Parkinson's disease — a degenerative disorder of the central nervous system — is diagnosed in 50, 000 Americans every year. In addition, more than a million people in the United States currently live with the illness. Parkinson's disease affects nerve cells (neurons) in the part of the brain that controls muscle movement, leading to symptoms such as trembling, rigidity, difficulty walking and problems with balance and coordination.

In about 5 percent to 10 percent of cases, Parkinson's disease begins before age 50. But for most people, the first symptoms develop after age 50, and the likelihood of developing Parkinson's disease continues to increase with age.

Parkinson's disease is progressive, meaning the symptoms become worse over time. Although the disease may eventually be disabling, signs and symptoms usually develop gradually and most people have many years of productive living after a diagnosis.

Furthermore, unlike other serious neurological diseases, such as Lou Gehrig and Huntington's disease, Parkinson's disease is treatable. For decades, the drug levodopa, commonly known as L-dopa, was the mainstay of Parkinson's disease treatment. But now newer drugs, including dopamine agonist medications, are also used — either alone or in combination with levodopa.

In addition, experiments using surgically transplanted stem cells, fetal nerve cells or genetically engineered cells to replace lost or damaged neurons are ongoing. In the past 10 years, some people with Parkinson's have regained their mobility after receiving transplanted fetal neurons. But this procedure, which is still in the experimental stages, only appears to benefit people under age 60 and may cause severe side effects in some people.

Deep brain stimulation (DBS) is another form of surgical therapy for Parkinson's disease that has had encouraging results. It involves implanting a brain stimulator, similar to a heart pacemaker, in an area of the brain called the thalamus. It has been used for the past decade to treat parkinsonian tremor, and researchers believe that implanting this device in a part of the brain called the subthalamic nucleus may help treat other aspects of parkinsonism as well.

But for now, recognizing the signs and symptoms of Parkinson's disease and seeking early diagnosis are essential to beginning appropriate treatment and managing symptoms for as long as possible.

Signs and Symptoms 

The earliest sign of Parkinson's disease can be as subtle as an arm that doesn't swing when you walk, a mild tremor in the fingers of one hand or soft, mumbly speech that's difficult to understand. You also may have such symptoms as a lack pep, depression or trouble sleeping. Or you may notice that it takes you longer to shower, shave, eat or do other routine tasks.

Other signs of Parkinson's disease may include:

• Tremors. Tremors often start with a slight shaking in one finger that later may spread to your whole arm. Sometimes tremors in your hand cause a back and forth rubbing of the thumb and forefinger known as pill rolling. You also may develop tremors in your head, lips or feet. These symptoms may occur on one or both sides of your body and may be more noticeable when you're under stress. Although tremors can be very distressing, they're usually not disabling and often disappear during sleep.
• Slowed motion (bradykinesia). Over time people with Parkinson's disease may develop a slow, shuffling walk with an unsteady gait and stooped posture. They also may have a tendency to fall. In the later stages of the disease, their muscles may freeze up, making it hard to resume normal movement. This is especially distressing because it can make performing the simplest tasks difficult and time-consuming. Even the functioning of the digestive tract may slow down, causing problems with swallowing, digestion and elimination. In fact, constipation is often a major problem for people with Parkinson's disease.
• Rigid muscles. Muscle stiffness (rigidity) often occurs in the limbs and neck. Sometimes the stiffness can be so severe that it limits the size of movements. For example, the handwriting of people with Parkinson's disease often becomes extremely small.
• Loss of automatic movements. Blinking, smiling and swinging your arms when you walk are all unconscious acts that are part of human behavior. In Parkinson's disease, these acts tend to be lost. Sometimes people may develop a fixed staring expression and unblinking eyes — the so-called facial masking of Parkinson's disease. And instead of gesturing while talking, some people may lack animation when they speak.
• Impaired speech. Many people with Parkinson's disease have some trouble speaking, and the voice often becomes monotonous and very soft. This may be a special problem for older adults because the soft voice of a person with Parkinson's disease may not be audible to a spouse with poor hearing.

Causes 

In the nearly 200 years since Parkinson's disease was first described, researchers have come to understand some of the processes of this complex disorder. They now know that Parkinson's disease occurs when certain neurons in an area of the brain called the substantia nigra are damaged or destroyed. Normally, these nerve cells release dopamine — a chemical that transmits signals between the substantia nigra and another part of the brain, the corpus striatum. These signals cause your muscles to make smooth, controlled movements.

Everyone loses some dopamine-producing neurons as a normal part of aging. But people with Parkinson's disease lose at least 60 percent of neurons in the substantia nigra. Just what causes this is a subject of intense research. Right now scientists believe Parkinson's disease may result from a combination of genetic and environmental factors. Certain drugs, diseases and toxins also may cause symptoms similar to those of Parkinson's disease.

Genetic factors

Until recently, scientists believed that genes mainly played a role in an unusual type of Parkinson's disease that affects young people. But new research also shows a strong genetic component in older adults. In fact, studies have revealed that people who have a first-degree relative with Parkinson's disease — such as a parent, sibling or child — are at three times greater risk of developing the disease themselves, regardless of their age. Furthermore, one study found that having two first-degree relatives with Parkinson's disease can increase risk as much as 10 times.

Environmental factors

Studies show that people exposed to herbicides and pesticides are three times more likely to develop Parkinson's disease than people who don't have this exposure. The problem, however, is that so far no one has been able to connect a specific herbicide or pesticide to the disease.

In one recent study, a combination of the herbicide paraquat and the fungicide maneb — chemicals commonly used together on crops throughout the United States — was found to damage the same part of the brain in mice that is affected in people with Parkinson's disease. Unfortunately, this study doesn't provide conclusive evidence that combined paraquat and maneb cause Parkinson's disease.

Medications

A number of drugs can cause symptoms of Parkinson's disease. These include medications such as haloperidol (Haldol) and chlorpromazine (Thorazine), which are prescribed for certain psychiatric disorders, and drugs used to treat nausea, such as metoclopramide (Reglan) and prochlorperazine (Compazine).

The epilepsy drug valproate (Depacon) also may cause some of the features of parkinsonism. In fact, this drug is notorious for producing tremors, although these tremors are a little different from those seen in Parkinson's disease.

Toxins

Exposure to toxins such as manganese dust or the chemical MPTP — a byproduct of heroin production — can lead to parkinsonism. Scientists first became aware of MPTP-induced parkinsonism in the 1980s when heroin addicts using a street drug contaminated with MPTP developed all the symptoms of Parkinson's disease. Still, toxin-related cases are extremely rare.

Risk Factors 

Age is one of the main risk factors for Parkinson's disease. Although the disease can affect adults in their 20s, it ordinarily starts in middle or late life, and the risk continues to increase with age. Some researchers theorize that people with Parkinson's disease may have neural damage from genetic or environmental factors that becomes worse with aging.

Heredity also appears to play a role in Parkinson's disease. Recent studies have shown that people with a parent, sibling or child with the disease have a three times greater risk of developing the disease themselves. Those with two or more close relatives with Parkinson's disease have a 10 times greater risk of also developing the disease.

In addition, people who are exposed to herbicides and pesticides are at increased risk. Studies also suggest that people who are involved in farming, live in a rural area or drink well water are more likely to develop the disease. But these factors may ultimately be linked to herbicide and pesticide exposure as well.

New studies also indicate that reduced estrogen levels may increase the risk of Parkinson's disease. This means that menopausal women who receive little or no hormone replacement therapy (HRT) and those who have had hysterectomies may be at higher risk. Menopausal women using HRT appear to have a decreased risk.

Complications 

Many people with Parkinson's disease experience some degree of depression — both because of the emotional toll of living with their illness and brain chemical deficiencies that are a part of the disease. In addition, as many as a third of people with Parkinson's disease eventually develop dementia, a condition that can include memory loss and impaired judgment as well as personality changes.

Medications for Parkinson's disease also may cause a number of complications, including involuntary twitching or jerking movements of the arms and legs (dyskinesias), hallucinations, sleepiness and a drop in blood pressure when standing up (orthostatic hypotension).

Other complications of Parkinson's disease include:

• Difficulty chewing and swallowing. In the later stages of the disease the muscles used in swallowing may be affected.
• Urinary problems. Some people with Parkinson's disease may experience urinary incontinence while others may have trouble urinating. Certain medications used to treat the disease, especially anticholinergic drugs, also can cause urinary retention.
• Constipation. Many people with Parkinson's disease develop constipation because the digestive tract works more slowly. Constipation may also be a side effect of medications used to treat the disease.
• Sleep problems. People with Parkinson's disease often have no problem falling asleep, but they may wake up frequently throughout the night. They also may experience restless sleep and even act out their dreams (REM sleep behavior disorder).
• Sexual dysfunction. Some people with Parkinson's disease may notice a decrease in sexual desire (libido). In some cases this may result from a combination of psychological and physical factors. In others, it may be a direct result of the disease.

