Understanding Parkinson's disease

Parkinson’s disease is a chronic and progressive neurodegenerative movement disorder which effects 1% of people over 60 and the most common onset is between ages 65-70. It is more common in men than women. Many cases appear to be sporadic, however genetic factors are thought to contribute to 5-10% of cases. Environment can also play a role, such as head injury, cigarette smoking, alcohol use and vitamin D levels, however the actual cause of the disease is still not fully understood.

Parkinson’s disease is characterised by three main hallmarks of tremor, rigidity, and slow movement. It involves motor and non-motor symptoms. Many of the classic motor symptoms can present in an asymmetrical manner, including a ‘pill rolling’ tremor at rest in the hands or fingers. Other symptoms include a ‘cog-wheel’ form of rigidity in the limbs, which also impacts the trunk and contributes to a flexed, stooped posture, and an overall slowing of movement, which can include a ‘mask’ like face with limited expression and eye blinking. Patients may present with slow writing which becomes progressively smaller known as micrographia, and a stiff, short, shuffling gait with reduced arm swing, frequent freezing and trouble initiating again once stopped.

A fourth feature of postural instability is sometimes included, although this generally presents late in the disease progression. Other non-motor features include a decreased sense or loss of smell, constipation, REM sleep behavioural disorder where a patient physically acts out dreams with talking and uncontrolled arm and leg movements, plus postural hypotension, slow thought processes, dementia, psychosis, particularly visual hallucinations, as well as somnolence and fatigue. Dizziness and falls are typical of patients with advancing Parkinson’s disease and may be related to postural hypotension, a form of severe low blood pressure, and are also a side effect of dopaminergic medications.

No specific medical imaging tests exist to diagnose Parkinson’s disease. Imaging test such as MRI can help to rule out other disorders. A SPECT dopamine transporter scan can help to support a diagnosis, but ultimately diagnosis is made on the basis a of a patient’s neurological presentation.

The pathophysiology of Parkinson’s disease involves degeneration of the pigmented neurons in a part of the midbrain, called the substantia nigra. The subsequent loss of substantia nigra neurons results in depletion of dopamine. This occurs in the dorsal aspect of the putamen, which is a part of the basal ganglia. Projections from the substantia nigra to the basal ganglia facilitate smooth movement via the nigro-striatial pathway. As Parkinson’s disease progresses, Lewy Bodies develop when ⍺-synuclein proteins become tangled and accumulate within the brain, forming inclusions within the cells. If these are unable to be removed, they become toxic. Lewy body spread often closely relates to the degree of clinical progression and is outlined in Braak staging. The Lewy bodies continue to spread throughout the brain, and overtime ascend to the medulla and pontine tegmentum followed by the midbrain, basal forebrain and finally the neocortex.   

Medications for Parkinson’s disease increases levels of the neurotransmitter dopamine and block cholinergic receptors. They act to increases dopamine in the brain and peripheral tissues to assist in the replenishment of depleted striatal dopamine, helping to control some of the movement symptoms of Parkinson’s disease. Unfortunately, the medications used to treat Parkinson’s disease cause significant side effects and are unable to reverse the dopaminergic neuron loss. As the disease progresses, surgical options may be considered, including deep brain stimulation.

If you are concerned about someone you know, consult your GP, who will then refer the patient to a specialist for a definitive diagnosis. These days, a multidisciplinary health care team will be involved, allowing for holistic treatment of Parkinson’s disease. The team may include a neurologist, physiotherapist, occupational therapist, nurse, pharmacist, social worker, general practitioner, psychiatrist, dietitian and geriatrician. The team will work closely together to ensure a person living with Parkinson’s disease has the best outlook and quality of life possible.

What is iron deficiency anaemia?

Iron deficiency is simply a lack of iron. Iron is an essential mineral required to produce haemoglobin in red blood cells, which transport oxygen from the lungs around to every cell in the human body. Healthy red blood cells are important for cognitive functions, muscle strength, the immune system and energy. The body can’t manufacture iron by itself, so iron must be sourced from food or another external source. If a person has low iron, they develop anaemia.

