Parkinson’s disease is the second most common form of neurodegenerative illness, only after Alzheimer’s disease. In fact, two percent of the population over age 70 has Parkinson’s disease.
This episode, for Parkinson’s Awareness Month, we’re talking with expert Dr. Rodolfo Savica. He’ll break down the difference between Parkinson’s and Parkinsonism; why doctors are seeing a triplication of risk of the disease; and the promising future of Parkinson’s management.
Powered by RedCircle
Listen to 3 early indicators of Parkinson’s disease
Read the Transcript:
Dr. Christina Chen: Today our conversation is with Dr. Rodolfo Savica, who is a professor of neurology and a Parkinson’s disease specialist at Mayo Clinic in Rochester, Minnesota. In fact, his work spans across all types of dementias and movement disorders, driving research in better understanding neurodegenerative conditions. Welcome, Dr. Savica, to our podcast today.
Dr. Rodolfo Savica: Thanks for the invitation, Dr. Chen. Thanks a lot.
Dr. Christina Chen: Our discussion is on Parkinson’s disease, not just understanding it, but how to manage it. Most importantly, how do we live well with it? Just to start from the basics, really breaking it down. What is Parkinson’s disease?
Dr. Rodolfo Savica: There’s a lot of confusion about Parkinson’s disease. Parkinson’s disease is a degeneration for the most part — we will clarify what I mean with that. It’s a degeneration of a group of cells that cause a dysfunction in some of the neurochemicals of the brain.
What I mean is that because we are all producing a chemical called dopamine, it’s the chemical that allows us to be here today talking to you. Have dinner later, have fun with our friends, overall help us in our daily life, whatever we want to do. For whatever reason, people with Parkinson’s disease, the cells that contain dopamine, are dying earlier and this causes a problem with usual movements, but not only.
The fact that it’s a degeneration means that it’s a progressive disorder that causes the cell to continuously die. Classically we say that if you lose at least 50 to 70 percent of cells in one particular area of the brain called basal ganglia, which is deep inside the brain and contains dopamine, this is when the symptoms start.
Dr. Christina Chen: What is the prevalence of Parkinson’s Disease?
Dr. Rodolfo Savica: The disease is very common. It’s the second most common form of degeneration after Alzheimer’s disease. 2 percent of the population after the age of 70 has Parkinson’s disease.
Dr. Christina Chen: That’s quite a bit.
Dr. Rodolfo Savica: It’s quite a bit indeed. But after the age of 75, two out of the four symptoms of Parkinson’s disease can be seen in 40 percent of the general population without them having Parkinson’s, as a means of aging of the cells. As we get older there’s an increased risk because aging is a component of that.
There’s vascular damage, there’s things happening to the brain. If we all lived to be 150 years old, we’re all gonna have Parkinson’s. Why? Because our cells will die.
Dr. Christina Chen: Do we know more about why some people get it and others don’t? Why do some people have more risk factors?
Dr. Rodolfo Savica: Unfortunately, the problem is that there’s not one single factor that we can pinpoint. Very simplistically, we can say genetics versus environment. We know that there are some genes, some mutations that people have that increase dramatically the risk of Parkinson’s disease.
Together with environmental factors, the combination increases the risk. But also some people do not have any mutation and yet have Parkinson’s disease. Why? Likely because they have a much more environmental weight into their life. When I talk about environments, I’m talking about.
Lifelong exposure, even before we were born. When we are in the womb with our mother, we are already exposed to these factors: the food we eat, the oxygen we breathe. This is the environment.
Dr. Christina Chen: Right, right.
Dr. Rodolfo Savica: There are studies showing how pollution increases risk of Parkinson’s disease. How water wells contaminated with pesticides can increase the risk. There’s a number of important information for public health. But ultimately, there are some people that are predetermined to have an increased risk.
Dr. Christina Chen: Interesting. I just have to ask the role of stress in all this because I feel like our nation is chronically stressed and I mentioned this because I have a handful of patients who are fine.
My observation is that they went through something very stressful, either a health issue or major surgery or something that changed their physiology.
