Jill M. Farmer, DO, MPH

"Anyone who takes care of patients with Parkinson disease will tell you that the nonmotor symptoms can be even more problematic, whether its cognitive pain, balance issues—things like that. They can be quite overwhelming and difficult to manage simply with dopaminergic therapies alone."

Although Parkinson disease (PD) is typically thought of as a motor movement disorder, there are several other, nonmotor health problems related to the condition that some patients believe are more detrimental than the motor issues themselves. These nonmotor symptoms can include cognitive changes, constipation, early satiety, fatigue, hallucinations and delusions, loss of sense of smell or taste, mood disorders, and sleep disorders, among others.

Addressing motor issues such as slowness of movement, tremor, stiffness and postural instability has been the main focus of drug development, with little regulatory success to show for these nonmotor symptoms. As someone who treats patients with PD, 

, believes it is time to start exploring new mechanisms of action that have potential to treat these concerns. Farmer, assistant professor of neurology and director of the Parkinson’s Disease & Movement Disorder Program at Global Neurosciences, also feels it might be worth looking at medications that do not solely focus on dopamine, but other chemical markers that may be in play.

, Farmer discussed the need for new medications that address nonmotor symptoms of PD and why it is important to understand where the chemical imbalances are coming from. She also touched on the COVID-19 pandemic’s profound effect on both the motor and nonmotor symptoms for this population.

Videos

The assistant professor of neurology and director of the Parkinson’s Disease & Movement Disorder Program at Global Neurosciences Institute discussed the need to understand the chemical markers that trigger nonmotor symptoms of Parkinson disease. [WATCH TIME: 3 minutes]

Understanding How Nonmotor Symptoms Worsens Parkinson Disease Condition: Jill Farmer, DO, MPH

"Whether its technology to help with symptoms in a very robust way, like surgical interventions or something as simple as attaching a laser light to your walker, the access to different technological strategies run the gamut and can be helpful and applied."

For years, the standard therapy for patients with Parkinson disease (PD) has been levodopa, designed to replenish the brain’s dwindling supply of dopamine. Clinicians may prescribe other medications to treat PD symptoms, including dopamine agonists, enzyme inhibitors, anticholinergic drugs, and amantadine (Gocovri; Adamas Pharmaceuticals). For a condition that lacks a disease-modifying therapy, patients within the community have become reliant on the benefits brought on by new technology.

Deep brain stimulation (DBS), a surgical procedure in which implanted electrodes stimulate specific areas in the brain, has become an increasingly used option for those who do not respond well to medications. Other physical, occupational, and speech therapies have been shown to help with gait and voice disorders, tremors and rigidity, and decline in mental functions.

, the expansion of technology has been most beneficial in terms of capturing and assessing large-scale data. As part of Parkinson Awareness Month, Farmer, an assistant professor of neurology and the director of the Parkinson’s Disease & Movement Disorder Program at Global Neurosciences Institute, sat down to discuss the latest in technological advances for these patients. She commented on the new modalities being used, the differences in surgical options, and where the field may expand to next.

The assistant professor of neurology and director of the Parkinson’s Disease & Movement Disorder Program at Global Neurosciences Institute provided insight on how technology expands the capabilities of treating Parkinson disease. [WATCH TIME: 3 minutes]

How Technology Has Advanced Parkinson Disease Treatment: Jill Farmer, DO, MPH

"There is evolution in technology that is making the deep brain stimulation strategies even more robust. As far as the pipeline, there are disease modification therapies that are being looked at and currently investigated in clinical trials. None of them are available yet for clinical use, but the fact that there’s sort of a new frontier where research is focusing is exciting for patients."

Every April, the world comes together to raise awareness for Parkinson disease (PD), a neurodegenerative condition that affects nearly 1 million people in the US alone. This incurable disease is characterized by tremor, slowed movement, rigid muscles, and loss of automatic movements. In addition to motor and nonmotor symptoms, patients face an array of complications, including cognitive difficulties, swallowing problems, sleep disorders, bladder problems, and constipation, among others. Because the cause of PD is unknown, proven methods of prevention have remained a mystery.

