Parkinson Disease

What is Parkinson Disease?

Parkinson’s disease is a condition that occurs when parts of the brain that control movement begin to decline, usually in people of older age. The main symptoms include slowing down of movements, known as ‘bradykinesia’, and often a resting tremor or stiffness. Other related signs can include the loss of smell, troubles with sleep, mood changes, excess saliva, constipation, and frequent limb movements during sleep.

This disease affects about 1% of people over the age of 60. It usually develops due to the decline of a specific type of brain cell in a region called the ‘substantia nigra’ and the appearance of abnormal protein deposits called ‘Lewy bodies’. The cause is usually unknown. However, around 10% of cases are due to genetic factors, and these are often seen in young individuals.

Parkinson’s disease tends to start slowly but progressively gets worse. A tremor is often the first symptom but can later be combined with slowness of movement and rigidity. It’s common to see issues with balance and posture in the later stages of the disease, which can significantly impact daily life. Some patients may experience changes in their automatic body functions before they notice movement-related symptoms.

Generally, the diagnosis is made based on the patient’s medical history and observed symptoms. However, in uncertain cases, or to rule out other brain disorders, a special brain imaging test called a ‘SPECT’ scan might be used.

What Causes Parkinson Disease?

Over the last hundred years, our knowledge about Parkinson’s Disease (PD) has grown considerably. Back in 1919, it was observed that brain examination after death showed that PD patients had loss of coloration in an area of the brain known as the Substantia Nigra. Later on, in the 1950s, it was found out that the colored cells lost in PD are actually Dopamine-making cells, and the resulting lack of dopamine affects motor controls, causing PD’s movement disorders.

PD affects a part of the brain called the Basal Ganglia. This region gets signals from several other parts of the brain. The main issue in PD is the loss of cells that make dopamine, which leads to the distinctive symptoms of the disease.

Contact with certain chemicals has been linked to the onset of PD. This includes substances like pesticides and herbicides, and living close Industrial factories. Some people have shown Parkinson’s-like symptoms after coming into contact with a certain chemical called 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP), which harms cells by accumulating in their energy-generating components, the mitochondria. Other studies suggest that damaging substances called free radicals might be the reason behind damage to a specific part of the brain, Thalamic Nuclei.

Genes seem to play a vital role in PD as well. If a family member has PD, the risk of developing the disease seems to increase for his or her siblings. These instances can also happen earlier in life.

Protein called alpha-synuclein, when present in abnormal levels, tends to clump together in structures known as Lewy Bodies which were identified during autopsy examinations. This faulty version of alpha-synuclein might have a role in causing PD. Nowadays, research is working on ways to stop this protein from clumping together and spreading.

Risk Factors and Frequency for Parkinson Disease

Parkinson’s Disease (PD) is a condition that affects 1 to 2 out of every 1000 people at any given time. This condition becomes more common as people get older, impacting 1% of those who are over 60 years old. There’s a noteworthy fact that 5% to 10% of people with PD have a genetic element that makes them more likely to develop the disease. As we age, the chances of developing PD also increase. Also, PD is generally more common in men than in women.

Signs and Symptoms of Parkinson Disease

Parkinson’s Disease (PD) typically starts with a tremor, often just affecting one side of the body. This tremor is usually present when at rest, and may disappear for a short while during activity, only to return again during rest. This reemerging tremor is one of the defining characteristics of PD. Despite being a common early symptom, tremor is not always present and not required for a PD diagnosis.

Alongside tremor, patients often experience slowness or rigidity in their movements, both of which considerably impact their daily tasks. For instance, individuals might take a longer time to perform simple tasks, walk at a slower pace, and may struggle to quickly respond to threats. In a clinical setting, this slow movement consistency displays as patients struggling to rapidly tap their fingers together, tap their foot in a rhythmic pattern, or walk steadily. Paired with rigidity, this can result in small handwriting, a condition known as micrographia.

Physically, people with PD often appear stiff, and might find it challenging to stand up from a seated position without assistance. During walking, their arm swing may reduce, particularly more noticeable on one side as PD usually begins asymmetrically. These findings can be confirmed through muscle tone examination.

