Providing Holistic Care In Pd
James Parkinson was a strong believer in the role of medicine to go beyond treating the disease and recognised the importance of holistic care. Given the constellation of symptoms seen in PD the condition has previously been referred to as a geriatric syndrome . It therefore follows that management of the condition may well be suited to an approach analogous to the Comprehensive Geriatric Assessment employed by geriatricians . The skill-set of a geriatrician, along with the wider multidisciplinary team, may be particularly valuable as PD reaches the complex phase, where the burden of neuropsychiatric and non-motor complications is high. Furthermore, geriatricians have expertise in end of life care. As PD progresses towards the palliative phase, geriatricians often have a central role in ensuring patients autonomy is preserved and that potentially difficult conversations about advanced care planning are undertaken at the appropriate stage in the condition.
Parkinson recognised the importance of carers in his original description of the disease and made reference to the need for support with activities of daily living.
The patient walks now with great difficulty, and unable any longer to support himself with his stick, he dares not venture on this exercise, unless assisted by an attendant, who walking backwards before him, prevents his falling forwards, by the pressure of his hands against the fore part of his shoulders.
Drugs And Medication Used To Treat Parkinsons Disease
A number of different drugs can be used to treat Parkinsons.
Levodopa
Levodopa is the most common treatment for Parkinsons. It helps to replenish dopamine.
About 75 percent of cases respond to levodopa, but not all symptoms are improved. Levodopa is generally given with carbidopa.
Carbidopa delays the breakdown of levodopa which in turn increases the availability of levodopa at the blood-brain barrier.
Dopamine agonists
Dopamine agonists can imitate the action of dopamine in the brain. Theyre less effective than levodopa, but they can be useful as bridge medications when levodopa is less effective.
Drugs in this class include bromocriptine, pramipexole, and ropinirole.
Anticholinergics
Anticholinergics are used to block the parasympathetic nervous system. They can help with rigidity.
Benztropine and trihexyphenidyl are anticholinergics used to treat Parkinsons.
Amantadine
Amantadine can be used along with carbidopa-levodopa. Its a glutamate-blocking drug . It offers short-term relief for the involuntary movements that can be a side effect of levodopa.
COMT inhibitors
Catechol O-methyltransferase inhibitors prolong the effect of levodopa. Entacapone and tolcapone are examples of COMT inhibitors.
Tolcapone can cause liver damage. Its usually saved for people who do not respond to other therapies.
Ectacapone does not cause liver damage.
Stalevo is a drug that combines ectacapone and carbidopa-levodopa in one pill.
MAO-B inhibitors
What Lifestyle Changes Can I Make To Ease Parkinsons Symptoms
Exercise: Exercise helps improve muscle strength, balance, coordination, flexibility, and tremor. It is also strongly believed to improve memory, thinking and reduce the risk of falls and decrease anxiety and depression. One study in persons with Parkinsons disease showed that 2.5 hours of exercise per week resulted in improved ability to move and a slower decline in quality of life compared to those who didnt exercise or didnt start until later in the course of their disease. Some exercises to consider include strengthening or resistance training, stretching exercises or aerobics . All types of exercise are helpful.
Eat a healthy, balanced diet: This is not only good for your general health but can ease some of the non-movement related symptoms of Parkinsons, such as constipation. Eating foods high in fiber in particular can relieve constipation. The Mediterranean diet is one example of a healthy diet.
Preventing falls and maintaining balance: Falls are a frequent complication of Parkinson’s. While you can do many things to reduce your risk of falling, the two most important are: 1) to work with your doctor to ensure that your treatments whether medicines or deep brain stimulation are optimal and 2) to consult with a physical therapist who can assess your walking and balance. The physical therapist is the expert when it comes to recommending assistive devices or exercise to improve safety and preventing falls.
