Parkinsonism

What is Parkinsonism?

Parkinsonism refers to a group of conditions that share similar symptoms, often related to various diseases that harm your brain and affect your motor skills. These symptoms can include stiffness, shaking, slow movement, and trouble maintaining balance, which can notably affect how you walk. The majority of parkinsonism cases (about 80%) are due to Parkinson’s disease. The rest involve other brain-related diseases that cause similar motor problems. James Parkinson was the first person to document this condition, describing six patient cases in an essay he wrote in 1817, called “An Essay on the Shaking Palsy.”

Even though parkinsonism is mostly associated with Parkinson’s disease, similar symptoms can also occur as a result of other brain disorders, direct brain injuries, head trauma, certain medications, metabolic issues, and contact with harmful substances.

What Causes Parkinsonism?

Parkinson’s disease is the most common cause of a condition known as parkinsonism. This condition typically develops slowly, mainly affecting one side of the body more than the other. This happens because brain cells that produce a chemical called dopamine start to die off. When there’s less dopamine in areas of the brain that control movement, symptoms of Parkinson’s can arise.

Most people with Parkinson’s disease find that a medicine called levodopa helps their symptoms. However, there are other conditions that can cause parkinsonism, and these typically don’t respond as well to levodopa.

One such condition is normal pressure hydrocephalus (NPH). This involves a buildup of fluid in the brain, and it usually causes difficulties with balance, bladder control, and memory. Sometimes, the first noticeable symptom of NPH is parkinsonism.

“Vascular parkinsonism” is another condition that can cause parkinsonism. This term refers to conditions where the blood supply to the brain is disrupted, often due to problems like high blood pressure. These disruptions can lead to damaged brain tissue, which can cause motor problems similar to those seen in Parkinson’s disease. Brain scans typically reveal these kinds of damages.

Certain medicines that interfere with dopamine in the brain can also cause secondary parkinsonism. The likelihood of this happening depends on how the medicine is given to the patient, how strong it is, and how much of it is taken. For example, those taking these medications as an injection into a muscle or as a suppository are more likely to develop secondary parkinsonism than those taking it through a vein.

Long-term exposure to certain toxins, like heavy metals and industrial chemicals, can also result in a condition similar to Parkinson’s. The extent of the damage tends to be more severe than typical Parkinson’s disease.

Repeated head injuries can sometimes result in symptoms similar to parkinsonism, as can certain types of brain tumors.

There is also a rare form of parkinsonism that affects people 21 years old or younger. This condition acts similarly to Parkinson’s disease but starts at a younger age.

Other causes of secondary parkinsonism include conditions that reduce oxygen supply to the brain, after-effects of brain inflammation, and metabolic disorders. This can also be caused by genetic conditions that might resemble parkinsonism, such as early-onset Huntington’s disease or certain types of coordination disorders.

And finally, there are also conditions known as “Parkinson’s-plus syndromes.” These conditions include multiple system atrophy, corticobasal degeneration, and progressive supranuclear palsy.

Risk Factors and Frequency for Parkinsonism

Parkinson’s disease affects 1 to 2 out of every 1000 people in the population at any given time. It’s less common in those under 50, but its prevalence increases with age, impacting approximately 1% of individuals aged 60 and over. The disease is more common in men, with a 1.5:1 male-to-female ratio.

• Vascular Parkinsonism, is a different form of Parkinsonian syndrome, accounting for 2.5% to 5% of all cases. An estimated 5% of patients from the Rotterdam study had Parkinsonian symptoms due to cerebrovascular disease.
• Drug-Induced Parkinsonism, has a prevalence ranging between 1.7% to 2.7%, based on various studies. It’s more frequently seen in those aged between 60 and 80.
• Toxin-Induced Parkinsonism, is associated with areas having increased levels of manganese emissions. It was first reported in 1837 among workers in a manganese ore-crushing factory who were exposed to manganese dioxide.
• Juvenile Parkinsonism, typically starts around the age of 17. It’s more common in younger males, resulting in a 4:1 male-to-female ratio.

Signs and Symptoms of Parkinsonism

Parkinson’s disease is a condition that manifests with symptoms like sleep problems, less facial expression, increased clumsiness on one side, and persistent fatigue. It has particular defining features:

• Rigidity: This is characterized by more resistance during passive movement and is often asymmetrical. Patients might feel stiff, and a specific type of rigidity (“cogwheeling”) is common in Parkinson’s disease.
• Bradykinesia: This signifies slow movement, which can make everyday tasks difficult. Other symptoms may include a lack of facial expression, soft speech, and even trouble speaking.
• Tremors: These are generally the “pill-rolling tremor” that occur chiefly at rest. Although tremors can involve the lower limbs, lips, and tongue, they rarely affect the head. Stress can make the tremors worse.
• Postural instability: It leads to a balance problem, thereby increasing the risk of falls. The walking pattern of patients often comes off as slow and may be characterized by a shuffled gait and reduced stride length.

