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Mr X is a 76 year old retired insurance worker with an eight month history of idiopathic Parkinson’s disease (PD). His symptoms began four years ago when his wife started to observe a change in his posture, which was becoming more “stooped”. She noticed that he was struggling to do daily chores and his personality was gradually changing – he no longer seemed to enjoy his life, was becoming forgetful and slow in his thinking.

After medical attention was sought, the diagnosis of PD was made and he was prescribed Sinemet. Mr X has since been managed by doctors, occupational therapists, physiotherapists, district nurses, social workers and his wife (his carer), all of whom have played unique roles in improving his quality of life.

Idiopathic PD is caused by degeneration of dopaminergic neurones of the nigrostriatal pathway. Ask a medical student how it characteristically presents and they will deliver with pristine accuracy, “tremor, rigidity and bradykinesia”. PD patients might describe it as an illness in the brain that causes problems with walking. However, far less widely acknowledged, at least in the public domain, and arguably among the medical community, are the psychological issues, which seem to play ‘second-fiddle’ to the physical symptoms. To engage in a thorough discussion of Parkinson’s disease and the full remit of the different disciplines involved would be beyond the scope of this essay. Therefore, the focus of this piece will be on the psychological issues involved in Parkinson’s disease and the value of multi-disciplinary work in addressing these. The points made will be illustrated by the case of Mr X.

Adapting to physical disability - struggling with psychological issues
It is crucial to recognise symptoms of cognitive impairment, depression, anxiety, psychosis and dementia in PD patients as they can contribute to the morbidity of the disease and cognitive impairment has in fact been quoted as being the most important risk factor for institutionalisation of Parkinson’s disease patients.1 Another risk factor for institutionalisation is dementia, which is present in between 20-44% of Parkinson’s disease patients.2 The prevalence of depression in Parkinson’s disease patients is approximately 31%.3 The situation is complicated by the fact that PD drugs can also have neuro-psychiatric side-effects, for example, “psychosis is increasingly reported in patients treated with dopaminergic drugs.”4 The management of the aforementioned psychiatric problems requires a multi-disciplinary team, including carers, physicians, specialist PD nurses and liaison psychiatrists.1 As PD is a chronic and incurable disease, multi-disciplinary therapeutic interventions are not just of value in improving physical symptoms. They extend beyond that and have a psychological effect on patients, to build their confidence, make them feel that their quality of life does not have to be severely impaired and that the condition is manageable.

Mr X explained that he does not perceive his difficulty in walking or conducting daily tasks as too problematic. Although the situation is far from perfect, he feels that he is able to become accustomed to such symptoms. What has impeded his life more, however, are the changes in personality that he and others have noticed. He feels as if his thought processes have decelerated and he is no longer able to ‘keep up’ with what is happening around him. He has subsequently ceased meeting his friends and even struggles to understand conversation with his granddaughter. Prior to his diagnosis, among his social circle, he was the individual that initiated and organised large-scale events but over the last few years, he no longer has the desire to engage in pleasure-seeking activities. He feels embarrassed that he has become forgetful and is conscious of being laughed at if he gets the date wrong or makes mistakes. The aspect of his condition that saddens his wife the most is that he is no longer “himself” – not his trembling hands, altered appearance or any other physical symptom. They have adapted to the physical disability but it is the psychological issues that they struggle with.

At the same time, if the multi-disciplinary team does improve some of the physical symptoms restricting the patient, he may sustain a more positive state of mind and will perhaps be less likely to develop psychological symptoms.

Of course, before management plans are made, a thorough assessment must be carried out, in which psychological considerations are of the utmost importance. The patient’s communication skills and ability to take on board new information are vital in order to educate him/her about Parkinson’s, so that preventive measures can be taken to slow its progress. The patient’s motivation towards improving their condition is relevant with regard to compliance to medication as well as other forms of conservative management. It is important to screen for symptoms of depression, anxiety etc. that might hinder the patient’s progress and make other interventions counter-productive.

Once the patient is assessed, different roles intervene in individual ways. Various healthcare professionals have been involved with Mr X and can be used to illustrate the multi-disciplinary team that frequently manage Parkinson’s patients. Social workers may be able to provide financial advice and employment advice to prevent patients from having to take early retirement. This will help to alleviate any anxiety patients may have about how their disease will affect their livelihood and how they will cope; if they can maintain their jobs as a result, they will be more active and will be kept mentally stimulated. Social workers may also be able to provide housing advice.

Restoring personal sense of dignity
The value of occupational therapy in the management of PD was first recognised decades ago.5 Occupational therapists have an important role in making modifications within the patient’s home to limit the level of disability experienced as well as maximising the patient’s functional capacity. By making small changes such as adding hand rails and perching stools within the patient’s bathroom, it may make the difference between patients being able to do these personal tasks themselves and needing assistance; even if a carer is required to help, these interventions will ease the task for him/her in situations that would otherwise be not only unfamiliar but extremely challenging. Mr X has found that as a result of the perching stool in his bathroom, he is now able to wash himself, which has restored his personal sense of dignity and has made him feel less reliant on his wife.

7-38% of Parkinson’s patients are referred to physiotherapy.6 Physiotherapists intervened in Mr X’s care by taking him for regular walks and through exercise regimens in his home and the patient feels that his physical strength and stiffness have improved as a result. He also feels a sense of pride and achievement because he is able to walk around his home independently, which he was previously unable to do. He explained that the help of the physiotherapist has made him feel less sad and more hopeful. Clearly, the value of the physiotherapist in such cases lies not only in improving physical strength and reducing immobility, but also in its effects on the patient’s mental state.

Needless to say, the medical profession has a crucial role in management of PD patients. A medical assessment of the patient is carried out by a neurologist or by geriatricians, who diagnose the condition and provide education and pharmacological treatment. However, the other specialty that may make an important contribution is psychiatry, particularly old-age and liaison psychiatrists. Many PD patients will go on to develop psychiatric symptoms, either as a result of their drug treatment or in association with the disease itself. Close communication between the psychiatrist and the physician would be required in such cases to ensure the most effective drug regimen. Interestingly, despite the improvement in his physical symptoms, Mr X has found his medication the least helpful of all the different therapeutic options, reiterating again, the positive psychological effects provided by other disciplines.

The range of disciplines that may be involved in the care of PD patients is diverse and those that have been explored hitherto are by no means comprehensive. District nurses as well as specialist PD nurses play a vital role in the domiciliary care of patients. Parkinson’s patients particularly seem to have problems with micturition, constipation and sleeping habits and Parkinson’s disease nurse specialists have been introduced in recent years to help deal with such problems.7 Similarly, speech and language therapists have a role in improving the slowness of voice and symptoms of dsyphagia that many patients suffer with. Much less common contributors are surgeons and scientific researchers. Although it is a less common management option, a surgical technique known as deep brain stimulation has been used in patients whose symptoms have remained uncontrolled with prolonged pharmacological treatment.8 Scientific researchers have been working on more molecular therapies that might be of hope to PD patients both now and in the future and implantation of embryonic dopaminergic neurones has already been tested.9 Whilst, scientific researchers do not have an active role in management, as such, the potential contribution they make to PD management must be acknowledged.

In conclusion, the need for multi-disciplinary management of PD is widely recognised. However, the significance of the psychological symptoms and sequelae must not be under-estimated and treatment options offered by miscellaneous disciplines must aim to work on both a physical and psychological level and in conjunction with other disciplines in order to optimise the quality of life of these patients.

References

1. Thanvi BR, Munshi SK, Vijaykumar N, Lo TCN. Neuropsychiatric non-motor aspects of Parkinson’s disease. Postgraduate Medical Journal 2003; 79: 561-565
2. Cummings JL. Intellectual Impairment in Parkinson’s disease: clinical, pathologic, and biochemical coorelates. Journal of Geriatric Psychiatry & Neurology 1988; 1: 24-36
3. Slaughter JR, Slaughter KA, Nichols D et al. Prevalence, clinical manifestations, etiology and treatment of depression in Parkinsons’ disease. Journal of Neuropsychiatry and Clinical Neuroscience 2001; 13: 187-96
4. Thanvi BR, Lo TCN, Harsh DP. Psychosis in Parkinsons’ disease. Postgraduate Medical Journal 2005; 81: 644-646
5. Davis JC. Team Management of Parkinson’s disease. American Journal of Occupational Therapy 1977; 31(5): 300-308
6. No authors listed. MS, Parkinson’s disease and physiotherapy. Drug and Therapeutics Bulletin 2002; 40(5): 38-40
7. MacMahon DG. Parkinson’s disease nurse specialists: an important role in disease management. Neurology 1999; 52(7 Suppl 3): 21-25
8. Broggi G, Franzini A, Marras C, Romito L, Albanese A. Surgery of Parkinson’s disease: inclusion criteria and follow up. Neurological Sciences 2003; 1: 38-40
9. Trott CT, Fahn S, Greene P, Dillon S, Winfield H, Winfield L et al. Cognition following bilateral implants of embryonic dopamine neurons in PD: a double blind study. Neurology 2003; 60(12): 1938-43