Pharmacy & Therapeutics - October 2008 - (Page 592)

Medical Management of Parkinson’s Disease of normal individuals the same age. Death from PD usually results from a concurrent unrelated illness or from the effects of decreased mobility, aspiration, or increased falling with subsequent physical injury. who lean backward tend to step backward (retropulsion). A stooped posture may develop in which the patient’s head is bowed and the shoulders are drooped. As the disease progresses, walking may be affected. Patients may halt in midstride and “freeze” in place, possibly even toppling over, or they may walk with a series of quick, small steps as if hurrying forward to keep balance (festination). SYMPTOMS PD is a motor system disorder. The four primary symptoms are tremor (trembling) in the hands, arms, legs, jaw, and face; rigidity or stiffness of the limbs and trunk; bradykinesia (slowness of movement); and postural instability (impaired balance and coordination).20,24 As these symptoms become more pronounced, patients may have difficulty walking, talking, or completing simple tasks. Other symptoms include an expressionless face, reduced manual dexterity, handwriting difficulties, drooling, sleep problems, urination at night, depression and anxiety, constipation, and difficulty turning in bed at night. The disease is chronic and progressive, but it does not affect everyone in the same way. PD may appear to be progressing faster in some patients than in others. Some patients become severely disabled; others experience only minor disruptions in motor functions. Non-Motor Symptoms Many symptoms can be treated with appropriate medication or physical therapy. No one can predict which symptoms will affect an individual patient, and the intensity of the symptoms also varies among patients. None of these symptoms is fatal, but they affect quality of life.13,20 Depression. Depression may appear early in the course of the disease, even before other symptoms are noticed. It might not be severe, but it may be intensified by the drugs used to treat other symptoms of PD. Fortunately, depression can be successfully treated with antidepressant medications. Depression is also discussed under Cognitive Changes later. Emotional changes. Some people with PD become fearful and insecure. They may not want to travel or socialize. Some lose their motivation and become apathetic and dependent on family members. Others may become irritable or uncharacteristically pessimistic. Memory loss and slow thinking may occur, although the ability to reason remains intact. Whether people actually suffer intellectual loss or dementia from PD is a controversial area still being studied. Dysphagia. Muscles used in swallowing may work less efficiently in later stages of the disease. Food and saliva may collect in the mouth and at the back of the throat, which can result in choking or drooling. Medications such as levodopa and apomorphine can often alleviate these problems. Dysarthria. About 50% of all PD patients have problems with speech. They may speak too softly or in a monotone, hesitate before speaking, slur or repeat their words, or speak too fast. A speech therapist may be able to relieve some of these problems. Urinar y problems or constipation. In some patients, bladder and bowel problems can result from improper functioning of the autonomic nervous system, which regulates smoothmuscle activity, and from adverse drug effects. Some patients may become incontinent, whereas others have trouble urinating. Constipation may occur because the gastrointestinal (GI) tract operates more slowly; it can also be caused by inactivity, eating a poor diet, or drinking too little fluid. It can be persistent, and, in rare cases, can be serious enough to require hospitalization. Patients should not let constipation last for more than a few days before taking steps to alleviate it. Skin problems. It is common for the patient’s skin to become oily, particularly on the forehead and at the sides of the nose. The scalp may become oily too, resulting in dandruff. In other cases, the skin can become very dry. These problems result from an improperly functioning autonomic nervous system. Standard dermatological treatments can help. Excessive sweating, also common, is usually controllable with medications used for PD. Fragmented sleep. Sleep problems include difficulty staying asleep at night, restless sleep, nightmares, and drowsiness Motor (Physical) Symptoms Tremor. Tremor is the primary symptom for some patients, but it might be only a minor complaint for others, for whom other symptoms may be more troublesome. The tremor associated with PD typically takes the form of a rhythmic backand-forth motion of the thumb and forefinger at three beats per second. This is sometimes called “pill rolling.” Tremor usually begins in a hand, although sometimes a foot or the jaw is affected first. It is most obvious when the hand is at rest or when the patient is under stress. In 75% of patients, the tremor may affect only one part or side of the body, especially early in the disease; in later stages, tremor may become more generalized. Tremor is rarely disabling, and it usually disappears during sleep or improves with intentional movement. Rigidity. Resistance to movement affects most PD patients. A major principle of body movement is that all muscles have an opposing muscle. Movement is possible not just because one muscle becomes more active, but because the opposing muscle relaxes. Rigidity comes about when, in response to signals from the brain, the delicate balance of opposing muscles is disturbed. The muscles remain constantly tensed and contracted so that the person aches or feels stiff or weak. Rigidity is the increased muscular resistance to passive range of motion, and it often has a “cogwheel” quality.20 When a limb is moved by the examiner, it resists, then gives way in small, steplike movements as if it were being controlled by a cogwheel.25 Bradykinesia. The loss of spontaneous and automatic movement is particularly frustrating because it is unpredictable; one moment the patient can move easily but the next moment he or she may need help. This may well be the most disabling and distressing symptom of the disease because the patient cannot perform routine movements quickly. Activities that could previously be performed easily—such as washing or dressing— may take several hours. Postural instability. Impairment in balance and coordination causes patients to lean forward or backward and to fall easily. When bumped from the front or when starting to walk, patients 592 P&T® • October 2008 • Vol. 33 No. 10

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Pharmacy & Therapeutics - October 2008 Contents Editorial Medication Errors Prescription: Washington New Drugs/Drug News/ New Medical Devices Drug Forecast Medical Management of Parkinson’s Disease Why Is Health Care Regulation So Complex? The Next President’s Prescription for Action on Drugs Trends in Managing Multiple Sclerosis Product Profiler: Sancuso®

Pharmacy & Therapeutics - October 2008

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