Category Archives: Aging

Driving Under the Influence of Parkinson’s

“Have you ever noticed that anybody driving slower than you is an idiot, and anyone going faster than you is a maniac?” George Carlin

“If all the cars in the United States were placed end to end, it would probably be Labor Day Weekend.” Doug Larson

The Dilemma: At some age in our life, maybe, just maybe, we could lose the privilege of driving our car/truck.  If you are living with Parkinson’s, depending on the individual, losing the legal right to drive your motor vehicle might/could happen at an even earlier age.  A discussion of driving under the influence of Parkinson’s is presented here.

“I love driving cars, looking at them, cleaning and washing and shining them. I clean ’em inside and outside. I’m very touchy about cars. I don’t want anybody leaning on them or closing the door too hard, know what I mean?” Scott Baio

The Michon model of normal driving behavior:  In 1985, Michon proposed that drivers need to conduct problem-solving while driving; he divided it  into three levels of skill and control. The model includes strategic (planning), tactical (maneuvering), and operational (control) levels.   When you think about it driving really is a complicated task.   The strategic level is basically the general route and planning needed to successfully navigate the motor vehicle.  The tactical and control levels involve the individual driving circumstances and how one responds and our responsiveness to the action of driving.   And of course, it’s quite obvious, that unsafe driving is operating a motor vehicle in an unsafe manner regardless of your health status. Driving safely is important for the individual as well as for the people around you; thus, it is a serious task to evaluate someone’s competency to drive a motor vehicle. Shown below is a schematic drawing of the Michon model of normal driving behavior.

17.04.07.Driving.Model

“The one thing that unites all human beings, regardless of age, gender, religion, economic status, or ethnic background, is that, deep down inside, we all believe that we are above-average drivers.” Dave Barry

Decision-making while driving:   Below are some traffic signs that we might encounter in our usual driving pattern depending on where we live. When you think about decision-making you’re in your lane you’re driving down the road and you see signs like this, then what?  You can see how it takes all three levels of driving competency to navigate successfully while driving a motor vehicle in a complex maneuver.  Now add the complications of someone with Parkinson’s, you may need to re-think the entire situation. What this says is that when you’re driving a motor vehicle you’re trying to integrate many levels of sensory, motor and cortical function to the process. In Parkinson’s, we may have some sort of motor skill/task impairment, potentially mixed with a minor cognitive disorder, and further clouded by traditional drug therapy. Who makes the decision for the patient with Parkinson’s about being able to continue to drive?  Not an easy answer.

“Some beautiful paths can’t be discovered without getting lost.” Erol Ozan

 Possible problems that could occur while driving with Parkinson’s: The control or operational level of driving a car can be influenced by motor defects experienced by many with Parkinson’s, including rigidity, tremor, bradykinesia and dyskinesia. Futhermore, non-motor deficits could impair both route planning, strategic and tactical levels, and these would include cognitive decline, neuropsychiatric symptoms and/or visual impairment. And on top of that in the elderly population, many people with Parkinson’s have additional co-morbidity that could also contribute to diminish our ability to drive a motor vehicle. Thinking about just one aspect, slowness in cognitive function, the inability to make a decision quickly could lead to poor performance time and might affect driving in someone with Parkinson’s. Alternatively, you may have none of these problems and will be driving for many more years. But as we all start to exhibit signs and symptoms of motor and non-motor deficits, this will eventually become an important issue for each of us to deal with at some point in time.

“Always focus on the front windshield and not the review mirror.” Colin Powell

 What are some criteria for determining our fitness to drive a motor vehicle when you have Parkinson’s? In a very nice review, Jitkritsadakul and Bhidayasiri suggest there are five different red flags that should tell our neurologist that we may have an impairment that should limit our driving of motor vehicles. First, these include our clinical history, which would be a history of accidents, sleeping attacks while driving and combined with the daily dose amount of levodopa. Next would be a questionnaire to determine our level of daily sleepiness. Third, a motor assessment skills test. Fourth, a cognitive assessment. And fifth would be a visual assessment.  Look above at the Michon driving schematic and think about the three levels of skill required for driving and substitute someone with Parkinson’s and how that could diminish one or more of the skill sets over time.  What this says to me is that through a combination of family and friends and carepartner,  along with the advice of our neurologist, one should be able to make a critical assessment of whether or not we should continue to drive.

