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Parkinson's Disease

Parkinson Disease

Parkinson's disease is a form of neurological disorder characterized by gradual loss of those neurological functions that governs body movement. The disease is therefore also referred to as movement disorder.


Presentation

In the early stages of the disease, signs and symptoms are pretty less evident. However, as the disease progresses to more advance stages the following symptoms are prominent [7]:

  • Tremors characterized by shaking hands, fingers and legs.
  • Bradykinesia characterized by slowed movement making everyday simple tasks,difficult to achieve.
  • Muscle stiffness sets in as the disease advances.
  • Posture and balance of the individual get disrupted.
  • Individuals may experience difficulty in writing due to loss of motor movements.
  • Changes in the speech may occur.
  • Automatic movements such as blinking, swinging arms while walking and making gestures while talking are all lost.
Hypophonia
  • A person with PD may speak very softly and may be hard to understand (hypophonia). Speech impairment is referred to as dysarthria and is often characterized as weak, slow, or uncoordinated speaking that can affect volume and/or pitch.[caregiver.org]
  • These so-called mirror movements may be observed in early asymmetric PD. 76 Bulbar dysfunction manifested by dysarthria, hypophonia, dysphagia and sialorrhoea, frequently observed in patients with PD, can be equally or even more disabling than the cardinal[jnnp.bmj.com]
  • Treatment of Parkinson hypophonia with percutaneous collagen augmentation. Laryngoscope . 1999 Aug. 109(8):1295-9. [Medline] . Kim HJ, Jeon BS, Paek SH. Effect of deep brain stimulation on pain in Parkinson disease.[emedicine.medscape.com]
Falling
  • Fatal Falls Falls are a common secondary symptom of Parkinson’s disease. The risk of falling is greater in Stages IV and V. In these stages, you may not be able to stand or walk on your own.[healthline.com]
  • Falls are a frequent complication of Parkinson's disease (PD) .[my.clevelandclinic.org]
  • The person also might need to have railings installed around the house to prevent falls. If you know someone who has Parkinson's disease, you can help by being a good friend. Date reviewed: November 2017[kidshealth.org]
  • Early symptoms are often subtle, developing gradually as dopamine levels slowly fall. These can start on one side of the body, for example, a single limb or hand, before affecting both sides.[ucb.com]
  • Individuals may freeze in mid-stride and appear to fall forward while walking.[medicinenet.com]
Fatigue
  • These co-morbidities include constipation, depression, fatigue, and insomnia.[foodforthebrain.org]
  • Fatigue. Many people with Parkinson's disease lose energy and experience fatigue, and the cause isn't always known. Pain. Many people with Parkinson's disease experience pain, either in specific areas of their bodies or throughout their bodies.[mayoclinic.org]
  • We ask about general symptoms (anxious mood, depressed mood, fatigue, pain, and stress) regardless of condition.[patientslikeme.com]
  • MD, FRCP Professor, Clinical Ageing Reserach Unit Campus for Ageing and Vitality, Newcastle University Newcastle Upon Tyne, UK The defining feature of parkinsonism is bradykinesia, or slowness with decrement and degradation of repetitive movements (“fatigue[movementdisorders.org]
  • Yahr scale, a commonly used system for describing how the symptoms of Parkinson’s disease progress, Parkinson’s disease has the following stages: Prodromal symptoms (those symptoms that may develop many years before diagnosis): Depression, anxiety, fatigue[caregiver.org]
Difficulty Walking
  • Tremors, rigidity, slow movement (bradykinesia), poor balance, and difficulty walking (called parkinsonian gait) are characteristic primary symptoms of Parkinson's disease .[healthcommunities.com]
  • Balance and walking problems: Initially persons have difficulty walking at normal speeds or may find it difficult to fully lift a leg, causing the foot to “drag” behind the other foot.[caregiver.org]
Constipation
  • These co-morbidities include constipation, depression, fatigue, and insomnia.[foodforthebrain.org]
  • Constipation. Many people with Parkinson's disease develop constipation, mainly due to a slower digestive tract. You may also experience: Blood pressure changes.[mayoclinic.org]
  • OTHER SYMPTOMS Parkinson's disease may also affect mood, sleep, digestion (constipation is common), speech, swallowing, thinking, and memory. WHAT CAUSES THE MOVEMENT SYMPTOMS? The cause of Parkinson's disease is unknown.[medtronic.com]
  • Examples of non-motor symptoms include: apathy, depression, constipation, sleep behavior disorders, loss of sense of smell and cognitive impairment. In idiopathic Parkinson’s disease, progression tends to be slow and variable.[parkinson.org]
