What Are The Complications Of Parkinson Disease
Parkinson disease causes physical symptoms at first. Problems with cognitive function, including forgetfulness and trouble with concentration, may arise later. As the disease gets worse with time, many people develop dementia. This can cause profound memory loss and makes it hard to maintain relationships.
Parkinson disease dementia can cause problems with:
- Speaking and communicating with others
- Problem solving
- Paying attention
If you have Parkinson disease and dementia, in time, you likely won’t be able to live by yourself. Dementia affects your ability to care of yourself, even if you can still physically do daily tasks.
Experts don’t understand how or why dementia often occurs with Parkinson disease. Its clear, though, that dementia and problems with cognitive function are linked to changes in the brain that cause problems with movement. As with Parkinson disease, dementia occurs when nerve cells degenerate, leading to chemical changes in the brain. Parkinson disease dementia may be treated with medicines also used to treat Alzheimer’s disease, another type of dementia.
What Are The Treatments
Currently there is no cure for Parkinsons disease.
Symptoms can be mild in the early stages of the condition and people might not need immediate treatment. Your doctor and specialist will monitor your situation.
There are several different types of drugs used to treat Parkinsons disease. Drug treatments are tailored to each individuals needs and are likely to involve a combination of different drugs. Your medication should be reviewed regularly. It is likely that, over time, changes will be made to the types of drugs you take and the doses you take each day.
The main types of drug treatment for Parkinsons disease are:
- drugs which replace dopamine
- drugs which mimic the role of dopamine
- drugs which inhibit the activity of acetylcholine
- drugs which prevent the body breaking down dopamine
- other drugs such as anti-sickness medication
Everybody is affected differently by medication. The possible side effects of Parkinsons disease drugs include nausea , vomiting , tiredness and dizziness. Some people might experience confusion, nightmares and hallucinations. For some people, dopamine agonists have been linked to compulsive behaviour such as addictive gambling or hypersexuality .
The effectiveness of the main drug treatment levodopa can wear off over time and its long-term use can cause some people to develop involuntary twisting or writhing movements of the arms, legs or face . To reduce the risk, doctors might delay the use of levodopa for younger people.
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Other Tests Used To Diagnose Parkinsons Disease
Diagnosis of PD is generally made using a medical history and a physical/neurological exam. Imaging tests, such as MRI , PET scans, or DaTscans are expensive and are not routinely used.1,7
An active area of research is the development of biomarkers which are molecules in the blood, urine, or cerebrospinal fluid that can reliably indicate PD. Imaging tests that can detect aggregates of a molecule called synuclein, which is linked to PD, are also being actively researched.
Testing For Parkinsons Disease
There is no lab or imaging test that is recommended or definitive for Parkinsons disease. However, in 2011, the U.S. Food and Drug Administration approved an imaging scan called the DaTscan. This technique allows doctors to see detailed pictures of the brains dopamine system.
A DaTscan involves an injection of a small amount of a radioactive drug and a machine called a single-photon emission computed tomography scanner, similar to an MRI.
The drug binds to dopamine transmitters in the brain, showing where in the brain dopaminergic neurons are.
The results of a DaTscan cant show that you have Parkinsons, but they can help your doctor confirm a diagnosis or rule out a Parkinsons mimic.
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If Its Not Parkinsons Disease What Else Could It Be
There are several other conditions that might produce symptoms that can be mistaken for Parkinsons disease. Here are some possibilities:
- Medication side effects: Certain drugs can produce or exacerbate symptoms.
- Essential, or familial, tremor: This is a relatively common and benign cause of recurrent tremor and is often confused with the tremor of idiopathic Parkinsons. A general neurologist or movement disorder specialist is the best physician to help differentiate between these two conditions.
- A Parkinsonian syndrome: The symptoms of several neurologic conditions are similar to those of idiopathic Parkinsons, but they are often managed differently and often do not respond to the typical medications.
Remember: Only a general neurologist or movement disorder specialist can tell you with reasonable certainty if you have idiopathic Parkinsons. If for some reason you are not comfortable with the results of your first physician visit, getting a second opinion from another general neurologist or movement disorder specialist is always an option. It is important that you feel comfortable with your physician to ensure the best possible outcome for you.
Once you or your loved one has a diagnosis of Parkinsons disease, it is time to discuss treatment options with your physician.
Diagnosis Of Parkinsons Via Datscan And Clinical Exam Are Similarly Accurate
Despite the DaTscan being available to help diagnose Parkinsons, in most clinical situations, a DaTscan will not add information to what can be gleaned from the clinical exam. One study actually demonstrated that the accuracy of diagnosis in early PD was the same whether the diagnosis was reached using clinical exam or using DaTscan.
