Parkinson’s disease (PD)
Definition
Neurological disorders are the leading cause of disability and the second leading cause of death worldwide1. From 1990 to 2015, the number of people living with Parkinson’s disease saw the greatest increase, with the number more than doubling1.
Parkinson’s is associated with the progressive degeneration of dopaminergic neurons in the substantia nigra in the brain4. Other parts of the brain may also be affected, as well as other neuron systems (cholinergic, noradrenergic, serotonergic, ...). This also explains the variable presentation of this disorder as it progresses2.
The exact aetiology of Parkinson’s disease is uncertain. It is probably caused by a combination of genetic and environmental factors, such as exposure to pesticides. As far as genetic factors are concerned, 15% of all people with Parkinson’s have a family history of the condition2.
Epidemiology
Key figures1,3 :
Second most common neurodegenerative disorder1
An estimated 38,000 people live with this disease in Belgium1
The incidence is 1.5 times greater in men than in women1
It affects approximately 8.5 million men and women worldwide1
Parkinson’s disease is a slowly progressing disorder. For several years, non-motor symptoms may occur early on during the preclinical stage, as a harbinger of the disease4. A 50 to 60% decrease in dopaminergic neurons is observed before the onset of motor symptoms.
Long-term evolution5
During the first years of the disease, the motor disability may not be significant because the symptoms are often unilateral and mild.
As the disease progresses, increased motor disability affects a person’s daily life and routine. This situation is further complicated by the development of motor symptoms and dyskinesia (due to long-term levodopa therapy).
In the advanced stage, patients usually require assistance with most activities of daily life, including eating, dressing, turning over in bed, getting up from a chair, walking, etc.
Symptoms
Motor symptoms, the first to look for
Parkinson’s clinically manifests itself by a triad of cardinal motor symptoms that may be unilateral or asymmetrical. The asymmetry is persistent6.
Plastic-type or ‘lead pipe’ rigidity6
Akinesia, bradykinesia, hypokinesia2,6
Bradykinesia, akinesia and hypokinesia present in the following ways:
- Size of letters becomes smaller when writing (micrography),
- Fine motor movements become more difficult (shaving, buttoning up),
- Reduced facial expression (hypomimia),
- Slow, hesitant gait (small steps),
- Lack of spontaneous movements (blinking...),
- Monotone and expressionless voice,
- Irregular arm swing.
The frequency of non-motor symptoms increases with age, the duration and the severity of the disease7,8.
Non-motor symptoms affect 90% of all patients9
- Parkinson’s disease also manifests itself in non-motor, disabling symptoms, which patients fail to mention all too often and which occur at all stages of the disease7.
- Some of them, such as REM sleep behaviour disorders, depression, constipation, and olfactory dysfunction may precede the onset of motor symptoms by more than a decade7,8.
- An estimated 90% of Parkinson’s patients suffer from different non-motor symptoms: neuropsychiatric, dysautonomic, sensory, gastro-intestinal, and sleep problems as well as other wide-ranging symptoms such as fatigue or diplopia9.
- The symptoms that seem to have the greatest negative impact are mood fluctuations, apathy, sleep problems and fatigue10.
Complications
Advanced Parkinson’s is associated with more complex, worsening motor and non-motor symptoms and the development of motor and non-motor complications. These complications significantly impact the patient’s autonomy and quality of life. They are the consequence of the disease’s progression and/or dopaminergic therapy.
Motor fluctuations
These are defined by the intermittent reappearance of motor symptoms associated with Parkinson’s disease.
These “ON/OFF” fluctuations consist of sudden, unpredictable shifts in motor function.
The patient constantly transitions between periods when motor function improves (the “ON” period) and periods during which Parkinson’s symptoms worsen despite therapy (the “OFF” period)12.
Dyskinesia
Levodopa-induced dyskinesia presents as very disabling, involuntary abnormal movements. They occur in 80 to 90% of all patients, after 10 years of treatment12.
