Although there has been progress understanding the pathophysiology of PD, scientists still haven’t found a definitive cure for the disease. The goal of medical treatment is to optimize symptom alleviation while minimizing adverse effects. Dopamine replacement therapy is most commonly used to reduce PD symptoms and improve patient quality of life. Levodopa medication, in combination with substances that inhibit dopamine catabolism in the brain are often used and can have great results for many years. However, the patient response after 5 or 10 years of treatment can diminish and levodopa-induced motor complications, namely dyskinesias and fluctuations, can occur. That is why it is important at disease onset and depending on the patient’s age, to follow a tailored, moderate medication regimen, to push back in time the onset of motor complications. When a PD patient is relatively young and the symptoms are not severe, it is common to subscribe dopamine agonists, which are effective as monotherapy or in combination with levodopa [Reichmann, 2016], minimizing the side effects of both substances. A surgical option for advanced PD symptom alleviation is deep brain stimulation (DBS), but it cannot be applied to all patients.
The key to a well-managed symptom-free daily living for PD patients is the good communication with their treating physicians, so that the medication regimen, i.e., the schedule, the doses and the drug combination used, is tailored to their needs, symptom patterns and daily lifestyle.
Individual characteristics that could influence and ultimately dictate the treatment approach for a PD patient’s symptoms could be:
For example, patients following vegan diets, working at night shifts, working out daily, having impaired cognitive function, or a poor response to levodopa, suffering from rapid progression of symptoms, suffering from insomnia or other sleep disorders, etc., must provide accurate information on their medication response so that they can be treated specifically with their individual characteristics / habits in mind, possibly requiring multiple adjustments to their treatment regimen over a period of several months.
REFERENCES
H. Reichmann. Modern treatment in Parkinson’s disease, a personal approach. J Neural Transm, vol. 123, no. 73, 2016.
Early signs of Parkinson’s disease include the following:
• Tremor, usually affecting one limb
• Small handwriting
• Loss of smell
• Trouble sleeping
• Trouble moving or walking
• Constipation
• Softer or lower voice
• Reduction in facial expressiveness
• Dizziness or fainting
• Stooping or hunching over
• Subtle decrease in dexterity
• Decreased arm swing on the most affected side
(Source: Parkinson’s Foundation http://parkinson.org)
Motor signs have the following characteristics:
• In the beginning they are typically asymmetric, i.e., affecting one side of the body, right or left
• The most common initial finding is resting tremor in an upper extremity
• Over time, patients experience progressive bradykinesia, rigidity, and gait disturbances
• Postural instability is a late phenomenon
• The onset of ON/OFF fluctuations and dyskinesia as medication side-effect is very common after 5 to 10 years of treatment
The cardinal motor symptoms of PD concern:
• Bradykinesia
• Dyskinesia
• Freezing of Gait
• Gait disturbances
• Postural instability
• ON/OFF conditions
• Reduced activity
• Fluctuations
After a few years of treatment, PD Patients suffer from motor complications as side effects from the medication. These complications are called dyskinesias and are involuntary muscle movements similar to tics or chorea. Another unpleasant effect of long-term parkinsonian medication is the diminished response, which causes ON/OFF fluctuations. During ON, patients’ symptoms are well controlled, albeit at a later stage with dyskinesia. During OFF, which happens at irregular intervals, the response to the medication is poor and the symptoms emerge, well before the next scheduled medication dose.
Nonmotor symptoms are common in early PD [Chaudhuri et al, 2011].
These symptoms include:
• Cognitive changes, i.e., problems with attention, planning, language and memory
• Constipation
• Excessive sweating, often when the medication is wearing off
• Fatigue
• Hallucinations and delusions
• Orthostatic hypotension
• Loss of sense of smell or taste
• Mood disorders, i.e., depression, anxiety and apathy
• Sleep disorders, i.e., insomnia, excessive daytime sleepiness, REM sleep behavior disorder (RBD), Restless Legs Syndrome (RLS) and vivid dreams
• Urinary urgency, frequency and incontinence
• Vision problems
• Weight loss
(Source: Parkinson’s Foundation http://parkinson.org
Being aware of the range of nonmotor and motor symptoms and identifying them per case can promote early diagnosis and thus early intervention, which often results in a better quality of life for the patient.
REFERENCES
K. R. Chaudhuri et al. Parkinson’s disease: The non-motor issues. Parkinsonism and Related Disorders, vol. 17, no. 10, Dec 2011, 717e723.
