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Haran Sivapalan
King’s College London, School of Medicine
What are the challenges facing a new patient with Parkinson’s Disease?
Introduction
While clinically classified as a movement disorder, typified by a triad of resting tremor,
bradykinesia and rigidity; Parkinson’s Disease (PD) may also cause psychiatric,
cognitive, sleep, sensory and autonomic dysfunction. Indeed, it is this very
multifariousness in symptom expression that presents physical, psychological and
social challenges to patients in several aspects of daily life. The purported efficacy in
treatment of patients by a broad multidisciplinary team, ranging from speech
therapists to neurosurgeons (Trend et al 2002), also attests to the diversity of
problems engendered by Parkinson’s disease. Conversely, the drugs used to give
succour to these problems may themselves lead to other health difficulties.
Furthermore, these are compounded by other shortfalls in the quality of healthcare
provided to newly diagnosed patients. A new patient is thus not solely troubled by the
motor and non-motor components inherent to Parkinson’s disease, but also by their
interface with healthcare.
Motor challenges
The cardinal motor symptoms of PD are an intrinsic cause of profound disability. It is
easy to envisage how a resting tremor may interfere with personal and instrumental
activities of daily living. Yet, these motor symptoms may manifest and disconcert a
patient in more subtle ways; through falls, dysphagia, dysarthria, micrographia and
hypomimia amongst others.
-Falls
Postural instability and gait abnormalities such as ‘freezing gait’ may cause recurrent
falls in PD patients. Prospective studies suggest 70% of patients experience at least
one fall a year (Grimbergen et al 2004). Consequently, falls are a serious source of
both physical and psychological encumbrance for PD patients. From a mechanical
perspective, protective arm movements are attenuated and erroneously directed in
Parkinson’s disease. Adduction, as opposed to outstretching of the arms, during falls
leads to a greater incidence of trochanteric hip fractures (Grimbergen et al 2004).
Therefore it is not solely the increased risk of falling, but the graver sequelae of falls
that are problematic to the new PD patient. Augmenting this, psychological
challenges; specifically the fear of falls, may further restrict patient mobility.
- Dysarthria
Communication is critical in both clinical and non-clinical contexts, but this may be
compromised by speech disorders in PD. Hypokinetic dysarthria comprises reduced
voice volume, quality and inflection (Sapir et al 2008), properties which will negatively
affect patient interactions with family, friends and carers. In a clinical setting a new
patient may suffer difficulty in volunteering information to healthcare professionals
(an eventuality also worsened by micrographia). A corollary of this is that healthcare
professionals may themselves alter the information they impart to patients.
Sensory challenges
Non-motor features are also of salience in PD, impacting both by themselves and
through the complication of motor deficits. The ‘motor’ nature of the illness may mean
that sensory symptoms such as pain, paraesthesia and olfactory dysfunction are
often ill-addressed. Other sensory elements include the prevailing ‘inner
Haran Sivapalan
King’s College London, School of Medicine
restlessness’ of akathisia, which; when coupled with limited ability to move, may
prove particularly challenging.
- Pain
The unpleasantness and distress that is definitive of pain forms another obstacle in
the life of a new PD patient. A recent study of 176 Norwegian PD patients revealed
that 83% were in significant pain (Beiske et al 2009). Inadequacies in the provision of
analgesic medication worsen this phenomenon. Pain may result from five main
mechanisms, all of which severely limit the patient’s mobility, compounding existing
motor problems. Primary Parkinsonian rigidity, rheumatological disease or skeletal
deformity may cause musculoskeletal pain. Nerve root lesions or peripheral
neuropathy lead to radicular-neuropathic pain. Dystonic, central and akathisic pain
may follow anti-parkinsonian drug treatment. The latter three pain types may have
added implications in terms of reduced patient drug compliance.
- Anosmia
The complete loss of a special sense is a debilitating event. Anosmia, or the loss of
the sense of smell, is thought to eventually affect 90% of PD patients due to neuronal
degeneration in the olfactory bulb and anterior olfactory nucleus (Chaudhuri et al
2006). As an early symptom of PD, the anosmic new patient will inevitably have a
restricted sensory and emotional experience of their external environment.
Mental (Cognitive and Psychiatric) challenges
A multiplicity of neuropsychiatric disorders may affect sufferers of PD, ranging from
florid psychosis to mild anxiety. The superposition of mental illness upon physical
illness is testing for patients and clinicians alike. Complexities in treatment may arise,
as both symptom domains stem from neurotransmitter dysregulation. For instance
dopaminergic agonists used to curtail motor symptoms may also instigate visual
hallucinations.
