May 19, 2018

Archives for June 2011

Parkinson’s Disease Symptoms – Neuropsychiatric Dysfunction

 

As we learnt in Parkinson’s disease early symptoms, Parkinson’s symptoms can be categorized into the 4 Cardinal Signs, Associated Symptoms and  Neuropsychiatric Dysfunction.

Neuropsychiatric Dysfunction associated with Parkinson’s can be viewed in terms of a patient’s state of mental well-being, and possible issues related to Dementia.

Mental Well-Being

A Parkinson’s patients mental well-being can be affected by a reaction to the disease, chemical changes in the brain e.g. research indicates acetylcholine is linked to a person’s mental state and serotonin to one’s mood, or the side effects of medications used to manage the disease (therefore may not be due to dementia noted later). This can affect the patients daily life, relationships and ability to socialize significantly. Aspects of mental well-being include:

  • Behavior, personality and mood alterations:
    • Antisocial or becoming withdrawn.
    • Apathy.
    • Anxiety.
    • Depression.
    • Hallucinations and delusions occur in approximately 5% of patients.
    • Impulse control issues e.g. cravings.

PARKINSON’S DISEASE AND DEPRESSION


  • Cognitive disturbances :
    • Decreased attention span.
    • Executive dysfunction (executive function deficit (EFD): Ability to plan and execute appropriate actions.
    • Impaired memory and recall
    • Reduced mental:
      • Agility.
      • Clarity. Often described as a ‘dullness/dull thinking’
      • Flexibility.
      • Slowness (Bradyphrenia) including slow response to questions.
    • Visuospatial difficulties including facial recognition.

PARKINSON’S COGNITIVE AND MEMORY ISSUES


 

Dementia

  • Depending on the source of data:
    • Between 30-40% of patients will experience some degree of cognitive impairment and memory problems. Some research suggests this rises to 80% after 8-10 years of the disease.
    • Between 1/5 and 1/3 of Parkinson’s patients develop some form of Parkinson’s Disease Dementia (PDD). The figure commonly quoted is around 20%.
  • The rate of progression and severity of dementia varies considerably between individuals.
  • Parkinson’s Disease Dementia typically takes 10-15 years to develop from initial Parkinson’s diagnosis. It is therefore considered to occur towards the later stages of the disease.
  • Parkinson’s disease patients have a  4- 6X greater risk of developing cognitive impairment or dementia than the general population.
  • Various issues arise regarding Parkinson’s Disease Dementia including:
    • Significant symptoms noted above in Mental Well-Being.
    • Increased mortality rate.
    • Reduced quality of life for patient and increased burden for family and carers/caregivers.
    • Nursing home care more likely.
  • It must be remembered that dementia symptoms can be caused by a variety of unrelated conditions and medications e.g. Vit B12 deficiency, underactive thyroid gland, depression, Alzheimer’s disease.

GENERAL OVERVIEW OF DEMENTIA : Description-Assessment-Types

 

The next article will consider the fundamental question of What is Parkinson’s Disease ?

Parkinson’s Disease Symptoms – Associated Symptoms

Having previously looked at the 4 Cardinal Signs related to Parkinson’s disease symptoms, we now will address the issue concerning Parkinson’s disease associated symptoms.

The associated symptoms for Parkinson’s disease diagnosis are varied and although the side effects of medication can contribute, the symptoms are typically linked to autonomic failure:

Loss of Involuntary/Automatic movements or functions.

  • Orthostatic Hypotension: This refers to low blood pressure when standing up. Research indicates a possible link to a lack of noradrenaline in the brain associated with blood pressure control.
  • Little or no swinging of arms when walking.
  • Increased perspiration.
  • Increased salivation.
  • Constipation is very common and results both from the disease and side effects of medication.
Unconscious acts diminished.

  • ‘Parkinson’s Mask’ or ‘Masked Facies’ refers to the vacant/fixed stare commonly observed with Parkinson’s patients.
  • Visual disturbances. e.g. blinking and blink rate.
  • Lack of gestures/expressions/animation associated with emotion, smiling, frowning and grinning.
Speech Issues.

  • Hypophonia refers to softer/whispering voice.
  • Hesitation and stumbling over words.
  • Speaking in a monotonous tone.
  • Slurred speech.
  • Repeating words.
  • Speech therapy can make a significant improvement.

PARKINSON’S SPEECH ISSUES

Throat Issues.

  • Clearing throat.
  • Chewing and swallowing.
  • Prone to coughing, drooling (Sialorrhea) and choking.
Perceptual Changes. Examples include:

  • Olfactory disturbances.
    • Anosmia: an inability to perceive odors.
    • Hyposmia: decreased ability to smell.  Recent scientific evidence suggests this is a very early sign of Parkinson’s disease.
    • Can cause issues to due with a significant loss of appetite.
  • Tingling.
  • Numbness.
  • Altered sense of pain.
Sleep Issues.

  • Changing sleep patterns including:
    • Broken sleep.
    • Insomnia.
    • Sleeping in the day.
  • REM Behavior Disorder.
    • Associated with vivid dreams and nightmares.
    • Tendency to act out dreams during night.
    • Frequent dreams involving being threatened or attacked by person or animals.

