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Parkinson's disease

This factsheet is for people who have, or would like information about, Parkinson's disease.

Parkinson's disease is a movement disorder caused by a shortage of chemical transmitter (dopamine) in the brain. People with Parkinson's disease develop stiffness, tremors and slow movement that can become worse over time.

• What causes Parkinson's disease?
• How common is it?
• Why do people get Parkinson's disease?
• Symptoms
• Diagnosis
• Treatment
• Living with Parkinson's disease
• Further information
• Sources

What causes Parkinson's disease?

Parkinson's disease is caused by the loss of brain cells that produce a chemical called dopamine, resulting in low levels of the chemical in the brain. Dopamine is a chemical messenger, or neurotransmitter, involved in passing messages within the brain and from the brain to the muscles. The part of the brain affected is called the substantia nigra, which co-ordinates movement.

The level of dopamine in the brain is linked with the levels of other chemicals, including one called acetylcholine. Low levels of dopamine and changes in other chemicals, including acetylcholine, cause the symptoms of Parkinson's disease.

How common is it?

Around one to two percent of people over 65 have Parkinson's disease. Most people with Parkinson's disease develop the condition at around the age of 65, but five to 10 percent of people with the condition started getting symptoms before the age of 40.

Why do people get Parkinson's disease?

No one knows why some people get Parkinson's disease, but genetic factors seem to have a role. People who have a parent or a brother or sister with the condition are twice as likely to get it. In a small number of people with Parkinson's, the disease is inherited.

Certain chemicals in the environment that might be harmful to the brain, called neurotoxins, have been linked to Parkinson's disease. It's possible that people who are exposed to more of these neurotoxins are more likely to develop the condition. Doctors need to do more research on possible environmental risk factors for Parkinson's disease.

Symptoms

The symptoms of Parkinson's disease often start on one side of the body first and then affect both sides. The main symptoms are as follows.

• Shaking (muscle tremor). This is one of the first symptoms in three-quarters of people, and affects most people with Parkinson's disease. It often starts in the hand with circular movements in the thumb and forefinger. It can affect your arms, legs, and sometimes your head and jaw. The tremor is most obvious when you are at rest, and reduced when you are moving or sleeping.
• Stiffness (rigidity). This makes your limbs feel difficult to move.
• Slowness. Slow movement or an inability to move are common in people with Parkinson's disease. Walking may start with a hesitant step, followed by a shuffle without swinging the arms.

As different muscles become affected, symptoms that can develop include:

• problems with posture and balance - people with Parkinson's disease may fall backwards and have difficulty turning or getting out of a chair
• speech changes - speech may become soft or unvaried
• loss of facial expression - less smiling and frowning, slow blinking
• small handwriting
• problems with swallowing

Other symptoms that can develop are not related to movement. These can include:

• depression - around half of people with Parkinson's disease develop mild to moderate depression
• bowel and bladder problems - constipation is common and there may be a frequent need to urinate
• impotence
• sleep problems
• tiredness

Diagnosis

There is no single test for Parkinson's disease. Your GP will refer you to a specialist, such as a neurologist, if he or she thinks that you have Parkinson's disease.

Diagnosis is based on you having the symptoms described above and by ruling out other conditions that cause similar symptoms. This may be done with a scan called a SPECT (single photon emission computed tomography).

Symptoms similar to Parkinson's disease - known as parkinsonism - can be a side-effect of some medications, such as anti-sickness drugs and drugs used in the treatment of mental illness. If this is the case, changing the medication should reduce symptoms.

Once a diagnosis has been made, you should see your specialist every 6 to 12 months for a review.

Treatment

Treatment with drugs is aimed at restoring the levels of dopamine in the brain and controlling symptoms. The symptoms and progression of Parkinson's disease are different for each person. Drugs are prescribed depending on your individual needs.

There are several types of drugs available.

