Parkinson’s

Parkinson's disease is a chronic and progressive disorderIts evolution is highly variable and difficult to predict, with a life expectancy of 10-15 years from the onset of symptoms. In most cases the onset is slow and the course progressive. Risk factors for a rapid progression of the disease are late onset, the presence of and the predominance of stiffness and difficulty of movements. The mortality is between 2 and 5 times higher than in healthy people of the same age, and death is usually due to other causes, mainly complications such as aspiration pneumonia, pressure ulcers, falls, etc.

Causes

Its etiology is unknown and probably multifactorial. Genetic and environmental factors, oxidative damage, and accelerated brain aging may be involved. It has the same race and sex distribution. The mean age of onset is around 55 years, although there are early forms of the disease (5-10% of patients are less than 40 years old).

Symptoms

Sometimes its diagnosis is difficult, due to its course. Its onset is usually unilateral although later it becomes bilateral. The guiding symptoms are:

• Shaking. It is the first symptom in 75% of cases. It is characterized by being at rest, although it sometimes occurs when maintaining a posture, is wide, disappears with sleep and worsens in stressful situations. It affects the hands (coin count), feet, face (rabbit grimace), jaw and tongue muscles.
• Bradykinesia (slowing of movements), akinesia (difficulty in movement) and hypokinesia (reduced range of movements). It mainly affects the face and limb muscles, making it one of the most disabling symptoms. It is responsible for the difficulty or blockage to start some movements such as walking or turning in bed, as well as the micrograph, difficulty in buttoning the buttons, monotonous tone of voice, etc.
• Rigidity. Caused by increased tone, it leads to greater resistance to passive movement of the affected limb ("cogwheel stiffness").
• Likewise, the following can be objectified:
  • Alteration of postural reflexes.
  • Impairment of stability and balance, walking leaning forward on the shoulders and head, causing frequent falls.
  • Cognitive and neuropsychiatric disorders: cognitive impairment and dementia, depression, anxiety and panic attacks, hallucinations and psychosis.
  • Sleep disorders.
  • Speech and swallowing disorders.
  • Sensory disorders: restless legs syndrome, peripheral neuropathy.
  • Autonomic disorders: constipation, genitourinary disorders, orthostatic hypotension, alterations in thermoregulation, smell and sweating, pain, seborrhea and blepharitis.

Diagnosis

Its diagnosis is exclusively clinical. There is no biochemical marker to guide diagnosis. The determination of genetic tests would be indicated only in familial forms of Parkinson's disease.

Neuroimaging techniques can be used, such as computerized axial tomography (CT), magnetic resonance imaging (MRI), and other techniques for the differential diagnosis of idiopathic high school Parkinson's disease, which can also be performed with a correct clinical evaluation .

The differential diagnosis should be made with the following pathologies:

• Atypical parkinsonism, mainly in the initial stages of the disease: degenerative diseases such as Alzheimer's dementia or Lewy body disease.
• Secondary Parkinsonisms:
  • Drugs: antipsychotics, methochlorpamide, cinnaricin, amiodarone, lithium, alpha-methyldopa, serotonin reuptake inhibitors, acetylcholinesterase inhibitors, etc. It is usually transitory.
  • Cerebrovascular disease
  • Infections (viral encephalitis, HIV-associated infections, etc.).
  • Toxic substances (carbon monoxide, methanol, alcohol, etc.).
  • Repeated brain trauma (boxers).
  • Tumors
  • Hydrocephalus
  • Chronic subdural hematoma.

Treatment

Treatment requires a multidisciplinary and individualized approach so that it begins when there is a certain degree of functional impairment, although the exact moment depends on factors such as severity, functional disability, age, cognitive impairment, comorbidity, problems psychosocial and what the patient expects from treatment. There is no cure or prevention, but you can get control of most of the problems it causes.

Regarding drug treatment, in those over 70 years of age, L-dopa it continues to be the basis of it, starting with the lowest possible dose due to the higher frequency of adverse effects (hallucinations, postural hypotension, delirium, gastrointestinal problems). Subsequently, the dose should be progressively increased. Improves almost all symptoms of the disease although tremor and gait disturbances improve to a lesser degree. It does not stop the progression of the disease, despite the symptomatic improvement, being only a palliative treatment.

Among the rest of the therapeutic arsenal, there are other groups of drugs such as dopamine agonists and COMT inhibitors. They are of minor importance, although they can be used to delay the onset or improve the side effects of L-dopa. Regarding anticholinergics, they should be avoided routinely in the elderly due to their side effects, except as a therapeutic attempt in the presence of very disabling tremor or dystonia.

The surgical treatment, through stereotaxic surgery and chronic stimulation of certain encephalic nuclei with deep brain stimulators, and in the future surgery with various types of cell implants, are therapeutic options, not without risks, which are still under development and with some very specific indications.

The rehabilitation and maintenance of physical activity They are an essential essential complement to medical treatment, to fight against the decrease in physical activity, stiffness and its consequences, although it has no effect on tremor.

Important

Apart from specific preventive treatment of complications and secondary symptoms, that of the parkinsonian elderly and their caregivers is essential, especially in the advanced stages of the disease. In this sense, the collaboration provided by the Parkinson's associations, the Spanish Parkinson's Federation, social assistance and the different support groups is very useful.