Living Well with Parkinson's Disease with Rebecca Gilbert, MD, PhD

Many thanks to Rebecca Gilbert, MD, PhD, for joining me on Episode #166 of The Art of Medicine with Dr. Andrew Wilner. Dr. Gilbert is a movement disorders specialist at Bellevue Hospital in New York City and Chief Mission Officer of the American Parkinson’s Disease Association. She trained at Memorial Sloan Kettering and Columbia University, where she studied under renowned movement disorders specialist Dr. Stanley Fahn.

During our 35-minute conversation, Dr. Gilbert described the symptoms of Parkinson’s disease and emphasized the importance of dopaminergic medications and regular exercise to improve quality of life. We also explored the intriguing and still unexplained observation that music can enhance movement in people with Parkinson’s disease.

Dr. Gilbert highlighted the new American Parkinson’s Disease Association public service announcement launched for Parkinson’s Awareness Month, “Do What You Do.” This campaign showcases people with Parkinson’s who continue to pursue their passions despite the challenges of the disease.

Finally, Dr. Gilbert reviewed recent advances in Parkinson’s disease treatment, including adaptive deep brain stimulation and subcutaneous infusion pumps. She also discussed ongoing efforts to develop biomarkers that can diagnose the disease at an earlier stage.

For more information about Parkinson’s disease, please visit: www.support.apdaParkinson.org

#Parkinsons @APDA @RebeccaGilbert #movementdisorders @theartofmedicine #dopamine #DBS

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Transcript

[Andrew Wilner MD] (0:08 - 1:15)

Welcome to the Art of Medicine, the program that explores the arts, business, and clinical aspects of the practice of medicine. I'm your host, Dr. Andrew Wilner. I've planned a great program for today, but first, a word from our sponsor, locumstory.com.

Locumstory.com is a free, unbiased educational resource about locum tenens. It's not an agency. Locumstory answers your questions on their website, podcast, webinars, videos, and they even have a locums 101 crash course.

Learn about locums and get insights from real-life physicians, PAs, and NPs at locumstory.com. And now to my guest. Today, I'd like to welcome Dr. Rebecca Gilbert. Dr. Gilbert is a movement disorder specialist at Bellevue Hospital in New York City and the chief mission officer at the American Parkinson's Disease Association. Dr. Gilbert is going to share with us some of her experiences treating patients and her advice to living well with Parkinson's disease. Welcome, Dr. Gilbert.

[Rebecca Gilbert, MD, PhD] (1:15 - 1:16)

Thank you.

[Andrew Wilner MD] (1:16 - 1:40)

It's great to be here. Thanks, Dr. Gilbert. Yeah, I'm interested.

We're going to talk, you know, it's April and April is Parkinson's Disease Awareness Month. It won't be April anymore by the time this comes out, but at least I'm talking to you during April. So let's get started with your medical training and background and how you got interested in Parkinson's disease.

[Rebecca Gilbert, MD, PhD] (1:41 - 4:40)

Yeah, so I did a pretty straightforward MD-PhD program way back in the day. I worked at Memorial Sloan-Kettering. I got a PhD in cell biology and genetics along with the MD degree.

And then it was a matter of, okay, now what do I do? What subspecialty to do? And I really, really enjoyed the brain.

And the brain, and I know you're a neurologist as well, so you probably appreciate the sentiment, which is that the brain to me was kind of like the final frontier. You know, we didn't really figure it out and there was so much more we needed to know about it. And so I decided to go into neurology.

And then within neurology, Parkinson's disease and related disorders spoke to me because these were a group of diseases where we had medications that could help, but there was a lot more that we didn't know. So it was sort of that middle ground of being able to really help people in substantial ways, but knowing that there was a lot more we needed to discover. And so that's really how I thought about it.

And I did my residency and I did my fellowship training at Columbia in New York City. And then after that, and I trained under Dr. Stanley Fon, who is- Sure, I know Dr. Fon. Yeah, and the founder of the field.

And it was such a privilege to interact with him on a daily basis. And I do really appreciate that perspective now. After my training, I got a job at NYU in Manhattan and I saw people with Parkinson's disease.