Iron deficiency anaemia impacts up to one sixth of the world’s population. It is a major public health problem which affects premenopausal women, pregnant women, and children, as well as those with chronic diseases. Iron deficiency anaemia commonly presents in patients with chronic diseases such as chronic heart failure, heart transplants, digestive disease, kidney disease and cancer. Common blood thinning medications such as aspirin, heparin and warfarin can interfere with the body’s ability to make haemoglobin. A poor diet, digestive disease or significant bleeding from ulcers, cancers or menstruation can also contribute to the condition. Other conditions such as pregnancy and kidney disease increase the demand for iron which can deplete an individual’s iron stores.

Common symptoms of iron deficiency anaemia include fatigue, headache, shortness of breath, restless legs, dizziness, chest pain and trouble concentrating. Common signs include a very pale complexion, diffuse hair loss, dry and rough skin, atrophic glossitis (a smooth tongue), difficulty thinking, rapid heart rate, and cardiac murmur. Routine observations performed by medical staff may pick up many of the signs and symptoms of the condition such as visual paleness, shortness of breath, increased work of breathing, headache, dry skin, increased pulse rate, dizziness, reduced alertness/confusion, poor memory and concentration, and cold hands and feet.

Blood tests will pick up low haemoglobin levels. The normal reference range for adult men is between 130 – 180 g/L and non-pregnant adult females 120 – 160 g/L. However, more insightful information is gained by measuring serum ferritin and transferrin saturation levels, serum soluble transferrin receptors, and the serum soluble transferrin receptors–ferritin index rather than just the classic red cell indices.

Iron deficiency anaemia can be absolute or functional. Absolute iron deficiency occurs when there are severely reduced stores of iron in the liver, spleen, and bone marrow. Absolute iron deficiency is defined by serum ferritin less than 200 ng/mL. In functional iron deficiency, patients have adequate iron stored but they are unable to support adequate iron mobilisation which is defined as ferritin greater than 200 ng/mL with TSAT (transferrin saturation) less than 20%. This commonly occurs in patients with systemic inflammation, as iron is withheld from the plasma and leads to production of iron deficient red blood cells.

Oral supplementation and increasing iron in the diet is usually the first line of treatment for patients with iron deficiency anaemia. However, this can take up to 3 months to take full effect and is not always well tolerated. In some cases, restoring iron may be required urgently, particularly if there is a background of malabsorption or there has been significant blood loss. In several disorders, including chronic kidney disease and postpartum, intravenous iron replenishes iron stores more effectively than oral supplementation. The modern versions of parenteral iron formulations provide safe, rapid, total-dose iron replacement.

A doctor will calculate an appropriate infusion dose based on the patient’s weight. Following this, a health care professional will apply a tourniquet to the arm, inserting a small needle, and replacing this with a small intravenous catheter. A prescribed intravenous iron infusion will be connected, which includes a bag suspended above the patient, attached via a line to the venous catheter. The infusion usually takes between 15-30 minutes. Blood transfusions can also occur as a treatment for iron deficiency anaemia, but they are used as a last resort. The patient will be closely monitored before, during and after the infusion takes place.

Some side effects have been reported in association with iron infusions. These include nausea, dizziness, constipation, swelling, diarrhoea, skin staining, fainting and hypotension. Rarely, in around 1 in 250,000 cases, a person may experience a severe allergic reaction causing a rash, severe itching and difficulty breathing. Other rare side effects include hypophosphatemia (low phosphate) and finally infection which can occur anytime a needle is introduced into the body. For this reason, intravenous iron infusions should only take place at facilities where staff are adequately trained to deal with anaphylaxis.

In summary, iron deficiency anaemia is a common condition which presents frequently, causing significant morbidity in the general population. It is particularly common in pregnant women and patients with chronic diseases such as cancer, kidney disease and heart failure. A lack of iron impacts the haemoglobin in red blood cells, reducing the capacity to transport oxygen. The good news is it can be readily treated. Your doctor is in the ideal position to identify the common signs and symptoms of iron deficiency anaemia, so if you have any concerns, make a visit to your GP or specialist to discuss your symptoms.