PARKINSON’S  SLEEP ISSUES


Fine Motor Control.

  • Lack of fine motor control causes dexterity issues and co-ordination problems.
  • Micrographia. Parkinson’s patients handwriting typically becomes smaller, cramped and spidery.
  • Practical issues such as problems dressing oneself.
Slower Reaction and Movement Times.

  • These can impact the persons ability to carry out certain activities safely e.g. use of machinery or the ability to drive can be affected.
  • Worsening motor skills are related to reduced performance. As the changes are gradual, patients may not realize or be in denial that they are no longer able to carry out certain activities safely. Family members or the medical profession have a duty of care to intervene at this stage.
Fatigue. Aching and tiredness and being devoid of energy can be due to:

  • Sleep problems.
  • Depression.
  • Muscle stress.
  • Akinesia: This is the inability to initiate/carry out movements.
  • Incorrect medication levels.
Urinary Issues.

  • This can include urinary incontinence or retention.
  • Urination may be more frequent or even urgent.
Sexual Dysfunction. A common occurrence that may include:

  • Altered libido. Although a  lower libido is typical, hypersexuality can result from taking levodopa and dopamine agonists.
  • Males may experience erectile dysfunction.
  • Females may experience vaginal dryness.
Skin Issues.

  • Increased dry skin or scaling of face or scalp/dandruff.
  • Other patients may experience an increased oily skin at the side of nose, forehead and scalp.
  • Seborrheic dermatitis: Skin can look greasy, scaly and flaky and similar in appearance to ‘cradle cap’ seen with babies.

 

The next aspect related to Parkinson’s disease symptoms concerns Neuropsychiatric Dysfunction.

Parkinson’s Disease Symptoms – 4 Cardinal Signs

The article Parkinson’s disease early symptoms described a variety of signs that might be indicative of oncoming or early Parkinson’s. Given that many of the signs could be due to a variety of completely unrelated conditions, a more structured and formal classification is required to differentiate Parkinson’s from other diseases. This can be achieved by grouping the symptoms into primary motor related symptoms (4 Cardinal Signs), associated symptoms and neuropsychiatric dysfunction.

This article explains the 4 primary/major motor symptoms for Parkinson’s disease diagnosis, which includes:

Tremor

  • Caused by impaired conduction of signals/impulses from the brain to the muscles.
  • Affect about 70% of patients at start of disease. Not everyone will experience tremors although most go on to develop them at the later stages.
  • Typically starts on 1 side (unilateral) i.e. asymmetric, and progresses to both sides (bilateral) after several years.
  • Can possibly affect eyelids, jaw, tongue, lips, chin, arm, forearm, hand, fingers, leg, feet and some people experience a sensation as though their internals are ‘trembling’. However, people who experience head/torso or voice tremors tend not to have Parkinson’s (any apparent tremor is usually caused by the upper extremities shaking violently). Head tremor is a typical feature of the condition Essential Tremor (ET).
  • A useful diagnostic tool:
    Parkinson’s disease tremors: Resting tremors – Increase when the person is resting and decrease when the person begins to move.
    Non-Parkinson’s tremors: Active tremors – Increase when trying to use or move the part of the body and decrease on resting.
  • Characteristic ‘Pill Rolling’ action between the thumb and 1st finger.

 

Muscle Rigidity

  • Caused by increased and excessive muscle contractions and muscle tone.
  • Stiffness, lack of movement and associated pain in certain parts of body including face, neck, arms can be an early sign of the disease.
  • Abnormal muscle tone resulting in muscular spasm /cramps and abnormal posture (Dystonia) is associated with a lack of normal movement and rigidity.
  • 2 types of muscle rigidity that can attack at random:
    ‘Cogwheel Rigidity’: Non-uniform and ratchety.
    ‘Leadpipe Rigidity’: Uniform.
  • Unable to swing arms when walking. One side is usually more affected during early stages i.e. asymmetric.

 

Slow Movement (Bradykinesia)

  • Caused by impaired conduction of signals/impulses from the brain to the muscles.
  • Brady=Slow Kinesia= Movement
  • Freezing Episodes : Problem initiating voluntary movement. This can progress to freezing mid-action e.g. whilst walking (later stages of disease).
  • Walking characterized by small steps or shuffling action.
  • Issues of safety arise e.g. crossing a road becomes increasingly problematic.
  • Difficulty in rolling over in bed or standing up and getting out of a chair.
  • Associated with clinical evidence of asymmetry.

 

Postural Instability/Balance Disturbances

  • Caused by loss of reflexes.
  • Becomes more noticeable as the disease progresses and usually present at later stages. If it occurs early in the disease, it is normally an atypical Parkinson’s syndrome.
  • Stooped posture and gait disturbance.
  • Problem turning around and navigating stairways.
  • Issues of safety arise e.g.
    40% of patients have experienced a fall.
    10% of patients experience weekly falls.


ASPECTS OF PARKINSON’S DISEASE

Next, we will consider  Parkinson’s disease symptoms – Associated Symptoms