“Driving your car through deep pools of flood water is a great way of making your car unreliable. Smart people turn around and avoid it.” Steven Magee

A love of motor vehicles (a personal expression):  I grew up loving automobiles; and living on Air Force Bases, I saw many different types of sports cars  (e.g., Corvette, Jaguar, Triumph, Porsche, Shelby Mustang, Ferrari- you just had to believe that Air Force pilots live for speed in the air and their cars showed it on the ground). I can remember in 1964 (I was 11 years old) going to the Ford dealership with my dad to see the very first Ford Mustang cars; thinking how beautiful they were and remembering my dad’s comment that was a lot of car for $2,400.   I still have vivid memories of riding with my dad (yes, he was a former pilot) in his ~1962 white Porsche. I can still remember in 1971 getting my first car, a 1968 Chevrolet Camaro (red interior and red exterior) with standard transmission (three on the floor) and powered by a 327 cubic inch V-8 engine. [Please note, the pictures below are representative images because I could not find any actual old photos of these cars]

IMG_3832

Over the decades, I can recall the weekly car-washing sessions, typically on Saturday mornings. With the exception of one car in the early 1980’s, I have loved and truly enjoyed the automobiles I’ve driven.  Like many people I’ve named all my cars; my two current automobiles are named Raven and Portia. I still enjoy driving a standard shift car using the clutch that requires both cognitive function and motor skills to navigate the automobile. I have always thought “It’s going to be a cold day in hell before they take my car away”; however, it’s a reality in the future I now face with Parkinson’s. In fact one of the very first people I ever told about my Parkinson’s several years ago, the very first question she asked me was “Are you still able to drive?”  In summary, driving under the influence of Parkinson’s is something we all will need to consider with time; I wish you well with your driving experiences.

“Driving a car provides a person with a rush of dopamine in the brain, which hormonal induced salience spurs modalities of creative and critical thinking regarding philosophical concepts such as truth, logical necessity, possibility, impossibility, chance, and contingency.” Kilroy J. Oldster

https://www.ncbi.nlm.nih.gov/pubmed/27729986

1.    Jitkritsadakul O, Bhidayasiri R. Physicians’ role in the determination of fitness to drive in patients with Parkinson’s disease: systematic review of the assessment tools and a call for national guidelines. Journal of Clinical Movement Disorders. 2016;3(1):14. doi: 10.1186/s40734-016-0043-x.

Cover photo credit: s-media-cache-ak0.pinimg.com/564x/22/d1/75/22d175ac53a0a5dbb04e77ae52a49c52.jpg

Save

Save

Parkinson’s Awareness Month: Veterans Health Administration PD Video Series

“My motto was always to keep swinging. Whether I was in a slump or feeling badly or having trouble off the field, the only thing to do was keep swinging.” Hank Aaron

“Nothing worth having comes easy.” Theodore Roosevelt

Introduction: Several years ago, the Veterans Health Administration produced videos to educate/inform our veterans about Parkinson’s disease.   For more information, read about the VA Core Values and Mission Statement (click here); it is an admirable sentiment.

As we are living longer, so too are our veterans. Some service-related-experiences may have predisposed some of them to develop Parkinson’s.  All of these videos are available on YouTube.  However, since this is Parkinson’s awareness month, putting them all together might benefit others to better understand Parkinson’s.   I definitely learned something from watching these videos, they were all outstanding.

Each individual video features a veteran (frequently their care-partner too) who agreed to be videotaped (having done this type of interview myself, it is not an easy experience); I admire their courage to participate and to help educate all of us. Furthermore, the VA clinical and support staff were passionate and compassionate about their roles in dealing with our veterans with Parkinson’s.

