Parkinson s Disease. Diagnosis Causes Treatment PATIENT INFORMATION

Size: px

Start display at page:

Download "Parkinson s Disease. Diagnosis Causes Treatment PATIENT INFORMATION"

Arline Lang
6 years ago
Views:

1 Parkinson s Disease Diagnosis Causes Treatment PATIENT INFORMATION 1

2 Table of contents Parkinson s Disease Prevalence and forms of the condition Famous Parkinson s sufferers Parkinson s symptoms... 6 Diagnosis of the condition Causes/Pathogenesis in the Brain How are signals transmitted in the brain? Which region is affected by Parkinson s disease? What changes with Parkinson s disease? Treatment of Parkinson s Disease How does Parkinson s medication work? What difficulties can arise during treatment for Parkinson s? Neurosurgical treatment Other treatment options

3 Dear Patient, Parkinson s disease (Morbus Parkinson) is one of the most well-known and common disorders of the nervous system. It was named after the British natural scientist, James Parkinson, who was the first to describe in detail the typical symptoms at the beginning of the 19th century. Some years later, the condition was finally named after the person who discovered it. Parkinson himself at the time spoke incorrectly of the agitated paralysis (Paralysis agitans) in reality, however, Parkinson s disease has nothing to do with paralysis. Even today, the illness still poses many riddles. In the meantime, while it is known that the typical symptoms originate from an imbalance in the important messenger substances in the brain, the actual cause of Parkinson s disease remains unknown. There is currently no cure for Parkinson s disease. Nevertheless, the diagnosis of Parkinson s disease has meanwhile become far less daunting. This is due to fact 1

4 that the symptoms of the condition can be effectively treated in most patients, since the revolutionary advances achieved with the discovery, in the 1960s, of L-Dopa and later the dopamine agonists. In this brochure, we have put together useful facts for you about all aspects of Parkinson s disease and its treatment. Our medical service team UCBCares is happy to assist you should you have further questions or comments. You can find the contact details on the back page of this brochure. Further information can also be found on the internet: 2

Parkinson s Disease Prevalence and forms of the condition 1,2 Parkinson s disease is one of the most common disorders of the nervous system in this country.

5 Parkinson s Disease Prevalence and forms of the condition 1,2 Parkinson s disease is one of the most common disorders of the nervous system in this country. In Germany, it is estimated that there are a total of 250, ,000 Parkinson s patients. Approximately 13,000 new cases are added every year. Parkinson s disease appears mainly in older people. At 40%, the onset of the disease is most common between 50 and 60 years of age. 3

6 By way of contrast, to develop Parkinson s disease as a young adult or even in adolescence tends to be rarer: only one in ten of those affected experience Parkinson s symptoms before reaching age 40. For the most part, i.e. in approximately three quarters of all cases, Parkinson s syndrome occurs without any specific trigger being found for it. This Parkinson s disease is also called primary Parkinson s disease or idiopathic Parkinson s syndrome. In addition, there is a range of non-idiopathic or atypical Parkinson s syndromes, although here the typical Parkinson s symptoms are accompanied by other neurological disorders, mostly due to the damage to other areas of the brain. One refers to a secondary Parkinson s syndrome if symptoms similar to those of Parkinson s arise as the result of another condition with a verifiable cause. Triggering factors can be, for example, medication, brain injuries or congenital metabolic disorders. There is currently a number of hypotheses as to how Parkinson s syndrome could be triggered. Amongst other things, for example, the influence of environmental factors is being discussed. Genetic factors, also, have been identified; however, they alone play a role in only a small number of patients, so that it is currently not assumed that the disease is hereditary for the majority of patients. 4

7 3, 4, 5 Famous Parkinson s sufferers From Theodore Roosevelt to Mao Tse-tung to Leonid Brezhnev, from Raimund Harmstorf to Peter Hofmann the list of well-known Parkinson s patients is long. Many, such as Salvador Dali or Prince Claus of the Netherlands, for example, withdrew more and more from public life due to their illness. Other celebrities, such as the boxing legend Muhammad Ali, on the other hand, used their popularity to draw attention to the condition. In the case of Canadian actor Michael J. Fox, Parkinson s disease made its presence felt when he was just 30 years old with a slight shake in his left hand; seven years later the Hollywood star went public with his diagnosis. Despite his illness, Fox leads an active life, works as an author and producer and, with the foundation he founded in the year 2000, the Michael J. Fox Foundation for Parkinson s Research, supports research into the disease and the development of new treatments. German tenor Peter Hofmann walked a similar path, his involvement was, in particular, stem cell therapy in Parkinson s disease. Even the former heavyweight champion, Muhammad Ali, despite pronounced symp- 5

8 toms, never withdrew from public life up to the time of his death, and supported research into Parkinson s through his own foundation. Parkinson s symptoms 1, 6 Involuntary tremulous motion, with lessened muscular power, in parts not in action and even when supported; with a propensity to bend the trunk forwards, and to switch from a walking to a running pace: the senses and intellects being uninjured. This is how James Parkinson, in his famous 1817 Essay on the Shaking Palsy accurately described the typical symptoms of the disease which was later named after him. In actual fact, shaking, muscle stiffness and impaired movement for which the medical terms are tremor, rigor and bradykinesia as well as an unsteady gait, are the most prominent characteristics of Parkinson s disease. 6

But not every Parkinson s patient displays all these symptoms to the same degree. One of the earliest indications for Parkinson s disease can be difficulties with fine motor skills.

9 But not every Parkinson s patient displays all these symptoms to the same degree. One of the earliest indications for Parkinson s disease can be difficulties with fine motor skills. Tying shoelaces, buttoning a shirt, putting on make-up activities which healthy people normally don t think twice about, can only be achieved by Parkinson s patients with great concentration. All Parkinson s patients encounter bradykinesia, in other words deceleration of movement, which in the early stages possibly only appears as a small weakness. Later, the movements become ever slower, actions once begun are never completed. As the facial muscles can also be affected by this deceleration of movement, Parkinson s sufferers have restricted facial expressions (mask-like face) in many cases. If this is augmented by excessive sebum production of the facial skin, then one refers to it as facial seborrhoea. 7

10 The tremor (shaking) is another typical Parkinson s symptom: It often affects the arms and hands more than the legs, and one side more severely than the other. This type of shaking is a resting tremor; if the sufferer makes a movement, the annoying shaking usually disappears. This is often accompanied by muscle stiffness (rigor), which can restrict the sufferer s mobility. Often, Parkinson s patients can be seen bent forward and walking with small steps. In addition to these typical movement disorders, however, Parkinson s syndrome is often noticeable through other signs. In many cases, depressive moods or chronic tiredness, for example, precede the motor symptoms. Pain in the joints or in the back are other early signs of Parkinson s disease, in certain circumstances. The important point is: all these symptoms are unspecific. This means, while they can indicate Parkinson s syndrome, they may not necessarily do so. Similarly, these symptoms occur in other conditions, and it is possible that they also have a harmless origin. A doctor is best placed to make this assessment. 8

11 Diagnosis of the condition 7 The diagnosis of Parkinson s disease is guided, in the first instance, by the typical symptoms. This is not always easy, as all typical Parkinson s symptoms can also point to other conditions. If the doctor suspects the presence of Parkinson s disease on the basis of the signs described and the neurological examination, this is often accompanied by what is known as the L-Dopa test: This verifies whether the symptoms are improved rapidly following the intake of an L-Dopa product (60 minutes after L-Dopa has been administered). If this is the case, this confirms the Parkinson s diagnosis. In addition, under certain circumstances, further investigative methods, such as magnetic resonance tomography (MRT) or computer tomography (CT) can be useful. With the help of these imaging procedures, it is not possible to ascertain idiopathic Parkinson s syndrome; however, they are used to exclude other conditions which can result in similar symptoms. 9

12 Investigative methods such as positron emission tomography (PET) or single photon emission computer tomography (SPECT) are extremely complex procedures with which the loss of nerve cells containing dopamine in the brain can be rendered visible. They still currently play a secondary role in relation to the diagnosis, however can be consulted to confirm the diagnosis and to monitor the progress of the condition. Whether and which of these supplementary investigations are necessary varies from patient to patient. 10

Causes/Pathogenesis in the Brain 1 How are signals transmitted in the brain? The billions of nerve cells in our brains also known as neurons are interlinked via a myriad of connections.

13 Causes/Pathogenesis in the Brain 1 How are signals transmitted in the brain? The billions of nerve cells in our brains also known as neurons are interlinked via a myriad of connections. In this way, the brain is able to fulfil its various functions effectively. Dopaminergic neuron (substantia nigra) Storage vesicle with the body s own dopamine Postsynaptic neuron (striate body) Dopamine receptors Illustration of a healthy synapse: In order to transmit information, the dopamine must leave the storage vesicles and attach itself to the dopamine receptors opposite. 11

14 The smallest switch points in our nervous system are called synapses. At these junctions between neighbouring nerve cells, information is transmitted from one nerve cell to the next. In this process, firstly, an electrical signal, and secondly, certain messengers the neurotransmitters play a role. These important carrier substances are released by the first cell and then attach themselves to specific docking sites (receptors) on the next cell. In this way, the signal passes from one neuron to the next. In Parkinson s disease, the messenger dopamine plays the most significant role. Which region is affected by Parkinson s disease? While the cause of Parkinson s disease is still largely unknown, the regions of the brain in which changes occur have already been identified. This concerns a part of the brain which is situated deep within, which belongs to what are known as the basal ganglia. In this region of the brain, primarily involuntary movement sequences are coordinated and processed. 12

15 Longitudinal section through the brain: The basal ganglia with the substantia nigra are to be found in the area marked. In Parkinson s disease, in particular, a part of the basal ganglia, the substantia nigra, is affected. This region takes its name (in English black substance ) from the characteristic cells, which contain dark pigments and produce and release the important messenger dopamine. In addition to the substantia nigra, additional regions of the brain play a role in controlling our movements. The interaction between these areas depends primarily on the healthy equilibrium between the various messengers. 13

What changes with Parkinson s disease? In people with Parkinson s disease, the fine equilibrium between the various messengers in the basal ganglia has become unbalanced.

