parkinsons

As we age, we are more prone to illness. While some of them can be tackled effectively others just make it challenging to cope with their consequences with every passing day. One such debilitating and devastating condition is called Parkinson’s disease – a degenerative disorder that affects the brain and the central nervous system. Often this condition affects the elderly population but at times can also catch up with the younger lot.

What is Parkinson’s disease?

Parkinson’s disease is a neurodegenerative disorder and affects nerve cells which are responsible for motor functions of the body. Parkinson’s patients have difficulty in carrying out movements at a normal speed. Hence, they take longer to perform even normal day-to-day activities. 

Parkinson’s disease is found mainly in people over the age of 50 years and prevails in both the sexes. But if you consider the Indian statistics, it is more common in females than in males.

What causes Parkinson’s disease?

People with Parkinson’s disease suffer loss of nerve cells in the brain that are responsible for releasing a brain chemical or neurotransmitter called dopamine. Dopamine is a signalling chemical required for coordination and control of body movements. Once the neurons start dying, the production of dopamine is reduced causing loss of movement control and coordination in people suffering from the condition. But what exactly triggers death of those neurons is still a mystery. Scientists have found out several genes that were responsible for causing the disease in some cases.

Large population studies have indicated that people who have a family member or a relative suffering from the disease have a higher chance of developing the condition themselves. However, this is just an observation and further research on the inheritance aspect of Parkinson’s disease is underway.

 What are the signs and symptoms of Parkinson’s disease?

 In Parkinson’s disease the basic characteristic symptoms are those of tremors (trembling or shaking), stiffness, and slowness of movement, these are called motor symptoms. The non-motor symptoms might include difficulties in maintaining posture and balance, soft speech, problems with urinating, slow bowel movements and sleep disturbances. A characteristic of Parkinson’s is that the symptoms can change from day to day and sometimes even from hour to hour.

The motor symptoms in Parkinson’s are as follows:

Tremors: This happens usually in the limbs affecting the hands and feet but might sometimes also affects the lips, tongue, jaw, abdomen and chest. The tremors occur in the affected area when it is at rest and disappear during a movement. These tremors are often referred as resting tremors.

Rigidity: Rigidity of the muscle of the affected area is responsible for the aches and pains in the body. Such rigidity is called plastic or passive rigidity.

Bradykinesia: Slowness of bodily movements is termed as bradykinesia. This involves slowness in carrying out a movement, also hesitancy in initiating a new movement and fatiguing easily. There also appears to be a decrease in the performance of automatic movements like; eye blinking, swing of the arms while walking, hand gestures while talking, expressive facial movements etc.

Bradykinesia can also cause: 

  • Difficulties with rolling over in bed or getting out of a chair.
  • A distinctive change in the handwriting
  • Change in posture and difficulties in balance are other important motor related symptoms associated with PD.

 The non-motor symptoms of Parkinson’s disease is:

Constipation: This is caused when the muscles controlling the bowel movements slow down while the disease sets in.

Skin sensations and pain: Many affected individuals experience cramps, aches and feeling of numbness, tingling sensation, coldness, or burning. Though this happens mostly in the legs, lower back pain and headaches are also common.

Speech & swallowing difficulties: Parkinson’s disease can also affect the facial and throat muscles that can in turn affect the voice in some people with the disease, producing speech that may be quiet, hoarse, hurried or hesitant. Difficulties in chewing, swallowing, drooling and dryness of the mouth may be another outcome of facial and throat muscle distortion.

 Tiredness or Fatigue: It maybe one of the first symptoms to appear. This can be improved with regularized exercise and rest schedule. If the fatigue is associated with a secondary cause like depression or sleep problems then they should be assessed and treated first.

Depression: Helplessness due to the disease can lead to depression in some and in some depression can be a natural progression of the disease.

Motor Fluctuations:

In Parkinson’s disease, there are times when symptoms are in control with medications and such a phase is termed as “ON” time. At other times, the symptoms might be very poorly controlled despite medications; this phase is called “OFF” time. Motor fluctuations refer to a state where a person with Parkinson’s changes frequently between ON time and OFF time.

How is Parkinson’s disease diagnosed?

Although there are several tests like non-invasive diagnostic imaging tests that a neurologist uses to rule out the presence of other neurological conditions, there is no specific test that can confirm Parkinson’s disease. It is only based on individual description of symptoms and evaluation by a neurologist, a person is diagnosed of Parkinson’s. This the main reason why most cases of Parkinson’s go unnoticed. 

Though Parkinson’s is not a life threatening condition it is definitely a life-altering condition. With the help of appropriate care and therapy, patients can lead a fulfilling life. 

What are the treatment options available for Parkinson’s disease? 

The most devastating part about Parkinson’s disease is that one has to live with this condition lifelong as it has no cure. But that shouldn’t refrain patients from seeking treatment.  ‘A person with Parkinson’s requires various modalities of treatment along with medications,’ says Dr Maria Barrerto, CEO, Parkinson’s Disease and Movement Disorder Society. 

Following are the ways in which Parkinson’s can be treated and controlled.  

USING ORAL MEDICATIONS 

Oral medications to a certain extent can help manage Parkinson’s symptoms. But remember as one ages and the disease advances, medication alone won’t be of help to control the symptoms. The effects of oral medications wane out with the progression of the disease but they are the first line of treatment in managing Parkinson’s disease. Some of the medications that might be prescribed to a Parkinson’s patients are as follows: 

Levodopa: This medication is the most effective and primary medication prescribed to alleviate the Parkinson’s symptoms. Levodopa is a natural chemical that passes into the brain and is converted into dopamine, which then replenishes the deficiency of dopamine in the brain. By restoring dopamine it helps to regain motor functions, mobility and improves participation in the everyday activities.  Side effects of Levodopa may include nausea and lightheadedness. Sometimes it can also give rise to involuntary movements if taken in higher doses. It is advisable to talk to the doctor immediately once such side effects are noticed. 