Then all of a sudden, like a year later, they start to develop symptoms. It’s like, is there some sort of correlation there?
Dr. Rodolfo Savica: Dr. Chen, that’s a fantastic observation. As a clinician, you can see that. I also add stress in the sense of temporary cellular damage that can come from infection, as you mentioned, stress, surgery, anxiety, major loss, depression.
As you know, the inflammatory condition is a fuel to the fire. Clearly it’s true. Everything that you just mentioned so far. I would add the typical example we hear in a clinic is COVID. People had COVID and after COVID things went south. Why? Because COVID increased the inflammation, the systemic inflammation, the total inflammation of the body. It’s true to say that these patients maybe were going to have Parkinson’s anyway. The stressors, the infection, the surgery just accelerated.
Dr. Christina Chen: I see.
Dr. Rodolfo Savica: It made manifest something that was going to develop anyway.
Dr. Christina Chen: Okay, just earlier.
Dr. Rodolfo Savica: Maybe in a few years. That’s an important point because it’s telling, as you say very well, how unhealthy lifestyle, even mental health issues are a trigger for other diseases.
Dr. Christina Chen: Have you seen a general trend towards a younger age of onset now? Like, what was the previous average age and now what are you kind of seeing?
Dr. Rodolfo Savica: The average age of the population ranges between 65 years of age to 72, 73. We were trained that early onset, young onset Parkinson’s was something that happened only in very young people with a lot of genetic risk factors in large families.
They all have a gene that was defective. It’s not the case anymore. We are seeing a constant increase at any age. The overall age is still around 65. But the number of patients that are affected by Parkinson’s really estimates a triplication of the risk of the numbers.
Dr. Christina Chen: Wow.
Dr. Rodolfo Savica: Triplication to three times more. Which is a lot.
Dr. Christina Chen: Yeah.
Dr. Rodolfo Savica: Not just as we get older.
Dr. Christina Chen: Yeah.
Dr. Rodolfo Savica: But also in the younger people. It’s something that impacts public health massively. Healthcare massively, not only with the aging of the population, but if we see younger individuals having Parkinson’s disease more often now, those are people that, generally speaking, are still in the workforce.
They still have young families, they’re still active and they’re impacted by this condition. It’s a little bit different as a societal aspect. But also, most importantly, cause challenges from the diagnosis standpoint when you’re younger compared to when you’re older.
As a internal medicine doctor, a geriatrician, if somebody comes to you in your 30s and 40s, you’re not suspecting right away Parkinson’s disease. Epidemiologically you’re thinking, “Ah, it can be something different.” But sometimes there is.
Not to be cynical, but also, younger individuals in the past were dying earlier because they were involved in war. I see. They’ve become soldiers. They maybe weren’t making it to 40 and 50s. Yeah. Which is something that’s changed now. So, why we are seeing this change, we are not yet totally sure.
Dr. Christina Chen: Perhaps we’re seeing it now more because people are just living longer. Now, I want to spend some time kind of distinguishing between Parkinson’s disease and Parkinsonism, which is a little bit different. But can you describe what the difference is and when do you see Parkinsonism as opposed to the disease process?
Dr. Rodolfo Savica: Absolutely. This is one of the sources of major confusion sometimes that you see between patients and also clinicians.
Dr. Christina Chen: Yeah.
Dr. Rodolfo Savica: Parkinsonism is a term that includes everything including Parkinson disease. It’s a bigger term. Parkinsonism is a group of disorders where people have some specific features and symptoms.
Basically stiffness, what we call rigidity, slowness of movement, what we call bradykinesia, tremor and tendency to fall. If you have two out of these four, this is Parkinsonism, and one of them has to always be slowness of movement.
Once we define Parkinsonism, then we have to understand a subtype. Eighty percent of Parkinsonism is Parkinson disease. Parkinson’s disease is the most common form.
Usually, the first appointment that people are getting with a physician, we tend to use the word Parkinsonism because we don’t know quite yet what is what. But soon, we will know.
