How to Manage Chronic Conditions Through Parkinson’s Stages

While no two people with Parkinson’s disease (PD) experience the same symptoms or rate of progression, there are several chronic conditions they are at greater risk of developing. However, the changes associated with chronic conditions tend to occur slowly and are often manageable. Awareness of these conditions can help you take steps to achieve the best long-term outcomes.  

The following article is based on a Parkinson’s Foundation Expert Briefing about managing multiple chronic conditions in Parkinson’s, hosted by Christina Swan, MD, PhD, assistant professor of neurological sciences and fellowship director, Division of Movement Disorders, Rush University Medical Center, a Parkinson's Foundation Center of Excellence. 

How Parkinson’s Progresses

Parkinson's is a progressive disease influenced by an increasing loss of dopamine, a brain chemical critical for body movement and more, and imbalances in other brain chemicals, including:  

• Acetylcholine, which can impact memory and thinking (cognition).  

• Norepinephrine and serotonin, related to daytime fatigue and sleep disturbances. 

• Low serotonin can also increase depression and anxiety (often successfully treatable in PD). 

Early Stages of Parkinson’s

Slow movements, tremor and muscle stiffness (rigidity) are characteristic movement symptoms of Parkinson’s. Within the first five years of diagnosis, medications that replace dopamine, such as levodopa, are often divided into three daily doses to provide steady symptom control. 

As symptoms and needs change, you and your care team can explore medication adjustments, lifestyle changes and other treatment options. While levodopa can improve many movement symptoms of Parkinson’s, it generally does not treat non-movement PD symptoms.   

Constipation, due to nerve signaling changes in the gut, is common before and throughout the course of PD. It can cause stomach pain, bloating and nausea, and might slow the absorption of medicines. To ease constipation, exercise regularly, aim to drink between 48-64 ounces of water daily and eat a fiber- and plant-rich whole-food diet, along with prunes and bran flakes. 

When diet and lifestyle changes aren’t enough, your doctor might recommend fiber supplements, stool softeners, laxatives or a prescription medication or refer you to a gastroenterologist — a specialist in digestion. 

Mid-stage PD

After living with PD for some time, more frequent levodopa dosing or added medications may be needed. This can be referred to as stage 3 of Parkinson’s. A person with mid-stage PD might experience: 

• Dyskinesia: involuntary, erratic, writhing movements of the face, arms, legs or trunk that develop in response to levodopa.  

• Urinary frequency or urgency, which can increase risk of falls. 

• Neurogenic orthostatic hypotension: low blood pressure related to PD, identified by a drop of more than 20 points when rising. Low blood pressure can lead to fatigue, dizziness, loss of consciousness and falls, and can impact short-term memory.  

To address low blood pressure:

• Drink a minimum of 32 ounces of fluid daily, which can increase pressure throughout the body.  

• Wear above-the-knee compression stockings to prevent blood from pooling in the legs. 

• Talk to your doctor about increasing dietary salt to help your body absorb more moisture. Your doctor might also recommend certain medications, such as fludrocortisone, which helps the body retain salt and water, or midodrine or droxidopa — these help boost blood pressure. 

Advanced PD

After living with Parkinson’s for 10 years or more, people may experience more bothersome dyskinesias and levodopa may wear off more quickly, or sometimes not work at all.  

Swallowing changes (dysphagia) in advanced PD can make it hard to ingest medications, cause coughing while eating or drinking, lead to weight loss, choking or raise the risk for aspiration pneumonia, a complication from food or liquid entering the airway or lungs.  

To addressing swallowing issues:

• Talk to your doctor about seeing a speech-language pathologist, a trained healthcare professional who specializes in evaluating and treating speech, swallowing and other challenges.  

• Your pathologist may recommend a dietician, a nutrition specialist who can help modify diet to ease swallowing and reduce weight loss. 

