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PARKINSONS DISEASE
PARKINSONS DISEASE
Parkinson's disease (PD or, simply, Parkinson's) is the most common form of Parkinsonism, a group of motor system disorders.
Named after James Parkinson. a British physician who first described the disease in a paper he published as the shaking palsy in 1817
It is a slowly progressing, degenerative neurologic disease that is usually associated with the following symptoms,
tremor or trembling of the arms, jaw, legs, and face stiffness or rigidity of the limbs and trunk bradykinesia (slowness of movement) postural instability, or impaired balance and coordination
The primary symptoms are the results of decreased stimulation of the motor cortex by the basal ganglia, normally caused by the insufficient formation and action of dopamine, which is produced in the dopaminergic neurons of the brain. Secondary symptoms may include high level cognitive dysfunction and subtle language problems. PD is both chronic and progressive. Dopamine is a substance produced in the body which has many effects, including smooth and coordinated muscle movement.
Prevalence and Incidence 500,000 currently suffer PD in USA 50,000- new cases are reported each year Males are more affected than females Symptoms begin between 40 and 70 years of age with a peak onset on the 60s.
Risk Factors
The
believe the symptoms are related to a chemical imbalance in the brain caused by brain-cell death. Advancing age. The average age for the onset of PD is 60 years. Gender. Fifty percent more men are affected than women, according to the National Institute of Neurological Disorders and Stroke. However, the reason for this is unclear. Family history. Individuals with a parent or sibling who are affected have approximately two times the chance of developing PD.
a. synuclein- a member of a small family of proteins that are expressed preferentially in the substantia nigra. One of the major components of the Lewy bodies that are found in brain tissues of persons with PD. b. Parkin genes- encoding the protein parkin was linked to an autosomal recessive form of PD.
Risk Factors
Environmental causes are being researched and the strong consistent findings are that rural living, exposure to well water, and exposure to agricultural pesticides and herbicides are related to PD. Currently researchers believe that in most individuals the cause of PD is a combination of genetics and environmental exposure. *endotoxin or lipopolysaccharide a common airborne environmental and occupational contaminate in agriculture and other industries.
Gait and posture disturbances Shuffling gait Decreased arm-swing. Turning "en bloc" Stooped, forward-flexed posture Festination Gait freezing Dystonia (in about 20% of cases) Speech and swallowing disturbances Hypophonia Monotonic speech. Festinating speech Drooling Dysphagia
Other motor symptoms: Fatigue (up to 50% of cases); Masked faces (a mask-like face also known as hypomimia), with infrequent blinking; Difficulty rolling in bed or rising from a seated position; Micrographia (small, cramped handwriting); Impaired fine motor dexterity and motor coordination; Impaired gross motor coordination; Akathisia, the inability to sit still.
Sleep Excessive daytime somnolence Initial, intermediate, and terminal insomnia Disturbances in REM sleep: disturbingly vivid dreams, and rapid eye movement behavior disorder, characterized by acting out of dream content can occur years prior to diagnosis
Perception
Impaired visual contrast sensitivity, spatial reasoning, colour discrimination, convergence insufficiency (characterized by double vision) and oculomotor control Dizziness and fainting; usually attributable orthostatic hypotension, a failure of the autonomic nervous system to adjust blood pressure in response to changes in body position Impaired proprioception (the awareness of bodily position in three-dimensional space) Reduction or loss of sense of smell (hyposmia or anosmia) pain: neuropathic, muscle, joints, and tendons, attributable to tension, dystonia, rigidity, joint stiffness, and injuries associated with attempts at accommodation
Autonomic Oily skin and seborrheic dermatitis Urinary incontinence Nocturia up to 60% of cases Constipation and gastric dysmotility Altered sexual function Weight loss, which is significant over a period of ten years.
As the disease progresses, walking may become affected, causing the patient to stop in mid-stride or "freeze" in place, and maybe even fall over. Patients also may begin walking with a series of quick, small steps as if hurrying forward to keep balance, a practice known as festination.
Risk/Related Factors Age, Genetics, Drugs, Toxins,Headtrauma Destruction of dopaminergic neuronal cells in the substantia nigra in the basal ganglia Depletion of dopamine stores
Diagnosis
Neurological examination (including evaluation of symptoms and their severity) Trial test of drugs - when symptoms are significant, a trial test of drugs (primarily levodopa [L-dopa]) may be used to further diagnose the presence of PD. If a patient fails to benefit from levodopa, a diagnosis of Parkinson's disease may be questionable. Computed tomography scan (Also called a CT or CAT scan.) Magnetic (MRI) resonance imaging
a. OLDER DRUGS Anti-cholinergic Dopamine Agonist 2. Levadopa Combinations (levadopa and carbidopa ) 3. Amantadine (Symmetrel) b. NEWER DRUGS 1. Cathechol o-methyltranferase (COM) inhibitor 1.1. Entacapone (Contan)-used in combination of levadopa and carbidopa. 1.2 Stavelo a combination of levodopa,cabidopa and entacapone. 1.3 Tolcapone (Tasmar) 2. Monoamine oxidase (MAO) inhibitors Selegiline(Eldepryl) - may be prescribed to confer mild symptomatic benefit before initiating dopaminergics in the treatment of PD. Ex. Carbex, Eldepryl, Novo-Selegiline - reduce metabolic breakdown of dopamine c. INVESTIGATIONAL DRUGS 1. Coenzyme Q10 may slow the rate of functional declines 2. Dextromethorphan glial derived neurotrophic factor -- administered directly into the brain.
B. Surgical Treatment
Lesion surgery (burning of tissue) Deep brain stimulation (DBS) Neural grafting or tissue transplants Pallidotomy and thalamotomy are rarely done anymore. They involve the precise destruction of very small areas in the deep part of the brain that cause symptoms. Neurotransplantation surgery Fetal Tissue Transplantation is an experimental and highly controversial procedure. Fetal substantia nigra tissue either human or pig is transplanted into the caudate nucleus of the brain.
a. Encourage, teach and support the patient during ADLs to promote self care. b. Assist and encourage good grooming to enhance independence and self esteem.
3. Imbalanced Nutrition less than body requirements related to inability to ingest food due to biologic factors
a. Smaller, more frequent meals or commercial powder added to liquids may assist the client who has difficulty swallowing. b. Position client with head elevated to facilitate swallowing and prevent aspiration. d. The client should be weighed once a week and adjustment should be made on diet as indicated. e. Record food intake daily or as indicated. f. As disease progresses and swallowing becomes more of a problem, supplemental feedings become the main source of nutrition to maintain weight. g. Coordinate with a registered dietician to evaluate the clients food intake. h. If the client has difficulty swallowing coordinate with speech language pathology to conduct an extensive swallowing evaluation in order to develop an individualized dietary plan.