And I also interacted with the fellows there. I was fellowship director for a little while, gave a lot of lectures, did programming for people with Parkinson's disease, did clinical trials, all the kind of standard things that a person does when working at an academic center and Parkinson's disease was a great time and we enjoyed it. And then there was a position open at American Parkinson's Disease Association.

This is an organization that is a nonprofit organization that works very closely for people with Parkinson's disease, providing support, education, wellness programming, as well as funds research and does advocacy work in the Parkinson's disease space. It was a wonderful organization and they were looking for some additional medical leadership and it was a great fit. And I started working there in 2018 and I have not looked back.

I keep one day a week of practice specifically at Bellevue, which is affiliated with NYU. And I get to continue to see patients. I get to get familiarity with the new things that are coming out.

It's always new things. We can talk about that. And so that's great.

I get to keep my feet wet and know what's happening in the field clinically, and then be able to apply it to kind of a bigger platform at APA. So that's me in a nutshell.

[Andrew Wilner MD] (4:40 - 6:51)

Well, thank you for condensing what must be at least 25 years into 25 words or less. That was great. And it is very difficult these days to get a job with a clinical and a non-clinical component to achieve that balance.

So that's great. You're lucky to be able to achieve that. Now, when I was a resident, we treat Parkinson's patients and the good news was when you identified a new patient.

I remember I was working at the Mayo Clinic a number of years ago and I was doing the outpatient service and there was a guy in the waiting room and I walked by and it was like, I'd never seen this patient before, but it was clear to me that I thought, you know, I bet that guy has Parkinson's disease. And sure enough, after he came in and we were talking and he didn't know, he didn't know he had Parkinson's. It was new onset.

And he told me like classic story that he and his wife, this was in Phoenix, would go for these long walks and his wife always had trouble keeping up with him. And lately it was the other way around. And then he'd also had an experience at the airport, you know, where there's a lot of chaos and people moving in different directions where he would suddenly freeze.

Somebody would walk in front of him and he would just get stuck. And just looking at him, he was a little bit stooped and a little bit slow. And his face was sort of devoid of a lot of expression.

It was like, guess what? I think, you know, we'll do an MRI just to make sure it's not some strange imitator. And the good news was I'll give you this medicine, you're going to feel great.

The bad news is we don't have a cure for this and it's going to stay with you and we're going to have to fuss with it. A statistic I remember that, tell me if it's still true, that the life expectancy with proper treatment is not reduced. That you will still live your normal life expectancy, although perhaps with some disability towards the end, but it won't cut your life short per se.

Is that still?

[Rebecca Gilbert, MD, PhD] (6:52 - 7:03)

That is still, seems to be the case, which is great. It isn't a disease that is fatal. It's a disease, a chronic disease that needs to be managed.

[Andrew Wilner MD] (7:04 - 7:24)

So about that, let's talk about that. Right. It's a neurodegenerative disease.

There are cells that are not making the dopamine and there's a lot else going on too, but you can supplement the dopamine but what, as a clinician, what's the biggest, and for patients, what are the biggest challenges, do you think, living with Parkinson's?

[Rebecca Gilbert, MD, PhD] (7:24 - 10:43)

Really exactly what you said, chronic illness, we divide it into these two major categories of symptoms, things that affect movement and things that do not affect movement. So the things that affect movement are, just as you indicated with this gentleman, that you were describing slowness, stiffness. There is this very characteristic, these characteristic features where you may have a very characteristic posture where you're stooped or slow.

You may have decreased arm swing on one side, decreased heel strike on one foot, masked face, all these kinds of very characteristic movement symptoms. And I haven't mentioned tremor, which is what people tend to associate with Parkinson's. And it is true.

It is a very, very common symptom and a very characteristic sort of pathognomonic symptom where you look at someone and their hand is shaking when they're resting in their lap or dangling at their side. And you're like, well, it's very few things that do that. And Parkinson's is certainly right up there.

So those are all the movement symptoms. And then there are the non-movement symptoms, which also are part and parcel of Parkinson's disease, but they're a bit varied and people can have sort of a potpourri or selection of some of these. And they include problems with mood, depression, and anxiety are very common.

Problems with the gut, constipation is very common. Problems with sleep, something called REM behavior. Sleep disorder is very common where you act out your dreams.

There's problems with smell, problems with urination, problems with swallowing, all sorts of sort of non-motor features, which can affect people. Not everyone gets all of them. No one gets all of them, but you get sort of your own tailored version of them.

