Parkinson’s disease (PD) is a progressive neurological illness affecting the basal ganglia causing neuronal cell death of the dopamine producing cells within the substancia nigra as well as neuronal death in other parts of the brain including the brainstem. Rest tremors, rigidity, gait impediments, and marked slowness of movements (commonly referred as motor symptoms) are the hallmark of this disease. However, there are also many other non-motor symptoms involving sleep, cognition, behavioral problems, and autonomic dysfunction. Among these dizziness is a common complaint among people living with PD making up to 30% of those over the age of 65.
So what is dizziness?
Because the term dizziness is so imprecise due to the fact that it can refer to vertigo, syncope, disequilibrium, general weakness, or a non- specific feeling such as giddiness; It is often dismissed by healthcare providers as trivial if one complains of ‘dizziness’ purely as a non-specific symptom. First, we have to understand what we mean by feeling dizzy- some people think of this as the room spinning or a sense of self spinning- this is actually known as vertigo and implies a different cause (etiology). While a feeling of unsteady in your feet when walking and actually veering or falling to one side as opposed to just falling all over the place implies more than loss of balance but rather a structural abnormality within the brain or ear canal. Some people feel lightheaded instead- feeling faint, and may complain of feeling a sensation of swimmy headed/ water inside the head.
So as you can see there are a multitude of causes of ‘dizziness’ and in order to get the right treatment you must learn to be specific with your problem.
The Medical definition of dizziness is- either someone who is mentally confused or is having a feeling of whirling in the head with a tendency to fall.
In order for someone to walk normally without unsteadiness or loss of balance, one must have intact sensory input (eyes, ears, nerves in feet referred to proprioception as well as intact cerebellum; extrapyramidal system-one involved in PD; and cerebral cortex). As you can see there are a lot of places where we can have a deficit causing us to feel ‘unsteady’ and ‘dizzy’ making us prone to fall or become confused.
Causes of Dizziness in PD:
- Neuro-otological- meaning inner ear problems
- Cardiovascular disease
- Multisensory dizziness syndrome- meaning poor input from various sources i.e. eyes, ears, nerves, etc.
- Cervical vertigo
- Postural hypotension
- Postural instability due to tremors/dyskenesias
- Pisa syndrome- antero-flexion of the trunk leading to loss of balance by shifting gravity forward- treat with brace, botox and medication adjustment.
- Migraines- occipital (basilar migraines) may present only as dizziness and nausea without headache- common change in people who had migraines all of their lives. Stalevo and levodopa compounds are more likely to trigger. treatmnent migraine medications – e.g. maxalt, imitrex & preventive meds such as Topamax or keppra
- BPPV-Benign Positional Vertigo- treated with vestibular therapy
Treatments of dizziness:
The most important thing to discovering and treating the cause of your problem is a good detail history. This includes:
- What do you mean by dizziness? Is it vertigo or light-headedness or swimming sensation in head or a feeling of confusion, etc.?
- Are you falling? Or simply unsteady?
- When does it occur? (After medication, before medication?)
- How long does it last?
- What makes it better? What makes it worse?
- Other symptoms? Ringing in ears? Hearing loss? Numbness in feet? Weakness? Headaches?
- Chest pain?
- Only when you stand still? Or walking?
- Neuro-otological– it is important to have yearly check- ups of hearing and sight especially as we age. This is the number one cause of falls and unsteadiness in older people because the sensory input from these areas are no longer functioning as well as we would like. Especially in PD we already have vision problems including loss of contrast and difficulty moving eyes more so if you have PSP – vision is extremely limited in the vertical plane resulting in frequent falls because people are not able to see changes in sidewalks, like small steps. The other group who might have had essential tremor initially and then developed PD may suffer from significant hearing loss which is one of the hall marks of ET- which may then contribute to poor equilibrium.
- Get hearing aids and/ or prisms to help with these types of problems that lead to disequilibrium. This means seeing an ENT doctor and possibly getting an MRI brain, an electronystagmogram (ENG)- this test helps distinguishes between abnormalities in the vestibular system, brainstem, and cerebellum, and having a hearing test done. Also may need to see a specialist called neuro-opthalmologist if your regular eye doctor is not able to detect any eye abnormalities but have trouble seeing resulting in falls.
