Parkinson disease

Parkinson disease, also called primary parkinsonism, paralysis agitans, or idiopathic parkinsonism, a degenerative neurological disorder that is characterized by the onset of tremor, muscle rigidity, slowness in movement (bradykinesia), and stooped posture (postural instability). The disease was first described in 1817 by British physician James Parkinson in his “Essay on the Shaking Palsy.” Parkinson disease is the primary form of parkinsonism, a group of chronic disorders in which there is progressive loss of motor function due to the degeneration of neurons in the area of the brain that controls movement. Parkinson disease is distinguished from other types of parkinsonism because it is idiopathic, meaning it occurs in the absence of an identifiable cause.

Risk factors

It is thought that, in the majority of cases, Parkinson disease arises from a combination of genetic predisposition and certain environmental factors, such as exposure to pesticides or certain solvents, including trichloroethylene. Although Parkinson disease is rarely inherited, individuals who have first-degree relatives with the disease appear to be at increased risk. In addition, mutations in a gene called PRKN, which encodes a protein known as parkin, have been associated with early-onset (before age 40) Parkinson disease and with some cases of late-onset (after age 50) Parkinson disease. Mutations in several other genes have been linked to noninherited forms of the disease.

Onset and symptoms

The onset of Parkinson disease typically occurs between the ages of 60 and 70, although in about 5 to 10 percent of cases onset occurs before age 40. The worldwide incidence of Parkinson disease is estimated to be about 160 per 100,000 persons, with about 16 to 19 new cases per 100,000 persons appearing each year. Men are slightly more affected than women, and there are no apparent racial differences. Parkinson disease often begins with a slight tremor of the thumb and forefinger, sometimes called “pill-rolling,” and slowly progresses over a period of 10 to 20 years. Advanced disease is often characterized by loss of facial expression, reduced rate of swallowing leading to drooling, severe depression, dementia, and paralysis.

Neuropathology

A marked decrease in the level of dopamine, a neurotransmitter that plays an important role in the inhibition of nerve impulses in the brain, has been noted in patients with Parkinson disease. This decrease, which occurs primarily in a region of the brain called the substantia nigra, has been attributed to the loss of so-called dopaminergic neurons that normally synthesize and use dopamine to communicate with other neurons in parts of the brain that regulate motor function. The cause of decreased dopamine levels is unclear. A protein known as alpha synuclein appears to be involved in neuronal degeneration. Alpha synuclein is produced by dopaminergic neurons and is broken down by other proteins, such as parkin and neurosin. Defects in any of the proteins that break down alpha synuclein may lead to its accumulation, resulting in the formation of deposits called Lewy bodies in the substantia nigra. However, other mechanisms affecting the accumulation of alpha synuclein have been identified, and it is not clear whether Lewy bodies are a cause of or occur as a result of the disease. Other findings in people affected by Parkinson disease include mitochondrial dysfunction, leading to increased production of free radicals that cause significant damage to brain cells, and heightened sensitivity of the immune system and neurons to molecules called cytokines, which stimulate inflammation.

Treatment

The most effective treatment for Parkinson disease is administration of the metabolic precursor to dopamine, known as levodopa (l-dopa). Levodopa crosses the blood-brain barrier (a physiological partition blocking the entry of large molecules into the central nervous system) via special transport proteins and is converted to dopamine in the brain, primarily in the region containing the substantia nigra. Although initially beneficial in causing a significant remission of symptoms, levodopa frequently is effective for only 5 to 10 years, and serious side effects—including uncontrolled movements, hallucinations, persistent nausea and vomiting, and changes in behaviour and mood—often accompany treatment. Cotreatment with a drug called carbidopa, which inhibits an enzyme that breaks down levodopa prior to crossing the blood-brain barrier, allows higher concentrations of levodopa to reach the brain. Thus, levodopa-carbidopa combination therapy enables lower doses of levodopa to be administered, thereby reducing side effects. This combination therapy has allowed many patients to live reasonably normal lives. A drug known as entacapone, which slows the metabolism of levodopa, may be given with levodopa and carbidopa.

Other drugs used to relieve the symptoms of Parkinson disease include agents that stimulate dopamine production in the brain, such as pergolide and bromocriptine, and agents that slow the degradation of dopamine, such as selegiline. In addition, the antiviral agent amantadine can reduce certain symptoms of the disease. In some cases, surgery may be necessary to alleviate advanced symptoms. For example, a surgical procedure known as deep brain stimulation (DBS) has been successful in decreasing involuntary movements, improving debilitating problems with gait and slowness of movement, and reducing doses of medications. In DBS an electrode is implanted in the brain and is attached via a lead wire to a neurostimulator inserted under the skin, usually near the collarbone. The neurostimulator sends electrical signals to the electrode. These signals work by disrupting the physiological impulses that cause disordered movement.