Parkinson's disease is a disease that mainly affects mobility. The patient's movements are slow (up to the point of complete immobility especially in advanced stages of the disease or when the patient is in confined spaces), the muscles are stiff (rigidity) and in 90% patients a characteristic tremor (tremor) occurs in the upper and lower limbs but also on the head (lower jaw, tongue, lips), especially when it is at rest. There is usually an expressionless, "frozen" mask-like countenance, and the squeals are reduced. Speech is monotonous, prosody is lost, and voice volume is low. The patient's handwriting changes and he writes in small letters. And we say that it is "mainly" a movement disorder because the disease (as a neurodegenerative disease) also shows so-called non-motor symptoms such as pain, memory disorders that even reach dementia in the most advanced stages or some psychotic elements such as and olfactory disturbances already in the early stages. Other symptoms are cramps, depression but also a lot of anxiety, sleep disorders as well as some disorders of the Autonomic Nervous System that can become very persistent and bothersome (such as orthostatic hypotension aggravated by medication with L-Dopa).
However, the patient will resort to the neurologist mainly because of the motor symptoms of the disease. The first examination of a patient, with symptoms that he may or may not complain of, and which must be questioned or found by the neurologist, takes at least an hour. The diagnosis of the disease is purely clinical and in many cases the regular follow-up of the patient is needed for several months in order to check his response to the treatment and for the neurologist to safely enter the diagnosis of "Parkinson's disease" in the patient's file.
I believe that the diagnosis of the disease, the correct long-term planning of a strategy to deal with it as well as the complications of the drugs and the coexisting polypharmacy, but also its worsening manifestations as the disease progresses, makes Parkinson's Disease one of the most difficult and demanding diseases that the clinical neurologist has to deal with in daily practice. The patient, feeling trapped in his own body, expects a lot from the treating doctor, and so do the relatives. In such a disease, many small but also big everyday problems arise for which simple solutions must be given, which often becomes quite difficult.
The disease is also characterized by gastrointestinal symptoms such as salivation (in more than half of patients), dysphagia, nausea and constipation. Up to 25% of patients suffer from nausea and vomiting, while 45% of them complain of "bloating". These symptoms are usually quite annoying and bother the patient who takes self-relief measures, especially when it comes to constipation which can be a source of excessive stress for the patient. Dysfunctions of the gastrointestinal system, in addition to the subjective discomfort they cause, may also play a role in the weight loss experienced by sufferers. A 2012 meta-analysis by van der Marck et al. of 12 published studies and a total of 812 patients found that patients with Parkinson's disease had a lower Body Mass Index (BMI) compared to healthy controls. Low body weight and therefore low BMI is observed especially in the more advanced stages of the disease. Thus, patients who are in stage 2 of the Hoehn & Yahr scale have a BMI of around 25, while in stage 3 the corresponding index is below 22. Although it is not clear why the weight loss is caused, factors such as dyskinesia, dysphagia, hyposmia are suspected or anosmia, general anorexia and increased energy requirements.
One of the symptoms of the gastrointestinal system is dysphagia, as already mentioned. Dysphagia mainly concerns the oropharyngeal phase of swallowing - just think that a percentage of patients have tremors in the tongue, lips and lower jaw. It is known that dysphagia in general affects the quality of life of patients with Parkinson's disease and clearly increases the risk of aspiration and pneumonia. But first, how common is dysphagia? A meta-analysis by Kalf et al found dysphagia in one third of patients with the disease. Patients are three times more likely to have swallowing disorders than healthy individuals. The more advanced the disease, the greater the likelihood of dysphagia. Therefore, when a patient presents with dysphagia from the early stages of the disease, the clinical neurologist should also consider possible atypical parkinsonian syndromes. And this is because in Multiple System Atrophy (MSA) or Progressive Supranuclear Palsy (PSP) dysphagia appears in 73% and 83% respectively. Also, dysphagia in Parkinson's disease is usually milder than in atypical parkinsonian syndromes or other neurodegenerative diseases.
More rarely, dysphagia may be associated with esophageal dysfunction, such as slow passage of food through the esophagus or lower esophageal sphincter dysfunction. It is not known whether dysphagia from esophageal dysfunction is a byproduct of disease or age, and whether it has the same prevalence in age-matched nonparkinsonians. However, it is reported up to a percentage of 60-70% of parkinsonian patients according to Pfeiffer in a 2011 study.
Dysphagia in the disease can be subclinical and manifest e.g. with slow and careful chewing. Sometimes it may not be apparent due to the minimal amount of food consumed by patients. Also, they may often drink a small amount of liquid with their meal to aid swallowing. On the other hand, elderly patients, as is the case with Parkinson's Disease, may uncomplainingly accept chewing and swallowing difficulties, attributing them to old age. Clinically, dysphagia can be manifested by difficulty in the initiation of swallowing, with nasal reflux of fluids but also with frequent and annoying coughing immediately after swallowing. Patients may simply report to the doctor that they cannot swallow their medication, especially if they are off-phase during the day.
Dysphagia leading to choking and aspiration can also lead to aspiration pneumonia. In a series of 252 patients with the disease and inhalations, 10% of them developed pneumonia. And pneumonia (not specifically aspiration pneumonia) is known to be the leading cause of death in Parkinson's patients. More generally, however, there are neurological diseases and conditions that are causes of suffocation, aspiration and pneumonia. Such are vagus nerve lesions (contralateral or bilateral), myopathies and diseases of the neuromuscular synapse (myasthenia) or Motor Neurone Disease.
In addition, lesions in the medullary tract affecting the nucleus of the solitary bundle or lateral medullary infarcts in strokes or trunk tumors or lesions of the syringomyelia or syringopromecia type. Uncoordinated swallowing is also caused by diseases that interrupt the cortical and protuberans connection, such as pseudoprometical paralysis, or by large hemispheric strokes. All of these potential causes of harm should be considered if dysphagia either occurs as a new symptom or pre-existing dysphagia rapidly worsens in patients with Parkinson's disease.
BIBLIOGRAPHY
– Heetun ZS, Quigley EMM. Gastroparesis and Parkinson's disease: A systematic review. Parkinsonism and related disorders 18 (2012): 433-440
– Kalf JG, Swart BJM, Bloem BR, Munneke M. Prevalence of oropharyngeal dysphagia in Parkinson's? disease: A meta-analysis. Parkinsonism and related disorders 18 (2012): 311-315
– Pfeiffer RF. Gastrointestinal dysfunction in Parkinson's disease. Parkinsonism and related disorders 17(2011): 10-15
– Van der Marck, MA, Dicke HC, Uc EY, Kentin ZHA et al. Body mass index in Parkinson's disease: A meta-analysis. Parkinsonism and related disorders 18 (2012): 263-267
– Silbergleit AK, LeWitt P, Junn F, Schultz LR et al. Comparison of dysphagia before and after deep brain stimulation in Parkinson's disease. Movement Disorders 27, Issue 14 (2012): 1763- 1768
– Asahi T, Inoue Y, Hayashi N, Araki K et al. Alleviation of dysphagia after deep brain stimulation: results from a Parkinson's disease patient. Movement Disorders 27, Issue 2 (2012): 1763- 1768
– Mendenopoulos G, Bouras K. Parkinson's Disease. University Studio Press, Thessaloniki 2008. – Adams and Victor?s. Neurology. 2nd Paschalides, 2003.