- Depression
While depression may be a condition reactive to physical illness; it is highly likely to
be an immanent component of Parkinson’s disease. A review has found that between
20% and 40% of PD patients suffer from major depression (Lieberman, 2006). This
has various ramifications upon the new patient. Firstly, at the diagnostic stage,
difficulty in distinguishing depressive symptoms such as anergia, apathy and
anhedonia from motor symptoms means depression is often under-diagnosed.
Secondly, these depressive symptoms are themselves a burden to a patient, causing
perturbations in mood, sleep and cognition. The latter; as in Beck’s cognitive triad
with negative views of oneself, the world and the future, may impair a patient’s ability
to cope psychologically with the new physical challenges of PD. The obverse
situation, whereby motor vacillations lead to depression and anxiety is also seen in
PD (Lieberman, 2006). Finally, at a therapeutic stage, drug treatment of depression
with tricyclic antidepressants, SSRIs and SNRIs may exacerbate the fatigue,
insomnia and possible orthostatic hypotension already established in PD.
- Parkinson’s disease dementia
Depression itself is a risk factor for a Parkinson’s associated dementia syndrome that
afflicts 40% of PD patients (Emre, 2003). This is largely a ‘dysexecutive syndrome’
involving difficulties in attentional and memory processing and executive functions i.e.
Haran Sivapalan
King’s College London, School of Medicine
the planning, organisation and regulation of goal-directed behaviour (Emre, 2003).
Clearly such fundamental abilities are essential in personal and instrumental
activities of daily living. Getting dressed, for example, requires successful planning,
visuospatial memory and temporal sequencing processes. If these are defective in
the new patient, substantial disability will ensue. As with depression, issues of
symptomatic overlap between motor and dementia-like syndromes leads to problems
in diagnosis that may delay treatment.
Sleep-related and dysautonomic challenges
Parkinson’s disease presents challenges to patient by both day and night.
Dysregulation of brainstem and thalamocortical sleep centres may cause REM
(Rapid Eye Movement) sleep behaviour disorder, characterised by abnormal
movements and acting out of dreams (Chaudhuri et al 2006). This may cause harm
to both patients and their partners – possibly those largely responsible for the care of
the patient. Throughout the day, excessive daytime somnolence will further
encumber the new patient. Sleep may also be interrupted by bladder dysfunction, an
autonomic feature of PD. Other dysautonomic characteristics include constipation,
orthostatic hypotension and erectile dysfunction, each with unique physical and
psychological implications.
Challenges related to drug and surgical treatment
The requirement to take daily medication with rigid dosing schedules may itself be
daunting to the new PD patient. Exacerbating these anxieties, is the potential for side
effects of anti-Parkinsonian drugs. Every year, 10% of those on levodopa therapy
develop dyskinesias (Davie, 2008); a cause of considerable disability. Dopamine
agonists may additionally cause hallucinations, fibrotic degeneration of heart valves
and even pathological gambling (Davie, 2008). It is thus apparent that the side effect
profiles of the myriad of utilised drugs pose a quandary in terms of accepting and
complying with treatment. This will also apply to surgical techniques used to control
PD, such as deep brain stimulation (DBS).
Challenges associated with access to healthcare
While the unwanted effects of treatment are problematic, an earlier issue may be the
ease of access to these treatments in the first place. A large-scale survey issued by
the Parkinson’s Disease Society (2008) served to highlight the gravity of this
healthcare deficit. It surmised that 30% of patients were not given adequate
information and medication on the disorder. Lack of understanding of the symptoms
that afflict them will undoubtedly distress patients. Furthermore, over 25% of patients
had never met with a nurse specialist, a team member critical in aiding a patient
through the multiple burdens of the disease. The same is true of occupational
therapists, speech and language therapists and physiotherapists, all of whom have
had sub-optimal contact with PD patients. Pharmacological therapy alone is limited in
its scope to assuage the mutli-factorial challenges posed by PD; and poor access to
a mutli-disciplinary team will only serve to heighten these challenges.
Conclusion
This essay has served to highlight the multitude of symptomatic expressions in
Parkinson’s disease and their diverse repurcussions on physical, mental and social
wellbeing. The ‘new patient with Parkinson’s disease,’ however, connotes a
heterogenous subset of people with respect to symptomatology and socio-
Haran Sivapalan
King’s College London, School of Medicine
demographic variables. As a study of health-related quality of life in Asians with PD
has shown, the challenges facing patients are contingent upon several personal,
cultural and societal factors (Zhao et al 2008). Therefore, in concordance with a
Health-Belief model of illness, the challenges faced by new patients differ
significantly from person to person.
References
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