World Parkinson’s Day

10th April 2018

#uniteforparkinsons

In honour of World Parkinson’s Day, we are writing about Parkinson’s disease; causes, symptoms, and perhaps most importantly, treatment and management.

Parkinson’s disease (PD) was first described by James Parkinson in 1817 in an essay ‘The Shaking Palsy’, and is clinically distinct from other parkinsonian syndromes.

A key characteristic of PD isthe presence of neuronal inclusions in the brain called “Lewy bodies” – these contain tangles of certain protein strands that become gradually more widespread as the condition progresses, spreading from one part of the brain to the main area of motor control. Different areas of the brain control different actions using a complex navigation system, where the information gets relayed and the action is then carried out, for example, moving your hand. Likewise, there is an area of the brain that is considered the motor hub that harbours the cells that produce dopamine. In PD, there is a gradual loss of dopamine-producing cells, and the extent of the loss of these cells is linked to the slowing of movement.

 

Causes

The cause of PD is still not fully understood, and the relatively uniform worldwide prevalence suggests that a single environmental influence may not be responsible.

  • Age and gender – prevalence is known to increase sharply with increasing age, especially over 70 years, with a prevalence of 1 in 200 over 80 years. Prevalence is also higher in men.
  • Environmental factors – some studies illustrate a small increase with rural living and drinking well water, while pesticide exposure in animal models has shown a plausible biological link. Observational research has also interestingly shown that non-smokers have a higher risk of PD than smokers, a link that is difficult to explain.
  • Genetics – PD is not only a condition of the elderly; patients presenting with the disease before 40 years of age are generally designated as having ‘early-onset’ PD. Among them, those beginning between 21 and 40 years are called ‘young-onset’ PD while those beginning before the age of 20 years are called ‘juvenile Parkinsonism’. More work is needed to determine whether mutations in genes related to PD or other genes may, in combination, constitute a susceptibility to PD that may be triggered by the environment or the ageing process.

Symptoms

PD almost always presents with the typical asymmetrical onset of motor symptoms of tremor and slowness of movement, though it is very likely that the process begins many years before these symptoms come to surface. Unfortunately, by the time of the first presentation, these patients have already lost an average of 70% of dopaminergic cells. Patients can develop a variety of non-motor symptoms before the motor symptoms become apparent.

Non-physical symptoms include:

  • Loss of the sense of smell (anosmia – can be present in 90%)
  • Depression/anxiety (50%)
  • Aches and pains
  • Rapid eye movements
  • Sleep behaviour disorder
  • Urinary disturbances and constipation

Physical symptoms develop slowly. The core physical characteristics of Parkinson’s are:

  • Slowing of movement (bradykinesia) leading to loss of and power voluntary movement (akinesia). This is the main cause of disability, with a progressive fatiguing and decrement in the amplitude of repetitive movements. The upper part of the body is usually affected first, and is almost always one-sided for the first few years. Rapid movements that require complex use of fingers are impaired, including doing up buttons and zips and writing, which becomes small and spider-like.
  • Resting tremor (70%) almost always starts in the fingers and hands, and is one-sided initially, spreading later to the leg on the same side and then to the opposite side.
  • Rigidity
  • Postural and gait disturbance – a stooped posture is distinctive, with a shuffling manner of walking with a small stride length, slow turns, freezing and reduced arm swing. With deterioration, falls can occur which presents as a late feature.
  • Speech and swallowing – speech can become distinguishingly quiet, indistinct and flat. Drooling and swallowing difficulty presents late.
  • Cognitive and psychiatric disturbances – cognitive impairment is common in late stage PD (80%) and may develop into dementia. Depression is also common, and an important cause of reduced quality of life in PD, as well as anxiety.

Close ones may also notice an impassive face, exhibiting no facial expressions. Key to note is that idiopathic PD is almost always initially more prominent on one side.

Diagnosis

Diagnosing PD is carried out clinically, and although MRI imaging may be helpful, is not necessary. There are other conditions that must be ruled out before confirming idiopathic PD, and your physician may employ a tool to help diagnose PD called the ‘Unified Parkinson’s Disease Rating Scale’, a comprehensive 50-question assessment of both motor and non-motor symptoms associated with Parkinson’s.

