15.3 Parkinson's Disease and Parkinsonism
15.3.4 Mobility Considerations
15.3.1 Introduction
(i) Parkinson's disease (Parkinsonism) is a complex clinical syndrome associated with decreased concentration of a naturally occurring chemical, called dopamine, in certain parts of the brain. It is characterised by tremor, rigidity of muscles and difficulty in initiating movement.
(ii) Parkinson's disease affects 100 people per 100,000 of the population in the United Kingdom. Men and women are affected equally. Symptoms usually begin after the age of 50 years, but it can also affect younger people. After the age of 50, the incidence rises rapidly with increasing age. There are probably between 60,000 & 80,000 people suffering from Parkinson's disease in the United Kingdom at any time.
15.3.2 General
(i) The earliest manifestation is a general, barely perceptible, impairment of movement. This leads to loss of facial expression, less frequent gestures, slowing of gait and a gradual increase in the time taken to perform any task including dressing and eating. Tremor may appear, initially in the hands, and muscular rigidity develops. As the disease progresses these symptoms become more marked. Mobility is particularly affected. The gait becomes short stepped and shuffling. Involuntary, progressive acceleration of steps (festinating gait) may occur making it difficult to stop and predisposing to falls.
(ii) Alternatively the person may become rooted to the spot and unable to move. All tasks become more difficult especially those requiring fine movements of the fingers (tying shoe laces, doing up buttons, handling cutlery). Speech becomes slurred, weak and may be difficult to hear. At night the person may have difficulty turning in bed and so be unable to sleep because of pain and stiffness in the limbs. Mental function is not affected in the early stages, but in the late stages a proportion of sufferers become demented.
(iii) The management of Parkinsonism has been revolutionized by the introduction of the drug L-Dopa, and other drugs, which increase the level of dopamine in the brain. Drug treatment reduces symptoms in 80% of cases; people who untreated would have required considerable attention are enabled to remain independent for some years. However, as the disease progresses treatment may lose its effect, symptoms increase and independence is lost.
15.3.3 Care Needs
(i) Attention needs arise principally from muscle rigidity, paucity and slowness of movement and tremor. The amount of attention and/or supervision required by day will depend upon the severity of symptoms and the stage the disease has reached in the individual case. In people first diagnosed as suffering from Parkinson's disease who have just embarked upon an appropriate drug regimen, the beneficial response is usually achieved quickly, resulting in a dramatic improvement in the disablement and its associated needs. If after a year significant improvement has not occurred the situation is unlikely to change.
(ii) Those already in long-term receipt of drugs who still have substantial needs because of persisting muscle rigidity, tremor or slowness of movement, are unlikely to show any further beneficial response. People in this category will probably progressively deteriorate and have increasing needs throughout the remainder of their lives.
(iii) Independence is likely to be maintained by most sufferers in the early stages of the disease. As the disease progresses slowness of movement may make it impossible to undertake household tasks. Later assistance may be required with dressing and undressing and cutting up food. In some cases the person continues those tasks unaided but takes an inordinate length of time. Feeding, including chewing and swallowing, may also become very slow. In these circumstances assistance is a reasonable requirement. In the later stages of the disease the need for attention during the day will normally increase. The likelihood of falls occurring, and the danger they pose, is an important factor in determining whether there is a need for supervision.
(iv) A requirement for attention at night is unlikely to be encountered until the later stages of the disease. Needs for attention at night arise in those who have difficulty in changing position in bed and in getting out of bed. The ability to use a portable urinal will also be impaired in those whose upper limb function is markedly affected by rigidity and tremor.
15.3.4 Mobility Considerations
The disturbances of gait and mobility described in paragraph 15.3.2 will be important considerations in the assessment of walking ability.