PARKINSON'S DISEASE

                            PARKINSON'S DISEASE

Introduction:

 Parkinson disease is named for the English doctor James Parkinson. In 1817 he described a chronic, slowly progressive disease of the nervous system characterized by a combination of tremor, rigidity, and stooped posture. 11 April is considered as World Parkinson day on the birthday of James Parkinson. Red tulip is the symbol of this disease.

Definition:

It is a progressive brain disorder characterized by loss of neurons in an area of midbrain known as substantia nigra.

Pathophysiology:

Etiogical causes leads to degeneration of monamine containg cell population in brain stem & basal ganglia particularly dopamine affecting to brain & spinal cord  causing neurotoxicity causing cell death

Etiology & risk factors:

• Idiopathic Parkinsonism
• Secondary Parkinsonism:

1. Drug induced: Neuroleptics, antiemetics, lithium
2. Hydrocephalus
3. Hypoxia
4. Toxins: carbon monoxide, cyanide, methanol
5. Infections: AIDS
6. Metabolic: Hypo/Hyper calcemia, Wilson's disease, chronic hepatocerebral brain degeneration
7. Psychogenic
8. Trauma
9. Vascular causes
10. Parkinson plus syndromes:
11. Multiple system atrophy
12. Progressive supranuclear palsy
13. Corticobasal ganglionic degeneration
14. Progrssive pallidial atrophy
15. Lytico-Bodig : It is referred to by neuroscientists as amyotrophic lateral sclerosis-parkinsonism-dementia.

• Heredodegenerative disease:

1. Alzheimer's disease
2. Dementia with lewy bodies
3. Pick's disease
4. Huntington's disease
5. X linked dystonia parkinsonism

• Genetic factors:

1. Alanine 53- threonine mutation
2. The parkin gene dominant

Sign & Symptoms:

Cardinal features:

Bradykinesia:

• It means decreased movements characterized by delay in initiation & execution of willed movements & a general reduction of automatic movements.
• It manifests:

1. Facial Hypomania
2. Reduced blinking
3. Impaired ocular convergence
4. Bradylalia
5. Anarthria
6. Drooling of saliva
7. Micrographia
8. Slow shuffling gait with reduced associated movements

Muscle Rigidity:

1. It is characterized by resistance to passive movements that affects flexion, extension, pronation & supination.
2. Axial & proximal limb muscles rigidity will be present.
3. Cogwheel Rigidity: It is characterized by periodic modification of muscle tone due to superimposed tremor that can be seen & felt when passively moving the extremity.
4. Akinetic rigid syndrome is the characteristic of PD which is seen in due to abnormal dopaminergic input in to brain.

Resting tremors: 

1. It is characterized by pill rolling between thumb & index finger
2. Illegible writing
3. Tremors may increase due to emotional response, fatigue, stress, anxiety & disturbed sleep pattern.
4. It typically affects the distal appendicular muscles causing:

• Abduction- adduction movemen ts of thumb [pill rolling]
• Pronation-supination movements of wrist
• Often unilateral involving thumb & fingers
• Lower limp of same side will be affected before involving opposite side of body.
• Tremors of lips, head & jaw may be seen

Disorder of postural fixation:

1. May affect head, trunk & limbs causing:
2. Instability of trunk
3. Forward displacement of head
4. Difficulty in maintaining erect posture
5. Slight leaning forward while standing
6. Parkinson's gait

Freezing phenomenon:

1. Motor act stucks in place lasting for seconds
2. The voluntary acts are halted as agonist & antagonist muscles are spontaneously contracting.
3. This phenomenon include:
4. Freezing when initiating gait [start hesitation]
5. Freezing when turning [turn hesitation]
6. Freezing when approaching the target [destination hesitation]
7. Freezing when obstacle is encountered 
8. Repetition of first syllable
9. Apraxia of eye opening
10. Freezing of limbs [during writing & brushing teeth]

Other features:

1. Parkinson Posture: Forward flexion of trunk, flexion of elbows & partial flexion of knees
2. Prkinsonian hand: Dorsiflexion of wrist, extensoion & adduction of fingers, slight ulnar deviation, flexion of metacarpophalangeal joints
3. Dystonic foot posture: Extension of great toe, flexion of toes, arching of sole & inversion of foot
4. Hpokinetic dysarthria
5. Palilalia
6. Bradyphrenia
7. Hypophonia

Behavioural Signs:

1. Depression 
2. Sudden onset of sleep
3. Bent spine syndrome

Medical & Nursing Management:

• Antiparkinsonian drug: Levadopa, carbidopa levadopa
• Dopamine receptor agonists: Pergolide, Bromocriptine, Pramipexole
• Selegiline
• Catchechol O- methyltranferase: entocapone, tolcapne
• Acetylcholine blocking drugs: Biperiden, Procyclidine
• Monitor neurological status
• Encourage respiratory changes
• Encourage exercise
• Passive ROM 
• Weight Patient
• Advice patient to take medicines & reduces risk of falls
• Encourage diet high in protein & calories
• Encourage soft diet

Distinctive facts:

• Ix: CSF analysis shows decrease in dopamine levels
• Sx: Thalomotomy, pallidotomy, deep brain stimulation
• Cx: Dementia
• Dopamine level will decrease 
• Occurs between 45-65 years
• Lewy bodies may be absent
• Autosomal dominant & autosomal recessive gene inheritance may be identified

Prognosis:

It is progressive disorder with no cure. symptoms may be managed with medicines & may come off when medicine stops.