Parkinson's Disease: Clinical Update, Diagnosis, and Treatment

This clinical update provides a comprehensive overview of Parkinson's disease, a progressive neurological condition characterized by motor impairments. The report delves into the aetiology and pathogenesis, discussing causes and risk factors such as genetics, environmental exposure, and aging. It examines the pathology, including the anatomical progression of the disease, the formation of Lewy bodies, and the impact on various brain structures. Clinical manifestations, including tremors, bradykinesia, muscle rigidity, and postural instability, are detailed. The diagnostic process, involving general practitioners, neurologists, and mental health nurses, is explored, along with various diagnostic tools. The report also covers pharmacological and non-pharmacological treatments, including dopamine agonists, Sinemet, and exercise therapy. Public health implications, such as the increasing prevalence due to an aging population, are discussed, emphasizing the need for improved workforce capacity and medical resources. The update concludes by highlighting the importance of comprehensive care and multidisciplinary approaches in managing Parkinson's disease.

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Table of Contents
Clinical Update: Parkinson’s Disease......................................................................1
Introduction..............................................................................................................1
Discussion................................................................................................................1
Aetiology and Pathogenesis.................................................................................1
Causes and Risk factors...................................................................................1
Pathology: Anatomical Progression.................................................................3
Complications and Public Health Implications................................................4
Clinical Manifestations........................................................................................5
Diagnostic Process...............................................................................................6
Treatment.............................................................................................................7
Pharmacological Implications..........................................................................7
Non-Pharmacological Treatement...................................................................8
Health Promotion.............................................................................................8
Conclusion...............................................................................................................9
References..............................................................................................................10

Clinical Update: Parkinson’s Disease
Introduction
Parkinson’s disease is progressive neurological condition associated with impairments
in the motor movements across individuals (Cookson, 2017). In Australia, Parkinson’s
disease is regarded as one of the most common neurological disorders associated with
impaired movement with approximately 81, 000 to 111, 000 Australians living with the
condition in the nation. It has been further estimated that with increasing rates of ageing in
Australia, the prevalence rate of individuals with the condition is likely to increase by 4%
within the next 2 decades (Parkinson's Australia, 2019). The Australian Bureau of Statistics
(ABS, 2019) further denote that Parkinson’s disease contributed to almost 20.2% of deaths
across the elderly in the year 2012, which calls for the need to evaluate and implement
essential components of preventive and therapeutic interventions to ensure health and
wellbeing.
The following paper will demonstrate on the key clinical updates and insights relevant
to the neurological condition of Parkinson’s disease, that its pathology, anatomical
progression, clinical manifestations, public health implications, diagnostic processes and
treatment interventions.
Discussion
Aetiology and Pathogenesis
Causes and Risk factors
Parkinson’s disease is associated with a gradual damage and atrophy of cerebral
neurons, which further results in a reduction in dopamine – an essential neurotransmitter
responsible for transmission of neuronal messages and impulses across the nerve cells
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(Tysnes & Storstein, 2017). When dopamine decreases, the transmission of nerve impulses
associated with motor movements decreases hence resulting in the characteristic tremors and
delayed dexterity in Parkinson’s disease. The reasons for such neuronal damage is relatively
unknown (Ascherio & Schwarzschild, 2016). However, the following environmental and
genetic factors have been implicated to be plausible causes of Parkinson’s.
Family history and genetics: An individual with a family history of the condition, is
suscpetible of developing the same in later life. Additionally, Parkinson’s has also been
considered to be caused to the presence of specific genes. It has been evidenced that an
individual with parents having the PRKN, PINK1 and PARK7 genes, is likely to inherit the
condition in an autosomal recessive manner. Mutations in genes like the PARK7, LRRK2,
PRKN, PINK1 and SNCA genes have been implicated to cause Parkinson’s disease (Lill,
2016). In criticism however, it has been evidenced by Pickrell and Youle (2015), that
mutations may not be inherited.
