Parkinson's Disease in the Older Patient

Dr Jeremy R Playfer, John Hindle

• Publisher: CRC Press
• Year: 2018
• Print ISBN:
  9781846191145
• eBook ISBN:
  9781315347257
• Topic: Medicine
• Subtopic: Geriatrics

"Parkinson's Disease in the Older Patient, Second Edition" has been fully revised, updated and expanded to include new treatments and entirely new chapters. This authoritative text is written by recognised national specialists in the field and provides accessible, easy-to-read information. The practical and versatile approach comprehensively covers all aspects of treatment, and although it focuses on the older patient, it is also highly relevant for younger patient groups with an emphasis on multidisciplinary assessment and management. Detailed information on the aetiology and pathogenesis of the condition, drug and surgical treatments, sleep disturbances, quality of life and careers is now included, along with the more prevalent older patient issues such as neuropsychiatric disturbances, speech and swallowing problems, balance and falls, and autonomic disturbances. The updates also include new advice on the management and services in primary care, linked to the recent NICE guidelines.With official endorsement from The Parkinson's Disease Academy of the British Geriatrics Society, this new edition is highly recommended for general practitioners, geriatricians, neurologists and psychiatrists. Physiotherapists, occupational therapists, speech therapists, dieticians, and psychologists will also find it invaluable. It is suitable for general and specialist nurses, and will be of great use to researchers with an interest in Parkinson's disease.

PART 1

Background

1

A history of Parkinson’s disease

John Hindle

• Introduction
• Background
• James Parkinson
• Parkinsonism: clinical features
• Parkinsonism and neurotransmission
• Pharmacotherapy: dopa and levodopa
• Neurosurgery
• Modelling the condition
• References

Introduction

Symptoms suggestive of Parkinson’s disease (PD) have been described for many centuries, having been found in Egyptian papyrus and Sanskrit texts and other documents in ancient times. PD was first distinguished from other causes of tremor and weakness by Dr James Parkinson in his famous paper of 1817 entitled ‘An Essay on the Shaking Palsy’. In this, he defined the condition as ‘involuntary tremulous motion, with lessened muscular power, in parts not in action and even when supported; with a propensity to bend the trunk forwards, and to pass from a walking to a running pace: the senses and intellect being uninjured’.¹ The history of the development of the concept of Parkinson’s disease, its symptoms and treatment is fascinating. As with all of history there are many different interpretations which reflect the biases and interests of the writer. This is my own personal view of some aspects of the development of our understanding of PD.

Background

It is difficult to understand this contribution by James Parkinson and the subsequent evolution of his ideas without awareness of the concepts of neurological disorder used at the time. Parkinson called his disease the shaking palsy, or paralysis agitans, and at that time the use of the term palsy or paralysis was very wide, and included the loss of motion and sensation.² In his treatise, Parkinson concentrated mainly on the tremor and gait disturbance, because the concepts of rigidity and akinesia had not yet been defined. Parkinson’s understanding of tremor was based on the developments of the concepts of Galen. These concepts were the most important influences on the development of ideas on tremor over a period of more than 1500 years. Galen of Pergamum was a Greek physician who founded experimental physiology and was one of the most distinguished physicians of antiquity. Galen’s influence on medical theory and practice was dominant in Europe throughout the Middle Ages, and particularly during the Renaissance. Galen learned much of his practical knowledge of medicine through the medical school attached to the shrine of the healing god Asclepius. Here he was also attached as chief physician to the Gladiators, and gained practical knowledge of anatomy and tested remedies for treating wounds. Galen became particularly renowned as a physician in Rome where he treated the Co-Emperor and the heir to the throne.³ Between AD 169 and 180, Galen wrote a short text, ‘De Tremore’ in which he distinguished voluntary motion (due to impulse and mediated by nerves and muscles) from vital motion (activated through arteries and the heart). Galen described tremor as occurring on intended motions and caused by weakness of the force that supports and moves the body. Shaking at rest was described as palpitation, and was thought to be due to unnatural expansion and collapse of heart and arteries.⁴

