Advanced Phases Of Parkinson's
What is the advanced phase of Parkinson's?
When we talk about advanced Parkinsons disease, we are talking about something that's not exactly defined, but most of us who are engaged in the treatment of Parkinsons disease think about people who are having a poor response to medication - the medication doesn't work very well or it may work for a very short period of time and require a lot of dosing during the course of the day. Or, people are requiring more and more medication - not just the individual doses are higher or the number of doses are higher, but even other medications being added in, using two, three, four different medications in trying to maintain mobility for people with Parkinsons disease. In some cases, in a case that I would describe as advanced, having diminishing success in accomplishing that. I want to emphasize that advanced Parkinsons disease is not a natural outcome for everybody with this diagnosis, that some people never develop the scenario that I just described. People can do very well indefinitely with a medication regimen, so not everybody's going to find themselves in this situation. In addition, as the number of medications are increased to try to maintain symptom control, we run into problems with increase of side-effects as a consequence of the medication. These things, such as involuntary movements and the visual hallucinations, or the blood pressure disturbance or drowsiness induced by medication, all of these things become increasingly difficult for people and the clinician, the treating clinician. So it gets tougher and tougher to come up with a medication regimen that both keeps people mobile and doesn't create other problems that are worse than the things that we're trying to treat.
What signs of tremor do people show in advanced phase Parkinson's?
Somebody with advanced Parkinson's disease may have a tremor that is simply persistent, that is poorly controlled throughout much of the day. This is highly variable, as one of the issues with Parkinson's disease is that no two people are exactly the same. Some people have a lot of tremors, some people have almost no tremors, some people have a lot of stiffness and others none. Somebody that I would call having advanced Parkinson's disease does not necessarily have tremor as a prominent symptom.
What signs of rigidity do people show in advanced phase Parkinson's?
In advanced Parkinsons disease, rigidity may be one of the features that are increasingly difficult to control. That is, recurring more often during the course of the day, that the medications simply aren't adequate despite increase doses, despite increase numbers of medication. The drug regiment is not adequate to keep the rigidity at bay or under control to the satisfaction of the patient.
How does advanced phase Parkinson's affect dexterity?
Some people with advanced Parkinsons Disease may have a great deal of difficulty in their daily activities, because of dexterity. They may have a great deal of difficulty in cutting their own food, in brushing their teeth, in combing their hair, for example, and may require increased assistance in these fundamental daily activities.
How does advanced phase Parkinson's affect posture?
Some people with advanced Parkinsons disease will have a more marked postural change. The lean or stoop can be more severe, causing additional difficulties with balance and mobility, for example. That's a hard feature to correct with medications or with surgery, the postural change that occurs in some, not in everyone but some with Parkinsons disease, and particularly advanced Parkinsons disease.
How does advanced phase Parkinson's affect body movement?
In advanced Parkinsons disease, body movement is further affected. People are having increased slowness, increased stiffness, perhaps increased tremor, making it all the more difficult to get through their daily activities without assistance. In some cases people will need a hired caregiver to help them with daily activities such as dressing, or bathing, or eating.
How does advanced phase Parkinson's affect balance?
Balance problems, when they occur in Parkinsons Disease, and they don't always, but they may, usually occur later in the course in Parkinsons Disease, many of us think of this as being a component of advanced Parkinsons Disease, where people have been falling, and frequently. So that people, when they're getting up to walk across the room just to answer the phone or go to the bathroom, they'll fall. This is of great concern because of the obvious implications of hip-fracture or other kinds of injury, which I do see, unfortunately, occasionally in my patients. So that balance problem does become a feature for some, as the disease progresses over time.
How does advanced phase Parkinson's affect the face?
Somebody with advanced Parkinson's disease may have an unblinking facial expression, they may not really show much facial expression at all. The lips may be part of the mouth as held open, just at rest, with an unblinking stare. And again this is not the course with everybody with Parkinson's disease, but somebody who's unfortunate, and is having a progression of the disease to this point may experience exactly that sort of thing. This unblinking, mouth open kind of expression.