Environmental causes: A risk of Parkinson’s disease has been evidenced to be linked to
high exposure to toxins prevalent in pesticides and herbicides (Bellou, Belbasis, Tzoulaki,
Evangelou & Ioannidis, 2016). In criticism however, as evidenced by Delamarre and
Meissner (2017), the possibilities of such environmental causative links have been evidenced
to be rare.
An individual is likely to suffer from Parkinson’s disease is he or she is in possession of
the following risk factors:
Old age: Elderly individuals, belonging to the age group of 65 or above, are at
increased risk of acquiring the condition. This is due to the fact that ageing is associated with
increased inflammation and wear and tear associated loss of neuronal structure and nervous
system functioning (DeMaagd & Philip, 2015).
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Family history and heredity: An individual with a family history of Parkinson’s is
likely to acquire the disease in later life. However, in criticism it has been evidenced that such
risks are rare and only possible if a large number of individuals in the same family have been
inflicted with the condition (Gaare, Skeie, Tzoulis, Larsen & Tysnes, 2017).
Gender: Males have been evidenced to pose a higher susceptibility to acquire the
disease in comparison to females (Emamzadeh & Surguchov, 2018).
Toxin and environmental exposure: An individual encountering a prolonged and
chronic exposure to toxins like pesticide and herbicides are likely to have a higher risk if
acquiring the condition (Verma, Raj, Sharma, Singh, Srivastava & Srivastava, 2017).
Pathology: Anatomical Progression
The primary pathological process underlying Parkinson’s disease is the deposition of
aggregates of α-synuclein which results in the formation of Lewy bodies, lamellated and
round eosiniphillic inclusions in the cytoplasm of the neuronal bodies and Lewy neurites of
insoluble polymer fibrils comprising of α-synuclein (Carboni & Lingor, 2015). Such toxic
accumulations in the oligodendroglial cells and astrocytes of the substantia niagra causes
damage to the endoplasmic reticulum, mitochondrial and lysosomal structures of neuronal
bodies resulting in their atrophy and decrease in dopamine secretions (Onyango, Khan &
Bennett Jr, 2017).
As per the Braak’s hypothesis, researched by Rietdijk, Perez-Pardo, Garssen, van
Wezel and Kraneveld (2017), the key anatomical structures prevalently impacted by
Parkinson’s disease progression include the substantia niagra, the cerebral cortex, the
medulla, the olfactory bulb and the enteric nervous system. This theory necessitates the
importance of non-motor abnormalities like sleeping and olfactory sensory losses as key
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diagnostic cues of the disease prior to well-known motor symptoms (Engelender & Isacson,
2017). Parkinson’s disease is evidenced to progress in the following stages (Pasquini et al.,
2018):
Stage one: Individuals report localized and mild tremors and alterations in posture,
facial expression and walking which do not impact daily life significantly.
Stage two: Individuals now find it increasingly difficult to engage in daily activities as
symptoms of tremor and rigidity in posture and movement increase to other parts of the body.
Stage three: Individuals lose balance and are likely to encounter falls and slowing of
movement thus impairing daily activities.
Stage four: Progressive worsening of the above symptoms resulting in an inability to
live alone and independently.
Stage Five: Complete loss of movement with significant cognitive abnormalities like
delusions, incoherent speech and hallucinations.
Complications and Public Health Implications
An individual impacted by later stages of Parkinson’s is likely to lose normal cognitive
functioning and be affected with secondary diagnosis of cognitive impairment and dementia
resulting in an inability to undertake daily tasks involving logic, reasoning and decision
making (Picconi, Hernández, Obeso & Calabresi, 2018). Impaired sensory and motor
functioning in Parkinson’s also hinders an individual’s capability to execute activities of daily
living like eating, toileting, personal hygiene, sleeping, bathing or even grooming (Lopez,
Weintraub & Claassen, 2017). The affected individual is also likely to encounter frequent
episodes of depression and mood fluctuations. Such complications call for the need to
provide comprehensive multidisciplinary care in order to provide complete assistance for
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people affected with Parkinson’s which may in turn exert financial difficulties and emotional
upheavals upon the concerned family (Bjornestad, Forsaa, Pedersen, Tysnes, Larsen & Alves,
2016).