7 ways to improve your heart health

Everyday habits play a crucial role in determining the health of your heart. Prolonged stress, poor eating habits and being sedentary can all contribute to poor cardiac health. Sadly, more Australians die of heart disease than any other cause. However, the good news is, just small changes in lifestyle habits can substantially improve your heart health.

1. Check your cholesterol levels and your blood pressure. Cholesterol levels and blood pressure are important indicators of cardiac health. Some times high cholesterol can run in families, so it is a good idea to be screened when appropriate. Elevated LDL cholesterol contributes to atherosclerosis which is a narrowing of the arteries and, high blood pressure puts you at a higher chance of having a heart attack or stroke. By knowing these numbers, you can be more aware of your cardiovascular risk.

2. Check your waist circumference. You can get a good idea of whether or not you are at risk of cardiac disease and other chronic diseases just by measuring your waist circumference. For adult women, a waist circumference of 80 centimetres or more indicates an increased risk of chronic disease, and for adult men, a waist circumference of 94 centimetres or more indicates an increased risk of chronic disease.

3. Reduce your stress. Living in a constant state of stress is not healthy for your heart. Stress may be derived from a range of sources including work, relationships, illness, finances, living arrangements or other factors. Proactively managing stress by employing self care strategies such as meditation, yoga, deep breathing and taking time out for yourself can help to manage day to day stress. Seek professional help when you need it.

4. Eat heart healthy food. Fill up your plate with foods rich in omega 3 fatty acids such as salmon, nuts and avocados. These also contain polyunsaturated and monounsaturated fats, which may help lower bad cholesterol. In addition, fruit and vegetables provide key vitamins and minerals, and contain naturally occurring plant sterols which also contribute to lowering cholesterol. Keep an eye on the salt in your diet as high sodium levels can increase blood pressure and put extra pressure on the heart.

5. Quit smoking. Smokers have a two to four fold increase in the risk of cardiovascular disease. Smoking decreases the amount of oxygen available to the heart, and increases blood pressure, blood clotting and damage to the blood vessels. Reducing or quitting smoking will not only save money, but make you feel healthier and will prolong your life. If you have tried before, keep trying, as many people take a few attempts before they are successful. Any reduction in smoking will have immediate benefits for your health.

6. Lift weights. Everyone knows they should be doing 30 minutes of cardio each day, but combining this with resistance training adds extra benefits. Building muscle helps to improve your body composition, and assists in soaking up sugar from the blood stream while improving your overall metabolic rate.

7. Sleep more. Well that is welcome news! Long term sleep deprivation and shift work is linked to chronic disease and poorer cardiovascular health. Being active during the day and practicing good sleep hygiene will help to you sleep better. Simple things such as winding down before bed, going to sleep at the same time each day, and having a cold, dark room facilitates better sleep which all has a positive impact on your heart.

Looking after yourself during lockdown

With half of Australia currently in lockdown due to Covid-19, we hope you are staying safe and well. Sudden changes brought on by a change in our situation can understandably cause feelings of disorientation and distress. Here, we explore some strategies that can help you to look after yourself during this lockdown period.

1. Accept what is outside of your control. Humans love to have control over their environment, but during a global pandemic, this is not always possible. By acknowledging what is inside your control, you can focus on those things which you can change, and let go of those that you cannot.

2. Stick to a daily routine. If you have always worked in an office environment and are suddenly required to work from home, with home schooling thrown in as well, this can be very challenging. You may have to set up a new work space and/or new technology. While it may be tempting to sleep in, you’ll likely feel much better if you get up at your usual time, and get dressed in comfortable clothing instead of staying in your pajamas all day.

3. Stay connected with friends and family. We are social animals. So while we may be physically distancing, we can still stay socially connected but using our phones, Facetime, Zoom and social media. Check in on your elderly relatives or friends who may be isolated. They will appreciate your calls.

3. Use the time to tackle projects or hobbies. Many of us have tasks around the house that we have been putting off, such as cleaning the windows, re-organsing our pantry or doing our tax return. Lockdown can mean we finally have the time required to get on top of these projects. You may even find you are able to get back to playing a musical instrument, bingeing on Netflix or baking your favourite treats.