Parkinson, again, is the most common one, and has some features similar to Parkinsonism, which includes slowness of movement, falls, stiffness, and Tremor. But the tremor needs to be at rest. The tremor has to usually be one side when the hand or when the leg is completely at rest, and is not moving, and is not active.
Sometimes people confuse the action tremor, the one that is present when we are drinking a cup of coffee and people are shaking, as a feature of Parkinson’s. It’s not a feature of Parkinson’s, it’s something different.
Other than Parkinson’s disease, there’s a number of other disorders that are really close cousins of Parkinson’s disease. Such as multiple systematography, PSP, CBS. They are very similar, but they’re not Parkinson’s disease. They’re still called Parkinsonism because they’re part of this bigger umbrella term. But then it’s one of the subtypes.
Dr. Christina Chen: I see a lot of patients with Alzheimer’s dementia and in their late stages, they become more bradykinetic and slow. Like you mentioned, they don’t say as much, but they may not have the tremor aspect, but that can also be under the umbrella of Parkinsonism.
If someone has not yet been diagnosed with Parkinson’s disease, are there early ways that we can spot some signs and symptoms, perhaps decades beforehand?
Dr. Rodolfo Savica: Yes. Historically, we have been told that there’s a number of symptoms that are quite specific. But when you see them in retrospect, after the diagnosis, you can identify them as present for 20, 30, 40 years. One of them is the lack of sense of smell, what we call anosmia, but anosmia is very common in many circumstances, allergies, COVID and other things.
It’s not everyone who has anosmia. Another one that is very common can occur two to three decades before the start of the disease is constipation. But as you can imagine, constipation is like half of the population.
Or another one that is way more specific, however, is what is called the dream enactment behavior disorder. They’re having bad dreams and they start to thrash, punch, kick and talk, to the point that sometimes they can be aggressive to their bed partners because they are dreaming of being assaulted, so they punch back.
This is a condition that we know is a precursor of all sorts of disorders, and we know 98 percent of patients with this particular condition have the risk of developing Parkinson’s or Dementia Lewy bodies within 20 years.
But it’s fair to know and fair to say that when you ask our patients, sometimes you’ve been told that they have been doing this ever since they were kids.
Dr. Christina Chen: Well, you’re describing my husband, too.
Dr. Rodolfo Savica: You see, it’s not necessarily, again, specific. Another important thing I want to mention about these symptoms is that for a while they were considered pre-motor symptoms, the one that occurred before the tremor, the stiffness. Still, we have to understand that this is very valid for people who have late onset Parkinson’s disease. People in their 70s and 60s and so forth.
When people are younger, this is not valid. That’s not exactly what we see. It has to do with the biology underlying the two different conditions. But this is a race, if I identify something that I know can then become Parkinson’s, I would like to do anything I can to stop it and to identify this early group of people.
Currently, people that have dream enactments, so living out their dreams, are the ones that we should pay more attention to in terms of being precursor of the disease.
Dr. Christina Chen: As the symptoms progress what do you feel like has been the hardest part for people to live with Parkinson’s as far as the motor components, the functional aspects? And are there different parts of the disease that make it very difficult to live with?
Dr. Rodolfo Savica: That the most challenging part of having this disorder is that there’s a group of patients that have what we call fluctuations. In other words, they respond well to the medication.
Dr. Christina Chen: Yeah.
Dr. Rodolfo Savica: But they are swaying between having too much meds or too little meds. Therefore, the response is quite short, like maybe one hour, and the rest of the day they feel very bad. Nowadays, thankfully, technology has improved so much. We have a number of advanced treatments for people that fluctuate, and a number of medications that we can use.
The problem that we have nowadays is that we are still thinking that Parkinson’s disease is one disorder, and it’s not. Even when you have fluctuations, you cannot treat people the same way. That should be tailored for the patient.
This is what we are trying to do in Parkinson’s, tailoring medication, treatment, adjustment. That is challenging for the physician. That is challenging for the patients, also because sometimes you go online, and you’re looking for support and you find that your disease is quite different from somebody else’s.
Dr. Christina Chen: Right, right.