How does advanced phase Parkinson's affect the voice?
In advanced Parkinsons disease, speech may become very difficult to understand. The intelligibility may markedly be reduced, causing people to repeat themselves. I would find that uncommon, but it does occur unfortunately in some cases with more severe or advanced Parkinsons disease. In advanced Parkinsons disease, speech may become unintelligible, in some cases where a large part of it may become unintelligible. It can be a very difficult problem in advanced Parkinsons disease.
What are the sexual effects of advanced phase Parkinson's?
In advanced Parkinsons disease, sexual difficulties are continued and it may become impossible for people with more severe manifestations of Parkinsons disease. Again, this usually falls along the lines of impaired libido, and impaired erectile functioning.
How does advanced phase Parkinson's affect mental health?
People with Parkinsons disease do sometimes develop cognitive decline or impairment along the lines of developing dementia. It correlates mostly to the severity of the motor findings, and also age. It's not necessarily correlated to the duration of the disease - how long somebody's had it. Somebody who is 85 or 80, with severe Parkinsons, meaning a lot of difficulty with mobility, somebody requiring a lot of assistance in the daily routine would be more likely to have these kinds of problems; cognitive decline and frank dementia.
What kind of pain does a person feel in advanced phase Parkinson's?
In advanced Parkinsons, pain can also be present as rigidity increases, and as mobility declines. People may have other appearances of pain in the form of a sense of stiffness, also because of reduced mobility - discomfort of the limbs because of not moving very much.
How can the autonomic system be impaired by advanced phase Parkinson's?
In advanced Parkinson's disease, people may have a lot of difficulty with bladder and bowel function, mostly with urinary problems. They may develop frank incontinence. It may be difficult to control the bladder, to the point of actually getting to the bathroom in time. Some people do require assistance, using these adult-type diapers to prevent wetting their bedsheets and so forth during the night.
How does advanced phase Parkinson's affect swallowing?
Swallowing and drooling both can become increasingly problematic in advanced Parkinsons disease. Occasionally, people have swallowing difficulties to the point that they actually aspirate food or liquid into their lung. Instead of swallowing it into their stomach, they put it into their lung instead, which is a serious complication. It can lead to aspiration pneumonia, which in some cases can be a life-threatening problem. Some people need adjustment of the type of food that they eat, and in rare cases, even use of a feeding tube is undertaken by patients who are agreeable to do so. The tube is placed directly through the abdominal wall into the stomach or into the intestine to deliver food and water that way. Drooling can also be a problem, not necessarily in advanced Parkinsons disease, but even early in Parkinsons disease, drooling can be an issue that's troubling to people. Sometimes it's just present at night; people will notice that they're drooling on their pillow more or during the day, they'll have a little bit of saliva running out of the corner of their mouth. It does not necessarily coordinate to motor severity.
How does advanced phase Parkinson's affect sleep?
Sleep is a problem throughout the course of Parkinsons disease, and people with advanced Parkinsons disease will continue to have difficulties with fragmented sleep at night and may for a number of reasons have more difficulty with somnolence, or excessive drowsiness during the course of the day. This again is probably due largely to the disease itself, but as medications are increased to try to better control symptoms of Parkinsons disease, the sleep inducing side effects or the drowsy side effects of the medication may become more of a problem.
What treatments are available for advanced phase Parkinson's?
In advanced Parkinsons disease we use the same medications that we use in earlier stages or less severe Parkinsons disease - we just use them more often. Actually, as the disease progresses in some people we may, in fact, ultimately reduce the number of medications. If the medications are not achieving the effect of improving quality of life and are creating side effects like hallucinations or difficulties of disturbance of maintaining the blood pressure, then in that situation I might recommend reducing medications with the goal of maximizing the quality of life, and not necessarily eliminating all of the symptoms. If the medications, in the judgement of the patient, their spouse and also the clinician are causing more trouble than good then in that setting I might suggest reducing medications.