That sort of panoply of symptoms needs to be treated. And so, as you suggested, we have medications that are specific to giving back the dopamine. That's the chemical that's lost when nerves, specific nerves in the brain degenerate, the nerves that usually help out the movement symptoms.

And those dopaminergic medications are, have been around for a very long time. We have modifications of them that are new, that work better for some people, which is great. We have a whole kind of armamentarium of various ways to give dopamine out, but that only helps the movement part of the condition.

So that would help the tremor, the slowness, the stiffness, the balance, the walking problems. But we also, as movement disorder physicians are eager to address the non-motor symptoms as best we can. And that may require treating depression, treating the sleep disorder in some way, treating the constipation, treating urinary problems, treating blood pressure problems.

So we really try to take a holistic approach and treat whatever we can to improve quality of life. Having said that, one of the most important things we do is try to empower our patients to do what they can to keep the disease at bay. And the number one thing that that involves is movement or exercise.

And so we really cannot emphasize that enough. And we feel that that's sort of part of our mantra, part of our prescription is to make sure people understand that that's, we have to, they have to need us halfway. There's only so much medications can do.

Keeping moving is essential.

[Andrew Wilner MD] (10:44 - 10:53)

You see these videos on YouTube of Parkinson patients dancing. What's going on there?

[Rebecca Gilbert, MD, PhD] (10:53 - 14:45)

Yeah. So the whole topic of what does exercise do for people with Parkinson's disease? It's very multifaceted.

So there's a lot of, it used to be in back in the day that exercise may have been mentioned or physical therapy was prescribed and that was considered important. Now there's really a lot of research that's kind of goes behind why is exercise so important. I mean, it's intuitively obvious.

A body at rest tends to stay at rest. A body in motion tends to stay in motion. So if you're going to sit on your bottom all day, you're just not going to be as fast and fit and everybody kind of feels that that's intuitively true.

And that's really true for people with Parkinson's sort of in spades. So that's sort of the bottom line. But the reason, the molecular mechanisms behind why exercise is so important, there's research that suggests that dopamine receptor density, for example, increases with exercise or that nerve growth factor production increases with exercise.

So there are these molecular sort of theories as to what exercise is doing. And then of course, exercise makes the blood vessels nice and clean. So the same reason why exercises and that whole kind of controlling the metabolic syndrome of diabetes, high blood pressure, et cetera, et cetera, is good for the heart because it makes sure that the blood vessels are nice and clean and the blood's going really well.

The same holds true for the brain. So you want the brain to, the blood to get to the brain in a similar sort of way. And as you indicated, Parkinson's disease can, one of the mimics of Parkinson's disease are these multiple strokes in the brain that can make a similar sort of clinical picture.

And so we don't want any of that involved either. And so exercise can help that good blood flow to the brain. And that's also very important sort of mechanism as to why exercise is important.

But there's another element, which is novelty. So there's these lovely experiments that were done at UCLA that I love talking about, which is that a researcher had two sets of rat wheels. One rat wheel was a regular rat wheel and the rat was able to run as fast as they could.

And then there was another rat wheel where the slats were removed in a random way. And the rats had to learn where to put their feet in order to run on the wheel and fell off if they didn't learn it, et cetera, and couldn't run as fast. And so the two sets of rats were given their wheels, and then they were sacrificed for science and their brains were left out.

And the blood flow and the integrity of the brain was better in the rats that learned how to use the wheel as opposed to the rats that ran really fast. And so this concept that not just moving is important, but moving in a novel sort of way is important. And so that's where a lot of the boxing or pickleball for Parkinson's or kickboxing for Parkinson's or all these sort of new tasks that we're asking our bodies to do kind of incorporates the exercise with the novelty.

And that can be a really, really powerful thing in people with Parkinson's. And so that's one aspect of dance where you're learning steps, you're doing multiple things, you have to remember them, you do them in a certain order and along with the exercise. And I think that is very interesting kind of element of dance.

And in addition, dance requires you to test your balance in ways that regular movement doesn't. And balance can be very problematic for people with Parkinson's. And so stressing that balance muscle, if you will, is also a great element of dance.

So all of the above.

