! Register today for our October APDA Virtual Optimism Walk taking place on Saturday, October 17 at 11:00 am ET. You’ll join an inspiring group of participants from our St. Louis, Connecticut, Iowa, and Long Island Walks (and beyond) as we come together for a fun Online Ceremony & Celebration and then set out to walk locally in our own neighborhoods. Photos and stories from across the country will be shared using #OptimismWalk to add to the camaraderie and sense of community! Register today by clicking here.
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KEEPING IN TOUCH ONLINE

KEEPING IN TOUCH ONLINE
Virtual events have been a great source of information and activity as we all work to adhere to various health regulations and social distancing guidelines. For APDA, keeping people with PD and their families connected, motivated, and informed has been a top priority. As a result, APDA has created many virtual programs and resources, including two special series: Dr. Gilbert Hosts, a live Q&A series featuring expert guests, as well as Let’s Keep Moving with APDA, a series of fitness-focused webinars to help people exercise safely at home.
Stay Informed with Dr. Gilbert
Early on in the pandemic, we saw that our PD community was very concerned about COVID-19 and had a lot of questions about their personal risk. Dr. Gilbert Hosts began as an online series of expert interviews and Q&A sessions to educate people weekly on specific issues related to COVID-19 and PD. Due to the popularity of the program, it is continuing monthly through the end of 2020. You can register for upcoming programs or watch previous sessions online here.
Each episode features Dr. Gilbert and an expert in the field of PD to discuss timely topics and answer questions from the audience.
Coming up next on October 19, Dr. Gilbert will speak with a care partner about the challenges and blessings of caring for someone with PD. We hope you’ll join us. All sessions are recorded and archived in the Educational Video Library on our website, in case you miss an episode.
Keeping Active with APDA
In partnership with the APDA National Rehabilitation Resource Center for Parkinson’s Disease at Boston University, Let’s Keep Moving with APDA was created to help people with PD and their families stay motivated and learn how to exercise properly at home. These short (approximately 30 minutes long) sessions are led by licensed physical therapists and include lots of great Q&A’s from the audience.
Available through APDA’s Educational Video Library, you can view any of the Let’s Keep Moving with APDA sessions, including topics like Be Active at Home: Exercise tips for people with PD; How to Stay Motivated for Physical Activity with Social Distancing; Setting up for Success at Home: Creating an Exercise-Friendly Area; a three-part series on balance and PD; and so much more.
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Planning for the What Ifs – Progressive supranuclear palsy and corticobasal degeneration

Atypical parkinsonian syndromes
Progressive Supranuclear Palsy and Corticobasal Degeneration
As part of our Planning for the What Ifs series, today we expand the definition of advanced Parkinson’s disease (PD) by discussing atypical parkinsonian syndromes (APS), neurodegenerative disorders that are related to PD. Our guest author, Dr. Pravin Khemani, a Movement disorders neurologist at Swedish Medical Center in Seattle and Medical Director of the APDA Northwest Chapter, will discuss two of these disorders – progressive supranuclear palsy (PSP) and corticobasal degeneration (CBD).
PSP and CBD can mimic each other and can also mimic PD early in the clinical course, so it can be confusing and difficult to diagnose. As the diseases progress however, they produce clinical signs and symptoms which assist in their distinction as separate neurodegenerative disorders. Because there can be a significant overlap between PSP and CBD, it makes sense to discuss them together. Both diseases are caused by abnormal deposition and spread of misfolded tau protein in the brain. Hence, they are referred to as tauopathies.
CBD is less common than PSP, and both are significantly less common than PD. Based on one recent study, the combined number of new cases of PSP and CBD per 100,000 people per year was between 3 and 5. Based on these results, PD is about 5 times more common than these two diseases combined. However these diseases are still seen relatively frequently in Movement disorders clinics and many of our readers are grappling with these conditions.
Progressive supranuclear palsy (PSP):
 Since its recognition as a distinct neurodegenerative disorder in 1964, PSP has undergone more than one reorganization into various subtypes based on the increased recognition of its clinical symptoms. In PSP, the distribution of tau protein in specific brain regions is associated with progressive death of neurons which causes clinical signs and symptoms unique to this disorder. The most recent consensus classifies PSP into several clinical subtypes (Table 1). However, the following four primary clinical signs are key features in a majority of cases, although they may not be present all at once in every patient:

Eye movement abnormalities

These are detected by a careful examination which can reveal difficulty shifting the eyes down when not moving the head. Patients may also complain of difficulty walking downstairs, double vision, blurred vision or light sensitivity, and frequent involuntary blinking or forceful closure of eyelids (or blepharospasm).