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Who Was James Parkinson
Born in London in 1755, James Parkinson was a polymath whose interests included palaeontology, geology and politics. Under the pseudonym Old Hubert he was a leading campaigner for social reform and was an advocate for the underprivileged and universal suffrage . In 1784, he was approved as a surgeon-apothecary by the City of London Corporation.
Parkinson, a social reformer and a critic of Pitts government, joined the secret political reformist group the London Corresponding Society . In 1794, five members of the LCS were implicated in a sham conspiracy to assassinate King George III with a pop-gun, a form of poisoned dart . Parkinson was called as a witness for the defence. The so-called conspirators were eventually freed. Disillusioned by this experience, Parkinson effectively retired from his political life and focused his energies on medicine, publishing several medical papers. The most famous of these was the Essay on the Shaking Palsy published in 1817 .
Living With Parkinsons Disease
Depending on severity, life can look very different for a person coping with Parkinsons Disease. As a loved one, your top priority will be their comfort, peace of mind and safety. Dr. Shprecher offered some advice, regardless of the diseases progression. Besides movement issues Parkinsons Disease can cause a wide variety of symptoms including drooling, constipation, low blood pressure when standing up, voice problems, depression, anxiety, sleep problems, hallucinations and dementia. Therefore, regular visits with a neurologist experienced with Parkinsons are important to make sure the diagnosis is on target, and the symptoms are monitored and addressed. Because changes in your other medications can affect your Parkinsons symptoms, you should remind each member of your healthcare team to send a copy of your clinic note after every appointment.
Dr. Shprecher also added that maintaining a healthy diet and getting regular exercise can help improve quality of life. Physical and speech therapists are welcome additions to any caregiving team.
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Signs Of Parkinsons Disease
In 1817, Dr. James Parkinson published An Essay on the Shaking Palsy describing non-motor, as well as, motor symptoms of the illness that bears his name. Parkinsons is not just a movement disorder, explained Dr. Shprecher. Constipation, impaired sense of smell, and dream enactment can occur years before motor symptoms of Parkinsons. The latter, caused by a condition called REM sleep behavior disorder, is a very strong risk factor for both Parkinsons and dementia . This has prompted us to join a consortium of centers studying REM sleep behavior disorder.
The Evolution Of Treatments
The history of Parkinson’s disease is tightly linked to therapeutic interventions, ranging from serendipitous observations to controlled clinical trials of specifically designed agents.
Parkinson devoted a chapter of his monograph to considerations respecting the means of cure . In humility and perhaps with a vision toward current concepts of neuroprotection, he hoped for the identification of a treatment by which the progress of the disease may be stopped . To this end, he advocated very early therapeutic intervention when signs were largely confined to the arms without balance and gait impairments. Reflecting therapeutic approaches of the early nineteenth century, Parkinson recommended venesection, specifically advocating bloodletting from the neck, followed by vesicatories to induce blistering and inflammation of the skin. Small pieces of cork were purposefully inserted into the blisters to cause a sufficient quantity of purulent discharge . All these efforts were designed to divert blood and inflammatory pressure away from the brain and spinal cord, and in this way, decompress the medulla that Parkinson considered the seat of neurological dysfunction.
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What Is Parkinsons Disease
Parkinsons disease is a nervous system disease that affects your ability to control movement. The disease usually starts out slowly and worsens over time. If you have Parkinsons disease, you may shake, have muscle stiffness, and have trouble walking and maintaining your balance and coordination. As the disease worsens, you may have trouble talking, sleeping, have mental and memory problems, experience behavioral changes and have other symptoms.
What Are The Surgical Treatments For Parkinsons Disease
Most patients with Parkinsons disease can maintain a good quality of life with medications. However, as the disease worsens, medications may no longer be effective in some patients. In these patients, the effectiveness of medications becomes unpredictable reducing symptoms during on periods and no longer controlling symptoms during off periods, which usually occur when the medication is wearing off and just before the next dose is to be taken. Sometimes these variations can be managed with changes in medications. However, sometimes they cant. Based on the type and severity of your symptoms, the failure of adjustments in your medications, the decline in your quality of life and your overall health, your doctor may discuss some of the available surgical options.