• Sucking on hard candy can stimulate swallowing and can help clear pooling saliva; botulinum toxin injections can reduce saliva production to match the slower swallow in PD; oral atropine drops can also decrease saliva but can cause confusion in the older population. 

Falls and Balance Issues

Fall risks increase as Parkinson’s progresses. Falls can cause fractures and bleeding, particularly dangerous for someone taking a blood thinner, and are a major cause of hospitalization in PD.  

Balance problems, shuffling or freezing of gait — the temporary inability to move — are common risk factors for falls. To manage freezing of gait, use: 

• A wide stance and take big steps. LSVT BIG Parkinson's-certified therapists are trained to help improve walking. 

• Visual aids, such as painter’s tape or a laser-cue can help a person visualize stepping over a line to maximize movement. 

Medication side effects such as drowsiness and confusion, age-related double-vision (with distance) and PD-related double-vision can raise the risk of falling. Fall risks can be higher in the morning before Parkinson's medications kick in.  

To minimize fall risks:

• Share symptoms with your neurologist and monitor any issues with medication changes. 

• Stay active, exercise regularly and consider physical therapy, which helps people with PD keep moving.  

• See a physical or occupational therapist, who can also recommend mobility aids, such as a rollator, walker or cane.  

• Keep mobility aids near the bed for nighttime bathroom trips. A bedside commode can also decrease fall risks. 

• See your ophthalmologist or seek a neuro-ophthalmologist (a specialist with expertise in vision issues related to neurological diseases) regularly to screen for vison changes.  

• Declutter your home and remove unused furniture to reduce tripping hazards. 

Chronic Medical Problems and PD

There are 90,000 people diagnosed with PD each year in the U.S. The average age of diagnosis is 60. This puts them at risk for other common age-related medical conditions, including: 

• Cardiovascular disease, which leads to more than 800,000 annual heart attacks in the U.S. 

• Arthritis, which impacts more than 1 in 4 American adults and can occur in large joints, such as the hips or knees, or the spine and can further increase pain, numbness and rigidity in someone with Parkinson’s.  

• Osteoporosis decreases bone density, which increases the risk for fractures with falls. Exercise, physical therapy and medication for low bone density can help. 

Diabetes

Diagnosed in 1.2 million Americans, diabetes can lead to damage in organs, blood vessels and nerve endings — causing neuropathy (numbness) in the feet and elsewhere. Along with diabetic vision changes, neuropathy can increase issues with balance for people with PD.  

Persistently high blood sugar can impact memory and thinking, as can Parkinson’s brain changes. Consider:  

• Regular foot exams to detect neuropathy, careful monitoring of blood sugar, periodic monitoring of kidney function and consistent exercise can help detect and manage diabetes in someone with PD. 

• Diabetes can damage the kidneys. Common medications used in Parkinson's, such as amantadine and gabapentin, are solely processed by the kidney. These may need to be adjusted or eliminated in someone who also has diabetes. 

Avoiding Medication Interactions

Work with your healthcare team to coordinate care and share information across specialists to ensure everyone has a picture of your medical management — including prescribed medications and possible interactions. 

Parkinson's medications generally have a low interaction risk. Of note:  

• Iron can decrease the absorption of levodopa.  

• Medication such as metoclopramide (to treat slow stomach emptying in diabetes) or prochlorperazine, can block dopamine receptors and worsen PD symptoms. 

• Monoamine oxidase B (MAO-B) inhibitors rasagiline and selegiline, used in PD care, can interact with medications used for cough and colds, such as Sudafed, dextromethorphan or phenylephrine, causing dangerously high blood pressure.  

• Some anti-depressants, such as mirtazapine, can also interact with rasagiline and selegiline to spike blood pressure. 

Learn More

To discover more about managing health in Parkinson’s, explore these resources: 

• Managing Comorbidities with Parkinson’s Disease 

• Tackling Neuropathy, Fatigue and GI Issues in PD 

• 4 Ways People with Parkinson’s Can Avoid Common Hospital Complications