Treatment 

No standard treatment exists for the earliest symptoms of Parkinson's disease. Some doctors may begin drug treatment at the first signs of the disease. Others may delay this form of treatment until symptoms become more pronounced. Depending on your symptoms, your doctor first may try lifestyle changes, such as diet, exercise and physical therapy.

Physical therapy can be extremely helpful for people with Parkinson's disease — both in the early stages and later, as the disease progresses. It can help improve mobility, range of motion and muscle tone. Although specific exercises can't stop the progress of the disease, improving muscle strength can help you feel more confident and capable. A physical therapist also can work with you to improve your gait and balance and can help strengthen muscles to make speaking and swallowing easier.

When lifestyle changes are no longer enough, your doctor will likely recommend certain medications, either alone or in combination.

Medications

Medications are primarily used to help manage problems with walking, movement and tremors by increasing the brain's supply of dopamine. But drug therapy can have serious side effects, and the dosage and timing of medications need to change as your symptoms do. For these reasons, you and your doctor will work together to design a program that best suits your needs, especially as the disease progresses. The medications used to treat Parkinson's disease include:

• Levodopa. Since it's introduction in the 1960s, levodopa has been considered the gold standard drug therapy for Parkinson's disease. Levodopa is the formulation of a chemical found in plants and animals that is converted into dopamine by nerve cells in the brain. The increase in dopamine may reverse many of the disabling symptoms of Parkinson's disease, but as time passes, side effects may increase and adjustments of the doses will be necessary.

  Treatment with dopamine itself isn't possible, because dopamine doesn't cross the body's blood-brain barrier. This is a meshwork of tightly packed cells in the walls of the brain's capillaries that screen out certain substances. Levodopa, on the other hand, does cross this barrier, but only a small amount actually reaches the brain. Combining levodopa with another drug, carbidopa (Sinemet), causes more levodopa to get to the brain and helps reduce some of the side effects of this therapy. Sinemet CR is a prolonged-release version of this drug.

  During early treatment side effects from levodopa therapy are usually not a major problem. But as the disease progresses, the drug works less evenly. As a result some people may experience involuntary movements (dyskinesias), especially when the medication is having its peak effects. Waxing and waning of the response to the drug (wearing off effects) is also common. This means that the period time that each dose is effective begins to decrease, leading to more frequent doses. Other side effects may include hallucinations, a drop in blood pressure — especially in the standing position — and nausea. Still, levodopa often allows people with Parkinson's disease to extend the time they're able to lead relatively normal lives and in many cases is effective for a number of years.

• Dopamine agonists. Unlike levodopa, these drugs aren't changed into dopamine. Instead, they mimic the effects of dopamine in the brain and cause neurons to react as though sufficient amounts of dopamine were present. Dopamine agonists are primarily used as adjuncts to levodopa therapy, but they are sometimes used initially in early Parkinson's disease, especially in younger adults. The side effects of dopamine agonists are similar to those of levodopa. This class of drugs includes the older dopamine agonists, bromocriptine (Parlodel) and pergolide (Permax) and the newer drugs, pramipexole (Mirapex) and ropinirole (Requip). You should not use dopamine agonists if you already have experienced hallucinations or confusion.
• Selegiline (Carbex, Eldepryl, Atapryl). This drug, used as an adjunct to levodopa therapy, helps prevent the breakdown of both naturally occurring dopamine and dopamine formed from levodopa. It does this by inhibiting the activity of the enzyme monoamine oxidase B (MAO-B) — the enzyme that metabolizes dopamine in the brain. At one time it was thought that this drug might slow the progression of Parkinson's disease, but this now appears not to be the case. Toxic reactions have occurred in some patients who took selegiline with the narcotic drug, meperidine (Demerol).
• COMT inhibitors. A newer class of drugs, COMT inhibitors prolong the effect of levodopa therapy by blocking an enzyme that breaks down dopamine in the liver and other organs. Tolcapone (Tasmar) is a potent COMT inhibitor that easily crosses the blood-brain barrier and in clinical trials reduced the amount of levodopa needed by 25 percent. But because Tasmar has been linked to liver damage and liver failure, the drug is normally only used in people who are not responding to other therapies. Entacapone is a milder COMT inhibitor that may help manage fluctuations in the response to levodopa in people with Parkinson's disease.
• Anticholinergics. These drugs were the main treatment for Parkinson's disease before the introduction of levodopa. In general, they help control tremors in the early stages of the disease. Even so, they are only mildly beneficial and sometimes the benefits are offset by side effects such as dry mouth, nausea, urine retention — especially in men with an enlarged prostate — and severe constipation. Anticholinergics can also cause mental problems, including memory loss, confusion and hallucinations. A number of anticholinergic drugs, such as trihexyphenidyl (Artane) and benztropine (Cogentin), are currently available. The antihistamine diphenhydramine (Benadryl) and antidepressants such as amitryptilline (Elavil) work much like anticholinergics and may be used in older adults who can't tolerate anticholinergics themselves.
• Amantadine (Symmetrel). This antiviral drug may be prescribed for people in the latter stages of Parkinson's disease, especially if they have problems with involuntary movements induced by levodopa (dyskinesias). Side effects include swollen ankles and a purple mottling of the skin.

If you're using medications for Parkinson's disease, it's extremely important not to stop taking them on your own. If you're troubled by side effects or any other problems, talk to your doctor.

Surgery

Surgical procedures were once commonly used to treat Parkinson's disease, but fell out of favor with the advent of levodopa and other drug therapies. Now, surgical approaches are being re-evaluated. The following procedures may be an option when symptoms can't be controlled with medications:

• Thalamotomy. This procedure has been used for years to reduce tremors in people with Parkinson's disease. Thalamotomy involves the destruction of small amounts of tissue in the thalamus — a major brain center for relaying messages and transmitting sensations. But because the surgery can cause extreme weakness and slurred speech if it's performed on both sides of the brain, the benefits are usually confined to one side of the body.
• Pallidotomy. There has been renewed interest in pallidotomy since improved imaging techniques have allowed surgeons to pinpoint the areas to be treated with greater precision. In this procedure, an electric current is used to destroy a small amount of tissue in the globus pallidus, a part of the brain responsible for many symptoms of Parkinson's disease. Pallidotomy may improve tremors, rigidity and slowed movement (bradykinesia) by interrupting the neural pathway between the globus pallidus and the thalamus. It may also counter the involuntary movements (dyskinesias) caused by drug therapy.

  But although pallidotomy has been helpful for some aspects of Parkinson's disease in certain people, it's not a cure, and in many cases benefits may not last. In addition, the surgery carries a number of risks, including slurred speech, disabling weakness and vision problems, especially when performed on both sides of the body.

• Deep brain stimulation. In 1997, the Food and Drug Administration approved a new brain implant device that can help control the disabling shaking and trembling caused by Parkinson's disease. The deep brain stimulator (DBS) consists of a pacemakerlike unit implanted in the chest that transmits electrical pulses through a wire to an implant in the thalamus. The pulses appear to interrupt signals from the thalamus that may play a role in causing tremors. Potential risks exist with the DBS, including infection caused by the wire connecting the electrode to the stimulator and the need to perform minor surgery to change the unit's battery.

  More recently, deep brain stimulation has been extended to other brain areas, particularly the subthalamic nucleus. Simulation within this brain center may markedly improve many aspects of parkinsonism.

Experimental treatments

Although researchers continue to work to develop new drug treatments for Parkinson's disease, great interest also exists in finding a way to replace the dopamine-producing cells in the substantia nigra. One approach has been fetal cell transplantation — a procedure in which fetal cells are implanted into the brains of people with Parkinson's.

Unfortunately, one large study, published in the March 8, 2001, issue of the New England Journal of Medicine, suggested that fetal cell implants only benefit people under age 60. Furthermore, about 15 percent of study participants later developed severe involuntary movements (dyskinesias) as a result of too much dopamine.

In addition, the use of fetal cells raises a number of moral and ethical issues that will not be easily resolved. The answer, many researchers believe, is the use of embryonic stem cells.

Stem cells are the parent cells of all tissues in the body. To date, researchers have been able to capture and culture undifferentiated human stem cells in the laboratory. The hope is that they may one day be able to direct these cells to become specific types of cells — such as dopamine-producing neurons — that can be used to treat disease. Stem cells used in research are derived from embryos that were produced in a laboratory to treat infertility, and they are used only with the informed consent of the donors.

Researchers are also investigating genes that code proteins responsible for producing dopamine, drugs that block the action of glutamate — an amino acid that destroys nerve cells — and the role of the antioxidant coenzyme Q-10 in stopping the progression of Parkinson's disease.