[Andrew Wilner MD] (14:45 - 15:27)

I'm going to address one more thing. I have a special interest in music. And we did a program actually very recently with Philip Pearl, who's a pediatric neurologist and a professional musician.

And we talked about the effect of music on the brain. And so there seems to be this phenomenon that Parkinson's patients who can barely walk, if you turn on their favorite tune, the next thing they can glide across the room. And I don't think anybody really understands the molecular basis of that yet.

But do you agree that it's a phenomenon that it happens?

[Rebecca Gilbert, MD, PhD] (15:28 - 17:10)

Absolutely a phenomenon. When you had mentioned, you started mentioning music, I thought you were going to talk about cognition. And so there's a whole literature about in people with memory issues and Alzheimer's disease specifically, who may not talk, but can sing and along similar lines where they'll remember music.

So something about music sort of uses different circuits in many ways. And I think you see a similar phenomenon in Parkinson's. Another element of that is what we call cueing.

So there's this abnormal gate pattern in Parkinson's called freezing of gate, where you mentioned this with the gentleman you were describing where a person may take multiple steps in place, their upper body's trying to move forward, their lower body's stuck, and they have this very characteristic looking walk, which can lead to falls. It's very problematic, very annoying for people, this freezing of gate. And the way people get out of the freezing of gate is they give themselves some kind of cue and there's all sorts of ways people do it.

It could be a visual cue. They look on the floor and they step over a line. Very commonly it's a rhythmic cue or walking to music where there's sort of silence.

They can't get themselves going, but if there's a beat, they can generate that step to the beat. So what is that? Where does cueing fit into the brain?

And obviously music is rhythmic and using music to get out of a freeze also can be helpful. There's a lot we don't understand, but it does seem to work, which is very interesting. A lot more we don't know about the brain, that's for sure.

[Andrew Wilner MD] (17:11 - 17:17)

I read something about a PSA campaign. Can you talk about that?

[Rebecca Gilbert, MD, PhD] (17:17 - 18:53)

Oh, absolutely. So PSA stands for Public Service Announcement. When you're in the non-profit world, that's one of the things you learn.

And this is our attempt or our chance to, in 60 seconds, get the word out about what Parkinson's disease is and what it means. It's sort of a public awareness. The statistics are that there are 1 million people with Parkinson's in the United States now.

There are 330 million people of the population of the United States. So there's a good chance you know someone with Parkinson's, but you may not. It may not be center of your mind.

And so a PSA sort of introduces to the general population what Parkinson's is. And APDA just released a new PSA on April 1st in time for Parkinson's Awareness Month. And the campaign is do what you do, even if you keep doing what you're doing, even if you have to do it differently.

And so it highlights people with Parkinson's disease, genuine people with genuine stories who have passions about what they love to do. We have one gentleman who's a beekeeper, one gentleman who loves to travel, a woman who loves to cook, a woman who loves to dance. And we filmed their stories and pieced them together to tell the story of individuals who are continuing to do what they love to do, despite the fact that they have Parkinson's and despite the fact that they may have to do it a little differently.

We are extremely proud of PSA. It is beautiful and I challenge you to watch it and not cry.

[Andrew Wilner MD] (18:54 - 20:01)

So I think one of the problems, and this is generic of living with a chronic disease, and maybe even more so with neurodegenerative diseases like Parkinson's, is depression and social isolation. And that can be more limiting and affect the quality of life even more than the difficulty moving, if you will. Certainly additive, right?

Absolutely. Absolutely. So I think this idea of keep doing what you're doing, not only is going to make you stronger, right, and keep your muscles active and, you know, keep you going, but also is going to counter some of that depression you get if you're just stuck in your armchair watching TV 12 hours a day and you can't do what you want to do.

Absolutely. That sounds like a great campaign. Now, back in the day, you know, we were using dopamine supplements, which we've discussed.

Is there anything sort of new on the horizon that's going to be helpful?

[Rebecca Gilbert, MD, PhD] (20:02 - 24:21)

So the newest things on the horizon are other ways, the newest things that are available clinically right now that a couple were released in the last year are new ways of introducing dopamine. So, you know, I always get the question, my father had Parkinson's and he took dopamine in 1979 or whatever. And why am I also taking dopamine?