  • Constipation is common in people with PD. Help to reduce the chance of this by having lots to drink and eat plenty of vegetables, fruit, and foods high in fibre. Exercise can also improve constipation.[patient.info]
Muscle Rigidity
  • Parkinson’s disease symptoms include muscle rigidity, tremors, and changes in speech and gait. After diagnosis, treatments can help relieve symptoms, but there is no cure. Symptoms Symptoms of Parkinson's disease differ from person to person.[webmd.com]
  • These medications are most useful in the treatment of tremor and muscle rigidity, as well as in reducing medication-induced parkinsonism.[aans.org]
  • Parkinson’s is a movement and mood disorder typically presenting with symptoms such as slowness of movement, muscle rigidity, instability, tremor, depression and anxiety.[parkinsonsnsw.org.au]
  • rigidity and slowness of movements.[bbc.com]
  • Parkinson's Disease is a progressive disorder of the nervous system marked by muscle tremors, muscle rigidity, decreased mobility, stooped posture, slow voluntary movements, and a mask-like facial expression.[patientslikeme.com]
Drooling
  • Gradual loss of automatic movement, which may lead to decreased blinking, decreased frequency of swallowing and drooling A stooped, flexed posture with bending at the elbows, knees and hips Unsteady walk or balance Depression or dementia Presently, the[aans.org]
  • A person who has Parkinson's may experience some of these more common "hallmark" symptoms: Bradykinesia - slowness of movement, impaired dexterity, decreased blinking, drooling, expressionless face.[mayfieldclinic.com]
  • Saliva may accumulate in your mouth due to slowed swallowing, leading to drooling. Sleep problems and sleep disorders.[mayoclinic.org]
  • Dysphagia is often subclinical, particularly in the early course of the disease. 81 PD related drooling may result from a decrease in swallowing. 25 A number of neuro-ophthalmological abnormalities may be seen in patients with PD.[jnnp.bmj.com]
  • People with Parkinson’s can develop some of the following symptoms as the disease progresses: Swallowing difficulties (usually a later symptom): At least 50% of people with Parkinson’s develop swallowing problems (dysphagia) that may cause the person to drool[caregiver.org]
Blepharospasm
  • Practice Guideline Update Summary: Botulinum Neurotoxin for the Treatment of Blepharospasm, Cervical Dystonia, Adult Spasticity, and Headache April 2016 Current guideline.[aan.com]
  • These include decreased blink rate, ocular surface irritation, altered tear film, visual hallucinations, blepharospasm and decreased convergence. 82 The degree of abnormality in ocular pursuit and saccades as well as antisaccades 83 is related to the[jnnp.bmj.com]
Hypomimia
  • Other manifestations of bradykinesia include loss of spontaneous movements and gesturing, drooling because of impaired swallowing, 25 monotonic and hypophonic dysarthria, loss of facial expression (hypomimia) and decreased blinking, and reduced arm swing[jnnp.bmj.com]
Tremor
  • Table 2 Features differentiating Parkinson’s disease from essential tremor Some patients with PD have a history of postural tremor, phenomenologically identical to essential tremor, for many years or decades before the onset of parkinsonian tremor or[jnnp.bmj.com]
  • Common movement symptoms are: TremorTremor or shaking is often the most obvious symptom of Parkinson's, though not everyone has it. Tremor usually starts in the fingers, hand, or foot and may eventually spread to the rest of your limb.[medtronic.com]
  • Functional lesional neurosurgery for tremor-a protocol for a systematic review and meta-analysis. BMJ Open. 2017 May 9;7(5):e015409. doi: 10.1136/bmjopen-2016-015409. Alshaikh J, Fishman PS. Revisiting bilateral thalamotomy for tremor.[fusfoundation.org]
  • Spasms can often be controlled with sensory tricks to suppress the movement. essential tremor : involuntary rhythmic tremors of the hands and arms. Tremors occur both at rest and during purposeful movement.[mayfieldclinic.com]
  • Parkinson's signs and symptoms may include: Tremor. A tremor, or shaking, usually begins in a limb, often your hand or fingers. You may notice a back-and-forth rubbing of your thumb and forefinger, known as a pill-rolling tremor.[mayoclinic.org]
Bradykinesia
  • Table 1 Parkinson’s disease symptoms Bradykinesia Bradykinesia refers to slowness of movement and is the most characteristic clinical feature of PD, although it may also be seen in other disorders, including depression.[jnnp.bmj.com]
  • Subtle “bradykinesia” has been reported to occur in the “normal elderly” population, but this may reflect a non-specific slowness rather than bradykinesia as defined above.[movementdisorders.org]
  • Tremors, rigidity, slow movement (bradykinesia), poor balance, and difficulty walking (called parkinsonian gait) are characteristic primary symptoms of Parkinson's disease .[healthcommunities.com]