A longitudinal study found hypertension and diabetes as the most frequent comorbidities in PD patients [Santos Garcia et al, 2017]. During their life, 90% of them will at some point be affected by psychiatric disturbances, such as depression, anxiety, cognitive impairment, psychosis and apathy, usually with more than one of them being present [Ayano, 2016]. Other usual comorbidities include hypertension, hyperlipidemia, diabetes and arthritis [Mithal et al, 2017]. An interesting fact is that PD patients have a decreased risk of cancer, compared with the general population [Lethbridge et al, 2013].
REFERENCES
D. Santos García, et al. Comorbid conditions associated with Parkinson’s disease: A longitudinal and comparative study with Alzheimer disease and control subjects. Journal of the Neurological Sciences, vol. 373 , 210 – 215, 2017.
G. Ayano. Parkinson’s Disease: A Concise Overview of Etiology, Epidemiology, Diagnosis, Comorbidity and Management. J Neurol Disord, vol. 4, no. 298, 2016, doi:10.4172/2329-6895.1000298.
A. Mithal, B. Lingala, A. Niyazov, A. Guo, C. Marras, G. Singh (2017) Parkinson’s disease and comorbidity: A US national perspective. Mov Disord 2017, vol. 32 (suppl 2), 2017.
L. Lethbridge, G. M. Johnston, G. Turnbull. Co-morbidities of persons dying of Parkinson’s disease. Progress in Palliative Care, vol. 21, no. 3, 140-145, 2013.
A trained and experienced physician will look for a combination of the following symptoms to diagnose PD:
• Tremor, mainly a pill-rolling movement between the thumb and forefinger occurring at rest
• Rigidity, expressed as a smooth or oscillating increased resistance to applying external force on a joint, usually the arm below the elbow
• Bradykinesia, translated to a reduction in spontaneous movements, facial expressions, blinking or even soft speech
• Stooped posture
• Gait disturbances, manifested as taking small shuffling steps with lack of regular arm swinging
• Impaired memory or concentration.
Although there is no objective test to offer a definitive PD diagnosis, presence of two or more of the aforementioned symptoms, combined with good response to PD medication, is evidence enough that PD is the correct diagnosis. In special cases with atypical features, such as, very early onset, bilateral symptoms at onset and lack of tremor, additional tests, such as CT, MRI, PET or DaT SPECT scans could be used to further investigate.
Although there has been progress understanding the pathophysiology of PD, scientists still haven’t found a definitive cure for the disease. The goal of medical treatment is to optimize symptom alleviation while minimizing adverse effects. Dopamine replacement therapy is most commonly used to reduce PD symptoms and improve patient quality of life. Levodopa medication, in combination with substances that inhibit dopamine catabolism in the brain are often used and can have great results for many years. However, the patient response after 5 or 10 years of treatment can diminish and levodopa-induced motor complications, namely dyskinesias, can occur. That is why it is important at disease onset and depending on the patient’s age, to follow a tailored, moderate medication regimen, to push back in time the onset of motor complications. When a PD patient is relatively young and the symptoms are not severe, it is common to subscribe dopamine agonists, which are effective as monotherapy or in combination with levodopa [Reichmann, 2016], minimizing the side effects of both substances. A surgical option for advanced PD symptom alleviation is deep brain stimulation (DBS), but it cannot be applied to all patients.
The key to a well-managed symptom-free daily living for PD patients is the good communication with their treating physicians, so that the medication regimen, i.e., the schedule, the doses and the drug combination used, is tailored to their needs, symptom patterns and daily lifestyle. Individual characteristics that could influence and ultimately dictate the treatment approach for a PD patient’s symptoms could be:
• levodopa tolerance and response
• years from onset
• daily activity and training habits
• diet
• comorbidities
• working conditions / employment
• cognitive state
• sleeping patterns
For example, patients following vegan diets, working at night shifts, working out daily, having impaired cognitive function, or a poor response to levodopa, suffering from rapid progression of symptoms, suffering from insomnia or other sleep disorders, etc., must provide accurate information on their medication response so that they can be treated specifically with their individual characteristics / habits in mind, possibly requiring multiple adjustments to their treatment regimen over a period of several months.
REFERENCES
H. Reichmann. Modern treatment in Parkinson’s disease, a personal approach. J Neural Transm, vol. 123, no. 73, 2016.
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