Our Parkinson's Place: "EARLY MORNING OFF" IN PARKINSON'S DISEASE

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Monday, April 25, 2016

"EARLY MORNING OFF" IN PARKINSON'S DISEASE

25th April 2016

Early Morning Off (EMO) is a symptom experienced by people at every stage of Parkinson's Disease. However, few studies have assessed how common it is, leaving the extent of its impact almost completely unknown. A graph showing the effects of EMO:

EMO occurs as there is a delay in the effect of the initial dose of oral medication, possibly due to gastroparesis.

The analysis assessed the responses from 2205 completed surveys. People with Parkinson's Disease who felt they had EMO amounted to around 80%, with 37% of them stating that EMO was a daily occurrence. The prevalence of EMO increased as Parkinson's Disease worsened. However, even 52% of people with early Parkinson's Disease had EMO. The Quality of Life of those with EMO was also significantly reduced and the odds of caregivers feeling a sense of burden was higher.

The prevalence of EMO in the survey results was high, and significantly lowered the persons Quality of Life. EMO was also observed in the early stages of Parkinson's Disease.

Reference : Journal of Neurological Science [2016] 364 : 1-5 (R.Onozawa, J.Tsugawa, Y.Tsuboi, J.Fukae, T.Mishima, S.Fujioka)

Complete abstract : http://www.ncbi.nlm.nih.gov/pubmed/27084204

http://www.viartis.net/parkinsons.disease/news/160425.pdf

Gastroparesis is a chronic (long-term) condition in which the stomach cannot empty itself in the normal way.

It means food passes through the stomach more slowly than usual, leading to symptoms such as:

feeling full very quickly when eating
nausea (feeling sick) and vomiting
loss of appetite
weight loss
bloating
abdominal (tummy) pain or discomfort
heartburn

These symptoms can be mild or severe, and tend to come and go.

If you think you may have gastroparesis you should see your GP, as it can lead to some potentially serious complications, including:

dehydration from repeated vomiting
gastro-oesophageal reflux disease (GORD) – where stomach acid leaks out of your stomach and into your gullet
malnutrition – when your body is not getting enough nutrients
unpredictable blood sugar levels – this is a particular risk in people with diabetes (see below)

What causes gastroparesis?

Gastroparesis is thought to be the result of a problem with the nerves and muscles controlling the emptying of the stomach. If these nerves are damaged, the muscles of your stomach may not work properly and the movement of food can slow down.

In many cases, the cause is unknown – this is known as idiopathic gastroparesis.

Known causes include usually poorly controlled type 1 diabetes or type 2 diabetes. The nerves to the stomach can be damaged by high levels of blood glucose. Therefore it's important to keep your blood glucose levels under control if you have diabetes. Read about healthy living with diabetes.

Gastroparesis can also be a complication of some types of surgery, such as weight loss (bariatric) surgery or a gastrectomy (removal of part of the stomach).

Other possible causes include:

medications such as opioid painkillers (for example, morphine) and some antidepressants
Parkinson's disease – a condition in which part of the brain becomes progressively damaged over many years
scleroderma – an uncommon disease that results in hard, thickened areas of skin and sometimes problems with internal organs and blood vessels
amyloidosis – a group of rare but serious diseases caused by deposits of abnormal protein in tissues and organs throughout the body

Diagnosing gastroparesis

To diagnose gastroparesis, your GP will ask about your symptoms and medical history, and may arrange some blood tests.

You may be referred to hospital for some of the following tests:

a barium X-ray – you swallow a liquid containing the chemical barium, which shows up on X-ray and highlights its passage through your digestive system
a gastric emptying scan using scintigraphy – you eat food (often eggs) containing a very small amount of a radioactive substance that is detected on the scan; gastroparesis is diagnosed if more than 10% of the food is still in your stomach four hours after eating
a wireless capsule test – you swallow a small, electronic device that sends information about how fast it moves through your digestive tract to a recording device
endoscopy – a thin, flexible tube (endoscope) is passed down your throat and into your stomach to examine the stomach lining and rule out other possible causes

Treating gastroparesis

Gastroparesis cannot usually be cured, but dietary changes and medical treatments can help you control the condition.