  • Symptoms usually show up in one or more of four ways: tremor, or trembling in hands, arms, legs, jaw, and face rigidity, or stiffness of limbs and trunk bradykinesia, or slowness of movement postural instability or impaired balance and coordination.[parkinsons.org]
  • Clinically, this disease is characterized by bradykinesia, resting tremors, and rigidity due to loss of dopaminergic neurons within the substania nigra section of the ventral midbrain.[cellsignal.com]
Postural Instability
  • Postural instability Postural instability due to loss of postural reflexes is generally a manifestation of the late stages of PD and usually occurs after the onset of other clinical features.[jnnp.bmj.com]
  • Symptoms usually show up in one or more of four ways: tremor, or trembling in hands, arms, legs, jaw, and face rigidity, or stiffness of limbs and trunk bradykinesia, or slowness of movement postural instability or impaired balance and coordination.[parkinsons.org]
  • Hoehn and Yahr Scale I: Unilateral disease II: Bilateral disease III: Postural instability—mild IV: Postural instability—marked V: No independent ambulation An algorithm has recently been proposed for the symptomatic management of PD.[clevelandclinicmeded.com]
  • Motor symptoms The main physical motor symptoms are: Resting tremor: trembling of the hands and feet Muscular rigidity: causes stiffness during movement Bradykinesia: slowness of movement Postural instability, risk of falls and fractures.[ucb.com]
  • Parkinson disease is classically characterised by a triad of features: resting tremor rigidity bradykinesia (postural instability: sometimes added as a fourth cardinal feature 3 ) Dementia can be a late feature.[radiopaedia.org]
Resting Tremor
  • Characteristically, rest tremor disappears with action and during sleep.[jnnp.bmj.com]
  • Clinically, this disease is characterized by bradykinesia, resting tremors, and rigidity due to loss of dopaminergic neurons within the substania nigra section of the ventral midbrain.[cellsignal.com]
  • Parkinson disease is classically characterised by a triad of features: resting tremor rigidity bradykinesia (postural instability: sometimes added as a fourth cardinal feature 3 ) Dementia can be a late feature.[radiopaedia.org]
  • Motor symptoms The main physical motor symptoms are: Resting tremor: trembling of the hands and feet Muscular rigidity: causes stiffness during movement Bradykinesia: slowness of movement Postural instability, risk of falls and fractures.[ucb.com]
  • The cardinal motor signs and symptoms of PD, include the characteristic clinical picture of resting tremor, rigidity, akinesia, and impairment of postural reflexes. It evolves slowly.[movementdisorders.org]
Dystonia
  • Related Associations and Societies: USA and Canada: American Academy of Neurology , Movement Disorders Society , Parkinson Society Canada , The International Parkinson and Movement Disorder Society , Canadian Movement Disorders Group , Bachmann-Strauss Dystonia[parkinsons.conferenceseries.com]
  • Click on the following links to learn more about the conditions we treat: Essential Tremor Huntington's Disease MSA Dystonia PSP Watch this video to learn about focused ultrasound surgery , the new, innovative way our doctor's are treating essential tremor[umm.edu]
  • Provide comprehensive, individualized care to individuals and families affected by movement disorders including Parkinson’s disease (PD), Multiple System Atrophy (MSA), Progressive Supranuclear Palsy (PSP), Huntington’s disease, tremor, chorea, athetosis, dystonia[bumc.bu.edu]
  • GCH1 gene and Parkinson's risk A study published in Brain, led by researchers at UCL Institute of Neurology, has shown that genetic mutations which cause a decrease in dopamine production in the brain and lead to a form of childhood-onset Dystonia, also[ucl.ac.uk]
  • Our excellence in treating, researching and teaching about movement disorders, including ataxia , dystonia , essential tremor and Parkinson's disease , allows us to provide the best care for all our patients.[hopkinsmedicine.org]
Sexual Dysfunction
  • Sexual dysfunction. Some people with Parkinson's disease notice a decrease in sexual desire or performance. Prevention Because the cause of Parkinson's is unknown, proven ways to prevent the disease also remain a mystery.[mayoclinic.org]
  • The major complication in Parkinsons disease are blood pressure changes, depression, emotional changes, thinking difficulties, fatigue, sexual dysfunction, smell dysfunction, pain and sleep disorders .[parkinsons.conferenceseries.com]
  • dysfunction, seborrheic dermatitis) A general feeling of weakness, malaise, or lassitude Depression or anhedonia Slowness in thinking Onset of motor signs include the following: Typically asymmetric The most common initial finding is a resting tremor[emedicine.medscape.com]

Workup

So far no laboratory tests exist for diagnosing Parkinson's disease. A neurologist will diagnose the disease based on the past medial history of the affected individual followed by thorough analysis of the signs and symptoms. In addition, certain tests may also be required to rule out the possibility of any underlying disease condition. In order to arrive at an appropriate diagnosis, the neurologist will give medications meant for Parkinson's disease to the individual. If the individual benefits from the drug then the diagnosis is confirmed [8].

Treatment

Parkinson's disease cannot be cured; the symptoms can be effectively managed and progression of the condition slowed down with appropriate treatment methods. Medications form an important part of treatment regime. In more advanced stages, however surgery may be advised. The following are the various medications prescribed for treating Parkinson's disease.

  • Carbidopa-levodopa is one of the most effective medications for Parkinson disease. This is a natural chemical that gets converted to dopamine when it reaches the brain [9].
  • Medications containing dopamine antagonists are prescribed which unlike levodopa do not get converted to dopamine but mimic the effects of the brain chemical.
  • Monoamine oxidase B (MAO-B) inhibitors do not allow the breakdown of dopamine. However, this class of medication has various side effects when taken with other drugs.
  • Anticholinergics help in controlling the tremors; however are seldom prescribed due to associated side effects.
  • Amantadine is prescribed for short term relief from the symptoms. It is also given in association with levodopa to reduce dyskinesias that may accompany as a side effect of carbidopa-levodopa drug [10].

Prognosis

As the disease progresses, there is gradual loss of neurological functions in the affected individuals. Individuals who do not receive proper treatment often suffer from other secondary debilitating conditions. There is absolute loss of movement making the individual completely bed ridden for rest of the life. However, with introduction of newer generation medications, it has now been possible to effectively manage the symptoms and improve the quality of life [6].

Etiology

Parkinson disease occurs due to necrosis of certain nerve cells in the brain which are responsible for producing dopamine. The exact cause that triggers the development of such a type of movement disorder is yet to be known. However, interplay of several factors such as environment and genetic are known to play a role. Genetic factors attribute to 10% cases of Parkinson disease.

Genetic factors

Certain genes have been identified to play a major role in causation of Parkinson's disease. Individuals with family history of this disease are at an increased risk of contracting it as they age.

Environmental factors

Exposure to certain toxins can predispose an individual to develop Parkinson's disease [2].

Epidemiology

Parkinson disease is the second most common neurological disorder affecting about 7 million individuals across the globe. An estimated 1 million individuals of United States suffer from this neurodegenerative disorder [3]. Individuals aged 60 years and above fall easy prey to this disease. Men are 1.5 times more likely to contract Parkinson's disease, compared to women. Statistics have revealed that a small percentage of individuals (5 – 10%) between the age group of 20 – 50 years have been known to develop this kind of movement disorder [4].