16 What changes with Parkinson s disease? In people with Parkinson s disease, the fine equilibrium between the various messengers in the basal ganglia has become unbalanced. For as yet unknown reasons, in the substantia nigra, an increasing number of those nerve cells which produce the dopamine die. As a result the controlled implementation of movements is made more difficult, and the typical Parkinson s symptoms appear such as, for example, shaking, increased muscle tension and deceleration of movement. 14

17 Treatment of Parkinson s Disease 1 As recently as 50 years ago, approximately, treatment of people with Parkinson s disease was hardly satisfactory. In the meantime, however, thanks to the discovery of the underlying mechanisms, this has changed. The condition itself is still not curable; however targeted Parkinson s treatment can significantly alleviate the symptoms of the illness. Medication, in particular, which compensates for the dopamine deficiency, permits many Parkinson s patients today, in their everyday lives, in their careers and in their families, to lead an independent life without significant limitations. Two types of Parkinson s medication in particular have contributed to this development: L-Dopa as well as the group of dopamine agonists. How does Parkinson s medication work? The loss of dopamine-forming cells means that less dopamine reaches the special receptors in the brain. This reduction in dopaminergic nerve signals then leads to the symptoms of Parkinson s disease. This is where the modern Parkinson s treatment begins, and tries to compensate for this deficit. 15

18 In order to stimulate the orphaned dopamine receptors, two methods in particular are selected: On the one hand, Parkinson s patients can take a dopamine precursor, called L-Dopa. This is absorbed by the body, reaches the brain and is there converted into the active carrier substance dopamine, which can then attach itself to the dopamine receptors. To ensure that as much L-Dopa as possible reaches the brain and is not already degraded in the blood, L-Dopa products are combined with active substances which inhibit the degradation of L-Dopa in the blood (decarboxylase inhibitors and COMT inhibitors). Decarboxylase inhibitors and COMT inhibitors therefore optimise the L-Dopa efficacy. The MAO-B inhibitors inhibit the inactivation of the active dopamine in the brain. In the early stage of the illness, or where few symptoms are present, the administration of an MAO-B inhibitor alone can be useful in order to delay the degradation of the dopamine still being generated by the cells of the substantia nigra. Unfortunately, medication such as COMT inhibitors and MAO-B inhibitors can also exacerbate the side effects of an L-Dopa course of therapy. In modern Parkinson s treatment, what are known as dopamine agonists play an important role. These are medications which attach themselves to the same nerve contact points (receptors) in the brain as dopamine. In this way, they imitate the efficacy of the missing messen- 16

Dopamine agonist Storage vesicle with the body s own dopamine Dopamine receptors Illustration of a synapse in Parkinson s disease with a reduction in the body s own dopamine: A dopamine agonist

19 Dopamine agonist Storage vesicle with the body s own dopamine Dopamine receptors Illustration of a synapse in Parkinson s disease with a reduction in the body s own dopamine: A dopamine agonist attaches itself to dopamine receptors thereby compensating for the dopamine deficiency. ger in the brain effectively. The modern dopamine agonists, in particular, can be well tolerated and are effective, and supposedly display fewer undesirable long-term effects than L-Dopa therapy. For this reason, they are readily administered to many Parkinson s patients particularly at the onset of the condition and to those who develop the illness at a young age. The messenger imbalance which exists in Parkinson s disease can also be partially compensated for by blocking the docking sites from other carrier substances (glutamate and acetylcholine). This takes place e. g. 17

20 by means of the NMDA receptor antagonists, which can be given alone or in combination with other Parkinson s medication. Anticholinergics can also bring about an improvement in certain clinical signs such as the shaking or the excessive movement in the case of long-term L-Dopa use. What difficulties can arise during treatment for Parkinson s? 1, 7 The Parkinson s treatments currently available can therefore compensate for the dopamine deficiency in the receptors in the brain (via L-Dopa or dopamine agonists). However, as the concentration of the medication in the brain can fluctuate significantly shortly after intake, a large quantity of active substance reaches the brain, subsequently the level decreases continually unfortunately this does not happen as consistently as nature intended. It is possible that undesirable accompanying symptoms of Parkinson s treatment (e. g. movement disorders or a loss of efficacy) can be promoted by this unnatural wave-like stimulation of the dopamine receptors. The aim of modern Parkinson s treatment is, therefore, the most consistent stimulation possible of the dopamine receptors. Firstly, Parkinson s medication must therefore 18