The following can be distinguished:
- Middle or peak dose dyskinesia corresponding with choreic and/or dystonic involuntary movements, predominantly in the upper limbs, coinciding with peak plasma levodopa level.
- Beginning/end of dose or biphasic dyskinesia corresponding with stereotypic involuntary movements or flexion-extension of the lower limbs with very painful dystonia, occurring at the beginning and end of therapy efficacy.
- The “OFF” period dystonia that appears when dopamine levels are low. They are characterised by generally painful dystonic postures, often of the lower limbs12.
Non-motor fluctuations
- Non-motor fluctuations are associated with the “ON/OFF” periods during treatment9.
- Neuropsychiatric fluctuations are the most frequent and typically include apathy, depression, anxiety, and bradyphrenia during the “OFF” period as well as euphoria, hypomania, impulsiveness and disinhibition during the “ON” period11.
- The presence of non-motor fluctuations must be taken into account when adjusting dopaminergic therapy9.
Other types of non-motor complications may occur such as impulse control disorder or addictive behaviours.
Need for multidisciplinary care
Many health care professionals are involved in the care and support for the patient.
A multidisciplinary approach optimises patient follow-up, enabling the team to provide continuous and coordinated support at every stage of the disease2.
The approach differs from one patient to another, depending on the stage of the disease and the patient’s location. It is formulated based on the available medical resources, existing networks, etc.
As a rule, the professionals involved in the care pathway should be the following2:
GP: General practitionner
After HAS - Guide Parcours de soin, Maladie de Parkinson - September 2016
- Bulletin Epidémiologique Hebdomadaire (BEH) 2018. https://solidarites-sante.gouv.fr/IMG/pdf/2018_8-9.pdf
- HAS. Guide du parcours de soins Maladie de Parkinson. Septembre 2016.
- CNAM 2017 - CNAMTS/DSES/DEPP & DEOS mise à jour le 09/07/2019 Fiche pathologie « Personnes prises en charge pour maladie de Parkinson en 2017 »
- https://www.inserm.fr/information-en-sante/dossiers-information/parkinson-maladie
- Gershanik O. Clinical problems in late-stage Parkinson’s disease. J Neurol 2010; 257 (Suppl 2) : S288-S291
- Maladie de parkinson » - Collège des enseignants de neurologie - Disponible sur : https://www.cen-neurologie.fr/deuxieme-cycle/maladie-parkinson (Consulté le 11.01.2021)
- Chaudhuri K et al. Non-motor symptoms of parkinson’s disease : dopaminergic pathophysiology and treatment. Lancet Neurol 2009; 8: 464-74.
- Chaudhuri K et al. Non-motor symptoms of parkinson’s disease : diagnosis and management. Lancet Neurol 2006; 5: 235-45.
- Storch A et al. Non-motor fluctuations in Parkinson disease : Severity and correlation with motor complications. Neurology 2013; 80 : 800-809
- Martinez-Martin P et al. The impact of non-motor symptoms on health-related quality of life of patients with Parkinson’s disease. Mov Disord 2011;26(3):399-406.
- Béreau M. et al. Maladie de Parkinson au stade avancé : indication aux traitements complexes. Rev Med Suisse 2018 ; 14 : 875-8.
- Bastide M. et Bézard E. Les dyskinésies L-dopa induites dans la maladie de Parkinson. Bull. Acad. Natle Méd., 2015; 199 (2-3) : 201-212
- Instruction DGOS/R4 no 2013-403 du 10 décembre 2013 relative aux missions des centres experts à vocation régionale et centres interrégionaux de coordination pour la prise en charge de la maladie de Parkinson et des syndromes parkinsoniens.
- Les centres experts / ressources compétences maladies neurodégénératives . https://solidarites-sante.gouv.fr/IMG/pdf/2018-07-17-les_centres_experts_mndv3-2.pdf
AbbVie SA/NV - BE-ABBV-210115 (v2.0) - November 2021