Dr. Rodolfo Savica: Then you hear horror stories about how things have been terrible. They maybe don’t represent the truth, they represent one truth, one story, but it’s not the global story of what’s going on.
Dr. Christina Chen: Yeah.
Dr. Rodolfo Savica: That is to me the most challenging part.
Dr. Christina Chen: Everyone’s presentations are different and everyone responds differently to treatment.
Dr. Rodolfo Savica: Absolutely so.
Dr. Christina Chen: Yeah. Let’s quickly talk about just the diagnostic part.
Dr. Rodolfo Savica: Walk us through how you approach a new patient with a diagnosis. What does that process look like? In general in neurology, in movement disorders, we are still putting a lot of effort, a lot of time into collecting a medical history. A very good medical history is still the main part of our journey.
Family history can be important, but it’s more important to have the personal medical history, the symptom history, how things developed, and so forth. Every patient comes to see me for tremor, I will ask tons of questions to understand the nature of the tremor.
You see your physician, they ask you their questions, do the neuro exam, and they examine you thoroughly to look at all the possible motor features of Parkinson’s disease.
Once this is there, you may already have a good idea that we are dealing with Parkinson’s disease. If the features are not quite classic, you may order some additional tests. As we know, many people nowadays do a brain MRI, mostly to exclude other causes.
It’s common nowadays to obtain something called a DAT scan. This looks at the level of dopamine in some part of the basal ganglia. It can confirm the absence of the activity of dopamine.
Therefore it can give me strength to start the medication safely, and can give me some information regarding the diagnosis, but is not able to differentiate between Parkinson’s and other Parkinsonism. It just tells us that there’s a deficiency of dopamine. That’s it.
Dr. Christina Chen: Any other tests? What about other tests?
Dr. Rodolfo Savica: Nowadays, there are tests on the spinal fluid. Looking at the presence of this particular protein called alpha synuclein, which is the protein that tends to accumulate in the most common cause of Parkinson’s disease.
It’s a spinal tap, so we have to take some fluid from the back of the patient, look under the microscope, and see if the protein is present or not present. Again, it’s not telling us more than that present, no present.
Another new trend that we are seeing is the presence of skin biopsy, which is basically the same story, looking at alpha synuclein in the skin. But unfortunately, the test has been, I’m sorry to say, abused. People are thinking that with this test you can know whether you have Parkinson’s or not.
You cannot use this test to say, Parkinson, yes, Parkinson, no. The test is telling us if you have an accumulation of alpha synuclein in the skin. It doesn’t tell you the nature of the disease. You may have an accumulation of alpha synuclein for many other reasons.
Let’s assume that I am pretty sure that somebody has Parkinson’s disease. I would tell them, “I think you have Parkinsonism,” likely Parkinson’s disease, DAT. A Dat scan was done. It was positive.
Okay. Maybe order a genetic test because they’re young, maybe not, depending on what I want to be doing there. What I would say, one of the most important things is to do an adequate trial with medication. The medication I’m talking about is Levodopa.
It’s been around for a while. We know everything about this drug, it’s still the gold standard for the treatment of Parkinson’s disease if the patients are taking the medication properly. They should be taking it one hour before every meal, not with food, three times per day, with an escalating dose, increasing the dose every week, up to the maximum tolerated dose. If I’m able to do that, I want to see a 50 to 70 percent response.
It means that the patients will come back to us and tell us, after a few weeks, “I’m doing 70 percent better, 50 percent better.” If this is the case, then you can say this is likely Parkinson’s disease.
It’s possible that with time we have to adjust doses, changing a little bit of things, see what are the side effects. But this is the prototypical journey of somebody. The problem is that, as you know, sometimes the difficult part is doing the initial referral, coming to the proper specialist or to the geriatrician, doesn’t really matter. It’s sometimes difficult to do the first step. That’s what can be the major delay.
Dr. Rodolfo Savica: It’s not in the diagnosis, but in reaching the point when you are looking seriously at the diagnosis.
Dr. Christina Chen: How about on the other end of the spectrum? Is there a role for all these diagnostic tests to be applied? Say, if you have a younger patient who can’t smell constipated, having dream enactment behavior in their forties. Is there a role of diagnosing early?