® sat down with movement disorder expert 

, assistant professor of neurology, and director, Parkinson’s Disease & Movement Disorder Program, Global Neurosciences Institute. Farmer provided insight on the top themes from Parkinson Awareness Month, which centered around bringing awareness to the cardinal features of the disease and promoting drug development. She also touched upon the advances being made within the field, including the expansion of deep brain stimulation and the potential for a non-stop levodopa/carbidopa pump.

The assistant professor of neurology and director of the Parkinson’s Disease & Movement Disorder Program at Global Neurosciences Institute provided insight on the areas of focus during Parkinson Awareness Month. [WATCH TIME: 3 minutes]

Themes Around Parkinson Awareness Month: Jill Farmer, DO, MPH

Medical language is full of acronyms, and I have always loved that the acronym for “women in neurology” spells out “win.” As we celebrate National Women Physicians Day, it offers me time to reflect on what a winning effort it has truly been empowering and supporting women in medicine.

For me, in large part, it has to do with a concerted effort of support. From my training through my attending career, I have been fortunate to find support from many women colleagues, near and far. I am a neurologist and a fellowship-trained movement disorder specialist. My subspecialty is made up of a high percentage of women, and I was lucky to go through training with some of the best. As I started fellowship, I was not only a new fellow but a new mom. My cofellow, on her own accord, took it upon herself to see the first and last patient of the day which allowed me time to pump in the morning and make it to daycare with some time to spare most days. The ripple effect of that act of kindness impacted me both personally and professionally. It helped me love my training and achieve some of that elusive balance that plagues many working parents so that I could be present and mentally and emotionally invested where I was needed for both my patients and my family.

A community of support is essential. The adage “it takes a village” is not new, and that is where the Women Neurologist Group (WNG) has been a fertile resource as well. I am 1 of 4 lead administrators who oversee a team of moderators with the sole purpose of creating a community of comradery for women neurologists from residency through retirement and the plethora of paths that get us from point A to point B. This online community is international and over 4000 strong, and links us to everyone from trainees to titans of industry and national clinical leaders. It allows a safe space to discuss cases, amplify accomplishments, seek opportunities, and vent when needed to an understanding audience.

A community helps shape the culture, and there has been a shift in the culture of medicine that was set in motion during the pandemic. That shift largely revolved around the adoption of telemedicine. Using the networking available through WNG and professional societies, advocating for telemedicine presented an opportunity for those who welcome this approach to keep the momentum of the movement going and to not lose the gains in flexibility this approach to clinical care affords. It does not work for everyone, but it works for many, and that needs to be defended.

Women in neurology are now in positions of influence—the president of both the Movement Disorder Society and the American Academy of Neurology are women—and more women are not just present in, but presiding over, committees and task forces. But looking at diversity, equity, and inclusion statistics leaves 

 that more needs to be done. I am still often the only woman in the room or at the table, but I am pulling out the chair and using my position to invite others in to participate and advocate for policies that continue to change the culture to move us forward. That is a win for the entire medical profession.

This piece was put together in partnership with the Women Neurologists Group. For more information about WNG, check out their Twitter account, 

Articles

Collaboration can result in greater success than what one can achieve alone, and for women physicians, this rings truer than ever before, writes Jill M. Farmer, DO, MPH.

Winning Together With the Community of Women in Neurology

APRIL IS PARKINSON DISEASE (PD) AWARENESS MONTH

, and I have always loved that it secured that spot on the calendar. The metaphor of spring and the symbol of the tulip are not lost on the clinicians who care for patients with PD and those who live with them. This April and this spring is even more symbolic as we come out of a year-long freezing episode that disrupted everyone involved in PD care. We know that coronavirus disease 2019 (COVID-19) has wreaked havoc on the PD community—uprooting routines, forcing isolation—and although having PD doesn’t increase the risk of contracting COVID-19, we know it increases the risk of a more significant clinical course. Results of a study of 358 people with PD showed those who had a higher COVID-19–related stressor load experienced more PD symptoms, and this effect was mediated by the degree of psychologic distress. Almost half (46.6%) of individuals with PD were less physically active since the pandemic began, and reduced physical activity correlated with worsened PD symptoms. Symptoms that worsened the most were rigidity, fatigue, tremor, pain, and concentration. The presence of neuropsychiatric symptoms (eg, anxiety and depression) before the pandemic, as well as cognitive dysfunction and several personality traits, predicted increased psychologic distress during the pandemic.