• Drugs that replace dopamine are the most effective treatment. These drugs are combinations of levodopa, which breaks down in the body to form dopamine, and a chemical that ensures there is the right amount of dopamine in the brain. They are effective at treating symptoms and can provide long-term improvement, although there are some side-effects. These include nausea, dizziness and constipation. Also, they can cause long-term problems such as unwanted movements of the face and limbs (dyskinesia) and they may become less effective over time, with symptoms fluctuating suddenly - often called the on-off syndrome.
• Drugs that mimic the action of dopamine are commonly taken together with levodopa. Or they may be taken alone before using levodopa to reduce the long-term side-effects of levodopa. Side-effects of dopamine agonists can include confusion, sickness and hallucinations. Examples include bromocriptine and cabergoline (Cabaser).
• COMT (catechol O-methyl transferase) inhibitors are a new class of drugs that stop the breakdown of dopamine. These are used with levodopa and are usually given when dopamine replacement drugs start to lose their effectiveness. They can affect bowel liver function. Blood tests are needed to check liver function. Examples include entacapone (Comtess).
• MAO-B inhibitors prevent the breakdown of dopamine. This can improve symptoms and delay the need for levodopa or allow a lower dose of levodopa to be used. Low blood pressure and irregular heartbeat are the most significant side-effects. Examples include selegiline (eg Eldepryl).
• Amantadine acts like a dopamine replacement drug but works on different sites in the brain. It has few side-effects, but can cause sedation at high doses. It is only mildly effective at improving symptoms.
• Anticholinergic drugs block the action of the brain chemical acetylcholine. These help to correct the balance between dopamine and acetylcholine. Side-effects can include dry mouth, constipation and blurred vision. Doctors no longer prescribe these drugs often, because they are less effective than the drugs that replace dopamine. They are not usually used in people aged over 70 as they can cause memory loss, and urine retention in men. Examples include procyclidine.

Surgery

Your doctor may recommend surgery if drugs are no longer helping. A device called a deep brain stimulator can improve the symptoms of Parkinson's disease. A surgeon inserts a pulse generator under the skin in the chest, and a wire runs under the skin from the pulse generator to the brain. Tiny electrical currents sent from the pulse generator to the brain can reduce the symptoms of Parkinson's disease in some people.

Other therapies

Other therapies that are important for managing and coping with Parkinson's disease include physiotherapy, speech therapy, and occupational therapy.

You will be cared for by health professionals who have a range of different skills. They will make sure you have access to therapies that are right for your stage of disease.

Future treatments

Treatments that are at an experimental stage and may one day become available include:

• gene therapy, where normal genes will be directly delivered to the brain to help prevent the death of brain cells
• stem cells, which can develop into different types of cells, could be transplanted into the brain to repair and renew brain cells

Living with Parkinson's disease

A diagnosis of Parkinson's disease can be very upsetting. Most people stay reasonably active, and symptoms may progress no further than a slight tremor. However, some people do become debilitated, needing help with washing, eating and dressing. With proper treatment, people with Parkinson's disease can have a normal life expectancy.

Further information

• Parkinson's Disease Society
  0808 800 0303
  www.parkinsons.org.uk

Sources

• Parkinson's Disease - Diagnosis and Management in Primary and Secondary Care. NICE, 2006, Clinical Guideline no 35.
  www.nice.org.uk
• Simon C, Everitt H, Kendrick T. Oxford Handbook of General Practice. 2nd ed. Oxford University Press, 2006
• Parkinson's disease. PRODIGY Guidance.
  www.prodigy.nhs.uk
  accessed 11 December 2006
• Deep brain stimulation for Parkinson's disease, NICE, 2003, Interventional Procedure Guideline no 19.
  www.nice.org.uk
• British National Formulary 52. 2006.
  www.bnf.org

Reviewed by Dr James Quekett, Bsc.MB Ch.B MRCGP DRCOG DFFP, partner/principal general practitioner at Rowcroft Medical Centre.

Published by BUPA's health information team, healthinfo@bupa.com, March 2007.

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