Parkinson’s has received a lot of media attention in the last few years. Michael J Fox’s diagnosis has hugely brought the disease into limelight.
Perhaps Eminem’s lyrics in Won’t Back Down subsequently come to mind,
“Girl, shake that ass like a Donkey with Parkinson’s. Make like Michael J Fox in the drawers playin’ with an etch-a-sketch.”
Of course this song was highly controversial when it debuted.
Kanye West also upset the American Parkinson Disease Association when he also poked fun in his song On Site,
“A monster about to come alive again / Soon as I pull up and park the Benz / We get this b*tch shaking like Parkinson’s.”
Part of me thinks, “Seriously boys- not cool.” The other part of me can’t help but recognize that their jests have shot the disease right into the eye of public awareness. I’m all for a good conversation starter if it eventually leads to progress and education.
More recently Tim Sr., winner of Canada’s Amazing Race, talked about the changes of being in the early stages of Parkinson’s while completing the race. This shows that the more people understand the disease, the more social stigma is erased.
I can remember when I first “noticed” the disease as a kid. I was in a shopping mall with my mother. An elderly lady, hair so white it was almost blue, was sitting in the food court. Her head was nodding rhythmically and my young mind assumed she had a Walkman on- kind of an anomaly at the time. As we walked by I realized that there was no music playing- in fact it appeared she had no control over her bobbing. Out of earshot my Mum explained to me that it was a disease that eventually stole the person’s ability to control their movements- hence the “shaking”.
This week at work was my personal “Parkinson’s week”. What I mean is, sometimes EMS calls seem coincidentally to be dominated by a certain disease or event. The previous week was “suicide week”, the week before that was obstetrics. This week I had a handful of patients with Parkinson’s, some being well controlled with medication, others not so much. Generally when a call pattern crops up it prompts me to want to brush up a little.
So let’s start at the beginning.
What is Parkinson’s?
Parkinson’s is a neurodegenerative disease. Movement is normally controlled by dopamine, a chemical that carries signals between the nerves in the brain. When cells that normally produce dopamine die, the symptoms of Parkinson’s appear.1 About 1 in 250 people over the age of 40, and about 1 in 100 people aged 65 or older, are affected by Parkinson’s disease. Although the average age of onset is 57, Parkinson’s occasionally appears in childhood. Men are more likely to develop Parkinson’s than women. 2
So far, no one is certain about the cause of the cells death in Primary Parkinsonism. Secondary Parkinsonism is due to some disease (e.g., nervous system conditions, heart disease, brain tumours, viruses) or chemical interfering with or damaging dopamine-producing cells in the brainstem (substantia nigra). The most common cause is side effects of medication for other problems. Medications that can cause secondary Parkinsonism include:
- Haloperidol* and other medications used to treat hallucinations
- Metoclopramide (an antinausea medication) 3
Parkinson’s is characterized by slowness of movement, rigidity, tremor and postural instability. Many people may experience other changes; sometimes even prior to their motor symptoms. These other changes, known as non-motor symptoms, can also impact one’s quality of life and many patients may not realize that these other symptoms are linked to Parkinson’s disease. As a result, these non-motor symptoms often go untreated.
Non-motor symptoms can vary substantially from patient to patient and can include the following*: drooling; change in taste and smell; choking and swallowing difficulties; nausea and vomiting; constipation; uncontrolled loss of stool; bladder dysfunction; unexplained changes in weight; dementia and cognitive impairment; hallucinations; depression and anxiety; sexual dysfunction, orthostatic hypotension; excessive daytime sleepiness; insomnia; REM sleep behaviour disorder; restless leg syndrome; leg swelling; excessive sweating; double vision; delusions and impulse control disorders. 4
Medications used in the treatment of Parkinson’s disease help to increase dopamine levels in the brain or mimic the action of dopamine. Dopamine can’t be given directly because it can’t cross the blood-brain barrier, a lining that insulates the brain from the rest of the body. However, a medication called levodopa does get into the brain, where it is converted to dopamine, which is then used to replace the missing dopamine and improve control of movements.
Levodopa is often given with other medications such as carbidopa, benserazide, or entacapone that allow for smaller doses of levodopa to deliver more benefit.
Other medications for Parkinson’s include bromocriptine, pramipexole, and ropinirole, which belong to a group of medications called dopamine agonists. Rather than replacing dopamine, these medications directly stimulate the areas that usually respond to dopamine. Other medications that may also be used include anticholinergic medications (e.g., benztropine), monoamine oxidase B inhibitors (e.g., rasagiline, selegeline), and amantadine. 5
Deep brain stimulation involves sending an electrical charge through a wire to the areas of the brain that control movement (thalamus, subthalamic nucleus, globus pallidus). This helps to block the abnormal signals produced in Parkinson’s disease. This is generally reserved for patients who no longer respond to medications. 6
Depending upon your age of onset, how you manage the symptoms, and your general health, you can live an active life with Parkinson’s. In most cases, one’s life is not shortened. However, as you age and as the disease progresses, there will be increased risks. For example, impaired balance can lead to falls; swallowing problems, if not managed, can lead to pneumonia and choking. Parkinson’s is known as a chronic (long term) condition that will require ongoing monitoring and management to maintain one’s quality of life. 7
It wasn’t until after this review that I understood the likely connection between one of my patients and their recent onset of disturbing hallucinations. At the time I did not realize it was probably connected to progression of their Parkinson’s or ineffective dosing. This is why you can never stop learning!