Of the neurological diseases we see, Parkinson’s disease is common. The disease is associated with what we call “neurodegeneration,” implying that there is a destruction, which can often be age-related, of the neurological cells. In this case, the neurologic cells that are most affected reside in the brain and impact movement and cognition.
Patients with Parkinson’s disease will develop memory loss at a later point in their disease course, which often resembles Alzheimer’s disease. However, the first symptoms involve difficulty with movement.
Autopsy and other studies have revealed a deficiency of a neurotransmitter chemical in the brain, dopamine, in patients affected with Parkinson’s.
However, other neurotransmitters may also be affected by the ongoing destruction of the neuron cells.
The basal ganglia is a region of the midbrain that is primarily responsible for the production and management of the neurotransmitter, dopamine.
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Although Parkinsons’ disease is the most common affliction resulting from dopamine deficiency, other movement disorders can also result from destruction of the basal ganglia.
Dementia with Lewy Bodies is a less common disease in which the motor symptoms and dementia usually occur closer together in time. Other diagnoses that overlap with Parkinson’s symptoms but have additional findings include multiple system atrophy, corticobasal syndrome, and progressive supranuclear palsy.
Symptoms are classified as motor (primarily involving movement) and nonmotor, which can affect sensations. Motor symptoms often begin with slowness. Think of taking more time to complete tasks. Resting tremors are seen but resolve with activity. Slow and rigid gait, often described as “magnetic,” where each foot takes effort to move.
Also, postural instability can be seen when there is trouble maintaining balance in changed situations, whether it is while bending or standing. Other symptoms include reduced eye blinking, drooling and a change in tone, leading to a softer voice.
Difficulty with swallowing, smaller handwriting compared to the patient’s usual handwriting and repeated falls can also be observed. Nonmotor symptoms can include changes in mood leading to depression, changes in the perception of pain, loss of smell and sleep changes, which can often manifest as sleep interruptions with increased awakening.
I have also seen changes in blood pressure with drops in pressure while standing, which the patient will often report lightheadedness with getting up.
Diagnosis is often clinical. After a primary care physician suspects the diagnosis a referral to neurology may be made. Often, the diagnosis can be made from obtaining a thorough history and performing a detailed neurologic physical exam in the doctor’s office. Imaging tests are usually unnecessary but may be undertaken if the diagnosis is in doubt. Positron emission tomography (PET) or single-photon emission computed tomography (SPECT) can be used to visualize the destruction of the dopaminergic centers in the brain.
Which people are often affected? Having multiple family members with Parkinson’s or having a heritage of Ashkenazi Jewish or North African Berber can increase the risk.
Not all Parkinson symptoms can be attributed to Parkinson’s disease. Several conditions can affect the brain’s ability to metabolize and manage dopamine. Strokes in the basal ganglia area may manifest as movement symptoms in a patient presenting to the Emergency Department.
Other less common conditions include a localized infection or trauma with head injury. Medications can also impact the handling of dopamine in the form of side effects, and are often used in a variety of medical conditions.
Most commonly, medicines used in psychiatric illnesses, such as depression, schizophrenia and other mood disorders, can deplete dopamine sources, leading to a temporary Parkinsonian-like state. Once these medications are removed, symptoms of Parkinson’s often recede. However, physicians will usually review all drugs a patient is on in the setting of the development of Parkinson like symptoms.
Treatment of Parkinson’s includes offering the much-needed and deficient dopamine in the form of levodopa. When combined with carbidopa, levodopa can reach the brain’s basal ganglia region to allow the action needed to facilitate body movement.
Not all changes seen as one ages are physiologic and expected to be “normal.” Disease states when appropriately identified and treated can lead to a difference in day-to-day function and enjoyment of life. Don’t delay the call to your doctor if you feel there may be a difference in how you move.
Dr. Naznin Jamal is a Jefferson Regional Medical Center hospitalist.