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[back] Report on the Medical Talk by Dr. Shahrin Tarmizi Sara Lew - 17 May 2008

Medical Talk by Dr. Shahrin Tarmizi Abduallah at Pantai Medical Center, Bangsar

It has been some time since MPDA held a medical talk for its member. Therefore, when Dr. Shahrin Tarmizi Abdullah, a Medical Specialist/Neurology Fellow attached with HUKM was invited to give a medical talk to our members on 17 May 2008, it was received with a good response. The talk titled "Non-Motor Complications in Parkinson's Disease (PD)" was not only a refreshing change from the usual talk on the motor complications in PD, it also offered the opportunity for the members to interact and share experiences with each other.

Dr. Shahrin delivering his talk. Sara Lew id in the backgroundAmy Chow listening intently to the talk

Following a short hiccup with the electronic equipment, Dr. Sharhrin took over the "stage" and began his talk with a short introduction of Parkinson's Disease. According to Dr. Shahrin, PD has traditionally been considered a motor system disorder, and the last 30 years have seen enormous advances in the management of the motor symptoms of PD. However, the non-motor complications (NMC) of PD have remained relatively unexplored until recently. It is now widely recognized that PD is a complex disorder with diverse clinical features that include NMC, for example, gastrointestinal and genito-urinary systems causing urinary symptoms, sleep disorders, etc.

In some patients, the non-motor features of PD may present before the motor ones. NMC such as psychosis or dementia may cause more disability than the motor symptoms and may be more difficult to treat. NMC contribute significantly to morbidity and may lead to increased cost of care and admission to a nursing home. Unfortunately, PD non-motor symptoms are not well recognised in clinical practice, either in primary or in secondary care, and are frequently missed during routine consultations.

However, all is not lost yet. The International Parkinson's Disease Non Motor group (PDNMG) was set up recently by a group of dedicated neuroscientists who met and felt that the NMC of PD need recognition, awareness and tools for assessment. This group comprises a multidisciplinary team - neurologists, geriatricians, psychologists sleep experts, nurse specialists, psychiatrists, and patient group representatives.

A screening tool was designed to draw attention to the presence of NMC and initiate further investigation. A survey was conducted on 99 patients at a PD specialty clinic for non-motor complications e.g. anxiety, depression, sleep disturbances, and sensory symptoms and the findings revealed that majority of patients had at least one non-motor symptom.

It's good to see Lock Kuan Hun back in action again. In the background is Tung Kai Seng"Make some facial exercises with your hands and mouth and you'll see good results in your speech articulation", advised Koh Hun Wai

Generally the nonmotor complications of Parkinson's disease can be divided into 5 subgroups:

  1. Neuropsychiatric symptoms (Disorders of mood)
    • Depression
    • Anxiety
    • Psychosis (hallucinations, paranoid delusions)
    • Apathy which is a state of indifference - where an individual has an absence of interest or concern to certain aspects of emotional, social, or physical life.

    Depression / Anxiety
    The presentation of anxiety can take 1 of 3 forms, typically:
    (a) Generalized anxiety disorder: Anxiety throughout the course of the day, most days.
    (b) Anxiety attacks or panic attacks: Discrete episodes of intense anxiety lasting minutes and accompanied by significant autonomic and physical symptoms.
    (c) Obsessive-compulsive disorder: Repetitive thoughts that are intrusive and inappropriate and lead to anxiety, often followed by repetitive behaviors or mental acts in response to the obsessive thoughts.

    Most patients diagnosed with anxiety also have depression, and vice versa.
    The causes are:
    (a) High prevalence of depression and anxiety up to 20 years prior to the onset of PD suggesting a strong neurobiologic component to the mood changes in Parkinson's disease.
    (b) Changes reported in specific brain regions.
    (c) Psychological factors play a role as well.

    The treatments are:
    (a) Identification is important
    (b) Referral to psychiatrist
    (c) Antidepressants newer antidepressants do have anti-anxiety effects in addition to their antidepressant effects.
    (d) Sometimes need to use low dosages of sedation e.g. benzodiazepines to manage anxiety.

    Psychosis and PD is more conceptualized as a complex interaction of many factors

    • Hallucinations or illusions occur in approximately 15-40% of patients,
    • 5% of such patients will also experience delusions (fixed false beliefs), in addition to the hallucinations.

  2. Cognitive symptoms (Disorders of thinking/memory)
    • Slowed reaction time
    • Impairment of executive function
    • Dementia

      Tends to occur late in the course of PD. The prevalence rates is 20-30%. A recent study shows a 8-year cumulative prevalence rate of 79% in PD, suggesting that dementia may be much more common than we had previously thought. The early stage show slowness of thought and progressing difficulties with memory and behavioural regulation in the later stages, dementia can present with psychosis, and agitation. Risk factors for dementia - similar to risk for depression

  3. Sleep disorders

    • Excessive Daytime sleepiness, Sleep attacks and Restless leg syndrome

    Sleep disorders are very common in Parkinson's disease, perhaps the most common complication of all. Up to 90% of PD patients have reported some sort of sleep disturbance and another up to 40% of PD patients take sleeping pills. The causes of sleep disturbances in Parkinson's Disease are due to:

    (a) PD motor symptoms
    • Uncomfortable and painful to have muscle cramp or be rigid and not be able to move in bed.
    • A correlation has been found between the severity of motor symptoms and sleep disturbances such as nightmares.

