Parkinson’s Disease 411
Parkinson’s disease (PD) is a complex movement disorder with motor, behavioral and cognitive symptoms that presents many challenges to affected individuals and their families. Shifting adversity to opportunity requires knowledge, a forward looking vision, a team spirit and courage. Mastering this process will optimize medical and social outcomes.
CLINICAL MANIFESTATIONS: PD is a movement disorder with multiple symptoms, including:
- Motor symptoms that are asymmetrical, including tremors, slowness of movement, stiffness, gait and balance problems (ie. falling), and a soft voice.
- Behavior symptoms may include anxiety, depression, irritability, hallucinations and delusions, aggressive behavior, pathological gambling and hyper-sexuality.
- Cognitive symptoms comprise of slowness of thinking, difficulty with vocabulary, forgetfulness and a decline in intellectual functioning.
- Autonomic symptoms, such as constipation, a loss of sense of smell, excess saliva, decreased sweating, weight loss, blood pressure dysregulation and erectile dysfunction.
CAUSES AND DIAGNOSIS: PD is a syndrome (a collection of varied illnesses with similar appearances) and as such, the course of the illness will depend on many factors, including the specific cause of the Parkinsonism. Aging males with a sedentary lifestyle are at a higher risk. Idiopathic PD often has an environmental basis, including exposure to industrial chemicals, head trauma, malignant melanoma or lifestyle toxins, such as cocaine and amphetamines. Family history (genetics) is also often a contributing factor. These factors lead to neurotransmitter deficiencies, particularly dopamine, serotonin, norepinephrine and acetylcholine, which produce the clinical symptoms.
Additionally, there is a group of so-called Parkinson Plus syndromes (PD+), which resemble PD but have additional specific features. These include Multiple System Atrophy (PD + autonomic dysfunction), Progressive Supranuclear Palsy (PD + impairment of upward gaze) and Corticalbasoganglionic Degeneration (PD + apraxia and limb dystonia). Lewy Body Disease has PD with fluctuations of alertness, visual hallucinations and gait disability. These PD+ syndromes are more symmetrical, have more gait disability and more dementia than regular PD.
TREATMENT: Knowledge related to the neurotransmitter deficiencies in PD provides the opportunity for replacement therapy with medications, such as:
- Levodopa and the dopamine agonists for the motor symptoms
- Antidepressants, anti-anxiety, antipsychotic and other mood stabilizer medications for the emotional/behavioral symptoms
- Anti-dementia drugs for cognitive symptoms
Beyond medication, physical, occupational and speech therapy can be very helpful. Deep Brain Stimulation (DBS) may be useful for those who have initially responded to medical therapy and then have become less responsive or developed complication of therapy, such as dyskinesia or wearing-off symptoms. PD+ syndromes and Lewy Body Disease are not very responsive to medications and deep brain stimulation is not recommended for these conditions.
PERSONAL INVOLVEMENT: While a health professional can help guide the treatment plan, success primarily depends to a great extent on the affected individual and their family’s involvement and attitude. One must strive to remain as physically, emotionally and intellectually active as is reasonably possible considering the amount of disability. Doing crossword puzzles, Sudoku, reading, learning languages, volunteering and other hobbies are useful endeavors. Spiritual activities are also helpful.
A daily exercise program can maintain and improve motor symptoms, such as stiffness, slowness of movement and gait disability, depression and even cognitive symptoms.
- Cardiovascular exercises including jogging
- Speech exercises to improve the voice
- Dance and Tai Chi for balance
Attention to diet, especially the texture and consistency of the food, can help with swallowing. A high fiber diet with fruits, vegetables and cereals can improve constipation. Being aware of the potential effects of protein on levodopa absorption can be useful in planning meals and medication ingestion for those with advanced PD. Vitamin and mineral supplements may be needed in some cases.
CARE ENVIRONMENT: Providing a support system is important to maintain an optimal lifestyle. While all want the best outcome, one must guard against caregiver stress and patient resentment. Remember:
- Time out and time apart may be needed
- Balance and moderation are golden
- Not too much and not too little
Psychological evaluations, counseling and geriatric psychiatry consultation may be indicated to treat mood disorders and cognitive symptoms. A driving evaluation may be needed to assess driving performance and address safety issues. Community resources such as a Parkinson Support Group can be invaluable. Legal assistance to prepare documents such as advance directives, power-of-attorney, medical power-of- attorney, and wills are important.
Knowing the limits of care is key. A thorough understanding of when to use personal care assistants, healthcare coordination, and long-term health facilities can improve the quality of life for patient and care partner alike. Knowing when to stop is also important. Palliative care and hospice care can help achieve the optimal balance in terms of maintaining dignity and control.
By: R. Malcolm Stewart, MD