Diet, supplements, and over-the-counter medications play a crucial role in mitigating the daily symptoms of Parkinson’s, which can range from low energy levels to constipation to anxiety and depression, according to a presentation hosted by The Parkinson Voice Project.
Susan Imke, FNP, GNP-C, a certified gerontological nurse practitioner who focuses on families living with Parkinson’s disease and other neurodegenerative disorders, talked about “Optimal Nutrition for Living Well with Parkinson’s,” in a free lecture on Jan. 12. A video of the presentation is available online, along with a flyer summarizing nutritional guidelines for patients.
The talk is part of the Parkinson’s Lecture Series presented by disease experts in PVP’s Clark and Brigid Lund Parkinson’s Education Center. Presentations can be viewed in person or through the website.
Hydration, diet, and medication absorption
Staying hydrated and balancing protein consumption are important ways to ensure any patient taking carbidopa-levodopa gets the maximum benefit from the treatment, said Imke.
“Adequate hydration is essential for nutrient and medication absorption,” she said, adding that water doesn’t just make pills easier to swallow, it also facilitates absorption of both the treatment and nutrients from food, maximizing efficacy of each.
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Carbidopa-levodopa, one of the most commonly used treatments for the disease, should be taken with half a cup of nondairy liquid for proper absorption.
Doctors recommend patients take carbidopa-levodopa at least 15 to 30 minutes before eating when possible, so that food doesn’t interfere with its effects.
Patients should continue to sip water throughout the day to prevent dehydration, which can lead to constipation, low energy, and even dangerous delirium.
Additionally, patients should pay close attention to their protein intake throughout the day. While protein is essential for a healthy diet, large neutral amino acids (LNAAs) in protein compete with carbidopa-levodopa — which is made up of two amino acids — for absorption.
To figure out if too much protein intake is affecting the body’s ability to absorb of the medicine, Imke suggests patients try eating a vegetarian diet for 2 to 3 days; if mood and energy improve, patients should consider limiting protein consumption, or adjusting the timing of protein-heavy meals in the long term.
Managing gastrointestinal symptoms at home
While neurologists may not focus on them, gastrointestinal symptoms, such as constipation, are a “very big deal,” said Imke, not a “second class worry.”
Bowel impaction — when the bowel can no longer push out stool, which then needs to be removed manually — is the second most common reason Parkinson’s patients are admitted to nursing homes.
There are options for patients to help manage these symptoms at home. Many stool softeners and laxatives come with warnings against using them for more than a week at a time without a doctor’s permission, but it is common for a gastroenterologist to recommend long-term use.
Imke enthusiastically advised patients to use probiotic supplements. “Everyone should be taking probiotics,” she said, explaining that Parkinson’s medications are “hard on the gut,” and supplements can help mitigate the damage more effectively than probiotic foods, such as yogurt.
Triphala, an ayurvedic tonic some people drink to help loosen stool, is also safe for patients, she said.
Sometimes patients may need more relief from gastrointestinal symptoms than oral options can provide. The evidence is limited, but many individuals like the Squatty Potty, a Shark Tank invention that claims to help reduce strain during bowel movements by encouraging a squat-like position on the toilet.
For those who need a little more assistance, infant-sized glycerin suppositories can help. Imke emphasized that the infant size is plenty for an adult, and even “leaves a little grease in the neighborhood” for the next bowel movement.
Apathy, depression, and anxiety are common symptoms in Parkinson’s, and can be impacted by hydration and nutrition. Depression — a mood disorder that can be directly associated with the dopamine depletion in Parkinson’s — is frequently diagnosed in patients, but Imke argues that anxiety, which is harder to recognize, can be just as agonizing for patients.
Anxiety may be triggered as medications wear off, when patients wait for another dose to kick in, causing them to hyperventilate and fear they won’t be able to catch their breath. Telling patients it will get better won’t help, but taking benzodiazepines can, Imke said.
It’s imperative to recognize the difference between delirium and dementia, she added. Delirium, an emergency which can be caused by a change in medications, dehydration, or an infection, is characterized by sudden, out-of-character behavior, and generally requires a trip to the emergency room.
Dementia associated with Parkinson’s is different from that of other diseases, and medications used for Alzheimer’s won’t help Parkinson’s patients, Imke said. Parkinson’s dementia is more subtle, comes on gradually, and tends to include confusion or difficulty finding words.
Supplements can help many patients, but it’s important to avoid large doses, and prioritize the ones that make each patient feel best, Imke stated.
Some vitamins to consider are lutein for preventing macular degeneration, vitamin D3 for maintaining bone health, and magnesium which can act as a muscle relaxant.
Low levels of vitamin B12 may be associated with quicker motor and cognitive decline, according to a March 2018 study, which pointed to supplements as a possible solution.
Some research has suggested that vitamin B6 may improve cognition and mood in elderly patients. Studies in the past showed that vitamin B6 can interfere with carbidopa-levodopa, but Imke says this is no longer a concern at “reasonable doses.”
While some doctors may recommend iron or calcium as patients age, these supplements can worsen constipation.
Other nutraceuticals that help some patients and are considered safe are crystallized ginger for nausea, gingko biloba for alertness, milk thistle for liver function, parsley for gastric reflux, St. John’s Wort for depression, and valerian root for sleep issues.
Supplements and over-the-counter treatments can be pricier than patients realize. Imke recommends tracking spending for a month, and then deciding which supplements are worth the cost for each individual.
She cautioned that for all the benefits that supplements may provide, when taking supplements, a patient becomes “a research population of one.”
Supplements are not tightly regulated, and “just because a supplement is all natural, doesn’t mean you should take it home with you,” Imke said. Therefore, patients should look for “reputable brands,” and research the manufacturers.
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