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It Is Important To Note When Reading An Essay On The Shaking Palsy That Parkinson Was Working In Uncharted Territory
James Parkinson died on 21 of December 1824 on Kingsland Road, only a few hundred yards from the house where he grew up. His passing was much lamented by the Parish of St. Leonards, and was noted with regret in the Parish records, as well as in the Gentlemans Magazine.
For many years there was no monument to his achievements. However a plaque commemorating James Parkinson and his work was placed in the nave of St. Leonards church in 1955, the 200th anniversary of his birth. Unfortunately, no image of James Parkinson has survived, but through his prolific writings, we can generate a good idea as to nature of this man. What emerges is a portrait of someone who was very much a product of the enlightenment, and in many ways ahead of his time clinically, scientifically and politically.
The plaque in St Leonards church, Hoxton, London, commemorating Parkinson
What would James Parkinson think now about the Shaking Palsy? He would certainly marvel at the progress that has been made in terms of diagnosing and understanding the causes of the disease that now bears his name. It is likely that he would be pleased at the range of drugs now used to ease the symptoms that he described so clearly in his essay. But undoubtedly he would be both surprised and disappointed to discover that, two centuries after he had first noted the existence of the disease, there is still no cure for this devastating disorder.
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Signs Symptoms And Diagnosis
The diagnosis of PD is a clinical one. A useful starting point is to begin by identifying parkinsonism as definite, probable, or possible. Using several clinical extrapyramidal features the clinician can confidently say that a patient has definite parkinsonism if any 2 of the 5 features are present, with 1 of the 2 being tremor or bradykinesia.
Once a diagnosis of parkinsonism is made, it is imperative for the physician to exclude pharmacologic causes. Since the recognition that reserpine can produce extrapyramidal side effects, the list of medications that can cause parkinsonism continues to grow each year . In addition, unexplained extrapyramidal disease in a young person should always prompt exclusion of Wilson’s disease, a metabolic disorder of copper metabolism that can lead to degenerative changes in the brain.
Table 1. Medications that can produce parkinsonism
| Drug classes |
|---|
| Metoclopramide |
| Valproic acid |
Table 2. Features suggesting parkinsonism rather than Parkinson disease
| Early falling |
| Absence of tremor |
| Gaze abnormalities |
There is a growing body of literature on the utility of magnetic resonance imaging of the head for distinguishing parkinsonism from true PD. Perhaps the most reliable and consistent findings are in vascular parkinsonism, wherein the discovery of multiple prior strokes provides a clear diagnosis.
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History Of Parkinson’s Disease
James ParkinsonEssay on the Shaking Palsy
The history of Parkinson’s disease expands from 1817, when British apothecary James Parkinson published An Essay on the Shaking Palsy, to modern times. Before Parkinson’s descriptions, others had already described features of the disease that would bear his name, while the 20th century greatly improved knowledge of the disease and its treatments. PD was then known as paralysis agitans . The term “Parkinson’s disease” was coined in 1865 by William Sanders and later popularized by French neurologist Jean-Martin Charcot. Paralysis
Diagnosis And Clinical Assessment Devices
The use of new technology-based tools allows quantitative assessment of the motor function of PD patients. Sensors, video-assessment methods or mobile phone applications are some of the techniques that improve the sensitivity, accuracy and reproducibility of the evaluation of PD patients . Portable devices that include inertial measurement units measure the orientation, amplitude and frequency of movement, as well as the speed of the part of the body where they are located. IMUs are usually made up of accelerometers and gyroscopes, and occasionally magnetometers. IMUs situated in different parts of the patients body make a precise record of tremor, bradykinesia, dyskinesias and even gait patterns . On the other hand, continual monitoring of the motor status in the domestic environment is also possible by using these technology-based tools . These new technology-based systems open up an unexpected range of specific and real-time data, thereby resulting in the prospect of better diagnostic accuracy, more sensitive monitoring of the motor and non-motor symptoms, and more precise adjustments of medical therapies. However, their use is limited in routine clinical practice due to the heterogeneity of the studies, which limit the extrapolation of results, and the high cost of the devices .
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What Is The Outlook For Persons With Parkinsons Disease
Although there is no cure or absolute evidence of ways to prevent Parkinsons disease, scientists are working hard to learn more about the disease and find innovative ways to better manage it, prevent it from progressing and ultimately curing it.
Currently, you and your healthcare teams efforts are focused on medical management of your symptoms along with general health and lifestyle improvement recommendations . By identifying individual symptoms and adjusting the course of action based on changes in symptoms, most people with Parkinsons disease can live fulfilling lives.
The future is hopeful. Some of the research underway includes:
- Using stem cells to produce new neurons, which would produce dopamine.
- Producing a dopamine-producing enzyme that is delivered to a gene in the brain that controls movement.
- Using a naturally occurring human protein glial cell-line derived neurotrophic factor, GDNF to protect dopamine-releasing nerve cells.
Many other investigations are underway too. Much has been learned, much progress has been made and additional discoveries are likely to come.
The Future: Parkinson’s Clinical Trials
Researchers are continuously working on ways to slow the progression of Parkinson’s disease, restore lost functioning, and help prevent the disease from developing in the first place. You can find out if you or a loved one is right for one of hundreds of clinical trials for Parkinson’s Disease at the Fox Trial Finder.
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What Are The Different Stages Of Parkinsons Disease
Each person with Parkinsons disease experiences symptoms in in their own unique way. Not everyone experiences all symptoms of Parkinsons disease. You may not experience symptoms in the same order as others. Some people may have mild symptoms others may have intense symptoms. How quickly symptoms worsen also varies from individual to individual and is difficult to impossible to predict at the outset.
In general, the disease progresses from early stage to mid-stage to mid-late-stage to advanced stage. This is what typically occurs during each of these stages:
Early stage
Early symptoms of Parkinsons disease are usually mild and typically occur slowly and do not interfere with daily activities. Sometimes early symptoms are not easy to detect or you may think early symptoms are simply normal signs of aging. You may have fatigue or a general sense of uneasiness. You may feel a slight tremor or have difficulty standing.
Often, a family member or friend notices some of the subtle signs before you do. They may notice things like body stiffness or lack of normal movement slow or small handwriting, lack of expression in your face, or difficulty getting out of a chair.
Mid stage
Mid-late stage
Standing and walking are becoming more difficult and may require assistance with a walker. You may need full time help to continue to live at home.
Advanced stage
A Little Bit Of History
A new important breakthrough took place in 1983 when Langston and colleagues reported a group of drug users who developed acute parkinsonism after MPTP exposure . These patients developed an acute syndrome indistinguishable from PD. This is due because the MPTP metabolite, MPP+, destroys the dopaminergic neurons in the substantia nigra after a series of alterations in the mitochondrial matrix and the electron transport chain. The SNc of Parkinson patients was also described as exhibiting a marked decrease in complex I activity . The fact that some PD patients have certain polymorphisms in genes that express subunits of complex I suggests that this could be a vulnerability factor in PD . New models based on MPTP intoxication allowed researchers to ascertain PD hallmarks both in vitro and in vivo . Due to the achievements of pharmacological DA treatments, search of cell-based DA replacement approaches were initiated with largely disappointing results . From the surgical and therapeutic point of view, discrete lesions of the BG improved parkinsonism . A monkey model of PD showed motor signs improvement as a result of the chemical destruction of the subthalamic nucleus , with evidence of reversal of experimental parkinsonism by STN lesions. This same year deep brain stimulation of the STN became effective for PD treatment .
Figure 1. Breakthroughs in Parkinsons disease history.
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