Additional conditions have symptoms similar to Parkinson’s disease. These include Normal Pressure Hydrocephalus (NPH), in which about 62% of patients show bradykinesia in the upper half of the body and about 71% report parkinsonism. Vascular parkinsonism involves posture and gait instability, gait resembling parkinsonian and ataxic features, and can even include pseudobulbar palsy, presenting as dysarthria and dysphagia. Then, there’s Drug-Induced Parkinsonism, which presents symptoms similar to Parkinson’s but is caused by medication. Meanwhile, Toxin-Induced Parkinsonism features increased muscle tone, leading to rigidity, bradykinesia, and a higher risk of backward falling.

According to a study, 0.3% of patients with a certain type of brain tumor exhibited parkinsonian features, often leading to a delay in diagnosis. Lastly, Juvenile Parkinsonism happens when Parkinsonism features like bradykinesia and rigidity occur in individuals under the age of 45.

Testing for Parkinsonism

Getting a definite diagnosis for parkinsonism requires a detailed physical examination to eliminate the possibility of other conditions with similar symptoms. While there isn’t a single confirmatory test for this condition, certain tests can be very helpful in examining other possible causes and potential contributing factors.

Parkinson’s Disease

Diagnosing Parkinson’s disease primarily involves observing common motor symptoms associated with the condition. These usually include slow movement (known as bradykinesia) and stiffness or shakiness. While no unique blood or imaging tests are needed for the diagnosis, a positive response to medication that increases the levels of dopamine, a chemical in the brain, supports the diagnosis. Some specific imaging techniques, such as transcranial color-coded sonography, might show changes in a brain region called the substantia nigra in people with Parkinson’s disease. An MRI scan can then be used to rule out other conditions that may cause parkinsonism, like brain tumors, normal pressure hydrocephalus (NPH), or strokes. Other advanced imaging techniques, like single-photon emission computed tomography (SPECT), or PET scans can also be useful. These techniques may show reduced levels of dopamine transporters, proteins that help move dopamine around in the brain.

Normal Pressure Hydrocephalus (NPH)

Normal pressure hydrocephalus (NPH) is a condition where cerebrospinal fluid builds up in the brain’s ventricles, causing them to enlarge. It can cause symptoms similar to Parkinson’s disease. Neuroimaging in these cases usually reveals larger than normal ventricles without significant brain tissue loss. PET scans may show decreased blood flow in regions of the brain such as the thalamus, caudate nucleus, and putamen. Dopamine transporter scans could also show reduced levels of dopamine in brain structures called the striatum.

Vascular Parkinsonism

Vascular parkinsonism is a type of parkinsonism caused by multiple small strokes. Diagnosis mostly involves imaging studies using CT or MRI scans. These scans might show the location of the stroke but are often inconclusive. MRI might also exhibit bright spots in the brain’s white matter and around the ventricles. A dopamine transporter scan can also be useful because they often show decreased dopamine uptake in a part of the brain known as the putamen.

Drug-Induced Parkinsonism

Some medications can lead to symptoms similar to Parkinson’s disease, a condition known as drug-induced parkinsonism. These drugs usually have a low affinity for dopamine transporters. On a dopamine transporter scan, there is typically symmetric uptake in the striatum, a part of the brain.

Juvenile Parkinsonism

In cases of juvenile parkinsonism, which starts in people younger than 20, genetic testing can be particularly helpful. This is especially true if the individual has a strong family history of the disease, because it may help identify the specific cause of their parkinsonism type symptoms.

Treatment Options for Parkinsonism

Parkinson’s disease is usually treated using certain medications that help manage the symptoms. These drugs, referred to as anti-Parkinsonian drugs, work by interacting with the brain’s chemistry and are most effective when Parkinson’s is the underlying cause.

Here are some typical medications used in the management of Parkinson’s disease:

Levodopa-carbidopa: This is a two-part medication. Levodopa is an amino acid that can go through the blood-brain barrier and is then changed into dopamine. As Parkinson’s disease leads to a deficiency in dopamine, levodopa helps make up for it. Carbidopa is also part of this medication. It supports levodopa by enhancing its effects. However, it’s important to know that long-term treatment with levodopa might lead to the medication’s effects wearing off slowly over time. As such, the patient may experience periods of improved mobility, only to have symptoms return before the next dose. It’s important not to abruptly stop treatment as it may lead to severe side effects.

Dopamine agonists: These drugs stimulate dopamine receptors in the brain, supporting the role of dopamine, which is usually deficient in Parkinson’s disease. Side effects can include nausea, vomiting, and low blood pressure when standing up.

Catechol-O-methyltransferase inhibitors: These drugs, such as entacapone, help boost the effects of levodopa by blocking an enzyme in the body that breaks down dopamine, allowing it to last longer.

Monoamine oxidase inhibitors: These drugs, including selegiline and rasagiline, work by reducing the breakdown of dopamine in the brain. It’s important to be mindful of potential interactions with certain foods that can lead to a sudden and dangerous increase of blood pressure.

Amantadine: This drug blocks certain receptors in the brain to help manage symptoms. Common side effects can include rash and fluid retention.

Anticholinergic drugs: These medications block receptors for a neurotransmitter called acetylcholine. They might be useful in managing tremors and muscle stiffness seen in Parkinson’s disease.

Depending on the specific cause of Parkinson’s-like symptoms, different treatments might be necessary. For example, for patients with typical causes like brain tumors, removing the tumor has often resulted in symptom improvement. In other cases, where medication is causing Parkinson’s-like symptoms, stopping or switching the medication may be the solution. In cases where Parkinson’s symptoms arise due to normal pressure hydrocephalus, a condition characterized by excessive fluid in the brain, surgery to relieve this pressure can help manage symptoms.

What else can Parkinsonism be?

Atypical parkinsonian disorders, also known as Parkinson-plus syndromes, are a group of conditions that resemble Parkinson’s disease, but don’t respond well to traditional Parkinson’s disease medications like levodopa. There are several distinct forms of these atypical disorders:

• Multiple system atrophy: This condition is characterized by both movement and non-movement symptoms such as problems with blood pressure, erectile dysfunction in men, and bladder control issues, along with Parkinson’s-like motor symptoms, impaired coordination, and muscle contractions in the face.
• Dementia with Lewy bodies: This involves cognitive problems and Parkinson’s-like symptoms. It is marked by fluctuating attention and alertness, visual hallucinations, and a type of sleep disorder, along with the movements symptoms associated with Parkinson’s.
• Progressive supranuclear palsy: This disorder results from stress and mitochondrial dysfunction in the cells and leads to features such as inability to move the eyes correctly, less frequent blinking due to eyelid muscle contraction, and balance difficulties that increase the risk of falls.
• Corticobasal syndrome: This condition manifests as uneven movement, including muscle contractions and myoclonus (spontaneous muscle twitches), sometimes resulting in a so-called “useless arm.” Patients may also experience problems with walking, sensory loss, and early-onset dementia.

What to expect with Parkinsonism

The outlook for Parkinsonism, a condition that causes similar symptoms to Parkinson’s disease, largely depends on its root cause, whether it can be reversed, and other factors such as the age when the symptoms first start showing. When Parkinson’s disease starts showing symptoms later in life, it tends to progress more quickly and can cause problems with mental functions earlier on. Generally, the disease lasts around 10 years and could lead to shorter lifespans.

Starting treatment early can help to extend life expectancy. Other conditions that cause symptoms similar to Parkinsonism also tend to develop and progress faster.

Possible Complications When Diagnosed with Parkinsonism

Parkinsonism is a condition that comes with many different complications. The most common issues include late-onset dementia, a decline in mental ability severe enough to interfere with daily life; autonomic dysfunction, including abnormalities like constipation, urinary incontinence, sexual dysfunction, and heavy sweating; mood disorders such as depression, hallucinations, and psychosis; and sleep disorders like insomnia and restlessness. Furthermore, treatment with high doses of a drug called levodopa can result in involuntary twitching and head shaking, a condition referred to as dyskinesia.

Complications include:

• Late-onset dementia
• Autonomic dysfunction
• Constipation
• Urinary incontinence
• Sexual dysfunction
• Excessive sweating
• Mood disorders
• Depression
• Hallucinations
• Psychosis
• Sleep disorders
• Insomnia
• Restless leg syndrome
• Dyskinesia caused by high doses of levodopa

Preventing Parkinsonism

Parkinsonism, in any form, can be very challenging to deal with, and it’s important to take precautions to lessen future complications.

People living with Parkinson’s disease are often at a higher risk of falling, which means it’s beneficial to take steps to improve safety in their environment. This can include things like adding handrails and grab bars around the home.

Driving safely can also be a concern for people with parkinsonism. If symptoms get worse, it might be best to stop driving until they improve.

Finding and joining local support groups can be a really great resource for both patients and their families. These groups are a place to get helpful advice and connect with others who are going through similar experiences.

Finally, regular meetings with a speech therapist can help to proactively manage any speech problems that may come up. This is an essential part of maintaining communication abilities.