(Idiopathic Parkinsonism or Paralysis Agitans



• Parkinson's disease (PD or, simply, Parkinson's) is the most common form of Parkinsonism, a group of motor system disorders.

• Named after James Parkinson. a British physician who first described the disease in a paper he published as the ―shaking palsy‖ in 1817

• It is a slowly progressing, degenerative neurologic disease that is usually associated with the following symptoms,
– tremor or trembling of the arms, jaw, legs, and face – stiffness or rigidity of the limbs and trunk – bradykinesia (slowness of movement) – postural instability, or impaired balance and coordination

PD is both chronic and progressive. normally caused by the insufficient formation and action of dopamine. . which is produced in the dopaminergic neurons of the brain. • Dopamine is a substance produced in the body which has many effects. Secondary symptoms may include high level cognitive dysfunction and subtle language problems. including smooth and coordinated muscle movement.• The primary symptoms are the results of decreased stimulation of the motor cortex by the basal ganglia.

new cases are reported each year • Males are more affected than females • Symptoms begin between 40 and 70 years of age with a peak onset on the 60’s.000 – currently suffer PD in USA • 50.000.Prevalence and Incidence • 500. .

• Gender. Fifty percent more men are affected than women. Individuals with a parent or sibling who are affected have approximately two times the chance of developing PD. however.Risk Factors • The believe the symptoms are related to a chemical imbalance in the brain caused by brain-cell death. The average age for the onset of PD is 60 years. However. • Advancing age. the reason for this is unclear. • Family history. specific cause of PD is unknown. according to the National Institute of Neurological Disorders and Stroke. medical experts .

.encoding the protein parkin was linked to an autosomal recessive form of PD.a member of a small family of proteins that are expressed preferentially in the substantia nigra. One of the major components of the Lewy bodies that are found in brain tissues of persons with PD. b. Parkin genes. synuclein.Two genes which are linked to PD a.

Currently researchers believe that in most individuals the cause of PD is a combination of genetics and environmental exposure. *endotoxin or lipopolysaccharide – a common airborne environmental and occupational contaminate in agriculture and other industries. exposure to well water. and exposure to agricultural pesticides and herbicides are related to PD.Risk Factors • Environmental causes are being researched and the strong consistent findings are that rural living. .

• parkinsonism that accompanies other neurological conditions such as Shy-Drager syndrome (multiple system atrophy). olivopontocerebellar atrophy.manganese and carbon monoxide poisoning. Alzheimer's disease.Parkinson's syndrome. metoclopramide for stomach upset. Huntington's disease. • toxin-induced parkinsonism . and dementia with Lewy bodies. Hallervorden-Spatz syndrome." • striatonigral degeneration . or Parkinsonism: • tumors in the brain • repeated head trauma • drug-induced parkinsonism . butyrophenones.the substantia nigra of the brain is only mildly affected. Wilson's disease. reserpine. progressive supranuclear palsy. • postencephalitic parkinsonism . post-traumatic encephalopathy.a viral disease that causes "sleeping sickness. while other areas of the brain show more severe damage. . Atypical Parkinson's. Creutzfeldt-Jakob disease.prolonged use of tranquilizing drugs. and the commonly used drug. such as the phenothiazines.

However. Bradykinesia .poor posture and balance that may cause falls.slowness in initiating movement. • • • • . Symptoms may include: Muscle rigidity .Four primary symptoms of Parkinson The following are the most common symptoms of Parkinson's disease. Resting tremor . each individual may experience symptoms differently. or neck is moved back and forth. Postural instability . gait or balance problems. leg.stiffness when the arm.tremor (involuntary movement from contracting muscles) that is most prominent at rest.

Other symptoms are divided into motor (movement related) and nonmotor symptoms. • The four cardinal symptoms of PD are listed above. . The symptoms may appear slowly and in no particular order.Other symptoms of Parkinson's disease (PD): • Symptoms of Parkinson's disease vary from patient to patient. Early symptoms may be subtle and may progress over many years before reaching a point where they interfere with normal daily activities.

forward-flexed posture • Festination • Gait freezing • Dystonia (in about 20% of cases) Speech and swallowing disturbances • Hypophonia • Monotonic speech. • Turning "en bloc" • Stooped. • Festinating speech • Drooling • Dysphagia .Gait and posture disturbances • Shuffling gait • Decreased arm-swing.

• Akathisia. • Masked faces (a mask-like face also known as hypomimia). • Impaired fine motor dexterity and motor coordination. with infrequent blinking. • Micrographia (small. the inability to sit still. • Impaired gross motor coordination. . cramped handwriting).Other motor symptoms: • Fatigue (up to 50% of cases). • Difficulty rolling in bed or rising from a seated position.

• Medication effects: some of the above cognitive disturbances are improved by dopaminergic medications. • Short term memory loss. while others are actually worsened.Cognitive disturbances include: • Slowed reaction time. procedural memory is more impaired than declarative memory. delusions and paranoia may develop. both voluntary and involuntary motor responses are significantly slowed. • Non-motor causes of speech/language disturbance in both expressive and receptive language: these include decreased verbal fluency and cognitive disturbance especially related to comprehension of emotional content of speech and of facial expression. • Executive dysfunction • Dementia • Hallucinations. . Prompting elicits improved recall.

intermediate. and terminal insomnia • Disturbances in REM sleep: disturbingly vivid dreams. and rapid eye movement behavior disorder.Sleep • Excessive daytime somnolence • Initial. characterized by acting out of dream content — can occur years prior to diagnosis .

