Understanding Parkinson’s Disease

12 July 2022

Parkinson’s disease is a more common condition among older people, affecting about one percent of people over the age of 60 and with the incidence rising significantly with increasing age. However, about five to 10 percent of people with Parkinson’s disease begin before the age of 50 and are termed to have “early-onset” disease. Men seem to be at a higher risk than women for developing Parkinson’s disease but the reasons for this discrepancy are unclear.

There is no simple way to deal with the lifechanging event of discovering your loved one is diagnosed with Parkinson’s disease. This could manifest into stress, anxiety and may even lead to depression among family members. Hence, as tough as it may be, having a clear understanding of the disease and how you can help improve their quality of life may benefit them in many ways.

We reached out to Consultant Neurologist from Sunway Medical Centre, Dr. Raymond Tan Yen Leong to share further insights in regards to Parkinson’s disease.

Could you briefly explain what Parkinson’s disease is?
Parkinson’s disease is a Neurological Disorder under the category of Movement Disorders. It is both chronic, meaning it persists over a long period of time and is progressive, meaning its symptoms worsen with time. It consists of four main symptoms:

• Bradykinesia or slowness in movements
• Tremor or trembling of the hands, arms, legs, jaw or head
• Rigidity or stiffness of the limbs and trunk
• Postural instability or impaired balance.

These symptoms often start gradually and worsen with time. Patients would eventually have difficulties to walk, talk or complete simple tasks as the disease progresses.

How is Parkinson’s disease diagnosed?
To date, there are no proven blood or laboratory tests that help in diagnosing sporadic Parkinson’s disease. The diagnosis, therefore, is based solely on a good medical history and neurological examination. In most patients with Parkinson’s disease, the diagnosis is relatively straightforward – individuals in their 50s or 60s presenting with asymmetric parkinsonian symptoms (bradykinesia, tremors during rest, rigidity or postural instability).

At times, it can be difficult to diagnose accurately, especially early in the disease, hence, multiple visits and observation from time to time are required until the symptoms are consistently and clearly present. At times, the patient might be asked to do a brain scan or laboratory tests, but this is more to rule out other diseases or disorders. The CT and MRI brain scans of people with Parkinson’s disease usually appear normal. Since many other diseases may have similar features, but require different treatments, it would be imperative to make a precise diagnosis so that the patient receives the proper treatment.

Does Parkinson’s disease run in the family?
People with one or more close relatives who have Parkinson’s disease may have an increased risk of developing the disease themselves, but the total risk is still about two to five percent. An estimated 15 to 25 percent of people with Parkinson disease have a known relative with the disease.

Some Parkinson’s disease cases appear to be hereditary and a few can be traced to specific genetic mutations. However, most cases of Parkinson disease are sporadic – meaning, the disease does not seem to run in families.

What are early warning signs of Parkinson’s disease?
Early symptoms of Parkinson’s disease may be subtle and occur gradually. This could include difficulties getting out of a chair or feeling mild tremors. Usual activities may take longer to complete and patients could notice stiffness or weakness of their limbs. Some might also notice changes in their speech and writing, becoming softer and smaller respectively. At times, family and friends may be the first to notice the early changes. Lack of facial expression and animation (masked face) as well as slowness in movements are often described.

These early symptoms sometimes last for a long time before developing the classical motor symptoms.

Non-motor symptoms also occur frequently. This includes non-specific symptoms such as:

• REM sleep behavior (dream-enacting behaviors with shouting or kicking during sleep).
• Constipation.
• Altered smell.
• Fatigue. 
• Anxiety.
• Depression.
• Slowness of thinking.
• Urinary frequency.
• Postural lightheadedness.

Some of these may even predate the development of the motor symptoms.

What causes Parkinson’s disease?
Parkinson’s disease occurs when specific nerve cells in the brain become impaired or die. The main area affected is near the base of the brain called the Substantia Nigra. Nerve cells or neurons produce special chemicals called neurotransmitters and the neurons in the Substantia Nigra produce two important neurotransmitters which are dopamine and norepinephrine.

Dopamine is responsible for transmitting signals between the Substantia Nigra and the next ‘relay station’ of the brain, the Corpus Striatum to produce smooth, purposeful movements. With the loss of dopamine, impaired movements occur as a result of abnormal nerve firing patterns. Most patients with Parkinson’s disease would have already lost 60 to 80 percent of their dopamine-producing cells by the time symptoms appear.

Norepinephrine is the main chemical messenger of the sympathetic nervous system, which controls many automatic functions of the body including pulse and blood pressure. The loss of norepinephrine might explain some of the non-motor features of Parkinson’s disease, including abnormalities in blood pressure regulation and fatigue.

Is there a cure for Parkinson’s disease?
At present, there is no cure for Parkinson’s disease. However, there are a variety of medications that provide good relief from the symptoms.