Likewise, Australia has a rapidly ageing population with an estimated 15% of the
Australian population comprising of person who are 65 years and older a reported by the
Australian Institute of Health and Welfare (AIHW, 2017). Such rates are estimated to
gradually increase in the succeeding years implying and increased susceptibility of the
population to acquire neurodegenerative complications like Parkinson’s in the future. Such
rates demonstrates a public health challenged and implies the need for government and public
health institutions to immediately improve upon the existing clinical and public heath
workforce capacity and national medical revenue (Cabreira, Soares-da-Silva & Massano,
2019).
Clinical Manifestations
The major clinical signs and symptoms include the following (Fereshtehnejad,
Romenets, Anang, Latreille, Gagnon, & Postuma, 2015).
Tremors: Patients are prevalently found to demonstrate shaking and tremors across
their limbs, especially in fingers and hands. Such tremors are observed in hands are at rest or
during any movement, such as holding an object.
Bradykinesia: With gradual progression, Parkinson’s is associated with a slowing,
difficulty and delaying of simple movements. This means that patients may find it
increasingly difficult take quick or large steps during walking or lifting themselves from a
chair or will tend to engage in dragging their feet for movement,
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Muscle Rigidity: Patients may gradually encounter stiffening in their legs and fit
which makes it painful for them to move and hence limits their range of motion.
Impairment in balance and posture: Due to difficulties in movement and motion,
patients face difficulty to maintain balance or gradually be observed to stoop in their
postures.
Movement disturbances: Patients with Parkinson’s disease will face difficulty to
conduct simple, everyday movements conducted unconsciously such as smiling, blinking or
moving their arms during walking.
Alterations in speech and writing: Individuals with Parkinson’s disease will be found
to demonstrate alterations in writing where their handwriting will appear small and cramped.
Alterations in speech will also be observed such as softening, slurring, hesitations or
fumbling and lack of speech variations and inflections.
Diagnostic Process
Individuals are likely to first engage into a discussion with their general practitioner
followed by a referral to the geriatrician who may also work collaboratively with a
neurologist. To assess the presence of cognitive, sensory and mental health issues within the
patient, the mental health nurse may conduct a mental state examination (MSE) within the
concerned patient presenting with Parkinson’s disease symptoms (Bhat, Acharya, Hagiwara,
Dadmehr & Adeli, 2018).The loss of essential neurotransmitter and nerve impulse
functioning along with Lewy body deposition in the brain can result in difficulties in
cognitive, speech, reasoning and decision-making activities within the individual with
Parkinson’s, which is why an MSE must be conducted (Nalls et al., 2015).
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While specific diagnostic processes have been identified for Parkinson’s, geriatric
nurses in collaboration with the neurologist and geriatrician may conduct a comprehensive
and holistic assessment comprising of past medical and family history, presentation of current
symptoms and recent incidence of exposure to toxins of the environmental or pharmaceutical
type (Mostafa et al., 2019). The neurologist with assistance from the mental health nurse may
conduct a neurological investigation to identify and measure the scale of muscle rigidity,
prevalence of tremor, bradykinesia and loss of balance within the individual. Prevalent
examples of these include the Hoehn and Yahr Stages Rating Scale and the Unified
Parkinson’s Rating Scale (Gupta, Sundaram, Khanna, Hassanien & De Albuquerque, 2018).
A number of conditions are evidenced to mimic the symptoms of Parkinson’s disease.
These include: dementia with Lewy bodies, multiple system atrophy, normal pressure
hydrocephalus, age associated essential tremor, corticobasal syndrome and progressive
supranuclear palsy (Rizzo, Copetti, Arcuti, Martino, Fontana & Logroscino, 2016). It is for
this reason, the neurologist may be required to conduct additional assessments to ensure to
rule out chances that such diseases may be contributing to Parkinson’s like symptoms in the
patient, which include (Heim, Krismer, De Marzi & Seppi, 2017):
Computer tomography to detected abnormalities in cerebral structure mimicking
symptoms of Parkinson’s.