5. Exercise daily. Exercise in nature has been proven to improve mood and wellbeing. Even a quick walk around the block can help to improve your state of mind, particularly if you have been inside all day. Sometimes you may not feel like doing it at the time, but you know you will feel so much better afterwards.

6. Eat well. Simple things like ensuring you eat a balanced diet of fruit, vegetables, protein, healthy fats and nuts will ensure you get your essential nutrients every day. The occasional comfort food delivery won’t harm you, but just make sure it doesn’t become a habit.

7. Don’t overdose on media. When everything is in a state of flux, it is natural to want to be up to date with all of the latest developments. However, watching back to back daily press conferences full of bad news can be quite depressing. Accessing just one update per day from a trusted news source can help you to get the important news you need, without overdosing. Consult government websites to source support that is available to you.

8. Show compassion for others. You may have heard the analogy that we are all in the same storm, but we are all in different boats. Some people may not be affected too much at all by the lockdown, where as other people may be hugely impacted. Many may have lost work, be experiencing stress to their business, or to their health. Others may be working on the front line with all of the anxiety which comes along with that. Be compassionate and think of others.

9. Look after your health. Some face to face medical appointments may not be possible at this time, but you can still access your doctor via telehealth, where appropriate. Emergency treatment and surgery will always be available. It is important that you don’t put off essential medical treatment.

10. Remind yourself that this temporary. It can be helpful to remember that no matter how tough things seem at the moment, this too shall pass.

10 ways to a better night's sleep

We can all struggle to get to sleep at some point in our lives. Here are some great tips for improving the quality of your sleep for when, no matter what you do, it seems to be evading you

1. Wind down before bed. Dim the lights and avoid screens for one hour before bed. The blue light emitted from devices can interfere with our natural sleep cycle. Have a bubble bath, play some relaxing music or read a book, anything that helps you transition from alert into a more relaxed state. This should make it easier to fall asleep more quickly.

2. Avoid alcohol and caffeine. If you think a little glass of wine will help you sleep, you are wrong! It has been shown that consuming alcohol prior to sleep will actually impair your ability to get a good night’s sleep. While it may initially help you fall asleep, alcohol reduces REM (rapid eye movement) sleep, the most restorative form of sleep. Likewise, caffeine is a stimulant which make it harder for the body to switch off. Try to have your last coffee by mid morning.

3. Go to bed at the same time each night and wake up at the same time each day. Research has shown those with a consistent routine are more likely to release hormones associated with sleep at the right time and this supports the body’s natural circadian rhythm, or body clock.

3. Avoid napping during the day. When you experience insomnia, those day time naps can be very tempting. However, daytime naps may perpetuate a cycle of reduced tiredness at night and therefore greater insomnia. If you must nap, try to keep it under 20 minutes.

5. Use a mediation app. One of the greatest developments of late has been the huge quantity of great meditation apps available. Meditation brings you in to the present moment, thereby assisting you to increase calmness, reduce stress and anxiety, improve concentration and get better sleep.

6. Make sure your bedroom is cool and dark. Being in a comfortable, dark environment is essential for good quality sleep. The best temperature for sleeping has been found to be around 18 degrees Celsius.

7. Know how much sleep you need. Most adults need 7-8 hours sleep a night, where as children and teenagers need more. Everyone varies a bit, so work out what duration of sleep is best for you.

8. Remove distractions from your room. If you having trouble sleeping, watching the clock can make it worse. Remove the clock or any other known distractions from the bedroom so you’re not tempted to look at them (phones included!)

9. Avoid sleeping pills. While they may appear as an easy fix, sleeping pills can be addictive and they don’t address the root cause of your insomnia. It is important to find out what is causing the sleep problem in the first place, particularly if despite all your best efforts to address the points above, it is still not improving.

10. Seek professional help. Not sure if you have a sleep disorder? If you find yourself persistently feeling tired and wanting a nap during the day, you may suffer from one. Common sleep disorders include snoring, sleep apnoea (a breathing abnormality) and insomnia. Not getting enough sleep can seriously impact your health and safety, so if you’re feeling sleep deprived, see your doctor for advice.