April is Parkinson's Disease Awareness Month

Louise Mooney, RN

My Mum who is 82 suffers from Parkinson's Disease (PD) and it breaks my heart to witness the suffering and variety of symptoms she has to face on a daily basis. Her medication and excellent nursing care help immensely and my Dad is an absolute saint as her carer, but there is no cure for her or anyone else dealing with this cruel condition. She has gone from being a fiercely independent woman, to relying on family and carers to look after her, and this above all is what bothers her the most. This article aims to provide a broad overview of the disease which according to The Parkinson's Foundation, is currently thought to affect around one million people in the United States. It is general and cannot touch on every point as this is a complex, vastly studied topic. Worldwide research has been undertaken on PD and there is still so much more to study. I live in hope that one day we will have a cure.

History and Background

James Parkinson was a British physician who published "An Essay on the Shaking Palsy" in 1817 after closely observing and interviewing six men on the streets of London. These individuals shared symptoms such as tremors, slowness, stiffness and walking hunched forward. His work opened up the idea that this collection of symptoms related to progressive stages of "the same slow-moving disease". April is now established as National Parkinson's Month in honor of Dr. James Parkinson whose birthday was April 11th.

Biology Lesson

Of the extensive research and studies carried out on patients with PD, the main finding in brains of affected patients is loss of dopaminergic neurons in the area of the brain known as the substantia nigra. This is where we produce most of the dopamine our brains use. Dopamine is the chemical messenger that transmits messages between nerves that control movements, as well as those involved in the brain's pleasure and reward centers. In normal aging, these cells begin to die off at a slow rate. In PD patients this process happens at a faster and more profound rate. When over half the cells are gone, the symptoms of PD begin to arise.

PD patients also lose another neurotransmitter known as norepinephrine, a chemical required in the sympathetic nervous system. This system controls autonomic functions in the body such as heart rate, blood pressure, digestion and breathing. With loss of norepinephrine, PD patients experience some non-movement related symptoms such as low blood pressure, fatigue, constipation and anxiety.

Possible Causes

There appears to be no one definitive cause of PD but various theories point to genetic, environmental and lifestyle factors playing a part. It is unclear why some people exposed to these examples develop the disease and some do not.

Genetic : Ted Dawson, MD., Ph.D., director for Cell Engineering at John Hopkins points out that about 15 percent of people with PD have a family history of the condition which can be the result of specific genetic mutations. However the interaction between genetic changes and a person's risk of developing the disease is not fully understood.

Environmental : Another theory is the belief that exposures in the environment such as pesticides, heavy metals, detergents and solvents contribute to the development of the disease.

Lifestyle : Repeated blows to the head such as in boxing and other contact sports where head injuries are common are thought to increase the risk of developing PD. Further studies are required to solidify this theory.

Symptoms

Tremor : Often starting in the hands or fingers a tremor can be present even at rest. Patients may rub their thumb and forefinger back and forth (pill-rolling).

Slowed Movement (Bradykinesia) : Walking becomes slow and steps may be shorter. It may be difficult rising from a chair and feet may drag.

Muscle Rigidity : Stiffness can occur in any part of the body and muscles can be painful with limited range of motion.

Impaired Posture and Balance : Patients often become stooped and have balance issues.

Loss of Automatic Movements : There may be a reduced ability to perform unconscious movements such as blinking and smiling. Arms tend to hang by the side rather than swing during walking, and the face can take on a mask-like appearance.

Speech Changes : Speech may become softer and patients may slur words or hesitate before beginning to speak. A monotone speech style may be apparent.

Writing Changes : Handwriting may appear small and become increasingly difficult to manage.

As Parkinson's progress, complications often arise such as cognitive difficulties, depression, swallowing problems, sleep disturbances, bladder control and constipation.

Some Lesser Known Symptoms

Swallowing Trouble : PD patients often lose weight without actively trying. This is due to the trouble they have chewing, eating and swallowing. They may also cough and choke during eating.