The theories of Galen were refined through the sixteenth to eighteenth centuries, particularly by Dutch physicians. The term palpitation gradually came to be applied to pathology of the heart and arterial pulsations. The distinction between action and rest tremor was further clarified, notably through the writings of the German chemist and physician Junker (1679–1759), the French physician Boissier De La Croix Sauvages (1706–1767) and the Dutch physicians Sylvius de la Boe (1614–1672) and Van Swieten (1700–1772).⁴ In his essay, Parkinson refers to Junker and Sylvius De Le Boe, and reviews the previous definitions of tremor.⁵ James Parkinson complained that ‘tremor has been adopted, as a genus, by almost every nosologist; but always unmarked, in their definitions, by such characters as would embrace this disease’.¹ He then went on to describe the natural history of the tremor of his own disease. It is unclear whether Parkinson had read the Latin texts by these previous authors prior to collecting his case histories, or whether he came across them in his search for literature after his interest was aroused by a stimulus closer to home.

James Parkinson

James Parkinson was born in 1755 as a son of a physician in Hoxton, a suburb in the Shoreditch area of London. Following the death of his father in 1784, James Parkinson took over the practice at Hoxton Square. He became a distinguished physician and the first recipient of the honorary gold medal of the Royal College of Surgeons in 1822. He was also a very committed family man, was married in 1781, and had six children.^1,6,7

James Parkinson was a man of eclectic interests. By the age of 25 he was well established as a formidable political writer and a prominent member of the London Corresponding Society. He published, under the nom de plume of ‘Old Hubert’, many pamphlets promoting the reform of the House of Commons and universal suffrage. He wrote on the iniquities of taxation, child abuse, the elderly, the lot of lunatics, and many other matters. His political writings ceased suddenly in 1794, probably following a subpoena to give evidence to a special court of inquiry in which he was cross-examined by William Pitt the younger, who was then Prime Minister. By that time he had also produced many medical texts, including a report of the first case of appendicitis found in English medical literature and an influential book on medical education entitled The Hospital Pupil. Following cessation of his political writings he took a great interest in chemistry and scientific palaeontology. He wrote several books on geology and was a founder member of the Geological Society.^1,6,7

At the time of Parkinson’s early medical career, John Hunter was becoming established as an influential teacher at one of London’s anatomy schools. He became famous for his anatomical dissection and as a lecturer attracted many students from around the British Isles. He held night courses, giving the prestigious Croonian lectures over a period of several years. At the age of 30 James Parkinson attended these lectures and took detailed notes, which were published posthumously in 1833, edited by his son. Much earlier, in 1776 at the age of 21, as an apprentice to his father who was an anatomical warden of the Surgeons Company, James Parkinson may have attended a lecture by John Hunter on muscular motion. In this Hunter described a case of Lord L, whose hands were ‘almost perpetually in motion and he never feels the sensation in them of being tired. When he is asleep his hands are perfectly at rest; but when he wakes in a little time they begin to move’.⁵ This condition sounds very much like Parkinson’s disease. James Parkinson’s famous essay was published in 1817 towards the end of his career, and presumably it must have taken him a long time to collect the six cases he presented. At this time neurology was a descriptive subject, and this is why Parkinson characterised the cases, even from a distance, but did not examine patients in detail. Some have suggested that it was John Hunter who inspired Parkinson to write his famous essay.⁵ Parkinson’s essay did break new ground and was extensively quoted. His conjecture that the illness was related to a diseased state of the higher cervical cord, extending into the medulla, was quite remarkable. Despite receiving many awards, mainly for palaeontology, the fellowship of the Royal Society still eluded James Parkinson by the time of his death in 1824.⁶

Parkinsonism: clinical features

Unfortunately, over the next 45 years, Parkinson’s treatise on the shaking palsy received little attention in England. During this period, however, Wilhelm Von Humboldt, in his letters from 1828 until his death in 1835, gave one of the clearest clinical descriptions of the condition by a patient. He described a resting tremor, akinesia, and was the first to describe micrographia. He called the problems in writing a ‘special clumsiness’, which he attributed to a disturbance in executing rapid complex movements. He described ‘internal tremor not visible by others, which causes a distortion of the continuity of my movements’. He...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Foreword to second edition
• Foreword to first edition
• Preface to second edition
• Preface to first edition
• Acknowledgements
• List of contributors
• Part 1 Background
• Part 2 Diagnosis and Assessment
• Part 3 Non-Motor Dysfunction
• Part 4 Motor Dysfunction
• Part 5 Therapy and Management
• Appendix 1: Useful rating scales
• Appendix 2: Useful addresses and websites
• Appendix 3: Clinical algorithm
• Index