Perception • Impaired visual contrast sensitivity. attributable to tension. joint stiffness. and tendons. muscle. usually attributable orthostatic hypotension. spatial reasoning. rigidity. convergence insufficiency (characterized by double vision) and oculomotor control • Dizziness and fainting. and injuries associated with attempts at accommodation . joints. dystonia. a failure of the autonomic nervous system to adjust blood pressure in response to changes in body position • Impaired proprioception (the awareness of bodily position in three-dimensional space) • Reduction or loss of sense of smell (hyposmia or anosmia) pain: neuropathic. colour discrimination.

. which is significant over a period of ten years.Autonomic • Oily skin and seborrheic dermatitis • Urinary incontinence • Nocturia— up to 60% of cases • Constipation and gastric dysmotility • Altered sexual function • Weight loss.

. walking may become affected. small steps as if hurrying forward to keep balance.• As the disease progresses. Patients also may begin walking with a series of quick. causing the patient to stop in mid-stride or "freeze" in place. and maybe even fall over. a practice known as festination.

Risk/Related Factors Age. Bradykinesia . Rigidity. Drugs. Genetics. Toxins.Headtrauma Destruction of dopaminergic neuronal cells in the substantia nigra in the basal ganglia Depletion of dopamine stores Degeneration of the Dopaminergic nigrostriatal pathway Imbalance of Excitatory (acethylcholine) and inhibiting (dopamine) neurotransmitters in the corpus striatum Impairment of extre pyramidal tracts controlling complex body movements Tremors.

Diagnosis .

a diagnosis of Parkinson's disease may be questionable. • Computed tomography scan (Also called a CT or CAT scan.when symptoms are significant. If a patient fails to benefit from levodopa. a trial test of drugs (primarily levodopa [L-dopa]) may be used to further diagnose the presence of PD.• Neurological examination (including evaluation of symptoms and their severity) • Trial test of drugs .) • Magnetic (MRI) resonance imaging .

Other Tests to Roll out Secondary Causes • Drug Sreening – to determine the presence of medications or toxins • Upper GI Series – shows delayed emptying. distention and possibly megacolon with severe constipation • CBC – shows low hemoglobin and hematocrit due to anemia • Chemistry Profile – reflect low protein and albumin levels related to the clients inability to buy and prepare meals .

Medication for Parkinson's disease: .

Dextromethorphan glial – derived neurotrophic factor -. Coenzyme Q10 – may slow the rate of functional declines 2. Ex.reduce metabolic breakdown of dopamine c. Amantadine (Symmetrel) b. . Cathechol o-methyltranferase (COM) inhibitor 1. Monoamine oxidase (MAO) inhibitors Selegiline(Eldepryl) . Entacapone (Contan)-used in combination of levadopa and carbidopa. NEWER DRUGS 1. 1.may be prescribed to confer mild symptomatic benefit before initiating dopaminergics in the treatment of PD.1. Eldepryl. Levadopa Combinations (levadopa and carbidopa ) 3. Carbex.2 Stavelo – a combination of levodopa. INVESTIGATIONAL DRUGS 1.a.cabidopa and entacapone. 1. Novo-Selegiline . OLDER DRUGS • Anti-cholinergic • Dopamine Agonist 2.administered directly into the brain.3 Tolcapone (Tasmar) 2.

Surgical Treatment • • • • Lesion surgery (burning of tissue) Deep brain stimulation (DBS) Neural grafting or tissue transplants Pallidotomy and thalamotomy are rarely done anymore.B. They involve the precise destruction of very small areas in the deep part of the brain that cause symptoms. . • Neurotransplantation surgery • Fetal Tissue Transplantation is an experimental and highly controversial procedure. Fetal substantia nigra tissue either human or pig is transplanted into the caudate nucleus of the brain.

d. c.1. improve coordination and dexterity. Daily exercise increases muscle strength. Stretching and ROM exercise to promote joint flexibility. Impaired Physical Mobility related to neuromuscular impairment a. Warm baths and massage help relax the muscle and relieve painful muscle spasms that accompany rigidity. reduce muscular rigidity and prevent contractures. b. Postural exercises are important to counter the tendency of the head and neck to be drawn forward and down. .

Self. Encourage.2. teach and support the patient during ADL’s to promote self care.Care Deficit related to tremor and motor disturbance • a. • b. . Assist and encourage good grooming to enhance independence and self esteem.

f. c.3. d. Eliminate unnecessary environmental noise to maximize the listener’s ability to hear and understand the client. b. Instruct client to organize his/her thoughts before speaking and to use facial expression and gestures if possible to assist with communication. the use of alternative methods of communication such as communication board or computer must be encouraged. If client cannot communicate verbally. Instruct client to speak softly and clearly and to pause and take a deep breath at appropriate intervals during each sentence. client and family in developing a communication plan. health care team. e. . Collaborate with the speech language pathologist. Asked client to repeat words that the listener does not understand and the listener watches the client’s lips and non-verbal expressions for cues as to the meaning of conversation. Impaired Verbal Communication related to neuromuscular impairment a.

3. d. The client should be weighed once a week and adjustment should be made on diet as indicated. f. Coordinate with a registered dietician to evaluate the client’s food intake. As disease progresses and swallowing becomes more of a problem. h. g. supplemental feedings become the main source of nutrition to maintain weight. b. Smaller. e. If the client has difficulty swallowing coordinate with speech language pathology to conduct an extensive swallowing evaluation in order to develop an individualized dietary plan. Record food intake daily or as indicated. Imbalanced Nutrition less than body requirements related to inability to ingest food due to biologic factors a. . more frequent meals or commercial powder added to liquids may assist the client who has difficulty swallowing. Position client with head elevated to facilitate swallowing and prevent aspiration.

4. Eat foods with a moderate fiber content. c. b. Increase fluid intake. Encourage a patient to follow regular mealtime pattern to establish regular bowel routine. Constipation related to medication and decreased activity a. .