Exhaustion : Patients may nod off during the day and feel generally fatigued possibly due to the added stress on muscles during tremor and contractions.

Losing the Sense of Smell : Compared to the other symptoms mentioned, this may seem like a trivial one, but it can affect the quality of life of the patient already struggling with food intake which can in turn reduce their enjoyment of it.

Orthostatic Hypotension : Some people may experience a drop in blood pressure when changing from sitting to standing position. This lightheadedness can lead to risk of falls.

Stages

According to the Hoehn and Yahr Scale (named after its authors), there are 5 stages of Parkinson's which get worse as the disease progresses through mild to moderate and lastly advanced stages.

Symptoms at this stage will mostly be mild and are often missed if they are not interfering with daily life. Tremors or movement challenges may be noticed on one side of the body.
The disease enters the moderate stage where symptoms such as trembling, stiffness and changes in facial expressions become more obvious. Symptoms begin to spread to both sides of the body. This progression may take months or years and patients progress at differing rates.
Patients begin to experience a decrease in reflexes and loss of balance. Movement becomes slower and risk of falls higher. Activities of daily life begin to get compromised and additional help may be required.
By now most patients are unable to live independently and may require a walker or wheelchair to get around.
This is the most advanced stage where patients need to be closely monitored to prevent falls. Confusion, hallucinations and delusions may be experienced among some and dementia may be a consideration too. At this stage the side effects of medication outweigh the benefits.

The earlier PD is detected, the sooner treatment such as medication, physiotherapy and occupational therapy can be implemented so it is important not to ignore the early warning signs.

Common Medications

Levodopa (L-dopa) is the most commonly prescribed drug for Parkinson's and is best for controlling the common motor symptoms previously discussed. Simply put, L-dopa works when the brain cells turn it into dopamine.

Sinemet is a mix of levodopa and another drug called Carbidopa (a medication which makes levodopa work better so less is needed). This helps with the common side effects such as nausea, vomiting and irregular heart rhythms.

Dopamine Agonists eg. Pramipexole (Mirapex) and Rotigotine (Neupro) are drugs which act like dopamine in the brain. They can be taken on their own or alongside Sinemet depending on the patient's symptoms and are often the first choice of treatment for Parkinson's.

Outlook

Medication together with lifestyle changes can help patients cope with their symptoms of PD and have the best quality of life available to them.
Homes can be adapted and there are many therapies available (Physio, Occupational Therapy) which can help patients with their activities of daily living. In the early stages, just after diagnosis, patients may wish to alter their home so they are prepared for when their independence is compromised.
Patients are advised to keep active when they can and try new exercises such as Tai-Chi or regular walks in the park.
Parkinson's Disease does not directly cause people to die, but the condition can place great strain on the body and in turn increase the risk of complications. The somewhat good news is that with advances in treatment, many people with PD can still lead active lives and have a near-normal life expectancy.

Personal

Unfortunately for my mum, even walking for her is now a challenge, thanks to a fall resulting in a broken hip! She experiences pain when mobilizing but at least she is still able to do it. Gone are the days when she could take up aerobics or brisk walking. One thing she has not yet lost is her creative talent. She has crocheted baby blankets for years and to this day is still managing to keep those needles going. Her finished work is impeccable - I wish I could be half as creative! As long as she's able, she will still crochet her beautiful legendary blankets and this is something solely for her - my dad isn't helping in that department! Good on you Mum!

References

Mayo Clinic: Parkinson's Disease

National Today: Parkinson's Awareness Month - April 2022

American Parkinson Disease Association

NIH: The History of Parkinson's Disease: Early Clinical Descriptions and Neurological Therapies

Parkinsons.org: Parkinson's Disease Information

Johns Hopkins Medicine: Parkinson's Disease Overview

Parkinson.org: Understanding Parkinson's/Statistics

Cleveland Clinic: Parkinson's Disease

ActiveBeat: Most Common Symptoms of Parkinson's Disease

Parkinson'sDisease.net

WebMD: Your Guide to Parkinson's Disease