Central  South  Dakota  Medical News
The Clinical View
by Phillip Hoffsten
10 December 2004

THE PROBLEM OF PARKINSON’S DISEASE

     Recently, a lady came for a clinic visit to follow up her blood pressure treatment.  Her pressure was slightly high and minor adjustments were made in her medications.  But then she said that the real reason for her visit was to discuss her brother who had recently come to live with her.  He had previously lived in another state and she hadn’t seen her brother for five years.  The last time she saw him, he was fine but now he was distinctly different.  Every movement that he made seemed to be slow.  Expression was gone from his face.  Previously, he could laugh or smile easily.  Now his face remained blank with little expression regardless of how he felt.  He previously had a loud booming voice but now it seemed that his voice was quiet, almost subdued.  When he started to walk, he had to first lean forward and then would take multiple short steps with a shuffling kind of walk.  He was very unsteady and had already had two falls even though he had lived with his sister for only a week.  Fortunately, he had not been hurt in the falls.  Lastly, she mentioned that he just didn’t seem to be sharp as he used to be.  He was a retired certified public accountant who had worked with the same firm for many years and was well respected.  She said that now his thought processes seemed to be slow and that he trouble making decisions.

     She said that his wife had passed away 5 years ago and neighbors had been close and supportive.  Recently the brother’s neighbor had called indicating that the brother needed some type of help because he didn’t seem to be doing well at home.  When she went to visit him, it was obvious that “something was wrong”.  She said that he never went to doctors and took no medications.  She said that she had heard about problems like this and a friend indicated that the problem might be Parkinson’s disease. My patient wondered if that was correct and what could be done about it.

     Indeed, this patient’s brother did have Parkinson’s disease.  Dr. James Parkinson, an English physician, first described this disease in 1817.  This is a condition that results from the degeneration of a very special part of the brain called the “substantia nigra”. For some reason, the nerve cells that reside in the substantia nigra begin to degenerate and cease to produce a chemical called dopamine.

     Dopamine produced by the substantia nigra allows coordinated muscle movement.  As a specific example, there are two sets of muscles in the human being’s upper arm.  One is called the biceps which is the muscle that young boys show off when they begin to get stronger.  The other muscle group is called the triceps muscle and is on the back of the upper arm.  The biceps muscle flexes the arm at the elbow allowing a fork full of food to get from your plate to your mouth.  The triceps muscle extends the arm so that you can get your fork back to your plate for the next bite.  When one of these muscles contracts, the other one is supposed to relax so that they don’t pull against each other.  Imagine what a problem it would be if both muscles pull at the same time.  It would be very wasteful of energy and very tiring.  Dopamine from the substantia nigra coordinates relaxation of one muscle when it’s opposing muscle contracts.  The example above is easy to understand but imagine the complexity of what happens when a person runs or swings a bat or throws a ball or simply chews.  In all of these cases, one set of muscles has to contract and the opposing set of muscles has to relax.  If Dopamine and the substantia nigra aren’t working right, the person struggles with every movement they make and rapid repetitive movements such as running are simply impossible.  This is the problem of Parkinson’s disease. The patient is not able carry on efficient coordinated movements anywhere in the body.  The condition seems to evolve over 5-10 years beginning slowly as increased fatigue and muscle aching.  The more alarming and disappointing aspect of Parkinson’s disease is that dementia tends to develop in the late stages of the disease.  This was the reason her brother “didn’t seem as sharp” he used to be.

     After the information above was discussed with my patient, she wondered what could be done to help her brother.  She was told that unfortunately, there is no clearly, predictable treatment that can cure the disease or even really stop its progression.  The disease seems to be slowly relentless over 5-10 years time. She was told that there are medications available to treat the symptoms.  The muscle rigidity and the shaking tremor that occurs can be effectively treated preventing falls, making the person more comfortable, stopping the pain of muscles constantly pulling against each other and giving the person a substantial improvement in their ability to carry on activities of daily living.

     Principles of treatment are really very easy.  If the problem represents not enough dopamine then treatment should be directed to make more dopamine or to get rid of  less dopamine.  Both types of treatment are available.  There are medications that will replace the lost dopamine and there are medications that will slow down the rate at which the body’s dopamine is disposed of.  The most common replacement drug is called Sinemet.  Previously, it was the standard drug treatment and was relatively cheap.  More modern patented medications seem to be more effective although much more expensive.  As a help for drugs that replace dopamine, there are also drugs that slow down the rate at which dopamine is disposed of.  These medications in combination with the Sinemet products can be very helpful.

     This story began in September when I first saw her brother.  He was initially started on a drug  called Mirapex (pramipexole) and initially had nausea along with worse sinus congestion.  By slowly increasing the dose these side effects resolved.  He was still somewhat stiff with only this one medication.  A second drug called Comtan (entacapone) was started and his walking was much improved.  When seen for follow-up this last week he was much improved and considering moving back to his own home.  I counseled him that independent living may work for a while; but in the long run he would probably be safer and more comfortable in a more supportive environment such as his sister’s home.  He wanted to think about that.

      The day to day care of a person with Parkinson’s disease is usually managed by local healthcare providers.  But care of a person with Parkinson’s disease can be very complicated with many pitfalls.  Frequently, problems arise that require consultation with a neurologist to adjust or change medications.  The healthcare providers at your local clinics are aware of the problems of Parkinson’s disease and how to support unfortunate patients and families afflicted with this condition.