“Losing the possibility of something is the exact same thing as losing hope and without hope nothing can survive.” Mark Z. Danielewski

Veterans Health Administration – My Parkinson’s Story:
My Parkinson’s Story:
Early Parkinson’s Disease [click here for video]

My Parkinson’s Story: Thinking and Memory Problems with Parkinson Disease [click here for video]

My Parkinson’s Story: Medications [click here for video] 

My Parkinson’s Story: Dyskinesias [click here for video] 

My Parkinson’s Story: Atypical [click here for video] 

My Parkinson’s Story: Driving [click here for video]

My Parkinson’s Story: Sleep Problems and Parkinson’s Disease [click here for video] 

My Parkinson’s Story: Genetics [click here for video] 

My Parkinson’s Story: Exercise [click here for video] 

My Parkinson’s Story: Environmental Exposure [click here for video]

My Parkinson’s Story: The Impact of Depression in Parkinson’s Disease [click here for video] 

My Parkinson’s Story: Impact of Falls and Parkinson’s Disease [click here for video]

My Parkinson’s Story: The Caregiver [click here for video] 

My Parkinson’s Story: Deep Brain Stimulation and Parkinson Disease [click here for video]

My Parkinson’s Story: Hospitalization [click here for video] 

My Parkinson’s Story: Speech and Swallowing [click here for video] 

My Parkinson’s Story: Advanced Parkinsons [click here for video]

“Not I, nor anyone else can travel that road for you. You must travel it by yourself. It is not far. It is within reach. Perhaps you have been on it since you were born, and did not know. Perhaps it is everywhere – on water and land.” Walt Whitman

“We can’t equate spending on veterans with spending on defense. Our strength is not just in the size of our defense budget, but in the size of our hearts, in the size of our gratitude for their sacrifice. And that’s not just measured in words or gestures.” Jennifer Granholm

Cover Photo Credit: http://wallpapersafari.com/w/Fy0h6Q/

Science of Advanced Age as a Risk Factor for Parkinson’s

“Spring passes and one remembers one’s innocence.
Summer passes and one remembers one’s exuberance.
Autumn passes and one remembers one’s reverence.
Winter passes and one remembers one’s perseverance.”
Yoko Ono

“Embrace aging.” Mitch Albom, Tuesdays with Morrie

Précis: The great majority of individuals with Parkinson’s reveal no genetic mutations, no past history of head injury, no prior exposure to pesticides/toxins, or any family history of the disorder.  Public health studies have consistently shown that advanced age is an adverse risk factor for developing Parkinson’s. The average age of Parkinson’s onset is ~60 years of age. Presented here is a brief overview about why advanced age is a major risk factor for Parkinson’s.

Parkinson’s and advanced age as a risk factor: Parkinson’s is a neurodegenerative disorder that affects movement. It starts slowly, usually a small tremor or stiffness in a hand. With time, Parkinson’s progresses; typically characterized by motor symptoms such as slowness of movement (bradykinesia) with rigidity, resting tremor (Parkinsonian tremor), balance and walking problems, and difficulty swallowing and talking. Parkinson’s has several non-motor symptoms including anxiety, depression, and insomnia (just to mention a few).

Following Alzheimer’s, Parkinson’s is the second most common neurodegenerative disorder affecting ~0.3% of the developed world population. Interestingly, the incidence of Parkinson’s increases to 3% for persons >65 years old, which strongly indicates that advanced age is a major risk factor for this disorder.

Aging can promote several detrimental events that damage the dopamine-producing neurons in the substantia nigra.  These pathological events accumulate and weakens the ability of these neurons to respond to further insults, which ultimately leads to Parkinson’s (see below).

The left-side of the composite picture below could be entitled “40 years of Frank (in my 20’s, 30’s, 50’s and 60’s).”  The title of the right-side of the composite picture could be “Somehow the neurons in my substantia nigra (top right) are making very little dopamine (chemical structure bottom right); thus, I have Parkinson’s.”

Frank+40yrs“As long as I am breathing, in my eyes, I am just beginning.” Criss Jami

Age of the U.S. population: Andy Rooney once said “It’s paradoxical that the idea of living a long life appeals to everyone, but the idea of getting old doesn’t appeal to anyone.”  As the table below shows, by each successive decade of life, females outlive males. However, between 2000 and 2010, the U.S. male population grew at a slightly faster rate than the female population. By contrast, mortality rates in older men differ from older women, where the census results showed that women tend to live longer than men.  A further breakdown shows the 65 to 69 year old age group grew by 30%; this age group represents the leading edge of the Baby Boomers who started turning 65 in 2011 (The Baby Boom includes people born from mid-1946 to 1964). We are living longer; when coupled with advanced age as a risk factor for Parkinson’s, this implies an increasing burden on health care systems to deal with this disorder.

Age.USA.150930
“Wisdom comes with winters.” Oscar Wilde

Science behind advanced age as an adverse risk factor for Parkinson’s:  Pat Benatar said this about aging, “I’ve enjoyed every age I’ve been, and each has had its own individual merit. Every laugh line, every scar, is a badge I wear to show I’ve been present, the inner rings of my personal tree trunk that I display proudly for all to see. Nowadays, I don’t want a “perfect” face and body; I want to wear the life I’ve lived.”  Advanced age contributes to many different diseases whether from a loss of organ function with time, diminished immune surveillance capacity, or the inability to remove naturally-accumulating toxic substances by the host defense mechanisms (just to describe a few of many possible outcomes of advancing age).

In evaluating a large group of elderly people without Parkinson’s (750 individuals with an average age of 88.5 years), it was noted that ~1/3 showed mild to severe substantia nigra neuronal cell loss. Thus, natural advanced aging results in some loss to the dopamine-producing substantia nigra mid-brain region. But what shifts the balance that leads to Parkinson’s in some individuals?  Reeve et al. (2014), in an outstanding article, reviewed the science behind why advancing age is the biggest risk factor for Parkinson’s.  They suggest three processes occur in the substantia nigra that ultimately leads to Parkinson’s: (1) detrimental changes to the microenvironment; (2) dysfunction of the subcellular organelles called mitochondria; and (3) disruption in the process of protein degradation (the drawing below highlights these processes).

Aging.SN(1) Detrimental changes to the substantia nigra microenvironment:  As an analogy, over time, with extended use and re-use, your laptop slows down and ultimately begins little processor-derived-hiccups-of-dysfunction.  As we age, some changes occur in the dopamine-producing neurons of the substantia nigra; these include increased oxidative stress, changes in calcium-neuron properties, modification of iron-neuron interactions, and accumulation of the pigment called neuromelanin.  Processing of dopamine in the substantia nigra generates detrimental oxidative stress; which is made worse due to an age-related reduction of a protein named the dopamine transporter (DAT). The DAT escorts dopamine from neuron-to-neuron to reduce oxidative stress. Calcium helps maintain dopamine levels; and sustained transport of calcium into the cell is detrimental to the energy-producing organelle, the mitochondria.  Iron is an essential element; however with age, iron accumulates to contribute to the oxidative stress. Neuromelanin is responsible for the color of the substantia nigra.  Evidently, neuromelanin accumulates with age; in contrast to the other factors mentioned above, neuromelanin may be neuroprotective.

(2) Dysfunction of the subcellular organelles called mitochondria:  As an analogy, over time, you charge the battery of many devices like your cell phone, laptop/tablet, toothbrush, and beard trimmer; eventually no matter what you do, slowly but surely these devices lose their charge.  Likewise, mitochondria are subcellular power factories that can become dysfunctional (and lose energy) with advancing age. The mitochondrial respiratory system (electron transport) is a major cellular energy producer; and it consists of five protein complexes named respiratory complexes I–V. Several mitochondria electron transport complexes are modified/inhibited with age, leading to a loss of mitochondria-derived energy. Inhibiting complex I (reduced NADH dehydrogenase–ubiquinone oxidoreductase) causes Parkinsonian-like symptoms; furthermore loss of complex IV (cytochrome c oxidase) promotes a respiratory deficiency. This leads to the reduction of energy production (ATP molecules), which would negatively impact “neuronal excitability” (engaging/activating the neuron). Linked to this energy drain is mutation of mitochondria DNA, causing further detriment to these dopamine-producing neurons. These mutations ultimately reduce mitochondria function and activity, which promotes the accumulation of mis-folded proteins (a very bad thing). A key disease-causing feature of Parkinson’s is the build-up and denaturation of the protein named alpha-synuclein (think of the changes of frying an egg, which goes from clear to cloudy-opaque as the heat cooks and denatures the egg proteins). Accumulation of alpha-synuclein protein aggregates advances further mitochondria impairment.