- Cardiovascular-of as we age we also have tendency to develop heart disease, women are not excluded from this- after menopause we have same risk as men. Furthermore, although it is still controversial and not well publicized most of the dopamine agonists do increase the risk for arrhythmias (this risk increases with age in my opinion and needs to be monitored especially if already have risks for heart disease or family history of such). I myself have developed a secondary heart degree block since I have been on my medications. This type of problem usually presents in the middle of the night but can occur anytime a person goes to the bathroom to void, they may experience near fainting or actual fainting- this is extremely serious and need to seek medical attention ASAP from cardiologist!
- Drugs-most of the drugs used for PD because they work on the neurochemicals can potentially alter cognitive status especially if have underlying dementia or a Parkinson’s plus syndrome. But in PD patients these medicines can often cause sleepiness making one feel somewhat unsteady and dizzy particularly when in a moving vehicle it may trigger actual spinning sensation even when the vehicle comes to a sudden stop. This feeling is more common with benzodiazepines (e.g. klonopin, valium, etc.) The dopamine agonists are more likely to cause sedation, the one least likely is Neupro patch. One way of counteracting is taking medications like Provigil & Nuvigil (narcolepsy drugs often used in PD to help maintain alertness). However, one simple solution is when you feel this way lay down and take a small nap- problem solved. If unable to function because feeling unsteady, and spinning talk to your doctor about adjusting your medication especially if you are actually experiencing outright confusion and disorientation.
- Multisensory dizziness syndrome– the biggest thing here is loss of proprioception- feeling or sensory input from the ground due to peripheral neuropathies. This is common from B12 deficiency, a common problem in PD easily corrected by checking blood work- levels should be in the 1000’s replaced only via IM B12 injections or nasal spray. Other common causes is diabetes – this is a risk that increases as we age plus as I mentioned in other blogs PD patients may be at higher risk of developing Diabetes due to insulin resistance cause by dopamine intake since it shuts down the pancreas. I suggest close monitoring of your sugars especially if had PD for a long period of time and/or have family history. * see how to tell if you are at risk of diabetes. Take B1- thiamine 100mg a day to protect against neuropathies. Another reason people may have sensory loss in their limbs is due to stenosis/herniated discs in neck and lumbar spine – frequent problems in PD. In order to avoid this from becoming chronic irreversible problem seek immediate medical attention if have pain, weakness or numbness shooting down a limb.
- Cervical vertigo- as I said above cervical stenosis can cause problems of proprioception- since head and neck move together any compromise of the neck disrupts the input into the brain- this may be one of the biggest problems in PD since so many of us as we advance in our disease experience problems in our neck due to dystonia/ dyskenesias/ and increased rigidity. Not only will this affect sensory input coming in as well as going out but may also disrupt blood flow into the brain by compromising the vertebral arteries if there is abnormal positioning of the neck. Hence it is extremely important that if you are experiencing neck issues especially in light of dizziness, vertigo or unsteadiness- seek immediate medical attention to adjust medications, get Botox, DBS or neck surgery and even take a blood thinner in form of aspirin to maintain blood flow if not contraindicated. The advantage is that an aspirin a day may also be beneficial (possibly neuro- protective) in PD.
- Postural hypotension –the #1 cause of dizziness and falls in PD patients. Most medications can cause low blood pressure upon arising quickly leading to loss of balance or falls as you first get up from sitting or lying down. Sometimes can be severe that it lasts several hours making gait difficult. When hypotension is medication related you will notice this symptom an hour -2 after medication intake and will improve as medication wears off. Usually most severe within first hour. Some patients if they have Parkinson’s plus syndromes like Shy dragger, LBD, or PSP may have symptoms from the beginning even before medication intake. These patients need to be on hypotension precautions like wearing support hose (ted hose, compression hose that go to their thighs), sleep with head of bed elevated at 45 degree angle (can get a bed tempurpedic mattress, or put a few bricks at head of bed), do not shower with hot water- only warm, drink cold water during an episode, and take medications like salt tablets, Northera, Midrodine, Fludrocortisone, and others like Rameron (because of increased BP potential). If you have advanced PD, you also may have this problem and may need to resort to similar symptoms. However, if you have early onset PD and are experiencing this type of side effects- one try adjusting medications or switching to another type. Sometimes taking meds on a full stomach helps decrease this side effects or taking meds early in am and going back to bed and sleeping symptoms off are some of the possible strategies to dealing with this issue. Talk to your doctor as soon as possible if you are experiencing light-headedness, dizziness, and disequilibrium and faint feeling upon arising. Also remember to get up slowly from sitting or lying down.
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