A. General Considerations

Parkinson’s was first described by James Parkinson in 1817. It is a progressive neurodegenerative condition characterized by tremors, slowness of movements, stiffness, and balance problems. In addition, Parkinson’s has many non-motor symptoms such as memory or cognitive issues, speech and swallowing problems, depression, and sleep difficulties. It affects almost 10 million individuals around the world.

Parkinson’s disease (PD) is the second most common neurodegenerative disorder in the elderly, and the most commonly seen movement disorder in neurology clinics

Although the Arab population of the GCC region shares religious beliefs and demographic characteristics with other Arabs, their environmental exposures and genetic makeup may be different. This could account for the relatively low prevalence of PD reported in the Al-Thugba study (27 per 100,000) compared with prevalence rates by most other studies on Arab (mainly North African) populations (> 31.4–557.4 per 100,000). PD prevalence was reported to be as low as 18 per 100,000 in a Chinese population and as high as 65–125 per 100,000 among the Europeans. A study from England in 1992 revealed a prevalence of 121 per 100,000. It is expected that PD incidence will further increase in the future, as there are far more people surviving beyond 65 years of age than in the past. With the improved life expectancy in countries of the GCC, PD in the area is likely to mirror the increase observed elsewhere.

Parkinson’s is a neurodegenerative disease and involves the loss of brain cells capable of producing dopamine. Dopamine is a neurotransmitter, a chemical involved in the transmission of signals between the neursons in certain parts of our brain. Dopamine helps facilitate the movements of our body, the deficiency of which results in slowness of the movements of our body which is one of the cardinal symptoms of Parkinson’s. Although Parkinson’s may be a complex disease with many implications on your life, it can be managed well with proper treatment and advice. There is not a cure for Parkinson’s yet but you can have a reasonable quality of life with this disease for many years.

What causes Parkinson?

Motor symptoms of PD result from the loss of the pigmented dopamine neurons (brain cells) in the substantia nigra region of the brain. Dopamine is responsible for smooth, purposeful movement. Despite advances in research, the exact cause of dopamine neuron loss is still unknown. Decreases in dopamine, however, do not account for all symptoms experienced in PD. Research is ongoing to better understand more about the biology of Parkinson’s and all of the changes that occur in the brain due to the disease.

B. Parkinson’s disease symptoms

The brain cells and nerves affected in Parkinson’s disease (PD) normally help to produce smooth, co-ordinated movements of muscles. When this system goes wrong, movement disorders (motor symptoms) occur. Three common PD symptoms that gradually develop are:

• Slowness of movement (bradykinesia). For example, it may become more of an effort to walk or to get up out of a chair. When this first develops you may mistake it as just ‘getting on in years’. The diagnosis of PD may not become apparent unless other symptoms occur. In time, a typical walking pattern often develops. This is a ‘shuffling’ walk with some difficulty in starting, stopping and turning easily.

• Stiffness of muscles (rigidity) and muscles may feel more tense. Also, your arms do not tend to swing as much when you walk.

• Shaking (tremor) is common, but does not always occur. It typically affects the fingers, thumbs, hands and arms but can affect other parts of the body. It is most noticeable when you are resting. It may become worse when you are anxious or emotional. It tends to become less when you use your hand to do something such as picking up an object.

The symptoms tend slowly to become worse. However, the speed at which symptoms become worse varies from person to person. It may take several years before they become bad enough to have much effect on your life. At first, one side of your body may be more affected than the other.

Some other symptoms may develop due to problems with the way affected brain cells and nerves control the muscles. These include:

• Fewer facial expressions such as smiling or frowning. Reduced blinking.
• Difficulty with fine movements such as tying shoe laces or buttoning shirts.
• Difficulty with writing (handwriting tends to become smaller).
• Difficulty with balance and posture and an increased tendency to fall.
• Speech may become slow and monotonous.
• Swallowing may become troublesome and saliva may pool in the mouth.
• Tiredness and aches and pains.

