Tuesday, 26 July 2011

More on Parkinson's

Published in Panorama

A little about a long term Illness – Parkinson’s Disease.

Seema couldn’t comprehend her husband’s trembling right hand: it was perfectly steady when he held his cup of coffee or a book for instance, but trembled when it was at rest! She wondered if he was heading towards some kind of paralysis. Abdul, 68, dismissed the tremor in his hand as a sign of ageing.

These two people could be suffering from Parkinson's disease (PD), says Dr.Rajni Ashok, Specialist, Internal Medicine, Zulekha Hospital, Sharjah. PD is a slowly progressive disorder that affects movement, muscle control, and balance, explains Dr.Rajni. “Very often when we see elderly people having shivering of the hand or of the jaw, we say it’s just old age. But what do we mean by “just old”? Does it mean that everyone who gets old will shiver? No. Obviously there is something different in ageing between this gentleman and some others who age in the same way but without shivering!”

The prevalence Parkinson’s in individuals over 65 years of age is roughly 2 - 3 per 1000 and between 1-2/1000 in people above the age of 70. However, since the disease is not infectious, it may be under-reported; hence incidence may be much higher. This again may be the reason why the incidence of PD is seen more in men than women and also because women do not seek medical advise earlier, says Dr.Rajni.

What factors cause this degenerative and often debilitating disease? While the cause of PD is yet unknown, it is generally believed that the deficiency of a certain chemical messenger or neurotransmitter, dopamine, in the brain is responsible for the disorder. Explaining the course of the disease, Dr.Rajni elaborates, “Dopamine dwindles down as part of degeneration along with age. In some people it becomes manifest a little more severe and that is when it becomes manifest as a disease where the person may have features of Parkinson’s.”

Although it is clear that dopamine deficiency is the primary defect in Parkinson's disease, environmental toxins, herbicides, pesticides exposure to carbon monoxide fumes may contribute to the problem.

Besides, PD may also be drug-induced, says Dr.Rajni. “This is known with certain psychiatric drugs, given for conditions like schizophrenia. These drugs can cause dopamine depletion and therefore cause PD. Similarly drug intoxications, drug abuse can also contribute in Parkinson’s.”

Is it then true that those below the age of 60-65 do not face the risk of PD? This may not entirely be true! “It can occur even around the age of 40 years,” clarifies Dr.Rajni. “There is one condition known as Juvenile onset Parkinson which can occur in the young. In these patients, rather than tremor and rigidity being the symptomatic features, they may have abnormal movement and stiffness as a major component.”

Dr.Rajni cautions, “But there are certain conditions where Parkinson’s can develop in the younger age group and when this happens, you have to rule out any other condition. These include certain categories of people like to which the basal ganglia is vulnerable. Similarly, when certain individuals have diffused brain disease like any meningo-encephalitis, they can suffer from several neurological conditions of which Parkinson’s can be one of them.”

So Parkinsonism is not the same as Parkinson’s? Dr.Rajni clarifies, “When we say Parkinsonism, it could be a group of symptoms with Parkinson’s features as one of them. When we say PD, we are usually separating a class which is of unknown cause, separating it from another group which is a mixed form in which Parkinson’s occurs as a part of many other associated disorders.”

What are the symptoms of PD? In 70-80% of people, the disease manifests with tremors in the hand which occurs mainly at rest, says Dr.Rajni. “Very often when you see an old man relaxing, his thumb and index finger alone may be having tremors. At the same time you give him a cup of tea or coffee, the tremors will vanish. When he holds something and goes into action, the tremors disappear. Also, the onset of the disease is normally one-sided and very often people mistake this for paralysis. But in PD, there is no loss of motor power; the person cannot initiate the voluntary movement because of the disorder. Movement slows down as a result of the disease. He might be able to hold things very well in the early stage of the disease, but gradually the movements slow down.”

Stiffness in the extremities and backbone is another symptom of PD due to which the individuals may have a stooped posture, difficulty in maintaining their postural reflexes and hence have a tendency to fall. Dr.Rajni clarifies that all symptoms don’t come on day one, but appear over the years. “As the disease progresses, you will find the tremors gradually increasing and slowness of movement coming up. This affects the loco motor muscles and it can also affect the face muscles and you find the person’s facial expressions going down and the face becomes mask-like. These individuals may have problems of excess salivation, difficulty in swallowing and consequent drooling. At this stage they may require to take soft and liquid diet and care has to be taken to see that they do not choke over food or have infection because of feeding problems.”

Besides shuffling gait, stooped posture and difficulty in coordinating fine movements, the individuals may experience cognitive slowing, memory disturbance and confusion, depression, slowing down of speech and micrographia where their handwriting becomes small and illegible.

Before treatment for Parkinson’s is begun, it is important that the right diagnosis be reached since there are other disorders and ailments which present symptoms similar to Parkinson’s. One of them is depression. Very often the elderly patient tends to become depressed, keeps to himself and is not interested in initiating movement or in his daily activities. This may be pure depression and could be mistaken for Parkinson’s, explains Dr.Rajni. “You have to rule out conditions like hypo thyroidism which is associated with slowness of movements, faces which have lost their expression and the individuals have mood swings and depression, not wanting to interact with their environment. The typical symptoms of Parkinson's also occur in meningitis and various types of poisoning from alcohol, carbon monoxide and heavy metals. Overdoses of manganese also cause Parkinson's symptoms. These other conditions are treatable as opposed to Parkinson’s which is not curable.

How is Parkinson’s diagnosed? The diagnosis of Parkinson’s is predominantly a clinical one, states Dr.Rajni. “In an era of investigations, there is no per se investigation which we can do and confirm the disease,” she explains. “Nevertheless we do CT Scan, MRI, EEG or blood tests in patients with PD because we want to rule out other treatable conditions which can cause PD, conditions which have got a Parkinsonism Syndrome.”

One of the most important things about PD which patients have to know is that, while PD is not a life threatening disease, what makes it tragic is that it is not predictable, preventable or curable and is progressive in nature.

So what is the treatment modality once diagnosis of PD is confirmed? There are several groups of drugs used in the treatment but the treatment given is only to improve the movements, says Dr.Rajni. “It is of utmost importance not to mislead the patient and his family members; it is imperative to explain to them that PD is a degenerative disease and hence the patient is not going to be cured. In fact 30% of these patients get depressed, as is only natural because the tremors come in the way of their daily activity; they find it a social inhibition and are conscious of people watching their tremor. Stress and emotional disturbances can aggravate these tremors. As a consequence, the patients become withdrawn and don’t want to socialize.”

What of the side effect of drugs used in the treatment of PD? “Sometimes some of these drugs produce nausea and vomiting. So we often tell the patients to take the medicines with some carbohydrate food. We tell them to take the medicine preferably half an hour before the meal so that its absorption is faster. At the same time we ask patients to avoid a protein meal since it is likely to interfere with the working of the drug. Since proteins are an important part of diet and need to be taken, it is better to shift the protein meal to the evening,” cautions Dr.Rajni.

Continuing on the mode of taking the drugs, Dr.Rajni explains, “It is important that the medicines be taken at the appropriate time since patients can get excessive movement or dyskinesia. For example, a patient who gets up in the morning, not able to brush his teeth, starts brushing his teeth after taking the tablet. However, by the time it’s time to run and catch the bus, he can fall off the bus because the movements are so violent, so much out of control that he cannot hold on to the bus! So you have to educate patients to strike an appropriate time for taking the medicine that he gets enough movement at the time he needs it most and subsequently when the effects of dyskinesia comes on, he is not doing any active movement.”

Certain drugs related to PD can cause severe visual hallucinations and it is also possible that the patient does not recognize his kith and kin. What is important in the treatment of PD is that the family and care takers should be fully explained the nature of the disease so that they can cope with the problem smoothly. Very often because of the postural problems, the victims need certain appliances or support at home which will help them prevent a fall. It is very important that these people be engaged in active conversations so that they continue to speak and don’t become withdrawn and introverted. Whatever skills they have, must be promoted because motivation is the name of the game. In treating PD a Doctor should not offer patient consultation but it should be a family consultation and counseling.


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