But looking ahead, as spring is blossoming, we can also take a nice deep breath and look at the changes that, although born out of necessity, can now be enjoyed as a convenience. The virtual world has much to offer and going forward when it is not a requirement but an option will afford much more access more readily and easily to specialists, to community resources, and to PD education. Telemedicine is changing the landscape of medicine. According to the Centers for Disease Control and Prevention’s data, the 154% increase in telehealth visits during the pandemic compared with the same period in 2019 is a direct correlate to telehealth policy changes and public health guidance.

 There is proposed legislation to continue these policies going forward. It is widely believed telehealth will continue to be an option for those that prefer it but getting back to face-to-face interactions in the office will also be refreshing. Patient education programs are now available on-demand from the convenience of wherever you want to be, but we are all looking forward to the community and comradery of doing these in person again soon. What is nice is that we will have the option of both, and options expand our experiences. As this month of awareness awakens our focus on the future and what is to come, again, the PD community does not disappoint. There are close to 3000 clinical trials investigating the treatment and pathology of PD currently. There is a shift of focus from treating the symptoms of the disease to figuring out how to actually alter the pathology to change the clinical course and modify it for the better through various established and novel mechanisms. 

In this issue, we will look at 2 opportunities on the horizon. Deep brain stimulation (DBS) has been around since the 1970s, and currently, about 150,000 people are implanted with a DBS device. In the past few years, the technology of DBS has entered a renaissance period. In this space, Medtronic has had to make room for Boston Scientific and Abbott device companies. This increased diversity has led to smaller rechargeable batteries, the utilization of different modes of stimulation through voltage or current, and the ability to precisely target the area of the brain with directional leads. In this issue’s cover story, Atom Sarkar, MD, PhD, director, functional neurosurgery, Global Neuroscience Institute, explores what is on the horizon not just through the hardware of the device but the software with sensing and reactive technology to adapt to changes in the brain that precede symptom return and modulate the stimulation accordingly. 

The changes coming to the surgical interventions are matched by changes coming to the medical management. Smaller pumps that can deliver continuous infusion of carbidopa/levodopa just under the skin, without a procedure, are currently in phase 3 clinical trials. While the symptomatic improvement this can bestow on patients is exciting, it still lacks the ability to modify the disease course in some way. That is the next frontier in research and the focus of Charbel Moussa, MBBS, PhD; Fernando Pagan, MD; and Yasar Torres-Yaghi, MD, of Medstar Georgetown University Hospital, in their feature that considers the pipeline of disease-modifying therapies and the hope they hold. 

While we are all experiencing fatigue—COVID-19 fatigue, caregiver fatigue, clinician fatigue—we are no strangers to it. As a community, patients with PD and those that care for them are resilient to fighting this fatigue, and the beauty of Parkinson Awareness Month is that it gives us a rejuvenating pause during the spring thaw, and reminds us to stop and smell the tulips, and with a deep breath of fresh air, keep moving forward. 

REFERENCES
1. van der Heide A, Meinders MJ, Bloem BR, Helmich RC. The impact of the COVID-19 pandemic on psychological distress, physical activity, and symptom severity in Parkinson disease.

. 2020;10(4):1355-1364. doi: 10.3233/JPD-202251.
2. Koonin LM, Hoots B, Tsang CA, et al. Trends in the use of telehealth during the emergence of the COVID-19 pandemic—United States, January–March 2020. 

. 2020;69:1595-1599. doi: 10.15585/mmwr.mm6943a3.

Guest Editor-in-Chief Jill Giordano Farmer, DO, MPH, shared her perspective on the importance of April as the annual Parkinson disease awareness month.