There are three categories of medications for Parkinson’s disease. The first category of drugs work directly or indirect to increase the level of dopamine in the brain. Dopamine precursors, substances such as levodopa that cross the blood-brain barrier and then change into dopamine are the most common drugs for Parkinson disease. Other drugs mimic dopamine or prevent or slow its breakdown.

The second category of drugs for Parkinson’s disease affects other neurotransmitters in the body to ease some symptoms of the disease. Anticholinergic drugs are sometimes used to reduce tremors and muscle stiffness. They act by interfering with production or uptake of the neurotransmitter acetylcholine.

The final category are medications that are used to control non-motor symptoms.

Surgical therapy in the form of selective destruction on a portion of the brain causing the parkinsonian symptoms, or insertion of a device that produces painless stimulation to the brain are sometimes considered when drug therapy is no longer sufficient.

How can I better cope with someone who has Parkinson’s disease?
Understanding what Parkinson’s disease as well as its progression would be the first step to caring for a person with Parkinson’s disease. The next step would be to define the carer’s role, and this needs to be modified as the disease progresses. This could include physical support, such as helping out with the patient’s activities of daily living, or emotional support to deal with symptoms of depression. Other responsibilities may include managing the patients’ medications and making financial decisions.

Having a strong support network is essential for both the patient and carer. This can help minimize stress and conflict, as well as create a productive partnership. Support networks may include one’s own family and friends, friends and family members of other patients with Parkinson’s disease, or even associations for Parkinson’s disease patients and their carers, such as the Malaysian Parkinson’s Disease Association (MPDA), which has been around since 1994.

How many stages of Parkinson’s disease are there and could you elaborate a little on each stage?
Whilst there are many rating scales to stage the severity of Parkinson’s disease, the most widely used and simplest would be the Hoehn & Yahr staging, which consists of 5 stages.

• Stage 1 consists of unilateral involvement only, usually with minimal to no functional disability.
• Stage 2 describes bilateral or midline involvement without impairment of balance.
• Stage 3 has bilateral involvement with mild to moderate disability and impaired postural reflexes, although patients are still physically independent.
• Stage 4 patients are severely disabled but may still be able to walk or stand unassisted
• Stage 5 patients are confined to the bed or wheelchair unless aided.

What physical changes should a person expect when they are diagnosed with Parkinson’s disease?
Apart from the motor symptoms described earlier, including tremors, stiffness of limbs and slowness in movements, Parkinson’s disease patients may experience weight loss and skin problems including dry skin or more commonly oily skin, particularly on the forehead, sides of nose and at the scalp, sometimes resulting in dandruff formation.

Leg cramps, due to lack of normal movements and rigidity, often occur, and this may also lead to complaints of muscle and joint pains. Their posture, especially when standing can change to one with a stooped posture. Fatigue and loss of energy, often late in the day can be expected as well.

How does Parkinson’s disease affect the patient’s lifestyle?
Parkinsonian symptoms can affect one’s lifestyle in many ways. Patients may not be as quick or energetic as before and may find it difficult to move around freely. Simple tasks like going to a mall to shop may suddenly feel much more challenging.

Another issue often seen is embarrassment, especially with their tremors and patients may sometimes hide from other people or the community. Communication becomes more difficult, more often when using communication devices like the phone or during video chats.

When a person is diagnosed with Parkinson’s disease, are there any changes that need to be made to the surrounding environment the person lives in? Such as to shield sharp corners and so on.
While Parkinson’s disease affects every individual differently, the majority will eventually have difficulties with mobility and balance and would be at risk of falls or injuries. To minimise and prevent this, modifications to the home environment should be considered. Common modifications would include access into and out of the bathroom or the house in general, for instance installation of ramps at the entrance and grab bars near the toilet and tub or showers for easier transfer. Handrails along walls, hallways and stairs can help with walking.

Rearranging furniture to make rooms less crowded would allow for more space to maneuver and avoid unnecessary accidents. Also, having chairs or couches with straight backs, secure armrests and firm cushions will make it easier to sit down and get up.

The other area of interest would be the kitchen. Try keeping commonly used food and beverages on shelves that are easy to reach. Place them in easy-to-handle containers. Place daily use items such as coffee mugs on hooks rather than harder to reach cupboards. Have special utensils such as forks and spoons with easy to grip handles. Consider having the kitchen countertop lowered so patients with Parkinson’s disease can access items from a chair or wheelchair.

Are there any tools that can help to improve the lifestyle of a person with Parkinson’s disease?
There are no specific tools, rather there are many items used day to day that can again be modified to improve one’s lifestyle. Adaptive products help retain independence of daily tasks such as:

• Using pen grips for instance, making it easier to write.
• Walking aids, such as a cane, walker or wheelchair help with ambulation as the disease progresses.
• Phones with either oversized button makes dialing easier for people with hand tremors.
• Voice amplifiers will also make communication easier for patients with low voice volume.

Source: 1Twenty80

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