And the bottom line is that's the disorder. The disorder is the lack of dopamine. So we're not going to get away from having to figure out ways to give dopamine, even if it's been 40 years, you know what I mean?

So, you know, that is the reality of what the disorder is. So we do need to find ways to give some dopamine. The problems with the old ways of giving medications, which are still very valid and lots of people are on them, that's the kind of bread and butter medicine called Sinemet, carbidopa, levodopa, is that as the disease progresses, what tends to happen is the pharmacokinetics of the medication become a little unwieldy, meaning that you would take the medication and it just doesn't last long enough.

It may last two hours and 20 minutes or, you know, two hours and a half and that's really short. And then people feel like they just need to be constantly taking their medicine and always worrying about, you know, when the dose will wear off and there's the stress around, you know, how long will the dose last? And it can be unpredictable and somebody's dose usually lasts two and a half hours and it doesn't last that long.

And then they're not moving as well. And there's this sort of up and down throughout the day. And the flip side is the receptors can get a little too sensitive to the medicine.

And when the dose is a little too high or the onset of dopamine levels are going up too quickly, then you can get dyskinesia or dance-like movements that are not part of the disease, but are actually a side effect of the medicine. And so people may fluctuate between the medicine doesn't work, it works too well, I have movements, and it can be really, really difficult. When you're in that situation, that's not good.

And we have accepted it in the past, but the focus of a lot of research was to try to treat that situation called motor fluctuations. And so one way that we have been doing it is surgery, deep brain stimulation, which is putting a wire deep in the brain. It gets tunneled under the skin attached to a battery pack in the chest and electricity is delivered deep into the brain.

And that's a great way to give an even stimulation throughout the day and allows people to pull back on their medications often and really get that more even symptom control as opposed to kind of the ups and downs that I was describing. So that's been in use and clinical use for many years now. There are brand new ways and technologies related to this surgical system, which are really exciting, something called adaptive DBS.

What that means is the new buzzword AI, artificial intelligence, kind of predicts what based on information that instead of just the lead delivering electricity to the brain, which is how DBS has always worked, this type of lead senses from the brain what's going on and makes adjustments to the stimulation based on those readings. So it's sort of feedback. It's very exciting technology that is now being rolled out.

Some people have that system active in their brain, so that's very exciting. And in addition, there are other ways to deliver dopamine that try to not be quite as spiky. So it's not like you take the medicine, you get a big spike and then it goes down and take another dose.

So these are more controlled release type medications. There are two that are available on the market, well actually three, one is a little bit older and then one called Ritari, one called Crexant. Those are a longer acting carbidopa levodopa formulations.

And then the newest kid on the block is a subcutaneous infusion, very analogous to an insulin pump where you infuse, you have a little pump that you wear and it infuses carbidopa levodopa over 24 hours into the subcutaneous tissue. So that's another very exciting advance. And there's more, but I sense you have another question.

[Andrew Wilner MD] (24:23 - 24:46)

You're right. I always have another question. So anything, I know there have been some trials, is there any medication that interferes with the progression of the disease?

In other words, that slows the disease progression or that stops the disease or making a headway or are we just treating the symptoms?

[Rebecca Gilbert, MD, PhD] (24:47 - 27:43)

So that was exactly what I was going to talk about, but then I stopped myself. So yes, what we do not have yet is that holy grail, which we've been looking for for 20 plus years, is that medication that's going to stop progression. So we've had a lot of clinical trials of all sorts of mechanisms of action to try to alter the biology of the disease and make the disease progression slower or stop the progression entirely.

We have not had success yet. However, there are many molecules in clinical trial currently that are the next sort of population of molecules moving through the system to see if any of them are going to be the one that we use. Now, what we have been saying all this time is why has there been so many failures?

And one of the common responses, and there is debate about whether this is true, is because we start too late. Meaning there is very, very good data that once you sort of presented as somebody with Parkinson's, meaning you have the tremor or you're already stooped and slow and can't keep up with your wife on your walk, you've already lost 80% of your dopaminergic neurons. And so intervening, even at that early, early Parkinson's, where all you're seeing is a little bit of rest from it, a little bit of slowness is too late potentially.

And really what we need to do is identify those people when they're just starting to have a problem. So pushing back that timeline and treating them there. And that's the theory or that's the impetus behind this series of conferences that have been ongoing since about 2022 at this point called Planning for the Prevention of Parkinson's Disease.