Unprovoked falls

Early in the disease course when turning, starting to walk or changing position; falls can occur in any direction, but falling backwards is suspicious for PSP.

Parkinsonism

A feature of PD which can be presented with slowness on one or both sides of the body, soft speech, reduced expression, and stiffness. However, a classic PD rest tremor is uncommon in PSP, and mobility does not show long-term improvement with Levodopa.

Behavioral, speech and cognitive problems early in the course:

impulsive and socially inappropriate behavior
apathy which can be misconstrued as indifference or lack of compassion
inflexibility of thought
laughing or crying out of context (also known as pseudobulbar affect)
difficulty following the steps in a task
stuttering speech with words running into each

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APDA Announces Funding For 2020-2021 Research Grants

New, Innovative Parkinson’s disease Research Being Funded by APDA
For people impacted by Parkinson’s disease (PD) the search for answers – the causes, a cure, better treatments – may seem elusive, too slow, frustrating. But all of us at APDA will not give up our pursuit, and rather than be deterred, we are inspired, energized and hopeful about the progress that has been made. And we are particularly optimistic when we see the exciting new work being done by some of the brightest minds in PD and we are extremely proud to support these researchers with funding through our grant process.
Today, APDA announced our research grantees for the year ahead. Our grant recipients are working tirelessly to understand the complexities of PD in an effort to develop new treatments and eventually, a cure, and we are honored to support their work. This year APDA awarded $1.4 million in grants that will support a wide range of fascinating research. This year, we also awarded the first-ever APDA Diversity in
APDA Scientific Advisory Board Members
Parkinson’s Disease Research grant to help address the issues and disparities regarding PD in underserved populations – more info about this new grant below.
The APDA Scientific Advisory Board thoroughly vetted each application and chose these grantees very carefully. While the science can seem complicated and the medical jargon confusing, rest assured that this work is not only significant, but exciting as well. Below, I present the research proposals to you and point out why they are important.
Post-doctoral Fellowships
Post-doctoral fellowships are awarded to support post-doctoral scientists whose research holds promise to provide new insights into our understanding of PD.
April Darling, PhD
University of Pennsylvania School of Medicine
Engineering therapeutic TRIM11 disaggregases
Major question to be answered: Can we create a molecule that efficiently prevents and dissolves aggregates of alpha-synuclein?
Why is this important? Such a molecule could serve as a new therapy for PD.
People with PD have protein deposits in their brain (Lewy bodies) which are composed of accumulated α-synuclein. Preventing α-synuclein aggregation and dissolving pre-formed aggregates may be an effective strategy for treating PD. A class of proteins known as protein disaggregases have the ability to dissolve protein aggregates. One recently identified disaggregase is TRIM11. This project aims to find the most effective variant of TRIM11 at dissolving aggregates and preventing clumping of α-synuclein.
 
Judit Pallos, Ph.D.
Oregon Health and Science University
Mechanisms of LRRK2-induced neurodegeneration
Major question to be answered: How does the protein Prospero, which is known to be involved in outgrowth of nerve cell projections, contribute to nerve cell death in an animal model of PD?
Why is this important? This work will further our understanding of why nerve cell death occurs in PD which may identify new targets for therapy,
Degeneration of the axon (the long projection of the nerve cell that extends out from the cell body to communicate with other nerve cells) is observed in the cells of people with PD as well as in animal models of the disease. Here, the role of the protein Prospero, known to control neuronal outgrowth, will be explored

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