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Parkinson’s disease: Made famous by Muhammad Ali and Michael J. Fox, the cause of this debilitating disease is generally unknown, and there is no cure. It is named after the English doctor James Parkinson, who published the first detailed description in 1817, in An Essay on the Shaking Palsy.
Parkinson’s affects about 1 of 250 people older than 40, about 1 of 100 people older than 65, and about 1 of 10 people older than 80. Most typically, it begins between the ages of 50 and 79. We are also more likely to have Parkinson’s if we have a close relative with the disease, or if we were exposed to various toxins. It is seen among boxers like Muhammad Ali due to repeated trauma to their brain, which can be a factor as well.
Early in the course of the disease, the most obvious symptoms relate to movement:
• Tremor is the most apparent and well-known symptom. It occurs at rest and disappears with voluntary movements. It’s sometimes referred to as a “pill-rolling tremor,” due to a tendency to roll the thumb and index fingers together in a circular movement.
•The second common feature is bradykinesia, which literally means “slowness of movement.” Movement becomes difficult, from the planning stage to execution. This is, in fact, the most disabling symptom in early Parkinson’s. Walking is affected, as are fine motor tasks such as writing or getting dressed. This symptom can vary depending on the task, time of day, and other stresses.
• The third hallmark is rigidity, or stiffness and resistance to movement of the arms and legs caused by increased muscle tone. It might be accompanied by joint pain. In the early stages of the disease, rigidity may affect the neck and shoulder muscles, but as the disease progresses, rigidity typically affects the entire body.
•Postural instability is the fourth main symptom. It becomes typical in the late stages of the disease, leading to impaired balance and frequent falls, with resulting bone fractures.
Other recognized motor signs and symptoms of Parkinson’s disease include gait and posture disturbances such as rapid shuffling steps and a forward flexed posture while walking (festination). Troubles with speech and swallowing, a mask-like facial expression, and small handwriting may also appear.
Parkinson’s can cause a host of neuropsychiatric changes, including difficulties with problem solving, planning, abstract thinking, rule acquisition, attention changes, slower cognitive speed, and problems with recalling learned information. Behavior and mood alterations include depression, apathy, impulse control, binge eating, hypersexuality, pathological gambling, and even psychotic symptoms of hallucinations and delusions. The risk of dementia is two to six times that of the general population.
We do understand the changes in the brain that result in Parkinson’s. The most seriously affected area is the sunstantia nigra, a part of the basal ganglia (a group of structures in the brain). This is where cells secrete the brain transmitter dopamine. The primary symptoms of Parkinson’s disease result from greatly reduced activity due to the death of these dopamine-secreting cells.
The diagnosis is based on taking a medical history, observation of symptoms, and a neurological exam. There are no lab tests that will clearly confirm Parkinson’s. Sometimes patients are given levodopa, which relieves the motor symptoms and can confirm the diagnosis. CT and MRI scans of the brain don’t help to make the diagnosis, but are useful in ruling out other diseases. Some experimental diagnostic techniques use PET and SPECT scans to measure brain dopamine activity.
No drug can cure the disease, but there are helpful measures used for Parkinson’s. Levodopa-carbidopa may make movement easier and enable patients to function effectively for many years. Treating the motor symptoms with surgery was once a common practice, but since the discovery of drugs that increase dopamine levels, the number of operations has declined. However, as the disease progresses and dopamine neurons continue to be lost, these drugs lose their effectiveness and can even worsen symptoms. The most recent promising approach in the later stages of the disease is a surgery with deep brain stimulation, which can block the impulses that cause tremors and other symptoms.
In addition to medication and surgery, it appears that speech and mobility problems can be improved with rehabilitation. Regular exercise can improve the quality of life, as well as improve flexibility, mobility, gait, and speed. However, patients eventually tend to require a high level of care, as their needs become more demanding and complex. Sadly, life expectancy is reduced, with double the mortality rate of the average population.
This is, unfortunately, a progressive incurable disease, and I am reminded of Robert Louis Stevenson’s observation:
Life is not a matter of holding good cards, but of playing a poor hand well.
Dr. Alan Frischer is former chief of staff and former chief of medicine at Downey Regional Medical Center. Write to him in care of this newspaper at 8301 E. Florence Ave., Suite 100, Downey, CA 90240.
Published: October 27, 2011 – Volume 10 – Issue 28