Self-Care 

If you've received a diagnosis of Parkinson's disease, you'll need to work closely with your doctor to find a treatment plan that offers you the greatest relief from symptoms with the fewest side effects. Certain lifestyle changes also may help make living with Parkinson's disease easier.

Eating a healthy diet

It's important to eat a nutritionally balanced diet that contains plenty of fruits, vegetables and whole grains. These foods contain natural antioxidants that help protect against free radical damage. They're also high in fiber, which is important for helping prevent constipation.

If you take a fiber supplement, such as psyllium powder, Metamucil or Citrucel, be sure to introduce it gradually and drink 8 to 10 glasses of fluid daily. Otherwise, your constipation actually may become worse. If you find that fiber helps your symptoms, use it on a regular basis for the best results.

In addition, avoid drinking caffeine and alcohol and try to reduce your consumption of fats — especially saturated fats. Foods that contain saturated fat include red meat, milk, cheese, ice cream, and coconut and palm oils. Try to restrict your total fat intake to less than 30 percent of your daily calories, with no more than 10 percent coming from saturated sources.

Although studies have not found that specific vitamins, including antioxidants such as vitamin E, help slow the progression of Parkinson's disease, some doctors may recommend vitamin or antioxidant supplements. If you're interested in supplementing your diet, talk to your doctor or pharmacist.

Eating and swallowing carefully

You may have difficulty swallowing in the later stages of Parkinson's disease. To help make eating and swallowing easier:

• Take small bites of food and chew each mouthful thoroughly.
• Swallow each mouthful before putting more food into your mouth.
• Try chopping food in a food processor or blender to make it easier to eat.
• Take your time eating. Use a warming tray under your plate so your food doesn't get cold before you're done.

Exercising

Regular exercise is extremely important for people with Parkinson's disease. It helps improve mobility, balance, range of motion and even emotional well-being. Your doctor or physical therapist may recommend a formal exercise program, but any physical activity, including walking, swimming or gardening, is beneficial. In fact, some studies have shown that weight-bearing exercises, such as walking, jogging and dancing, may be more helpful than physical therapy for people with Parkinson's disease.

Keep in mind that your energy level may go up and down, and you'll sometimes need to pace yourself. If you're tired, try doing one part of your routine at one time of day, and adding another segment later. Also, choose a time to exercise when your medicines are working well and you feel strong.

Be sure to stretch before and after you exercise. Stretching warms up your muscles, helps prevent stiffness and improves your flexibility and balance.

Walking with care

Parkinson's disease can disturb your sense of balance, making it hard to walk with a normal gait. These suggestions may help:

• If you notice yourself shuffling, slow down and check your posture. It's best to stand up straight with your head over your hips and your feet 8 to 10 inches apart.
• Buy a good pair of walking shoes. Avoid running shoes.
• Practice taking long steps and exaggerate lifting your legs and swinging your arms.
• If you become stuck in place — known as freezing — rock gently from side to side or pretend you're stepping over an object on the floor.

Avoiding falls

In the later stages of the disease, you may fall more easily. That's because Parkinson's disease affects the balance and coordination centers in the brain. In fact, you may be thrown off balance by just a small push or bump. The following suggestions may help:

• Ask your doctor or physical therapist about exercises that improve balance, especially tai chi. Originally developed in China more than 1,000 years ago, tai chi uses slow, graceful movements to relax and strengthen muscles and joints. To find a tai chi class in your area, contact your local senior center, YMCA or health club.
• Wear rubber-soled shoes. They're less likely to slip than shoes with leather soles.
• Remove all area rugs from your home and make sure carpeting is secured firmly to the floor.
• Install handrails, especially along stairways.
• Keep electrical and telephone cords out of the way.
• Install grab bars around your tub and beside the toilet.
• Make sure you can reach the telephone from your bed and carry a cordless phone with you during the day.

Dressing

Dressing can be the most frustrating of all activities for someone with Parkinson's disease. The loss of fine motor control makes it hard to button and zip clothes, and even to step into a pair of pants. These suggestions may help:

• Allow plenty of time so you don't feel rushed.
• Lay clothes nearby.
• Choose clothes that you can slip on easily, such as sweatpants, simple dresses or pants with eleastic waistbands.
• Look for clothes and shoes with Velcro fasteners, or replace buttons on clothes you have with Velcro.