It's a series of conferences organized by wonderful Dr. Michael Schwarzschild out of Mass General Hospital. And that's what he would like to do. He would like to identify this group that's enriched, very, very enriched with people who are going to develop Parkinson's and find the molecule that is promising and give it to those earlier people.

And so that's where we're headed. And I think that that potentially show some more promise in terms of outcomes. So there's a lot of people thinking about these exact issues.

In addition to that concept, so let's move the trial to earlier people. There are many molecules that are being tested on early people now. And the hope is that one of them will have a signal.

There's an antibody to alpha-synuclein. Alpha-synuclein is the abnormally accumulated protein in Parkinson's disease, sort of analogous to the beta and tau in Alzheimer's. And there's an antibody that's at the end of a phase three trial right now.

So there's some hope in that molecule as well. So a lot going on in the field.

[Andrew Wilner MD] (27:44 - 28:19)

Yeah, that's, that's very exciting. I'm going to ask you a little neurology. I remember, you know, one of the aspects of that we've talked about with Parkinson's disease, making the diagnosis that it's a clinical diagnosis, patient presents with symptoms and typical symptoms.

And then you figure out that must be if they don't have something else, that's what they've got. But that's problematic if you want to treat them early in a trial, right? Because you don't have all those symptoms yet.

So I remember reading something about a skin biopsy. Is that right? Yes.

[Rebecca Gilbert, MD, PhD] (28:19 - 31:13)

Yes. So yes, exactly. Right in with this planning for the prevention of Parkinson's disease idea is you need biomarkers.

You need a way to figure out who these people are. And so there's, there's many ways to go about it. It could be a set of non-motor symptoms.

So you know, a lot, some of the non-motor symptoms such as REM behavior, sleep disorder, lack of smell, constipation, anxiety, depression start can in many cases start decades before the motor symptoms. So maybe that's a way to identify these people, kind of enrich them for these non-motor symptoms. Another way to enrich them is potentially genetics.

So if we didn't discuss that at all, genetics versus environment, that's a whole other conversation, but there are certainly genes that increase your risk of Parkinson's. So maybe we enrich a genetic cohort. And then the third is finding a biomarker.

So there are kind of three potential biomarkers out there right now. One is a DAT scan, which is a SPECT scan for a dopamine transporter. One is a cerebral spinal fluid assay.

It's called an SAA seed amplification assay, where you sort of use the prion disease concept where you amplify the abnormally folded protein. In a test tube, if you have like a little seed of the abnormal protein, you throw it in there with your mix and you can amplify some, if there is abnormal in the sample, you amplify it and then you can have a readout. So that's the second kind.

And that right now is on cerebral spinal fluid only and not blood, but there's obviously a lot of interest in developing this for blood, make it a lot easier. There are other blood tests that are sort of in the works with other principles being operated on. And then there's the skin biopsy.

The skin biopsy is in clinical use. It's available for practitioners. Sometimes there are insurance hurdles, but the company is working really hard to try to sort that out.

And it requires three small skin biopsies. And then they're sent to the lab of the company that does it called CND Life Science. And with specific stains, they look for phosphorylated alpha-synuclein.

And so that is definitely on the table as well. And so sort of a combination of all, of all these possibilities, you know, to try to enrich this population early on. And then in terms of people who have symptoms and a doctor may just not feel comfortable diagnosing Parkinson's for a whole host of reasons.

Sometimes it's brilliantly clear, like you described across a crowded room, like that's what they got. You know, they don't need a skin biopsy, but sometimes it's not that clear. You know, there might be a mimic you talked about where, you know, somebody's had strokes or they have neuropathy or they're just, you know, deconditioned and you just don't quite know what's going on.

And you don't know if there's a neurodegenerative component, something like the skin biopsy or the cerebral spinal fluid assay or the DAT scan or a combination thereof could be very helpful. So we're heading in that direction as well.

[Andrew Wilner MD] (31:15 - 31:42)

One last clinical point. I remember reading that there's an overlap that people with essential tremor, right, which is just, you know, tremor, we used to call it senile tremor. People just get a tremor when they're old, that some of a certain percentage of those people that that that's really early Parkinson's and they're going to, they're more likely to develop Parkinson's than somebody that age without a tremor.