Dietary changes

You may find these tips helpful:

instead of three meals a day, try more frequent, smaller meals – this will mean there is less food in your stomach and it will be easier to pass through your system
try soft and liquid foods, which are easier to digest
chew food well before swallowing
drink non-fizzy liquids with each meal

It may also help to avoid certain foods that are hard to digest – such as apples with their skin on, or high-fibre foods like oranges and broccoli – as well as foods high in fat (which can also slow down digestion).

Medication

The following medications may help improve your symptoms:

domperidone – which is taken before eating to contract your stomach muscles and help move food along
erythromycin – an antibiotic that also helps contract the stomach and may help move food along
anti-emetics – medications that control nausea

However, the evidence that these medications relieve the symptoms of gastroparesis is relatively limited and they can cause a number of side effects, so make sure you discuss the potential risks and benefits with your doctor.

Domperidone should only be taken at the lowest effective dose for the shortest possible duration due to the small risk of potentially serious heart-related side effects.

A similar medication to domperidone called metoclopramide used to be frequently used to treat people with gastroparesis. However, it’s no longer widely recommended for the condition because of concerns about serious side effects such as muscle spasms and twitches that can occur when the medication is used for a long time.

Electrical stimulation

If dietary changes and medication don't improve your symptoms, a relatively new treatment called gastroelectrical stimulation may be tried. However, this is currently not routinely funded by many local NHS authorities.

Gastroelectrical stimulation involves surgically implanting a battery-operated device under the skin of your tummy.

Two leads attached to this device are fixed to the muscles of your lower stomach. They deliver electrical impulses to help stimulate the muscles involved in controlling the passage of food through your stomach. The device is turned on using a handheld external control.

The effectiveness of this treatment can vary considerably. Not everyone will respond to it and for many of those who do, the effect will largely wear off within 12 months. Therefore, this treatment is not suitable for everyone with gastroparesis.

There is also a small chance of this procedure leading to complications such as infection, the device dislodging and moving, or a hole forming in your stomach wall, which would mean removing the device. Speak to your surgeon about the possible risks.

For more information, read the National Institute for Health and Care Excellence (NICE) guidelines on gastroelectrical stimulation for gastroparesis.

Botulinum toxin

More severe cases of gastroparesis may occasionally be treated by injecting botulinum toxin into the valve between your stomach and small intestine, to relax it and keep it open for a longer period of time so food can pass through.

The injection is given through an endoscope, which is passed down your throat and into your stomach.

This is a fairly new treatment and some studies have found that it may not be very effective, so it is not recommended by all doctors.

A feeding tube

If you have extremely severe gastroparesis that is not improved with dietary changes and medication, you may benefit from a feeding tube.

Many different types of feeding tube are available – some only temporary, and others permanent.

A temporary feeding tube called a nasojejunal tube may be offered to you first, which is inserted through your nose to pass nutrients directly into your small intestine.

A feeding tube can also be inserted into your bowel surgically, through an incision made in your tummy. This is known as a jejunostomy. Liquid food containing nutrients can be fed through the tube, which goes straight to your bowel to be absorbed, bypassing your stomach.

Speak to your doctor about the risks and benefits of each type of feeding tube.

An alternative feeding method for severe gastroparesis is intravenous (parenteral) nutrition, where liquid nutrients are passed straight into your bloodstream via a catheter (a tiny flexible tube) that is fed into a large vein.

Surgery

Some people may benefit from having an operation to insert a tube into the stomach through the tummy. This tube can be periodically opened to release gas and relieve bloating.

Very occasionally, a procedure to create a new opening between your stomach and small intestine (gastroenterostomy) or to connect your stomach directly to the second part of your small intestine called the jejunum (gastrojejunostomy) may be recommended as a last resort.

These procedures may reduce your symptoms by allowing food to move through your stomach more easily.

Your doctor can explain whether any procedures are suitable for you, and they can discuss the possible risks involved.

Advice for people with diabetes

Having gastroparesis means your food is being absorbed slowly and at unpredictable times.

If you also have diabetes, this can lead to wide swings in blood sugar levels, so it's important to ensure you tightly control your blood sugar levels.

Your doctor can advise you about any changes you may need to make to your diet or medication. If you are taking insulin, you may need to divide your dose before and after meals and inject into areas from which absorption is typically slower (such as the thigh).

You will also need to check your blood glucose levels frequently after you eat.