21 be taken very regularly and a number of times daily, following a fixed schedule. Secondly an attempt is made as described to extend the duration of the efficacy of L-Dopa (or dopamine) in the brain, by delaying degradation in the body. Retard products, which do release their active substance into the digestive tract slowly, rather than abruptly, have the same objective. Even with Retard products however, fluctuations in effectiveness are often unavoidable. Various approaches, therefore, are designed to allow the body to receive the requisite Parkinson s active substance continually and consistently. Small pumps, for example, can be used to introduce the medication (L-Dopa or dopamine agonists) continuously in small Concentration of the active substance in the blood Excessive movement, nausea Hypothetical therapeutic window Impaired movement Tablet intake Time Diagram of the effective levels in the blood during tablet intake over the course of a day 19

22 doses into the small intestine or instead directly under the skin. A Parkinson s patch is another option, which affixed once daily can supply the affected patients with a dopamine agonist continuously over a period of 24 hours. Neurosurgical treatment 1, 7 Medication is currently the mainstay of Parkinson s treatment. In addition, there are other treatment approaches which could possibly play a greater role in the future. A still relatively recent, but very promising procedure is deep brain stimulation. This involves the implantation of stimulation electrodes into the affected areas of the brain, initially under local anaesthetic and then under full anaesthetic. Via a very fine wire, these probes are in contact with a small device which is implanted below the collarbone, and acts as a type of brain pacemaker. In this way, external stimuli can be transmitted to those parts of the brain which are affected by Parkinson s disease. This results in typical Parkinson s symptoms being successfully suppressed or improved by chronic stimulation of certain areas of the brain. As the method is extremely complex, deep brain stimulation has, to date, only been used in the case of Parkinson s patients in whom other therapies were unsuccessful or no longer successful. Treatment approaches to compensate for the loss of dopamine- 20

23 producing cells in the affected region by implanting stem cells are still in their infancy. Restoration of the equilibrium of the messengers in the brain is also being attempted with the help of gene therapy. Initial studies have, to some extent, already led to encouraging results, however whether this will generate actual tangible therapy options remains to be seen. Other treatment options 1, 7 The non-medicinal therapies such as physiotherapy, speech therapy or psychotherapy also have their established place in the comprehensive care of people with Parkinson s disease. Regular physiotherapy can definitively promote the mobility of the patients particularly at the onset of the condition. Specialised exercises protect against painful tension, train the sense of balance and improve fine motor skills. And with the help of special breathing and speech therapy, the speaking and swallowing disorders common in Parkinson s disease can be alleviated. In order to relieve unpleasant accompanying symptoms of Parkinson s disease e. g. tension, pain or sleep disorders, alternative therapies such as acupuncture can also help. However, whether this has also an influence on the actual symptoms of the condition is disputed. 21

Living with Parkinson s disease can be a very significant burden for many of those affected and their families, even if the diagnosis has today become far less daunting.

24 Living with Parkinson s disease can be a very significant burden for many of those affected and their families, even if the diagnosis has today become far less daunting. Mental disorders, particularly depression, are part of the clinical picture of Parkinson s disease, and should be dealt with in a targeted manner. Talk to your doctor about it! 22

25 List of sources: 1 Thümler R., Morbus Parkinson: Ein Leitfaden für Klinik und Praxis. Springer Verlag, Gerlach M., et al. Die Parkinson-Krankheit: Grundlagen Klinik, Therapie. Springer Verlag, (letzter Zugriff am ) 4 Parkinson aktuell, Ausgabe vom 5. August Parkinson aktuell, Ausgabe vom 7. Februar Parkinson J., An Essay on the Shaking Palsy, DGN-Leitlinie: idiopathisches Parkinson-Syndrom, 2016, Kurzversion 23

26 Notes: 24

28 Doctor s stamp You can get further information on the subject of Parkinson s disease from our medical service team UCBCares : Tel +49 (0) Fax +49 (0) UCBCares.DE@ucb.com Internet: DE/NU/1702/0036 UCB Pharma GmbH Alfred-Nobel-Straße Monheim

Overview. Overview. Parkinson s disease. Secondary Parkinsonism. Parkinsonism: Motor symptoms associated with impairment in basal ganglia circuits

Overview. Overview. Parkinson s disease. Secondary Parkinsonism. Parkinsonism: Motor symptoms associated with impairment in basal ganglia circuits Overview Overview Parkinsonism: Motor symptoms associated with impairment in basal ganglia circuits The differential diagnosis of Parkinson s disease Primary vs. Secondary Parkinsonism Proteinopathies: