July 21, 2016
Parkinson’s disease is a progressive multi-system neurodegenerative disorder that is characterized by progressive neuropathological changes in deep brain structures such as the medulla, pontine tegmentum, and olfactory bulb in preclinical stages; substantia nigra and midbrain (which drive the well known motor dysfunction); and forebrain (in later stages).
These changes are driven by the development of Lewy bodies (proteinaceous spherical bodies) and spindles (thread-like branching structures) in neurons. Although characterized by deficiencies in the neurotransmitter dopamine, Parkinson’s disease also affects the neurotransmitters glutamine, acetylcholine, and norepinephrine. In short, it is a very complex neurological disease defined by motor symptoms but is so much more.
The most common treatment for Parkinson’s disease is levodopa to replace the lost dopamine (cardinal symptoms appear when dopamine in the nigrostriatal system is reduced by 80 percent or more). Early on, levodopa is quite helpful but as the disease progresses the drug often has shorter duration of action (“wearing off”), alternating phases of good and poor response (“on-off symptoms”) as well as the development of involuntary movements of the head, trunk, or limbs (“dyskinesias”).
The primary features leading to diagnosis are a wide variety of motor symptoms – not all of these symptoms are present in every patient. Bradykinesia (slowness of initiation of voluntary movements), muscle rigidity, and resting tremor are common. Also common are stooped posture, gait disturbances, (shuffling, smaller more rapid steps leading to falls), lack of arm swing when walking, hypomimia (expressionless face), freezing of movements, and micrographia (handwriting is small). Finally, oral motor symptoms may include soft voice, hurried speech, difficulty swallowing, slurred speech, and dribbling saliva.
As if these were not enough for the afflicted and their caretakers to deal with there are also a myriad of nonmotor symptoms to manage. The nonmotor symptoms may develop 10 years before motor symptoms. There are three main classes of nonmotor symptoms in Parkinson’s’ disease: autonomic, neuropsychiatric, and sensory disturbances.
Autonomic features include orthostatic hypotension leading to dizziness and possible loss of consciousness, gastrointestinal symptoms resulting from slowing of the GI tract (sense of fullness after eating, gastric retention, and disturbance of rectal evacuation); erectile dysfunction; dermatological changes like excessive sweating, increased fat and scaling; decreased saliva, restless legs; sleep apnea; and sudden sleep attacks.
Neuropsychiatric symptoms are often seen leading to psychiatric treatment that may not be productive. Visual hallucinations and illusions of people, children, and small animals are most common. They usually last seconds to minutes and those without dementia can be treated with insight and patience. Paranoid delusions, depression/anxiety, euphoria/hypomania, hypersexuality, abnormal hoarding, impulsive behaviors (gambling, driving too fast), and cognitive disorders and dementia are possible in later stages.
Finally, sensory changes are frequent. Sense of smell is reduced or lost in 80 percent of those with Parkinson’s’ disease. Pain is reported in 40-85 percent of those with Parkinson’s disease. Although limb and joint pain are most frequent, oral, thoracic, abdominal, and genital pain is not uncommon.
I am overwhelmed just thinking about all the things to deal with (even in early stages) for those with Parkinson’s disease and their carers. Furthermore, many of these symptoms are also caused or exacerbated by the medications used to treat Parkinson’s disease. The good news is that there is dramatic variation in the progression and course of Parkinson’s’ disease. It is clearly more than just a disease of movement.
Dr. Beckwith is a neuropsychologist, speaker, and author of "Managing Your Memory: Practical Solutions for Forgetting." He can be reached at memoryseminars@aol.com or (239) 851-1968.
http://www.naplesnews.com/story/life/2016/07/21/symptoms-parkinsons-disease/87390302/
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