Speaking

Even in the early stages of Parkinson's disease your voice may become very soft or hoarse. To communicate more easily:

• Face the person you're talking to, and deliberately speak louder than you think is necessary.
• Practice reading or reciting out loud, focusing on your breathing and on having a strong voice.
• Speak for yourself — don't let others talk for you.
• Consult a speech-language pathologist who is trained to treat people with Parkinson's disease.

Coping Strategies

Living with any chronic illness can be difficult, and it's normal to feel angry, depressed or discouraged at times. Parkinson's disease presents special problems because it can cause chemical changes in your brain that make you feel anxious or depressed. Medications used to treat the disease also can cause depression and other mental changes. Furthermore, Parkinson's disease can be profoundly frustrating, especially in the advanced stages when ordinary tasks take longer to accomplish and walking, talking and even eating become more difficult.

Some of the following suggestions may help you deal with the stress of living with Parkinson's disease:

• Learn all you can about your illness. Find out how the disease progresses, your prognosis and your treatment options and their side effects. The more you know, the more active you can be in your own care. In addition to talking to your health care team, look for books and information on the Internet, including the Web sites of various Parkinson's disease organizations.
• Be proactive. Although you may often feel anxious or discouraged, don't let others — including your family and your doctors — make important decisions for you. It's vital that you take an active role in your treatment.
• Maintain a strong support system. More and more studies show that strong relationships are crucial in dealing with chronic illnesses. Although friends and family can be your best allies, the understanding of people who know what you're going through can be especially helpful. Support groups aren't for everyone, but for many, they can be a good resource for practical information about Parkinson's disease. You may also find that you develop lasting bonds with people who are going through the same experiences as you. Support groups also exist for the families of people with Parkinson's disease. To learn about support groups in your community, talk to your doctor, a Parkinson's disease social worker or a local public health nurse. 
• Minimize work-related stress. A diagnosis of Parkinson's disease doesn't mean you have to stop working. In fact, 25 percent to 35 percent of people with the disease continue to hold either full- or part-time jobs. But you may need to approach work differently. Start by breaking your job down into individual tasks. Then consider whether your symptoms will affect your ability to perform each task.

  Next, try to create a schedule that allows you to do the most challenging assignments when you're at your peak. In some cases, you may consider telecommuting, working part-time or even changing jobs. Keep in mind that the Americans With Disabilities Act (ADA) requires your employer to make reasonable accommodations to help you function more easily on the job. These accommodations include modified work schedules, reassignment to vacant positions, job restructuring and the use of special equipment or devices. For more information about the ADA, call the toll-free ADA information line at 800-514-0301. 

  Although you may not feel comfortable talking about your illness, in many cases it's best to be candid with your supervisor. That way, he or she can work with you to make the adjustments necessary to meet your needs. On the other hand, you're under no legal obligation to disclose your condition to your employer as long as you can do your job.

• Maintain good communication with your partner. It's extremely important for couples to be open about their feelings, especially when it comes to living with Parkinson's disease. The disease may change your life and the lives of your loved ones in a number of ways. It's best if you can talk honestly about these changes. For instance, if you're no longer able to work full time, there may be financial issues that need to be resolved. The amount of care a person with Parkinson's disease needs is also often an issue. Because it may take you longer to do ordinary tasks, your partner might want to help. But most people with Parkinson's disease like to remain as independent as possible. You'll need to let your partner know when you need help and when you don't.

  Sometimes couples also experience sexual problems. Parkinson's disease makes it more difficult to move easily, which can affect intimacy. In addition, some men with Parkinson's disease may have problems with impotence and women may experience decreased desire (libido). This may be the result of antiparkinson medications or of the disease itself. But these problems can often be helped. For instance, medications such as sildenafil (Viagra) have proved beneficial for many men with Parkinson's disease.

  In addition, try to schedule time together when your medications are at their peak and you're less likely to be troubled by symptoms. And keep in mind that intercourse is only one way to be intimate. Just cuddling or holding each other often can deepen a relationship and make it more emotionally satisfying.

  Most important, try to talk frankly about your feelings and concerns. Repressed feelings can be harmful to your immediate well-being and long-term health. If necessary, discuss your problems with your doctor or counselor.

• Be honest with children. If you have younger children, don't try to hide the diagnosis from them. Children can usually sense when something is wrong in the family, and the anxiety and fear of not knowing is often harder on them than knowing the truth. In addition, children need to be reassured that their mother or father will be all right and will still be there for them. Answering your children's questions honestly can help them cope.