COMMENTARY FROM PRACTICE: On Some Aspects of Care for Patients with Parkinson's Disease
What issues do we still encounter in the diagnosis and treatment of Parkinson's disease even today, despite medical advancements? How to fine-tune the management of care for these patients, facilitate their path to effective therapy, and improve their quality of life using current possibilities? What can their treating neurologist do for them, when is it necessary to consult a specialized center without delay, and how to mitigate the stigmatization associated with this disease? These aspects are also considered in the following commentary from practice.
In recent decades, a significant increase in the incidence of Parkinson's disease (PD) has been observed globally. Currently, more than 6 million patients worldwide suffer from it, and this number is expected to continue to rise.
We are currently encountering problems in diagnosing PD, which may be due to the fact that the diagnosis is still primarily clinical (i.e., based on clinical neurological findings). If a patient does not have sufficiently expressed motor symptoms (rigidity, bradykinesia, resting tremor), they may evade correct diagnosis for years. A fundamental problem, in my opinion, lies primarily in the diagnosis of young patients (disease onset before 40 years of age), where the neurologist does not primarily consider PD. Furthermore, in young patients, the disease may present atypically—the first symptom might be focal dystonia, or the parkinsonian syndrome might mimic, for example, a pyramidal tract lesion (hemiparetic gait pattern, etc.). Sometimes the patient themselves describes their issues not as rigidity or slowness but, for example, as limb weakness. The most important factor in this case is awareness among neurologists. It is good to know that in unclear cases, a DaTSCAN (scintigraphic imaging of presynaptic dopamine receptors) can help, and there is also the possibility to consult uncertain patients with specialized centers.
PD typically begins long before the patient develops classical motor symptoms. There is currently a great emphasis on being able to recognize the disease in this so-called premotor phase. However, there is no reliable biomarker for this period yet. The first symptom that may signal the development of PD could be REM sleep behavior disorder (RBD) or, for example, olfactory dysfunction. Once the patient develops classical motor symptoms, the diagnosis is usually straightforward.
The establishment of the diagnosis and the initiation of dopaminergic therapy (with levodopa or dopamine agonists) is usually a relief for the patient. Additionally, by adhering to basic rules (gradual slow dose increases, prevention of peripheral dopaminergic side effects with domperidone), there is no need to seek specialized centers at this stage.
A specialized center should be consulted when movement complications develop (fluctuations in mobility, the development of dyskinesias), and the patient does not thrive despite combined and timed oral therapy. In this situation, interventional methods, which are tied to three centers in the country (Prague, Brno, Olomouc), should be considered. Interventional treatment currently includes deep brain stimulation and pump systems. One of these methods should be considered practically for every patient with PD in the advanced but not late stage of the disease. If interventional treatment is indicated too late, it may no longer be suitable for the patient and may not bring sufficient improvement in quality of life. Therefore, awareness among patients is also crucial, so they know about interventional options and express interest at the right time. Finding solutions for patients with medication overuse and low compliance can also be problematic.
Every treating neurologist has the option to refer their patient for consultation to a specialized center, where the most appropriate treatment method will be offered after the condition is assessed. Centers providing interventional treatment collaborate with each other, as it is a relatively close professional community where practically all doctors know each other, have contacts, and it is not a problem for a patient, for example, to transfer from one center to another upon changing residence.
If a patient reaches the late stage of the disease, dopaminergic treatment already has a limited effect. At that time, we try to emphasize adequate energy intake, pain treatment, sleep disorder management, etc. An integral part is the timely offer of compensatory aids (walker, wheelchair, adjustable bed...) and help with their approval and directing the patient and family members to relief or institutional services. In recent years, I consider the expansion of comprehensive spa care for patients with PD to be a significant benefit—it is currently possible to apply for it once every 2 years.
Reducing the stigmatization of patients remains a major challenge for the entire society. We try to help with this through lectures, articles, and media appearances. Increased incidence of the disease in the population and the resulting shift towards viewing Parkinson's disease as a societal problem, similar to multiple sclerosis, could paradoxically bring certain progress.
MUDr. Petra Havránková, Ph.D.
Chief Physician of the Center for Interventional Therapy of Motor Disorders
Neurological Clinic, 1st Faculty of Medicine, Charles University and General University Hospital in Prague
For a video interview with the director of the patient organization Parkinson-Help Ing. Romana Skála-Rosenbaum about obstacles in the treatment of PD, you can watch here.
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