Aging Begins at 30

The Shaking Palsy

As a young intern, I had eight patients with Parkinson's diseaes in the chronic part of my 60-bed ward. There were no effective drugs available then to slow down the crippling effect of the disease and my inability to help them frustrated me.

Sir James Parkinson, in 1817, first described many of the typical symptoms: the tremor or shaking, loss of muscular power, and the way the body bends forward while walking, sometimes passing from a walking to a running pace to avoid falling.

A doctor determines whether or not patients have Parkinson's disase without taking any blood tests. Doctors look for stooped posture, stiffness and slowness of movement, fixed facial expression, and four per second rhythmic tremor of the hands.

It is the tremor that most often brings patients to the doctor's office. This is usually of the hands, but a woman I saw recently only had tremor of the chin. This is a "resting tremor" because it typically happens when the patient's hands are idle. Some people develop a tremor that is completely unrelated to Parkinson's disease, benign hereditary tremor. It happens when people are doing something, not at rest. It is not serious and can be treated.

Parkinson's disease is due to nerve cell loss in the substantia nigra (literally the black stuff) of the mid brain. It can be seen with the naked eye and it contains dopamine, which is essential for the control of movement. Why the cells in the substantial nigra die and stop making dopamine is unknown, but this area can be poisoned by carbon monoxide, manganese, a virus as in the epidemic of von Economo's encephalitis of 1918 to 1925, or a "street" drug chemical MPTP. This is a by-product of the street production of Demerol and astonished its producer and some friends by almost completely paralyzing them after intravenous injection.

Similar chemicals are being looked for as environmental insults which might be a cause of Parkinsonism. Other causes of Parkinson-like disease should be mentioned. Namely, punch drunkenness, like Mohammed Ali, or the necessary use or overuse of phenothiazine drugs, such as chlorpromazine used as major tranquilizers.

Dopamine will not enter the central nervous system, however, a mirror image precursor, levodopa, will. Combined with an anti-enzyme to prevent loss of active drug it becomes a combination drug called Carbidopa. Bromocriptin (trade name Parlodel) from the wheat rust ergot, chemically mimics the effect of dopamine and can be added. Other drugs with usefulness in the disease are propranalol, several anticholinergics, and the anti-influenza drug, amantadine. Use of sinus and the common cold medicines can seriously disrupt treatment. Even the most carefully managed drug program can only help to slow the progress of this presently incurable disease. A new breakthrough has been the prevention of advancement of the disease with Deprenyl, under active research study at present.

Good management requires cooperation between the physician, the patient, and the patient's relatives. In advanced cases, activity must be maintained and the patient must be given every assistance, such as an electric razor, shoes without laces, and clothing with velcro closures. Since patients may be capable of much more independence one time than the next, it is important that families realize that the patient is not "faking" weakness or inability.

Another experimental approach to the treatment of Parkinsonism is to try to put dopamine forming human tissue in the brain. Transplantation of adrenal tissue has been unsuccessful but the transplantation of fetal brain tissue has caused a small number of patients to live more independently with a 40% decrease in the need for drugs and an increase in their daily activities, leading to cautious optimism about a possible treatment for the future.

There are three important complications of Parkinsonism. One-third of advanced disease patients develop dementia and half of them develop depression. The depression is treatable with the usual anti-depressive drugs. Parkinsons may be complicated by the so-called on-off phenomenon where the patient abruptly alternates between marked immobility and mobility with added involuntary movements which is very hard to manage.

In 1944, I used to treat my Parkinsonism patients with tincture of stramonium (from jimsonweed) which was the only drug that we had. After a week's treatment, I would tell my chief that I was curing them. "Anecdotal research, Smith. Anecdotal research will lead you astray", he commented. In the decades from 1960 onwards, very sophisticated research has been done on Parkinson's disease and a successful program of drugs, exercise, and medical supervision can make it possible to live longer with a higher quality of life despite this previously totally disabling disease.

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See related Patient Topics Brain and Nervous System, Parkinson's Disease or Seniors' Health.

See related Provider Topics Brain and Nervous System, Parkinson's Disease or Seniors' Health.

All contents copyright © 1992-2004 the Author(s) and The University of Iowa. All rights reserved.

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