Various other symptoms develop in some cases, mainly as the condition becomes worse. Symptoms include:

• Constipation.
• Bladder symptoms and sometimes incontinence.
• Hallucinations – seeing, hearing or smelling things that are not real.
• Sweating.
• Sexual difficulties.
• Alterations in your sense of smell.
• Sleep problems.
• Weight loss.
• Pain.
• Depression.
• Anxiety.
• Dizziness on standing (due to a sudden fall in blood pressure).
• Problems with controlling impulses. For example, compulsive eating or shopping.

C. DIAGNOSTIC OF PARKINSON’S

Parkinson’s is diagnosed by history and physical examination conducted by a physician. There are no laboratory tests that can be used to confirm the diagnosis of Parkinson’s. A neurologist who specializes in Parkinson’s may observe you for a period of time to make sure the symptoms are consistent.

Additional tests, such as a brain scan, blood tests or additional examinations like testing the patient’s sense of smell, may also be done. Currently there is no cure, but there are many treatments and lifestyle modifications available to effectively manage PD. These include a combination of medications, exercise, rehabilitation therapies, interventions to address safety and mental health and sometimes surgeries.

Parkinson’s is considered progressive, meaning that many of the symptoms can worsen over time. The rate of progression is often hard to predict and varies from person to person. That being said, people with PD can live full, meaningful lives, especially if they manage their symptoms and safety appropriately and tap into the right care and resources.

Unfortunately, there can still be stigma associated with PD. This is primarily due to general lack of understanding of the disease and misconceptions about how it will progress. This can make people with PD can be reluctant to share their diagnosis; they may have concerns that others might pity or avoid them. Or they may fear PD-associated stigma, stemming from the misconceptions of people unfamiliar with the disease.

Every person who receives a PD diagnosis responds differently to the news. Some people react with anger or depression, perhaps feeling resentful that this happened to them, hopeless about what the future may hold or regretful that they did not better appreciate life before PD. Some wonder whether certain past lifestyle choices or factors “caused” their PD. Others respond with denial, which can look different from person to person. For some, a diagnosis may mean refusing to talk or learn about PD, holding unrealistic expectations about treatment or progression or seeking out opinions from multiple doctors in a search for any possible explanation for their symptoms other than PD. Yet others may respond with positivity, or even a sense of gratitude or relief, in having a specific diagnosis, knowing they were not “imagining” symptoms and having a better understanding of what they are dealing with and more definitive answers and treatment options.

Education is the key for the patient diagnosed with PD, for patient’s family and friends

People with PD benefit from regular visits with a general neurologist
or a movement disorders specialist – a neurologist who went through additional training in PD and movement disorders. Treatment options for PARKINSON’s symptoms can be offered to improve patient’s daily functioning and quality of life. By committing to an exercise routine, taking the medications as prescribed, finding the right care providers, building own support system and being adaptive, the patient itself can positively influence his quality of life with Parkinson’s.

C.1. Who develops Parkinson’s disease?

PD mainly develops in people over the age of 50. It becomes more common with increasing age. About 5 in 1,000 people in their 60s and about 40 in 1,000 people in their 80s have PD. It affects men and women but is a little more common in men. Rarely, it develops in people under the age of 50.

PD is not usually inherited and it can affect anyone. However, one type of PD, which appears in the small number of people who develop it before the age of 50, may be linked to inherited (genetic) factors. Several family members may be affected.

D. TREATMENT FOR PARKINSON’S DISEASE

There is no cure for PD, and no treatment prevents the disease from progressing. However, treatments can usually ease symptoms.

• At first, you may not need any treatment when the symptoms are mild. A specialist may simply see you every now and then to monitor how the disease is progressing.
• A medicine that eases symptoms is usually started when symptoms become troublesome.
• Therapies such as physiotherapy, occupational therapy and speech therapy may also be useful as the disease progresses.
• Surgery may be an option for severe cases.

Drug therapy is the mainstay of treatment of Parkinson’s. Physiotherapy and speech therapy are also helpful conjunction with medications.

Levodopa is a natural amino acid that has been used to treat Parkinson’s disease since the 1960s. Levodopa is converted into dopamine by an enzyme in the brain. This medicine has been used for many years. Nearly all people with PD notice a good improvement in symptoms after starting levodopa.

