Doctor, my husband walks very slowly but I thought it was just part of ageing. Until recently he had a few falls which made me think twice. Is there anything wrong with him?Madam L, a lady in her 60s brought her husband Mr L to my clinic. He walked in unassisted but his daughter cautiously walked beside him.
Mr L, also in his 60s, took small steps, with each feet barely lifted from the ground. He was trying his best to walk normally yet his back was slightly stooped and his left arm looked stiff. He took some time to get to the chair next to my desk.
After some questioning, Madam L revealed her husband seemed to be moving slower this past year. The family also noticed that he took longer to bathe, dress or get ready. Mr L admitted facing some difficulty in dressing and needed to sit on a chair to wear his pants as he felt imbalanced when attempting to wear them while standing.
These are some of the typical symptoms consistent with Parkinson’s disease, a disease affecting the nervous system.
An estimated 10 million people worldwide suffer from Parkinson’s. It is the second most common neurodegenerative disorder after Alzheimer’s disease and it affects 1% of people above the age of 60.
It may also affect younger individuals as approximately 4% of people with Parkinson’s are diagnosed before age 50.
It is a slow progressive nerve cell degeneration disease causing a fall in dopamine levels in the brain.
Dopamine is a brain chemical that is responsible for brain cell signal transmission. Lack of dopamine contributes to most of the Parkinson’s symptoms, consisting of both physical features (motor symptoms) and non-visible features (non-motor symptoms). These symptoms develop and progress gradually.
Mr L also explained that his writing is smaller and cramped to the point that his signature was declined by the bank.
Recently, he experienced difficulty getting up from the chair and turning in bed at night. This distressed him as his back was hot and drenched with sweat.
The daughter, who came back from Australia to visit him, said Mr L had reduced facial expression and a softer voice compared to eight months ago. He also wore a mask-like, stiff facial expression.
Madam L was doubtful when I explained to the family regarding my initial suspicion of Parkinson’s, as Mr L did not have any hand tremors.
That is the general misconception – not all Parkinson’s patients have shaky hands or tremors, as Parkinson’s may present in many ways. Mr L is a typical example.
Parkinson’s patients may have some of the motor symptoms, including tremors, limb or body stiffness, slow movement and imbalance.
The physical or motor signs in Parkinson’s are just the tip of the iceberg as there are non-motor features that may precede five to 10 years before the onset of motor or physical features.
I remember JT who came with her husband. She was concerned about her hand tremors but upon questioning, she had been talking, shouting and having violent dreams for more than 10 years.
Her husband was slightly bruised in one incident when she kicked him in the middle of the night.
JT had Parkinson’s with a sleep disorder called RBD (REM sleep Behaviour Disorder). It is a phase in sleep where REM (Rapid Eye Movement) and dreams occur. In Parkinson’s patients, their dreams appear to be intense and they tend to act out their dreams, resulting in personal or spousal injury.
I have seen more hazardous conditions where patients fell from the bed and fractured their hip or skull when RBD was not treated. They may have other sleep disorders like insomnia or excessive daytime sleepiness.
Not all non-motors symptoms are violent as some features may be subtle like reduced sense of smell, constipation, urinary incontinence, anxiety, depression, memory decline and monotonous speech.
Challenging to diagnose
The diagnosis of Parkinson’s is a challenge as there is no lab investigation or imaging to confirm it.
Parkinson’s is a clinical diagnosis. It takes a constellation of symptoms to diagnose Parkinson’s; patients generally exhibit slow movement (bradykinesia), limb stiffness (rigidity) and involuntary shaking hands or legs (resting tremor).
Many people think that the signs of Parkinson’s are normal signs of ageing. Thus, they suffer silently and delay seeking treatment.
Even though there is no cure for Parkinson’s, there are treatments that aim to control symptoms and improve quality of life.
It can be treated with medicines, surgical therapy and rehabilitation.
Parkinson’s medications consist of both oral and other forms like a skin patch or infusion therapies that deliver medication through the skin via a pump.
The aim is to replace the depleted dopamine levels to improve both motor and non-motor functions. The treatment of Parkinson’s needs to be tailored individually as patients may show different responses or side effects. Thus, it is advisable to seek treatment with a neurologist trained in managing Parkinson’s.
There are also surgical options and advanced therapeutics with modern devices like deep brain stimulation (DBS) for symptomatic control.
DBS is a medical device implanted in the brain via surgery. It helps send signals to the brain to modify movements. With the help of advanced therapeutics, there can be better regulation of Parkinson’s symptoms and less dependence on medications.
Parkinson’s patients will also benefit from physiotherapy, occupational therapy and speech therapy. Some of the aspects that needs special attention include balancing, gait training, posture correction, fine motor skills for activities of daily living and speech training.
These also include exercises to improve muscle strength, agility and stability. Interestingly, new evidences show that some leisure activities can actually help improve Parkinson’s symptoms.
Activities like dancing, cycling, tai chi and non-contact boxing are encouraged as they show good results and provide extra benefits like reduced falls, improved balance and coordination.
As Parkinson’s greatly affects the patient’s psychosocial well-being, it is of utmost importance to have a strong family or social support to help them face these challenges in life. Joining a support group may help patients better understand and cope with Parkinson’s. Such support groups include The Malaysian Parkinson’s Disease Association and The Penang Parkinson’s Disease Association.
Parkinson’s patients are encouraged to stay active and maintain a healthy, balanced diet rich in vitamins, fibre and fluid to help them stay energised and relieve constipation, which is a common problem in people with Parkinson’s.
Adequate hydration is important to prevent dehydration as Parkinson’s patients frequently experience low blood pressure that may cause dizziness or falls.
There is no need to consume supplements as there is no strong evidence to prove that supplements help in Parkinson’s symptoms or slow down disease progression.
Instead, try to actively exercise and participate in sports as plenty of evidence suggests that moderate intensity exercises help relieve symptoms.
Stay positive and take it easy. Parkinson’s symptoms can get worse when one is anxious or stressed.
Mind over body matters much in Parkinson’s. Better outcome is expected if medication works in sync with optimism.
Many people fail to understand that Parkinson’s is not the end of the world. Parkinson’s should be viewed like any other chronic diseases such as hypertension or diabetes mellitus.
It is a slowly progressive neurodegenerative disease that will not typically worsen overnight. In fact, with adequate treatment, most Parkinson’s patients will be able to live a near normal life.
They should never limit themselves or set unnecessary boundaries as maintaining an active lifestyle is the key to improving agility and motor function.
Dr Tan Kenny is a physician and neurologist with a subspecialty in Parkinson’s disease and movement disorders. For further information, email email@example.com. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.