Sex distribution
Age distribution

Pathophysiology

Parkinson's disease is a result of death of neurons in the brain. These are responsible for producing dopamine. Dopamine is a chemical messenger of the brain that transmits information to control the movements in various parts of the body [5]. The inability of the neurons to produce dopamine causes motor impairment which is the major cause of disability amongst the affected individuals. It has also been found that about 60 – 80% of necrosis of the nerve cells occurs even before the preliminary signs and symptoms of Parkinson's disease occur.

Prevention

Till date, no methods have been developed to prevent Parkinson's disease. Since the cause is unknown, ways to prevent the onset of the disease also remains a mystery. However, there have been some pieces of evidence suggesting the use of caffeine to help prevent Parkinson's disease.

Summary

Individuals over the age of 60 years are the most affected.The disease steadily causes disability greatly interfering with the individual’s ability to carry out daily functions. The preliminary stage of the disease may showcase little or no symptoms. Parkinson's disease cannot be cured. The symptoms can be effectively managed with appropriate medications. In some cases, surgical procedures may be required to improve the symptoms [1].

Patient Information

Definition

Parkinson's disease is a neurodegenerative disorder characterized by loss of neurological functions due to necrosis of the nerve cells in the brain. It is known to be the second most common neurological disorder after Alzheimer disease. Individuals above the age of 60 years are more prone to develop this condition. Parkinson's disease greatly affects the movement ability of the individuals and therefore the disease is also commonly referred to as movement disorder.

Cause

The exact factor that leads to development of Parkinson's disease is not clear. However certain genetic factors and exposure to environmental toxins is known to cause this type of neurological disorder.

Symptoms

In the initial stages, Parkinson's disease may show little or no signs at all. As the disease progresses to more advance stages, individuals experience tremors of the hands, fingers and legs. They also have difficulty in walking and their movements slow down to a great extent. Difficulty in talking is evident with slurred speech.

Diagnosis

No laboratory tests help in diagnosing the condition. A thorough examination of the signs and symptoms help in confirming Parkinson's disease.

Treatment

Medications form the basis of the treatment regime. Various classes of drugs are prescribed to keep the symptoms under control. Carbidopa-levodopa is the most effective drug for treating Parkinson's disease. It works by getting converted into dopamine once it reaches the brain.

References

Article

  1. Langston JW. The Parkinson's complex: parkinsonism is just the tip of the iceberg. Ann Neurol 2006; 59:591.
  2. Pezzoli G, Cereda E. Exposure to pesticides or solvents and risk of Parkinson disease. Neurology. May 28 2013;80(22):2035-41.
  3. Wirdefeldt K, Adami HO, Cole P, Trichopoulos D, Mandel J. Epidemiology and etiology of Parkinson's disease: a review of the evidence. Eur J Epidemiol. Jun 2011;26Suppl 1:S1-58.
  4. Van Den Eeden SK, Tanner CM, Bernstein AL, et al. Incidence of Parkinson's disease: variation by age, gender, and race/ethnicity. Am J Epidemiol 2003; 157:1015.
  5. Hornykiewicz O. The discovery of dopamine deficiency in the parkinsonian brain. J Neural TransmSuppl 2006; :9.
  6. Jeffrey S. Biomarkers for Parkinson's Diagnostic, Prognostic. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/810262.
  7. Politis M, Wu K, Molloy S, et al. Parkinson's disease symptoms: the patient's perspective. MovDisord 2010; 25:1646.
  8. Tolosa E, Gaig C, Santamaría J, Compta Y. Diagnosis and the premotor phase of Parkinson disease.Neurology. Feb 17 2009;72(7 Suppl):S12-20.
  9. Stocchi F, Rascol O, Kieburtz K, et al. Initiating levodopa/carbidopa therapy with and without entacapone in early Parkinson disease: the STRIDE-PD study. Ann Neurol. Jul 2010;68(1):18-27.
  10. Weintraub D, Sohr M, Potenza MN, Siderowf AD, Stacy M, Voon V, et al. Amantadine use associated with impulse control disorders in Parkinson disease in cross-sectional study. Ann Neurol. Dec 2010;68(6):963-8.

Symptoms

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