In order to prevent the levodopa being metabolized by this enzyme before it reaches the brain, it is given in combination with an enzyme inhibitor (eg, carbidopa) that blocks the enzyme in the gastrointestinal tract. The inhibitors are not able to pass into the brain and therefore, do not inhibit the conversion of levodopa into dopamine in the brain. Levodopa considerably improves symptoms such as stiffness and slowness of movement.

Dopamine agonists stimulate the parts of the brain where dopamine acts. They can be taken alone or sometimes in combination with levodopa and carbidopa. They produce fewer long-term side effects such as the on/off effect and are therefore often used in younger patients.

Anticholinergics are used to correct the balance between acetylcholine and dopamine by blocking the action of acetylcholine. They are often used in younger people with milder symptoms.

Monoamine-oxidase-B (MAO-B) inhibitors

These medicines are another alternative to levodopa for early PD. These medicines work by blocking (inhibiting) the effect of a chemical in the brain called MAO-B. This chemical is involved in the breakdown of levodopa and dopamine. If the action of MAO-B is inhibited then the effect of any dopamine lasts longer. Most people will require levodopa eventually. However, if you take an MAO-B inhibitor at first, it may delay the need for levodopa for months or years.

Sometimes these medicines are used in combination with levodopa in the later stages of PD.

Catechol-O-methyltransferase (COMT) inhibitors are relatively new medicines. These help to stop the breakdown of levodopa by the body, so more of each dose of levodopa can get into the brain to work. A COMT inhibitor is sometimes advised in addition to levodopa when symptoms are not well controlled by levodopa alone.

Dose schedules and timings are important. A pharmacist will be able to advise and help if the patient have difficulty in getting tablets out of blister packs, have difficulty in remembering when to take your medicines, or have any other queries about medication. The patient have to report any suspected side-effects to your doctor.

Other medicines are sometimes used to help relieve symptoms. They have various effects which try to correct the chemical imbalance in the brain. They include beta-blockers, amantadine and anticholinergic medicines. One of these may be tried when symptoms are mild. However, you are likely to need levodopa or a dopamine agonist at some point.

The use of surgery to treat Parkinson’s disease has been largely abandoned since the introduction of levodopa and other drugs. For example, chronic deep brain stimulation is a technique that involves putting a pulse generator (like a heart pacemaker) in the chest wall. Fine cables are tunnelled under the skin to electrodes placed in the brain. The electrodes stimulate the parts of the brain that are affected by PD and can help to ease symptoms. The long-term safety of this surgery is not certain and a trial is underway to look at this.

However, recently there has been renewed interest and new surgical techniques are currently being researched.

Complementary therapies for Parkinson’s disease

A specialist PD nurse can provide support, information, and counselling. A specialist nurse can also monitor response to treatment and give advice on how to adjust medication if necessary.

A physiotherapist can advise on posture, walking and exercises.

An occupational therapist can advise on such things as home adaptations which may ease many tasks.

If difficulties with speech, swallowing or saliva occur, a speech and language therapist can help.

The advice of a dietician and other therapists may be needed for some people.

A psychologist may be able to help if you have problems with depression.

Complementary therapies do not affect symptoms or the course of the disease. However, some therapies are good at easing stress and anxiety, which may help in your general well-being.

Self-help measures

• Keeping active can help to loosen stiff muscles and improve speech or posture.
• If you shuffle when walking, wear leather soled shoes to help you keep your balance.
• Try to keep your weight at a normal level as being overweight puts additional strain on your joints and may affect your mobility.
• Try to relieve symptoms of anxiety as this can make any tremor more severe and can also affect your sleep.

Research into PD is active. For example, one main aim of research is to find medicines that prevent the damage to the affected cells, rather than just treating the symptoms, which is the main value of treatment at present. Further research on these chemicals continues. Research is underway using stem cell therapy to help treat PD. Other researchers are looking at alpha synuclein, a protein that gathers around the junction between nerve cells and is thought to affect the way messages are conducted between the brain and the nerves controlling movement.

Contact a specialty consultation or advice from a neurology specialist/Parkinson’s disease  center: