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These are activities that expand general practice knowledge, skills and attitudes, related to your scope of practice.
These are activities that require reflection on feedback about your work.
These are activities that use your work data to ensure quality results.
Parkinson’s disease (PD), or just “Parkinson’s” as its more commonly known now affects over 200,000 Australians. While diagnosis still hinges upon motor symptoms such as tremor, bradykinesia and rigidity, it’s now widely recognised that PD is about more than just movement.
In fact, some experts now think of Parkinson’s more akin to a neuropsychiatric disorder, with non-motor symptoms like sleep issues, mood disorders and sensory changes occurring across all phases of the condition. –Jane Alty, a professor of neurology at the University of Tasmania and Neurology staff specialist at RHH tells us a bit more about these features.
Non-motor symptoms of Parkinson’s often predate motor features, sometimes spanning up to a 20-year prodromal period, Professor Alty says.
“This is when proteins are changing in the brain and there’s a degree of degeneration, but not to the stage that we would be able to detect it with motor features”
They also occur at other stages of the disease and can be grouped into five broad categories, she explains.
Depression, anxiety, and apathy are extremely common, affecting about a third of people with Parkinson’s. These can appear before diagnosis, often for the first time in a patient’s life.
“When people look back, they realise they developed depression or anxiety out of the blue, and we now recognise that was probably part of the prodrome,” Professor Alty says.
Left unmanaged, mood issues can worsen motor problems and reduce quality of life, she adds.
These include difficulty initiating sleep, daytime sleepiness, and REM sleep behaviour disorder (which manifests as people acting out their dreams).
Patients often describe slowness in thinking or issues with planning and sequencing (executive dysfunction).
These include constipation, urinary frequency and orthostatic hypotension.
These can include a change in sense of smell (hyposmia), which often occurs a decade before diagnosis, lack of taste sensation, and deep, often neuropathic, pain.
While non-motor symptoms like constipation and depression are common in the general population, some key indicators should prompt you to consider Parkinson’s, Professor Alty says.
REM sleep behaviour disorder is a condition where the person physically acts out their dreams during REM sleep. Unexplained onset of REM sleep behaviour disorder in otherwise healthy people is an early sign of neurodegenerative disease, with more than 80% of people who have the disorder developing Parkinson’s, Dementia with Lewy Bodies or multiple system atrophy.) in about 10-15 years.
It seems to be caused by alteration of the brainstem nuclei that control muscle tone during REM sleep.
They often describe quite vivid dreams, Professor Alty says. People with REM sleep behaviour disorder might call out or scream out in their sleep, punch the person they’re sharing a bed with or throw themselves out of bed. Often, they’re dreaming about something frightening, such fighting off attackers, or something sporting related – for example a dream about soccer might result in them kicking their bed partner. Other times the movements can be minor, such as little twitches.
However, it is hugely under-recognised so, it’s important to ask patients – and their bed partners – directly about sleep behaviours, Professor Alty says.
When motor symptoms begin to appear, the following constellation points to Parkinson’s:
A patient’s gait provides key diagnostic clues, she says.
“Just watching someone walk is a nice way of looking for that slowness and lack of symmetry. Are they not swinging one arm? Are they taking a few extra steps to turn around? Have they got reduced stride length?”
Once a diagnosis is made, the GP plays a crucial role in medication adherence, managing non-motor issues, and referral to allied health services.
Professor Alty strongly advocates for early and sustained use of levodopa.
“It’s the very best drug that we have for Parkinson’s,” she says. “And what’s really tough sometimes is when somebody starts levodopa, they might get some nausea or feel a bit lightheaded and then they give up. And I do my best to say to people, you might get this, just push through it. It’s not a reason to stop. Those side effects normally wear off in a few weeks.”
The common myth that levodopa “stops working” must be dispelled, she adds, noting it continues to work throughout the life course, but patients need a higher dose to manage symptoms as the condition progresses.
SSRIs should be started early if needed for anxiety and depression, she adds, stressing they do not interact with levodopa.
Early referral to allied health can support wellbeing and help reduce the risk of complications.
Referral for neuro-physiotherapy should be offered at diagnosis and onwards. A preventative approach focused on gait and balance, rather than waiting for the first fall, is recommended.
Helping patients reframe their condition—from a condition that may at first feel like a catastrophe to one that is manageable and people can live a good life with — is crucial.
“When someone says, ‘Parkinson’s now just sits to one side of my life rather than centre focus,’ that’s when I know we’ve done well,” Professor Alty says.
“For some people, referral on to a psychologist is actually quite transformative because we do see that some people get stuck at that point of diagnosis and they feel such stigma, and they don’t share the diagnosis with others and they cut themselves off. And then that becomes really hard to manage.”
Speech pathology and occupational therapy can also be beneficial.
While genetics and environmental factors (such as exposure to certain pesticides or dry-cleaning chemicals) may contribute to PD risk, exercise can actually help slow neurodegeneration, Professor Alty says.
“I very much “prescribe movement”, prescribe physical activity—and I’ll be quite prescriptive and say, I’d like you to aim for at least 30 minutes a day where you feel out of breath. You can choose the exercise. It doesn’t matter. Just do something you enjoy. Because I think we’re recognising that people with Parkinson’s who exercise do seem to progress more slowly.”
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