PD runs a chronic and slowly progressive course, being extremely variable in patients. During the initial years, the motor disability may not be significant as symptoms present one-sided and mild. As the disease progresses, the increasing motor difficulties can affect the daily living activities, leading to frequent falls, resulting in an increased risk of fractures. Most patients respond well to treatment but treatment-related fluctuations may develop which can be limiting, especially for patients with early-age onset.

Treatment

There are various therapies that can help people with Parkinson’s to manage their symptoms. This includes occupational therapy, to help you with everyday tasks when they become difficult to carry out; physiotherapy to help with everyday movements, such as walking or getting in and out of a chair; speech and language therapy and complementary therapies like acupuncture, Ayurveda and art therapy. Drug treatment is the main approach to control the symptoms of Parkinson’s. Drug treatments work to increase the level of dopamine that reaches the brain, and stimulate the parts of the brain where dopamine works. Current drug therapies can help to manage the symptoms of PD, but they cannot cure, slow, stop or reverse the progression of the disease.

As the disease progresses, medical therapy for PD becomes more problematic as higher doses of dopamine replacement therapy are necessary and response can become more unpredictable. Nonetheless, the response to dopaminergic drugs is never lost. Drug side effects are common, and include involuntary movements and eventually, on/off phenomenon (sudden, unpredictable transitions from mobile to immobile).

It is understandable that the impact of receiving a diagnosis of a disease such as PD can cause an initial emotional burden on the patient and family: they face an uncertain future living with a chronic disabling disorder. With the progression of the disease, there is a detrimental increase of motor impairment, which may make the patient feel like they’ve lost significant autonomy as the severity of the symptoms increases. A subsequent burden for the family may be indirectly related to the functional impact of the disease. Vida as a care company recognise that patients with PD want to be supported with independence and emotional wellbeing. This is why we train our carers to understand these type of situations, and provide physical as well as emotional support.

Tips to help you manage PD

If you’re having trouble with slowing down and freezing, try simple exercises. For example, if you’ve been just diagnosed, try walking or dancing. To help with balance, strength and movement, attempt Pilates, yoga or Tai chi. For complex PD, try chair-based exercises, or exercising whilst holding onto something sturdy.

You can try using special cutlery with easy grip or foam sleeves, and special tumble-not mugs and sip or sports cups with a lid to stop spillage. High-lipped plates and plate guards can also help stop food spillage. You should speak to your occupational therapist for more advice on this equipment.

Take your time to eat, and eat smaller frequent meals throughout the day. Semi-solid foods are easier to swallow, or food that is pre-mashed or pureed. Having a balanced diet rich in fruit and vegetables with fibrous foods and plenty of fluids can help with constipation. By increasing your fluid and salt intake and reducing sugar in your diet, you can prevent low blood pressure. In addition, avoiding alcohol, coffee, chocolate and fatty and spicy foods can help combat indigestion and heartburn.

At home, ensure you remove rugs or ornaments that may come in your way whilst you are trying to get around. Try using a shower stool and pump-dispensers for your favourite products in the bathroom. If you’re having difficulty buttoning up your clothes, maybe swap the buttons with press-studs or Velcro, and button-up trousers with elasticated belts to help you put them on easily. To aid bone health and decrease the risk of fractures, you can take vitamin D and calcium supplements, but be sure to consult your family doctor before starting on these.

Whilst out and about, make sure to carry your Parkinson’s alert card with a list of your normal routine to save you stress. A good pair of trainers and walking poles can help maintain your steadiness and balance and give you support. Always remember to carry your medication in your hand luggage whilst travelling abroad, and never take them on an empty stomach.

Communicating can be daunting at times, especially if you find yourself having difficulty speaking and maintaining a conversation. You can use lined writing paper underneath plain paper to help you write straight, or try downloading the creative toolkit from parkinsons.org.uk to give you more confidence. Breathing exercises and sing-alongs can be useful, and even using a wipe-clean whiteboard to write things down or apps that transcribe spoken word into text can help.


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