Another key feature of PD is gait disturbance. However, this symptom typically appears in advanced stages of the disease. Patients may have a bent posture, reduced arm swing while walking, and trouble with balancing, making several small steps to turn around, as well as freezing in response to certain stimuli such as a doorframe. These symptoms can be beneficial in diagnosing advanced-stage PD.

Besides the main symptoms, patients may also experience constipation, drooling, mood disorders, depression, REM sleep disorder, and loss of sense of smell. These are commonly related to the neurons degenerating due to the disease process. Even though these symptoms are subtle, they are frequently seen in conjunction with the more visibly noticeable symptoms of PD.

• Tremor
• Slowness of movement
• Rigidity
• Small handwriting
• Difficulty standing up from a seated position
• Gait disturbance
• Constipation
• Drooling
• Mood disorders
• Depression
• REM sleep disorder
• Loss of sense of smell

Along with these, individuals with PD often experience several autonomic symptoms. These can include low blood pressure upon standing, difficulty swallowing, urinary retention, and erectile dysfunction. Often, these symptoms may not improve with treatment. As PD progresses, depression and dementia, with significant cognitive dysfunction, are commonly observed.

Testing for Parkinson Disease

If you’re suspected to have Parkinson’s Disease (PD), your healthcare provider will usually start your evaluation by talking about your history and conducting a physical examination. The aim is to look for signs of Parkinson’s disease, such as tremors, stiffness, and slow movement. Some clinics specialising in movement disorders might use a specific scoring system, called the Unified Parkinson Disease Rating Scale, which measures and rates various aspects of the disease including behaviour, tremor, motor skills, and daily life activities.

Interestingly, there is no particular laboratory test or imaging study that can directly confirm the diagnosis of PD. The critical part of PD evaluation is to exclude some medicines that can cause motor problems, such as traditional antipsychotics, because these might make the symptoms of PD look indistinguishable. However, the non-motor symptoms of PD, such as loss of the sense of smell, will not be present when the symptoms are only due to medications.

It’s important to know that other neurodegenerative conditions can also share similar symptoms with PD, so these need to be ruled out. Conditions like Lewy body disease and multiple system atrophy can present similar symptoms but often have other distinguishing signs. For instance, patients with progressive supranuclear palsy will have difficulty moving their eyes, those with Lewy body dementia may have dementia and hallucinations, and those with multisystem atrophy will often have early problems with involuntary body functions and coordination.

While investigations like MRI might help to exclude conditions like normal pressure hydrocephalus or stroke, the diagnosis of PD mainly depends on a thorough clinical examination. In certain cases, a specific scan (called a DAT scan) might be used to investigate the loss of cells that produce dopamine in the brain, which can be a significant factor in PD. However, interpreting this scan can be challenging, and it’s not routinely recommended.

Interestingly, one of the best ways to establish if you have PD is through your response to a particular medication, Levodopa. If your symptoms noticeably improve with this treatment, it’s a strong indicator of PD. It is crucial to remember that there are high rates of diagnostic mistakes between PD and another condition known as essential tremor, so it’s important to be correctly diagnosed.

Imaging studies can be useful to rule out other conditions such as bleeding in the brain, stroke, hydrocephalus (a condition where fluid builds up in the brain), brain tumors, and Wilson’s disease (a rare genetic disorder). A procedure called a lumbar puncture might also be done to rule out normal pressure hydrocephalus.

Treatment Options for Parkinson Disease

Pharmacological treatment for Parkinson’s often includes the use of a medication called levodopa, usually combined with Carbidopa. This combination reduces side effects and improves the medication’s effectiveness in the nervous system. Younger patients might be prescribed a dopamine agonist, a type of drug that acts like dopamine, such as Pramipexole or Ropinirole. While these may not be as effective as levodopa, they usually have fewer side effects. If tremors are the main symptom, medications such as Anticholinergics or Amantadine could be used.

Selegiline is another drug used in the early stages of Parkinson’s and can offer slight relief of symptoms.

It’s worth mentioning that most Parkinson’s drugs can help manage symptoms for 3 to 6 years. After this period, the illness might advance and not respond as effectively to medications. Therefore, younger patients usually receive more aggressive treatment than older ones.

The management of Parkinson’s requires a multidisciplinary approach. Patients often see improvements through structured physical therapy programs aimed at Parkinson’s. Movement exercises can be particularly beneficial, helping patients to better control their balance and walk more effectively. Some patients might even be able to dance despite struggling with walking. Complementary therapies such as boxing, music therapy, and cycling have proven useful in helping manage Parkinson’s. Mental health issues often accompany Parkinson’s, such as depression, sleep disorders, paranoia, and psychosis, requiring their own course of treatment.

While some patients respond well to drug therapy initially, their response can decline over time. They might experience sudden movement changes (on/off motor symptoms) or face impairing dyskinesia, a type of movement disorder, as a side effect. Adjusting the timing and type of medication can have a significant impact on a patient’s quality of life.

Deep brain stimulation (DBS) techniques offer a promising alternative for patients who stop responding to other measures. It involves sending electric signals to the brain and moderating unique brain cells that cause the symptoms of Parkinson’s disease. Deep brain stimulation is now an exciting area of research and provides new hope for advanced Parkinson’s patients.

Non-motor symptoms such as psychiatric issues, autonomic, and sensory difficulties are more challenging to manage, and adding more medications may risk harmful side effects or drug interactions. Current practices include targeted treatments for specific symptoms like erectile dysfunction, day time sleepiness, constipation, and disturbed sleep.

For those qualifying, deep brain stimulation has become a preferred surgical procedure as it does not damage brain tissue and can be adjusted as the disease progresses. However, this method is not without complications, it is expensive, and the long-term benefits are still under investigation.

More and more evidence shows that regular exercise can improve walking, balance, and flexibility. Sadly, these benefits are not long-lasting, and the risk of falling remains high.

Lastly, for some patients, speech therapy can provide help and improve their communication capabilities.

What else can Parkinson Disease be?

These are various conditions that can exhibit similar symptoms:

• Essential tremor
• Huntington’s chorea
• Dementia with Lewy bodies
• Progressive supranuclear palsy
• Neuroacanthocytosis
• Normal pressure hydrocephalus

What to expect with Parkinson Disease

The development and severity of certain diseases can be predicted based on a few factors. For men who experience difficulty with balance or walking, they can anticipate a faster progression of the disease.

Also, patients who are older when the disease starts, those who have cognitive decline (dementia), and those who don’t respond to traditional medications that stimulate dopamine production (dopaminergic medications), often have to move into nursing homes early and have a lower life expectancy.

On the other hand, those who only have body shakes (tremors) when diagnosed, typically experience a slower, less severe progression of the disease. But if a person is diagnosed at an older age and they experience slow movements or stiffness (hypokinesia/rigidity), the disease usually progresses more quickly.

However, within ten years, the disease usually leads to disability for most patients. The death rate (mortality rate) for patients with this disease is three times higher than that of the average population. Even though treatments can help manage symptoms, the quality of life for these patients is often low.

Possible Complications When Diagnosed with Parkinson Disease

Possible health complications:

• Depression
• Memory loss (Dementia)
• Difficulty in voice box functions (Laryngeal dysfunction)
• Disruption in involuntary body activities (Autonomic dysfunction)
• Hunchback leading to heart and lung problems (Kyphosis leading to cardiopulmonary impairment)

Recovery from Parkinson Disease

People diagnosed with Parkinson’s disease (PD) – a condition affecting the brain and causing movement issues – need to have regular check-ins with their healthcare providers over time. This is due to the condition’s progressive nature and its impact on a person’s movement. Often, slight changes to medications will be required in most cases.

Furthermore, it’s quite common for individuals with Parkinson’s disease to experience changes in their behavior. This might include impulsivity (acting without thinking), psychosis (loss of touch with reality), paranoia (unfounded suspicions), and somnolence (excessive sleepiness). Understanding these changes can help manage the condition better.