Is that still true?

[Rebecca Gilbert, MD, PhD] (31:43 - 33:04)

Right. So that's a complicated topic. And certainly there are what, you know, these ET PD overlap cases where somebody may have had ET for their whole life or for a long time, not even all life, let's say as, you know, as they're aging, it seems very ET-ish in terms of that it's an action tremor and that, you know, there is no rigidity and there's no slowness and none of the other symptoms are involved.

It really seems like ET. And then those people start to develop Parkinson's. And so our, our radar is a little higher when we see those ET people.

Having said that it's the statistics are like about 4% of the population is ET, about 1% of the population is Parkinson's. So, you know, certainly there are many, many people that do not develop Parkinson's. I don't want to scare anyone out there, but but yes, we do see this combo combination for sure.

And families that are both, you know, so somebody will have a family history of both ET and PD in there. So there probably are some genes that, that combine or overlap that we haven't quite sorted out yet. So that, that's a, that's a very good point.

And in terms of like why one would get a DAT scan, for example, the SPECT scan, you know, sort of on the list is distinguishing ET from PD. That's sort of kind of one of the things that an insurance company will sort of allow the DAT scan to be done for. So yes.

[Andrew Wilner MD] (33:05 - 33:10)

Or skin biopsy. That's what I was thinking that maybe those people are sort of perfect for the skin biopsy.

[Rebecca Gilbert, MD, PhD] (33:10 - 33:19)

Yes, absolutely. Absolutely. That would be a good use.

So any situation where you, you know, the diagnostic certainty is not as clear, be a good use for these biomarkers.

[Andrew Wilner MD] (33:20 - 33:32)

Well, this has been exciting and informative. I feel like I should get a CME credit for this 40 minutes that we've had together. Before we close, is there anything you'd like to add?

[Rebecca Gilbert, MD, PhD] (33:33 - 34:20)

I just want to, you know, I'm not sure who, who's going to be listening, if it's going to be more practitioners or people with Parkinson's, but to speak to the people with Parkinson's, you know, as, as we said, this is not a death sentence. This is an unfortunate chronic disease that, you know, be great if you didn't have, but there is, there is a lot of hope, a lot of treatments that are available now, treatments that are being developed, lots of people working in your corner to get this solved more than it has been. And, and then we have APDA where you can come to us for resources, for education, for support.

So APDA, I'm sorry, APDAparkinson.org, and you can access everything we have.

[Andrew Wilner MD] (34:21 - 37:00)

I'll put that in the show notes. Excellent. Dr. Rebecca Gilbert, thanks for joining me on the Art of Medicine. Thank you so much for having me. And now a final thanks to our sponsor locumstory.com. Locumstory.com is a free unbiased educational resource about locum tenens. It's not an agency. Locumstory exists to answer your questions about the how to's of locums on their website, podcast, webinars, and videos. They even have a locums 101 crash course at locumstory.com.

You can discover if locum tenens make sense for you and your career goals. What makes locumstory.com unique is that it's a peer to peer platform with real physicians sharing their experiences and stories, both the good and bad, about working locum tenens. Hence the name Locum Story.

Locumstory.com is a self-service tool that you can explore at your own pace with no pressure or obligation. It's completely free. Thanks again to locumstory.com for sponsoring this episode of the Art of Medicine. I'm Dr. Andrew Wilner. See you next time. This program is hosted, edited, and produced by Andrew Wilner, MD, FACP, FAAN.

Guests receive no financial compensation for their appearance on the Art of Medicine. Andrew Wilner, MD, is a professor of neurology at the University of Tennessee Health Science Center in Memphis, Tennessee. Views, thoughts, and opinions expressed on this program belong solely to Dr. Wilner and his guests and not necessarily to their employers, organizations, other group, or individual. While this program intends to be informative, it is meant for entertainment purposes only. The Art of Medicine does not offer professional, financial, legal, or medical advice. Dr. Wilner and his guests assume no responsibility or liability for any damages, financial or otherwise, that arise in connection with consuming this program's content. Thanks for watching. For more episodes of the Art of Medicine, please follow on YouTube or your favorite podcast player. Please share with your friends and subscribe.

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