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Further Assessments And Investigations
- Perform a cerebellar examination: if concerned about cerebellar pathology.
- Measure lying and standing blood pressure: autonomic abnormalities are a feature of Parkinsons disease and multiple system atrophy.
- Assess eye movements: vertical gaze palsy and slow saccadic eye movements are associated with progressive supranuclear palsy .
- Perform a cognitive assessment
- Analyze the drug chart: medications such as neuroleptics, dopamine blocking antiemetics and sodium valproate can induce secondary parkinsonism.
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What Are The Limitations Of The Test
Currently, DaTscan that is in clinical use is not quantitative, which means that the test is not designed to determine how impaired the dopamine system is just whether it is or not. This means that the test is not used to tell you whether the disease has progressed over time and is not used to follow a patients disease. It also is not used currently as a clinical test to screen for the disease before motor symptoms are evident. Because of these limitations, the search continues for additional measurable indicators, known as biomarkers, to help diagnosis and manage PD.
Imaging Tests For Parkinsons Disease
While no lab or imaging test can definitively diagnose Parkinsons disease, several helpful imaging tools can be used to support Parkinsons disease diagnosis.
For example, while not approved by the FDA for Parkinsons disease diagnosis, positron emission tomography scans are often used during the diagnostic process to rule out other conditions.
Individuals with Parkinsons disease experience dopamine deficits in the striatum resulting from the destruction of dopaminergic neurons located in the substantia nigra. A dopamine transporter scan , a specific single-photon emission computerized tomography scan, can be used to visualize the dopaminergic neurons.
For this test, a radioactive tracer is injected into the bloodstream, where it then circulates around the body, making its way to the brain. The drug binds to dopamine transmitters in the brain, producing detailed pictures of the dopamine system in the brain. Not everyone with suspected Parkinsons disease will require this test, but it can help distinguish between other functional movement disorders, such as essential tremor.
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When Is Datscan Helpful
There are situations in which DaTscan can be very helpful in securing a diagnosis when neurologic exam findings are not clear-cut. Although DaTscan cannot distinguish PSP, CBGD, and MSA from PD, studies suggest that it may be able to distinguish drug-induced parkinsonism and vascular parkinsonism from PD.
The FDA indication for DaTscan is for distinguishing between PD and essential tremor . Usually it is quite straightforward for a neurologist to distinguish between the tremors of ET and the tremors of PD. PD tremors occur at rest and are accompanied by slowness and stiffness of the limb, whereas ET tremors occur with action and are not accompanied by slowness and stiffness of the limb. However, some people may have mixed tremor features making the diagnosis more difficult. In those cases, a DaTscan can be very useful.
Hereditary Forms Of Parkinson’s Disease And Their Clinical Features
A small but significant number of PD patients have a family history compatible with Mendelian autosomal inheritance , either dominant or recessive. Many of these are classified as young-onset or juvenile-onset PD . A number of levodopa-responsive parkinsonian syndromes have been described and linked to a specific locus or gene in the last few years, and some of them have been classified as PARK syndromes . Some of these denote true PD, whereas others represent more complex phenotypes and dissimilar diseases. Only the former group will be briefly approached here, as the clinical phenotype may be a useful pointer for the diagnosis in daily practice, guiding subsequent molecular testing. For more details on the genetics of PD please refer to Klein and Westenberger .
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Causes Of Parkinsons Disease
The cause of Parkinsons disease is unknown, but the disease occurs when the dopamine levels in the brain drop. Dopamine is the chemical in the brain that tells other areas of the brain when and how to move. Factors that can play a role in the development of Parkinsons disease include:
- Genes in rare cases where multiple family members have Parkinsons disease, patients may have a genetic mutation that can cause Parkinsons disease. In other cases, there are several genetic mutations that can increase your risk of developing Parkinsons.
- Environment environmental factors such as extended exposure to Agent Orange, herbicides, pesticides, fungicides and metals or leads used in factories could also play a role in causing Parkinsons disease.
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What Role Does Datscan Have In The Diagnosis Of Parkinsons Disease
Many patients with Parkinsons disease are frustrated and sometimes frankly suspicious about how it is diagnosed. As a neurologist, over the years Ive heard comments like:
- All the doctor did was have me make some movements with my hands and legs and watch me walk and then he told me I had Parkinsons disease! How is that possible?
- I dont believe my diagnosis. Arent there a bunch of other diseases it could be?
- How can they know for sure? I want a test to prove whether I do or do not have Parkinsons disease!
I understand how some patients and care partners can feel this way so I want to address this concern and discuss the role and limitations of a test that is available, known as DaTscan.