Dopamine agonists: Unlike Levodopa, dopamine agonist doesn’t convert into dopamine but just mimics their effects and help in restoring brain functions. Dopamine agonist is used in conjunction to levodopa. Some of the side effects of dopamine agonists are similar to the side effects of levodopa, but it also includes hallucinations, swelling, sleepiness and compulsive behaviors such as hyper sexuality, gambling and over-eating. It is important for the caregiver to watch out if there is any out of character behaviour by the patient. Seek the doctor’s help to check on the doses. 

Mono Amine Oxidase Type (MAO-B) Inhibitors: These medications help prevent breakdown of dopamine by inhibiting the enzyme monoamine oxidase which metabolizes dopamine. Side effects of this drug might include nausea or headaches. If used along with levodopa, these medications increase the risk of hallucinations too. These medications are not often used in combination with most antidepressants or certain narcotics due to potentially serious but rare reactions. 

COMT Inhibitors: This medication mildly prolongs the effect of levodopa therapy by blocking an enzyme that breaks down dopamine. Side effects include an increased risk of involuntary movements leading to a condition called dyskinesias. This is basically a result of an enhanced levodopa effect. Other side effects include diarrhea or other levodopa side effects like nausea or headaches. 

Anticholinergics:  These medications were used for many years to help control the tremors associated with Parkinson’s disease. However, their modest benefits are often offset by side effects such as impaired memory, confusion, hallucinations, constipation, dry mouth and impaired urination. 

Amantadine:  This medication is prescribed to provide short-term relief of symptoms of mild, early-stage Parkinson’s disease. It may also be given with levodopa therapy during the later stages of Parkinson’s disease to control involuntary movements due to levodopa. Side effects may include a purple mottling of the skin, ankle swelling or hallucinations. 

SURGICAL INTERVENTIONS 

A surgical treatment is offered to patients who have reached the advanced stage of the disease and medication ceases to provide any relief to their symptoms. The surgical options those are available for Parkinson’s patients are: 

Deep Brain Stimulation or DBS 

In deep brain stimulation two surgically implanted medical devices called neurostimulators, similar to cardiac pacemakers are planted in the chest near the collarbone. These devices deliver electrical stimulation to precisely targeted areas on each side of the brain. Stimulation of these areas appears to block the signals that cause the disabling motor symptoms of Parkinson’s disease. As a result, many patients achieve greater control over their body movements. 

A DBS system includes the following three components, which are implanted completely inside the body. 

Neuro-stimulator: A pacemaker-like device is the power source for the system. It contains a small battery and a computer chip programmed to send electrical pulses to control Parkinson’s disease symptoms. 

Lead: An insulated wire with four electrodes is implanted in the brain, with its tip positioned within the targeted brain area. 

Extension: An insulated wire placed under the scalp that connects to the lead and runs behind the ear, down the neck, and into the chest below the collar-bone where it connects to the neurostimulator. 

Once the system is in place, electrical impulses are sent from the neurostimulator up along the extension wire to the lead and into the targeted brain area. These impulses interfere with and block the electrical signals that cause Parkinson’s symptoms. 

With the DBS one of two areas may be stimulated either the subthalamic nucleus (STN) or the internal globus pallidus (GPi). These structures are deep within the brain and involved in motor control. These structures control movement and muscle function. A neurosurgeon would determine which structure would be stimulated for the concerned patient. 

While DBS can relieve some of the patient’s symptoms considerably it should be noted that it can target only some specific symptoms. It does not eliminate the use of drugs and medication nor does it result in the reversal of the PD symptoms. 

Lesioning 

This involves destroying or eliminating the specific part of the brain that is causing Parkinson’s diseases symptoms. However this surgery is rarely performed these days. 

ADJUNCT THERAPIES 

Apart from medications and surgery one might also be recommended certain lifestyle changes, especially to take aerobic exercises or other movement therapies. In some cases, physical therapy that focuses on balance and stretching also is important. ‘Parkinson’s treatment often needs a multidisciplinary approach, that includes therapies such as physiotherapy, speech therapy, occupational therapy, diet and nutrition, counseling, cognitive rehabilitation and creative therapies,’ says Dr Maria. The other additional therapies that might give respite to a Parkinson’s patient are: 

Physiotherapy: This can help one manage mobility problem including gait, posture, balance dexterity etc. Physiotherapy would include exercises to improve mobility, help overcome side effects of medication and improve movement strategies. 

Occupational Therapy: Occupational therapy promotes good health and well being by helping patients regain their independence and adapt to disability. It also uses practical aids to help one with various activities and ways to adapt to daily routine and surroundings. This therapy has to be designed differently for each Parkinson’s patient depending on their needs and severity of the condition. 

Speech and Language Therapy or SLT: Speech and language therapy help patients communicate to the best of their ability by treating speech, language and communication problems. SLT also helps people in eating, swallowing and drooling problems too. 

What do they do in speech and language therapy? 

  • Exercises to improve communication on a one-to-one basis, or in a group
  • Advice on specific communication difficulties
  • Breathing and postural techniques to facilitate better voice and overall communication ease chewing and swallowing difficulties etc.
  • Tips and strategies to make a particular activity easier, such as — talking on the telephone, eating etc.
  • Recommending special tools and equipment to aid communication
  • Assessing and treating difficulties with eating, drooling and swallowing 

 References 

  • http://www.parkinsonssocietyindia.com/index.aspx
  • Gourie-Devi M, Gururaj G, Satishchandra P, Subbakrishna DK. Prevalence of neurological disorders in Bangalore (India): A community based study with an urban-rural comparison

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