    (b) Drug-induced sleep disturbances
    • PD medications e.g. Levodopa, Entacapone, Selegiline, Dopamine Agonist, Anticholinergics
    • Other medications to treat co-existing condition.

    (c) Depression

    (d) Restless leg syndrome
    • The desire to move the limbs, with or without symptoms of numbness or tingling of the feet with exacerbation at night and at rest and some relief with leg movement.

    (e) Excessive Daytime Sleepiness
    • A very frequent complaint for PD patients which is probably more common than in the general population. Prevalence 15-50% and can occur even with a good nighttime sleep. It is likely multifactorial, e.g. mood or anxiety disorders, dementia, and PD medications (dopamine agonists).

    (f) Obstructive sleep apnoea
    • Occurs in 2-4% of middle-aged adults and increases with age. This rate is not believed to be different from the general population, although 1 study did find a higher prevalence of 20% in PD patients Risk factors include male gender and the obese.

    (g) Nightmares
    • Nightmares are not unusual occurrences in PD and are thought to occur in 30% of patients. They are correlated with disease severity and levodopa dose. Other conditions include nocturia and pain

    Treatment for Sleep Disorders include general sleep hygiene and drugs. More specific treatment depends on the exact underlying cause. Do avoid or substitute drugs which cause the sleep disorders:
    • Avoid caffeinated and alcoholic products in the evening and late dinner/supper
    • Going-to-sleep routines, e.g. read a book.
    • +/- glass of hot milk.

  4. Autonomic symptoms
    • Constipation
    • Hyperhydrosis (excessive sweating)
    • Urinary problems (incontinence, urgency, frequency)
    • Sexual dysfunction

    The autonomic nervous system was originally described by Langley in the 1800s to encompass parts of the nervous system that are outside of the brain and spinal cord. These parts of the nervous system are under autologous control, and thus the name autonomic nervous system. They can be affected in PD causing autonomic symptoms. Autonomic symptoms occur in up to 90% of patients and includes problems with:

    • Genitourinary symptoms:
      Urinary problems
      Urinary problems occur in 37-70% of PD patients. Urinary urgency, urinary frequency, nocturia, urinary retention, and urinary incontinence. Equal incidence in females and males. 2/3 of PD patients who complain of urinary problems have difficulty with bladder hyperactivity.

      Primarily treated with anticholinergic medications. In general, these medications may be difficult to use in PD patients due to their side-effect profile, including sedation, dry mouth, confusion and hallucinations.

    • Gastrointestinal symptoms:
      Highly prevalent in PD patients, with about 80% of patients complaining of some abnormalities. These include delay in stomach emptying (gastroparesis) and constipation, primarily. Gastroparesis often presents as nausea and vomiting and a bloating feeling in patients. Besides the discomfort, it can reduce the absorption of PD medication and increase the "off" time.

      Constipation is seen in 60% of PD patients. Initial therapies include conservative measures:
      • Increasing fluid intake and fibre intake
      • Increasing exercise and physical activity
      • Drug treatment include laxatives or stool softeners.
      • Enemas in extreme cases may be helpful when patients are severely constipated.

      Postural hypotension

      Affects 20-50% of PD patients. Symptoms are such as lightheadedness, dizziness, and fatigue. Episodes of sweating when they stand up. Tends to be less severe and easily treated than that due to Parkinson's plus syndrome e.g. Multiple System Atrophy

      The treatment includes elevating the head of the bed - less change in the position and less drop in the blood pressure when standing. Increasing salt and fluid intake. Compression stocking can help to maintain blood pressure with changes in position.
      Small frequent meals may help to prevent drops in blood pressure following a large meal. Discontinue any medications that may contribute to the postural hypotension, e.g. pills for high blood pressure and diuretics. Modify PD drug treatment e.g. stop selegiline and dopamine agonists.

    • Orthostatic (blood pressure) abnormalities, and Thermoregulatory (temperature) disturbances

  5. Sensory symptoms
    • Pain, Numbness,Tingling and Burning

    The treatments are:
    • Adjustment of PD medications
    • Medications for neuropathic pain e.g. gabapentin

Our Berita Parkinson co-editor, Bee Peng with Koh Hun WaiAmy Chow having a tete-a-tete with Dr. Shahrin over a cup of coffee

The medical talk ended with a Q and A session but not before our Committee Member, Mr. Koh Hun Wai shared his experience on how he delayed the onslaught of speech problems with some of the facial exercises that he does everyday.