Magnetic resonance imaging to detect the presence of neurological abnormalities
which may mimic Parkinson’s.
A metaiodobenzylguanidine (MIBG) scan for assisting in differential diagnosis
between Parkinson’s and dementia with Lewy bodies.
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Treatment
Pharmacological Implications
Considering that Parkinson’s results in losses of dopamine, dopamine agonists, which
replicate the functions of dopamine can be given, and hence assists patients in controlling
tremors and postural rigidity in Parkinson’s (Politis, Wilson, Wu, Brooks & Piccini, 2017).
While dopamine agonists like ropinirole, pramipexole, apomorphine and rotigotine provide
short term relief, they have been evidenced by Patel et al., (2017), to causes adverse effects
like excessive sleep, compulsive reckless behaviors ad hallucinations and thus, are not
considered the first line of treatment.
Sinemet, or carbidopa-levodopa, is a combination of two drugs and the most prevalent
pharmacological intervention for Parkinson’s disease. Levodopa undergoes conversion to
dopamine after surpassing the blood brain barrier and thus improves symptomatic
management of Parkinson’s (Espay et al., 2017). Due to side effects of nausea and orthostatic
hypotension, levodopa is administered along with carbidopa, in a ratio of 4:1 or 10:1, thrice a
day, respectively which counter these consequences and prolong the effects of levodopa
(Senek et al., 2017).
Non-Pharmacological Treatement
Occupational therapy and exercise, such as stretching and mild aerobic or strength
training have been evidenced to be effective non-pharmacological treatments which can
improve balance, strength, flexibility, posture and rigidity in Parkinson’s patients and hence
enhance wellbeing and quality of life (Paillard, Rolland & de Souto Barreto, 2015).
Additionally, consumption of a diet rich in antioxidants and particularly B vitamins have
been recommended as non-pharmacological strategies beneficial for reversing the harmful
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impact of age-associated inflammatory mechanisms on the brain and the cerebral cortex
(Barichella et al., 2017). However, in criticism, as evidenced by Cassani et al., (2017), there
remains little conclusive and valid evidenced based research which can scientifically justify
the benefits of the above interventions. Further, as researched by Chen (2016), considering
the reduced digestive and physiological capacities encountered during old age, the impact of
diet and exercise on the elderly with Parkinson’s remains questionable.
Health Promotion
Upon diagnosis, it is likely that an individual and their family with respond to the same
with fear, depression, stress, anxiety as well as concern for financial and social assistance
(Chlond, Bergmann, Güthlin, Schnoor, Larisch & Eggert, 2016). The geriatric nurse and
mental healthcare team must seek to comfort the patient and their family, and educate them
regarding the disease and relevant options for policy and financial assistance using patient
and family centered approaches (Boersma et al., 2016). Likewise, patients, maybe referred by
the neurologist to relevant support groups where individuals under the same age and
neurological condition can provide relevant mutual support and coping strategies (Aghaei,
Karbandi, Gorji, Golkhatmi & Alizadeh, 2016).
Considering the motor impairments exerted by the disease, it is likely that individuals
are susceptible to acquire injuries from falls. Patients and families should hence be educated
on the importance of falls prevention strategies like constant monitoring by family,
installation of bars and adequate lighting and removal of clutter and home to prevent slips
and trips (Lamont, Morris, Menz, McGinley & Brauer, 2017).
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Conclusion
Thus, this paper provides information on the clinical aspects underlying the
management of Parkinson’s disease. Rgistered nurses must strive to work collaboratively to
work with other health professionals for the purpose of delivering a comprehensive and
holistic multidisciplinary care to the patient. To conclude, educating the patient as well as
associated family members and the public on disease management and importance of non-
pharmacological as well as pharmacological interventions for the achievement of positive
health outcomes is an essential nursing intervention registered geriatric nurses must adhere
to.
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