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How I Examine My Patient: The Art Of Neurological Examination For Parkinsons Disease
aRadboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Department of Neurology, Nijmegen, The Netherlands
bLaboratory of Translational Parkinsons Disease Research, Center for Neurodegenerative Science, Van Andel Research Institute, Grand Rapids, MI, USA
The clinical arts also extends to the call for ancillary tests. When is a presentation of Parkinsons disease atypical enough to warrant the call for a cerebral MRI scan, or possibly even a more costly DAT scan, and when is the presentation sufficiently typical to refrain from any further ancillary tests? And while ordering the test is relatively easily done, the interpretation is not always straightforward, and it certainly requires a considerable degree of expertise to properly judge all the intricacies of e.g., a cerebral MRI in a patient with parkinsonism .
CONFLICTS OF INTEREST
Physical Exam For Parkinson’s
During a physical exam, the doctor examines the patients body for signs of disease. The doctor will include a visual inspection , palpation , ascultation , and percussion . The physical exam for PD is generally conducted by a neurologist and may also be called a neurological exam. It is recommended that a patient see a neurologist with special training in movement disorders as these specialists have the most knowledge about the symptoms and medications. During a neurological exam, the patient may be asked to sit, stand, walk, and extend their arms as the doctor evaluates balance and coordination. Most neurologists recommend a spouse or caregiver attend the exam with the patient to help with answering important questions.1,2
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Nonmotor Symptoms And The Premotor Phase Of Pd
PD has been traditionally regarded as a motor disorder, perhaps because the original account of the clinical features emphasized these symptoms, while failing to recognize the important nonmotor aspects of the disease. In addition, motor symptoms often meet the eye straightaway, even for untrained observers. However, in recent years there has been an increasing interest in nonmotor symptoms of PD , because their recognition is useful for diagnostic purposes, but also because they are a major source of deterioration in quality of life, and warrant specific management .
Gait & Balance Abnormalities
Parkinsons Disease Exam
Patients with Parkinsons disease can develop an alteration of the postural reflexes that causes instability in gait and balance control. Such alterations usually develop later in the course of the illness and are a major cause of disability, especially because of the high risk for falls that derives.
Using the exam to pick up postural instability is of the utmost importance for the management of patients with PD, since it will trigger either a medication adjustment or a physical therapy intervention both aimed at falls prevention.
We have three tests for this part of the PD exam:
1) Standing up from a chair
2) Free walking
3) Provoked pull test maneuver for balance
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Symptom History Of Parkinsons Disease
Diagnosis of PD is most often made when a doctor identifies the primary motor symptoms in a patient. Diagnostic criteria for PD called the Unified Parkinsons Disease Rating Scale recommend that the physician assess for symptoms such as tremor, rigidity, balance impairments, freezing episodes , posture, changes in handwriting, difficulty swallowing, and reduced facial expression.3,4
In addition to these primary motor symptoms, the symptom history for diagnosing PD should include investigating the presence of non-motor symptoms of PD, such as constipation, a frequent and urgent need to urinate, sleep disturbances, pain, orthostatic hypotension , reduced sense of smell , sexual dysfunction, and fatigue. In addition, many people with PD experience mood disorders like depression or anxiety and cognitive changes, such as memory difficulties, slowed thinking, or confusion.4,5
Determining Diagnosis Through Response To Parkinsons Medication
If a persons symptoms and neurologic examination are only suggestive of Parkinsons disease or if the diagnosis is otherwise in doubt, the physician may, nevertheless, prescribe a medication intended for Parkinsons disease to provide additional information. In the case of idiopathic Parkinsons, there is typically a positive, predictable response to Parkinsons disease medication in the case of some related Parkinsonian syndromes, the response to medication may not be particularly robust, or it may be absent entirely.
Unfortunately, there are no standard biological tests for the disease, such as a blood test. However, researchers are actively trying to find biomarkers in blood and other bodily fluids that could help confirm the diagnosis.
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Datscan: A Test To Help In The Diagnosis Of Parkinsons
In 2011, the Food and Drug Administration approved an imaging test to help diagnose PD. In this test, a radioactive tracer, Ioflupane 123I, also known as DaTscan, is injected into the blood, where it circulates around the body and makes its way into the brain. It attaches itself to the dopamine transporter, a molecule found on dopamine neurons. Several hours after the tracer has been injected, special imaging equipment scans the head to detect the presence of DaTscan.
People with PD will typically have a smaller signal in a part of the brain called the striatum, where the ends of the dopamine neurons are meant to be. Here is a normal scan on the left, which would indicate a healthy dopamine system, next to an abnormal scan on the right, which would indicate an unhealthy dopamine system.
It is important to note that conventional MRI imaging will appear normal in PD and is therefore not helpful in confirming the diagnosis. Other atypical parkinsonian conditions, such as vascular parkinsonism however, can have abnormalities on MRI, so the test may be done to rule out other diagnoses.