(3) Disruption in the process of protein degradation:  As an analogy, shaving with a new razor blade leads to complete cutting-off of the hair; however, over time, as the razor blade dulls you end-up with more and more uncut hair. Similarly, we use enzymes called proteases and they are somewhat like a razor blade; their goal is to cut-up (digest) proteins.  Proteases are used in many different biological settings (e.g., digestion of food, clotting of blood); in the substantia nigra, proteases help eliminate protein debris as a means of self-renewal of the neurons.  There are two types of protease processes that cut and remove accumulating damaged proteins (like alpha-synuclein aggregates); they are named the ubiquitin proteasome system and autophagy.  Due to their complex biology, neither the ubiquitin proteasome system nor autophagy will be further described here; suffice it to say that if both protease systems are diminished this will further impair mitochondria.  These checks-and-balances are lost with advanced aging, which leads to a concert of adverse events where an individual could develop Parkinson’s.

“There is a fountain of youth: it is your mind, your talents, the creativity you bring to your life and the lives of people you love. When you learn to tap this source, you will truly have defeated age.” Sophia Loren

A symphony combining (1) + (2) + (3) from above + advancing age = risk of developing Parkinson’s: The natural-biology of dopamine-producing neurons leads to declining function with advanced aging. The detrimental process of reactive oxygen species initiates a symphony of badness that leads to neuronal cell dysfunction/death. The larghetto first movement leads to the reduction of the DAT, accumulation of neuromelanin, increased iron deposits, and disruption of calcium transport. The next movement is fortissimo with mutation of mitochondria DNA, inhibition of complex I and complex IV to reduce both ATP levels and neuronal excitability; these events lead to the acquisition of other mitochondria defects. The cadenza results in the beginning phase of aggregating alpha-synuclein, which contributes to substantia nigra dysfunction.  In the final movement of our symphony, we reach a crescendo where toxic levels of aggregating alpha-synuclein accumulate that cannot be cut/removed by the protein degradation pathways. The symphony ends with substantial stress to the dopamine-producing neurons in the substantia nigra to eventually promote neuronal cell death, which results in Parkinson’s.  With advancing age, most individuals will stop at the end of the first movement (microenvironment changes to substantia nigra); while others will complete the entire symphony over-and-over again to develop Parkinson’s.

“Age has no reality except in the physical world. The essence of a human being is resistant to the passage of time. Our inner lives are eternal, which is to say that our spirits remain as youthful and vigorous as when we were in full bloom. Think of love as a state of grace, not the means to anything, but the alpha and omega. An end in itself.” Gabriel García Márquez, Love in the Time of Cholera

References Cited:
Reeve, A., et al, Ageing and Parkinson’s disease: Why is advancing age the biggest risk factor?, Ageing Research Reviews, Volume 14, March 2014, Pages 19-30, http://dx.doi.org/10.1016/j.arr.2014.01.004.

Abdullah, R., et al., Parkinson’s disease and age: The obvious but largely unexplored link, Experimental Gerontology, Volume 68, August 2015, Pages 33-38, http://dx.doi.org/10.1016/j.exger.2014.09.014.

Petralia, R.S. , et al., Communication breakdown: The impact of ageing on synapse structure, Ageing Research Reviews, Volume 14, March 2014, Pages 31-42, http://dx.doi.org/10.1016/j.arr.2014.01.003.

Mhyre, Timothy R. et al. Parkinson’s Disease. Sub-cellular biochemistry 65 (2012): 389–455. PMC. Web. 9 Nov. 2015.  doi:  10.1007/978-94-007-5416-4_16  PMCID: PMC4372387