PARKINSONS DISEASE

Submitted To: Mrs. Michelle Demape Submitted By: Sy, Cionelle Pauline Tan, Renee Angeli Tiu, Philip Timothy Tomimasu, Eris Uykingtian, Marc Francis Veraque, Ma. Fuerza Juris Ygay, Anwin Goebel

INCIDENCE Parkinsons Disease is one of the most common adult-onset degenerative neurological disorders. 3 classic symptoms: tremor (at rest), bradykinesia and rigidity. Incidence increases with age. At 55-74 yrs old, men > women After 74 yrs old, men < women. Etiology Often defined as a Parkinsonian Syndrome that is idiopathic. Family history is a (+) risk factor, with mutation in chromosome 4. Environmental factors such as: narcotics using 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP), manganese and hydrocarbons. Diet is also a risk factor: diet containing high in animal fat, while incidence is inversely related to diet high in nuts, legumes, and potatoes.

PATHOPHYSIOLOGY PD -associated with the substatia nigra, specially the pars compacta portion. -the pars compacta receives input from other basal ganglia nuclei and appears to serve as a modulator of striatal activity. -substantia nigra serves as one of the major output nuclei for the basal ganglia to other structure -as the disease progress, the substantia nigra nuclei undergo significant deterioration. 30-60% degeneration of neurons S. nigra cell loss is estimated at 10% per year and is more prevalent in the ventral cell group Significant reduction in dopaminergic neurons in substantia nigra par compacta produces a decrease in activity w/in the basal ganglia and an overall reduction in spontaneous movement: Tremor is viewed as a release phenomena, representative of loss of inhibitory influences w/in the basal ganglia Loss of dopaminergic neurons, intracytoplasmic inclusionos are found on postmortem examination w/in the substantia nigra. Cytoplasmic inclusion aka lewy bodies Deterioration is also seen in the locus cerulues, nucleus basilis, and hypothalamus

S.nigra pars compacta D1 striatum D2 Globus pallidus ext.

indirect
Subthalamic nucleus

Globus pallidus int

thalamus

cortex

CLINICAL PICTURE Parkinsons disease is characterized as a slowly progressive, degenerative movement disorder. Diagnosis: after age 55, may live an additional 20 to 30 years, with a progressive loss of motor function that eventually requires a specialized care. Dysfunction: Both voluntary and involuntary movements. Classic triad of symptoms: Tremor Rigidity Voluntary movement disorder Disturbance in voluntary movement: Difficulty initiating movement (akinesia) Clowness in maintaining movement (bradykinesia)

Rigidity - is the stiffness within a muscle that impedes smooth movement, occurs in both directions for each plane of motion at a specific joint. Resting Tremor - is the disturbance of involuntary movement often diminishes with activity but sometimes persists during performance of functional activities. Additional symptoms: o o o o o Disturbance of gait and postural reactions Masked face with decreased facial expressions and depression Autonomic dysfunction Dysphagia Dysarthria

Deterioration of gait is seen throughout the course of disease, may be fairly normal, but as the disease progresses, stride length decreases and speed of gait slightly increases , creating a shuffling effect. Reduced arm swing during ambulation is evident and trunk rotation decreases during walking. Freezing is a motor disturbance occurs when the person ceases to move, often after to initiate, maintain, or alter a movement pattern; may be seen as the client attempts to change direction or approach a narrow hallway or stairs, can also be seen during other motor tasks such as writing, brushing teeth and speaking. Bowel and bladder problems o reduced intestinal motility producing constipation. o Increase frequency and urgency of urination. Frequent complains of orthotic hypotension periods of sweating and abnormal tolerance of heat and cold are apparent. Speech volume decreases and is monotone. Dysphagia occurs in later stages, clients may be at risk for choking and aspiration pneumonia. Postural abnormalities associated include a flexed, stooped posture with head positioned forward. Client tends to stand with flexion at the knees and hips. A marked reduction of righting and equilibrium reactions, frequent falls. Approximately 50% exhibit depression appears to be related to a serotonergic deficit. Decrease in facial expressiveness caused by akinesia . Decrease in spontaneous facial expression (Masked-face), seen unilaterally, as progresses, decreases on both sides of the face. They tend to self-limit social interaction. Mental status: fairly normal(visual-spatial perception is often compromised) They have higher-order cognitive disorder. Difficulty shifting attention among various stimuli and processing simultaneous information are seen. Easier performance of sequential processed tasks. Approximately one third of people over 70 years old who have PD, display dementia.

Hoehn and Yahr established a scale identifying the progression of symptoms: Stage I - exhibits unilateral involvement, typically hand tremor, but no impairment of functional abilities. -Client is able to complete personal ADLs and IADLs, but often requires additional effort and energy. -Often employed but may require modifications to work site. -hand writing may become very small, with letters that are cramped together. -client also complains to muscle cramping when writing for extended periods. -Slight rigidity is seen when asked to rapidly open close the involved hand. Stage II-Progression of symptoms -Development of bilateral motor disturbances -usually seen 1 to 2 years after initial diagnosis -tremors and rigidity may be noted bilateral -Client can still perform ADL and IADL but may require modification because of motor difficulties. -Work requires additional modification and several rest breaks during the day. -Posture becomes slightly stooped, with flexion at the knees and hips. -Still able to ambulate independently. Stage III- Delayed Righting and equilibrium -Balance is impaired -Client has difficulty performing the tasks that require standing -Employment may be difficult -Safety in walking is a concern, home modifications are necessary. Stage IV-has significant deficits in completing daily living tasks -client is still able to ambulate, but motor control is merely compromised. Stage V- client is typically confined to a wheelchair or bed and depends on others for most selfcare activities. Unified Parkinsons Disease Rating Scale o o Evaluates clients motor skill, functional status and extent of disability by client interview that includes items addressing ADL skills and cognitive and emotional factors. Motor skills are evaluated by a trained observer.