Does that change outcomes if they were placed on medications earlier before full symptom onset? Because to your point we see patients when they’re already coming in with symptoms and by that time outcomes are different, but younger, catching it early. Is there a difference there?
Dr. Rodolfo Savica: Let’s preface by saying that currently in all this field of neurology, we don’t have a medication that can delay the progression of disease as a whole. If somebody’s young, having the opportunity of approaching this test and catching something early can be relevant for a couple of reasons.
In the meantime, you can improve the symptoms even earlier on, providing good years of living well without having pain, discomfort, tripping, falling on the ground, being slow and so forth. But also, when somebody’s young we have to consider alternative diagnosis. It’s fair to call people early onset Parkinson’s disease before the age of 50 for example.
But the vast majority of these patients have something different. The feature is Parkinson’s disease. But in reality they usually have adult onset children disease. There are pediatric diseases that occur later in life. Some of them we have a treatment for already. This can change quite markedly the outcome of the patient.
I know medications can’t cure the disease, but in terms of prevention and reducing the risks, I went to one of your lectures where you cited quite a few studies to show how exercise may have benefits to delay progression.
Dr. Christina Chen: I guess my thought is if we knew our risks of Parkinson’s is high and we had that earlier diagnostic image of it could we implement some of these lifestyle measures earlier on to prevent?
Dr. Rodolfo Savica: We have to. We have to. I mean, I would say, even if you don’t know your Parkinson’s disease, everybody should try to have a healthy lifestyle in general, because this will reduce a huge cardiovascular risk factor, and degeneration, but also can really delay the progression of disease.
We have experimental data on animals, on humans, showing that indeed, the seniors that are active socially, mentally, and physically, are the ones that are doing better.
The ones who are exercising, the ones who are doing this early on, the ones who didn’t start later in life, the ones who have had throughout their life, a good, healthy lifestyle. They can be affected by whatever condition, but they are better equipped to do that. In Parkinson’s disease specifically, exercise is key.
We are talking about something that is affecting the movements as such, we have to keep moving. Unfortunately, in the evolution in medicine, one of the reasons why people are thinking that Parkinson’s is on the rise is the sedentarism.
Sedentarism is not. I’m a couch potato watching reruns. It’s not that. Up until 120, 130 years ago, if you had to go to work, you had to take a horse, or you had to walk. You are always on the move.
Nowadays we are not as much. Even the most active people are still affected by this particular aspect of being sedentary. Way more than our ancestors.
Dr. Christina Chen: Can you share some personal stories of people that you’ve taken care of in your practice who’ve learned to live well with Parkinson’s and managed to live with this disease process?
Dr. Rodolfo Savica: Absolutely, more than a single story, I would like to mention something more generic. That a lot of people have Parkinson’s disease, we don’t even know they have.
You can see them in the street, you can see them actors maybe, and if they’re treated well you will never know they have Parkinson’s disease. People will be shocked that they have been having Parkinson’s maybe for 10, 15, 20, maybe 30 years.
We never know about that. You will never tell. Why is that? Because those are the people that are proactive, the ones who are careful, the ones who are doing the right things, the ones who are doing well.
I want to tell you about this patient that came from overseas with her husband. She couldn’t walk. She was in a wheelchair. She came to my office in a wheelchair, unable to walk a few steps without assistance, and she clearly had Parkinson’s disease. She was a bit older.
I started on the medication, and then I saw her back some time ago and she was doing great.
One day she told me, “I’m back, I want to see you,” and she said, “I don’t know how I’m doing, I’m not sure. But they showed me the video of their 50 year wedding anniversary celebration. In the background, she was dancing.
Dr. Christina Chen: Oh, my God.
Dr. Rodolfo Savica: I say, this is better than any test and examination. In the background, when you didn’t know that somebody was watching, you were dancing freely and you were perfect. Nobody would tell you that you have Parkinson’s disease. That’s exactly for me, much better than anything else.
Dr. Christina Chen: That’s a beautiful story. It’s amazing what a little bit of dopamine can do.
Dr. Rodolfo Savica: Correct. Correct.
Dr. Christina Chen: But not too much, though. You have to find that balance.
Dr. Rodolfo Savica: Whatever works for you, whatever works for the patient, again, as usual, it’s individual. But other than that, dopamine can do a lot.
Dr. Christina Chen: What’s in the future for Parkinson’s management? There’s stuff out there about stem cell transplants and these neuron repair treatments, gene therapies, hyperbaric oxygen. There are even clinics dedicated to just providing all these treatments in one place. You pay a lot of money for it. Like is any of this stuff working?
Dr. Rodolfo Savica: The short answer is no. All these, I tell you, you mentioned hyperbaric chamber, neural repair, even stem cells. This procedure is very helpful for the heart, for the joints, and for the liver. We cannot use this procedure for the brain. We don’t have the technology to make sure that the cells are going back to the brain, number one.
Number two, the cells of the brain are perennial. You’re born with a set number that can change a little, but it’s a set number. The same cells are with you basically all your life. Different in the liver, different in the joints, there’s a constant turnover. That makes things way more complicated for the brain.
Dr. Christina Chen: That’s all you got.
Dr. Rodolfo Savica: Correct. That’s all you got. But there are no clear studies to suggest using this procedure. It’s not free or risky. To me, if you ask me what the future, it is individualization.
Individualizing the treatment means that we will be able to identify the moment that patient we are seeing for the first time will be the group of medications, the group of treatment, the things that we can do to prevent the progression, or at least to stabilize the progression. That’s what I mean with individualization.
Customization of prognosis, customization of treatment, customization of the future. Because one of the questions that I’m more stressed about, because I don’t know how to answer correctly, is that, okay, you gave me this great diagnosis, so what? Now what’s next?
Dr. Christina Chen: Right, right.
Dr. Rodolfo Savica: We’re trying to answer this, what’s next? Because that’s exactly what will have an impact in the life of patients. In addition, let me say another thing that is super important. One of the most difficult things that we have to do, sometimes is taking the pills, taking the pills on time, having the reminder three, four, five times per day, short duration and whatever.
Dr. Christina Chen: Yes, prescription adherence is one of the hardest things for most patients. Is there anything to help?
Dr. Rodolfo Savica: One of the systems that is very interesting is the subcutaneous delivery which is already FDA approved and it’s been approved in Europe already. The same concept of the diabetes pump, the pump for the insulin A subcutaneous pump that people can remove when they need.
We deliver straight in the bloodstream, the medication 24/7. The medication would be levodopa, and would help a lot with compliance and with the fluctuation of response, and the future now means that we can use it now.
And we are having quite a success with the right candidate, but I see that as the future. To me, that would be what almost everyone would do.
Dr. Christina Chen: It makes sense. We need a steady stream of dopamine at all times.
Dr. Rodolfo Savica: Correct. You don’t need to go up and down. You just press start once a day.
Dr. Christina Chen: Yeah.
Dr. Rodolfo Savica: That’s it.
Dr. Christina Chen: We have a closing traditional question for our experts on our podcast. What does, aging forward mean to you, and how do you personally age well? How do you take care of your brain health?
Dr. Rodolfo Savica: The way I keep my brain healthy and well is to be active, and spend time with my family. But the most important thing is really working out and searching for pleasure. That’s crucial. As we age, we are enjoying things that we couldn’t enjoy before. I see aging as an opportunity, not necessarily a loss. Clearly I’m not in my 20s anymore. At times I wish I was, at times I am happy I am not. It’s an opportunity.
Dr. Christina Chen: Love that. Well, thank you so much for your time today and giving us such a great overview of Parkinson’s disease management.
The goal of our podcast is not just to help us stay more informed, but to help our readers and listeners find hope and empowerment. With how far science has taken us.
How do we find ways to live well just like Dr. Savica has shared in our current health situations and so thank you for contributing to that.
Dr. Rodolfo Savica: Absolutely. It’s a pleasure being here.
The post 3 early indicators of Parkinson’s disease appeared first on Mayo Clinic Press.
