A Family Doctor's Tale - PARKINSON'S DISEASE

                                             A Simple Guide To Parkinson's Disease        Kenneth Kee (C) 2007                              

DOC I HAVE PARKINSON'S DISEASE

Parkinson's Disease is quite common especially in the elderly patients of a family practice.
You can see them come in slowly , speak with a slurred speech and see their trembling hands and legs. 
More often than not a relative will accompany them. 
Many of them think that their condition is due to old age. 
That is true but their condition will only become worse with time. However there are new therapies which can improve their symptoms.

 Parkinson's Disease is a disorder of old age characterized by slow movement , rest tremors , rigidity and poor coordination.


 Parkinson's Disease usually after the age of  50 years.
Incidence is about 0.2% of population.
It is one of the most common neurologic disorders of the elderly.
It affects both men and women.

The cause of Parkinson's disease is still unknown.
Less than 5% of Parkinson's Disease patients gets the disease through genetic reasons.

A mutation of a gene (LRRK2) called G20135 has been found to increase the risk of Parkinson's disease in some families.

People with the mutated gene gets the illness at a younger age than the normal which is 60 and above.

The prevailing theory is that environmental factors such as exposure to high levels of pesticides is the cause of the disease.


 Parkinson's Disease results when the nerve cells in the part of the brain that controls muscle movement are gradually destroyed.
 Nerve cells use a brain chemical called dopamine to help send signals back and forth. Damage in the area of the brain that controls muscle movement causes a decrease in dopamine production. Low dopamine affects the balance between nerve-signalling substances (transmitters). As a result, the nerve cells cannot properly send messages. This results in the loss of muscle function.


Early symptoms may be nonspecific  and may include numbness, painful and tender muscles, stiffness and weakness  of limbs, fatigue and unexplained weight loss.


 As the disease progresses, the classical features of Parkinson's Disease appear:


1. Bradykinesia(slowness of movement)


2. leadpipe rigidity


3. rest tremors


4. Postural instabilty


  Parkinson's Disease is diagnosed when there are at least 2 of the four classical features are present.
  To improve diagnostic accuracy, bradykinesia must be present.
 1. Bradykinesia usually presents with lack of voluntary and automatic movement such as
 monotonous speech,
 lack of facial expression,
 Slow movements
Difficulty initiating any voluntary movement
Difficulty beginning to walk
Difficulty getting up from a chair
shuffling of feet movement 
 One way to demonstrate this is to have the patient tap  his index finger on his thumb. The movement is slow and lack momentum.


 2. Rigidity of  Parkinson's Disease is leadpipe in nature.
This rigidity contribute to the
 mask like facial appearance,
 Muscle rigidity
 stiffness of posterior neck muscles,
 diminished arm swing,
  cogwheel rigidity of the wrists .
  Difficulty bending arms or legs


 3.Rest tremor is classical of  Parkinson's Disease.
 There is this resting or pill rolling tremors of the hand which is worsened by anxiety and fatigue and disappears when the hand is in use. Tremor is usually unilateral.


 4. Postural instability usually occurs late in the illness.
 It is seen in the
 Unstable, stooped, or slumped-over posture
 freezing gait,
 retropulsion,
 loss of balance and falls
 Turning in bed, rising from the chairand turning when walking is difficult because of poor body and limbs coordination. 


 Additional symptoms that may be associated with this disease:


Depression
Confusion
Dementia
Seborrhea (oily skin)
Loss of muscle function or feeling
Muscle atrophy
Memory loss
Drooling
Anxiety, stress, and tension


 Untreated Parkinson's Disease  progresses to total disability, often accompanied by general deterioration of all brain functions, and may lead to an early death.


Treated, the disorder impairs people in varying ways.
Most people respond to some extent to medications.
The side effects of medications may be severe.
Varying degrees of disability
Difficulty swallowing or eating
Difficulty performing daily activities
Injuries from falls
Side effects of medications
A variety of gastrointestinal symptoms, mainly constipation
Daily activities such as bathing,dressing, walking and even writing may be difficult.


 Parkinson's Disease is not curable and the purpose of treatment is to:
1. improve functions and
2. treat symptoms


Treatment of  Parkinson's Disease can be broadly classified into:
1. Non-drug therapy:
    
     Good general nutrition and health are important.
     Exercises that improve strength, agility and flexibilty are useful to minimise the disability of  Parkinson's Disease. A range of motion exercises is useful to keep the joints supple and mobile. Patients are encouraged to exercise according to their ability. Good exercises include walking,swimming, stretching and riding stationary bicycles.
     Patients are taught sitting balance,walking techniques and the use of handrails. Activities of daily living is made more manageable
 with aids like:
 Buttoning     -replace buttons with velcros
 Eating           -use utensils with large handles
 Getting out of bed -install an overhead grab bar
 Prevents falling -install hand bars in bedroom and bathroom. use nonslip mats.
 Getting out of cair - use high seat chair


Railings or banisters placed in commonly used areas of the house may be of great benefit to the person experiencing difficulties with daily living activities. Special eating utensils may also be helpful.
2. Drug therapy
      There are 2 main types of drugs:
       1. symptom modifying helps to alleviate the symptoms but do not change the natural history of the conditions.
       depression:
       insomnia
       constipation,
       dysphagia,
       urinary frequency
      
       2. disease modifying drugs such as:
     
        Levodopa may be used to increase the body's supply of dopamine, which may improve movement and balance.
       Artane -is particularly good for reducing tremors
       Jumex-  is used in early Parkinson's Disease and helps reduce  bradykinesia
       Bromocriptine - enhance the effect of levadopa
       Deprenyl may provide some improvement to mildly affected patients.
       Amantadine or anticholinergic medications may be used to reduce early or mild tremors.
       Carbidopa reduces the side effects of levodopa and makes levodopa work better.
        Entacapone is used to prevent the breakdown of levodopa.
        Pramipexole and ropinirole are used before or together with levodopa.
        Rasagiline is approved for patients with early Parkinson's disease.  Rasagiline helps block the breakdown of dopamine.
        Neupro is a new skin patch that contains the drug rotigotine. This medicine helps dopamine receptors in the brain work better. The patch is replaced every 24 hours.
       
Additional medications to help reduce symptoms or control side effects of primary treatment medications include antihistamines, antidepressants, monoamine oxidase inhibitors (MAOIs), and others.


 It is important that the disease should be controlled before irreversible brain damage occurs.


3. Surgery:
In some cases surgery can help to alleviate symptoms especially when all other medications and measures failed.
Surgery to implant stimulators or destroy tremor-causing tissues may reduce symptoms in some people.
Transplantation of adrenal gland tissue and stem cells to the brain has been attempted, with variable results.