ANEMIA IN PARKINSON’S DISEASE PATIENTS

Abstract

Aim. The aim of this study was the examination of the Parkinson’s disease patients with anemia, it’s etiology and the investigations related to it.

Methods.This pilot study involved the investigation of Parkinson’s disease patients with other comorbidities and with secondary anemia and how it affected the patient’s outcome. Patients were evaluated using the motor part of the UPDRS (UPDRS III), the Parkinson’s Disease Fatigue Scale, red cell count, hemoglobin concentration, hematocrit, reticulocytes count and red cell indices during the study.

Results.Four Parkinson’s disease patients were showing better results of the exams after resolving of the anemia and it’s cause.

Conclusions. Based on this clinical study, the idea of anemia in Parkinson’s diseaase patients’ was elaborated due to both haematological and neurological areas.

Introduction

Parkinson’s disease is a common neurodegenerative disease represented by the damage of pigmented cell nuclei from the brain. From a neuropathological point of view, Parkinson’s disease is characterized by destruction of dopaminergic neurons of the substantia nigra pars compacta, situated in the midbrain and correlateded with Lewy bodies, which consists of cytoplasmic inclusions that contain insoluble alpha-synuclein aggregates.

Nontheless, Parkinson’s disease is defined also by extensive morphology in various brain areas and affects nondopaminergic neurons likewise. The clinical diagnosis of Parkinson’s disease is established principally on motor aspects, for example asymmetric resting tremor with a gradual evolution, rigidity, akinesia, bradykinesia and hipokinesia. Nonmotor aspects involve depression, anosmia, constipation, insomina, usually appear earlier. All along with the progression of the disease, in the final stages further nonmotor aspects may develop, including dementia, autonomic dysfunction and pain1.

The majority of the Parkinson’s disease cases appear due to multiple determinants, developing from the mixed results of environmental and genetic factors. The existence of Lewy bodies is the feature for sporadic Parkinson’s disease, while in various genetic hereditary forms of Parkinson’s disease featuring the loss of SN dopaminergic neurons lack of Lewy bodies aggregates. Alpha-synuclein has it’s function in the synapses, being implicated in the kinetics of vesicles. Alpha-synuclein is encountered in liver, muscle, lymphocytes, and redblood cells, with still unclear roles2.

Anemia is characterized by a decrease in the hemoglobin concentration or red blood cell mass. Iron deficiency anemia (iron deficiency, iron deficiency) is the most common form of anemia and probably the most common food deficiency in the world. The prevalence of this disease is estimated at around 600 million patients worldwide. Iron deficiency affects the production of red blood cells (hemoglobin). People with iron-deficiency anemia often have symptoms of fatigue or weakness and tend to bleach on the face. The most common causes of iron deficiency anemia are: poor nutrition and bleeding. Hemorrhages often occur in women and men in the gastrointestinal tract, which may also be of a tumorous nature, in young women the cause of iron deficiency may be menstruation too strong.

Prevention of anemia and not having adequate blood counts in the body requires efficient cooperation between the kidneys, spinal cord and organic nutrients found in the body. If something is wrong with one of the elements of this system, anemia appears.

Anemia itself is more a sign of a disease than an actual illness. Most of the time, anemia is considered by the doctors either chronic or acute. The chronic one occurs after a relatively long time, while the acute anemia suddenly starts. Only the specialized doctor can assess to what extent the anemia you have is of one type or another.

The red blood cells live on average 100 days, so the body is eternally placed to replace the dying red blood cells with new ones. In adults, hematomas are synthesized in the spinal cord. Therefore, the first investigations that are made, are aimed at the cause of anemia. They are trying to determine if it is a bleeding or a disorder of the process of synthesizing hematoma in the spinal cord. Anemia occurs in both young and old, but older people tend to be more often compared to other people3.

Only in America is it estimated that up to 10% of the population shows signs of anemia. The other countries have higher rates of those suffering from this condition. In addition, women appear to be twice as likely as men when it comes to cases of anemia.

Various conditions can cause anemia, for example: external bleeding (caused by menstruation, wounds or ulcer); iron deficiency (spinal cord requires iron to synthesize red blood cells); chronic diseases (any of such disease can lead to anemia); kidney diseases (the kidneys provide vital support to the spinal cord in the process of creating red blood cells); pregnancy (the accumulation of water and fluids during pregnancy dilutes the amount of red blood cells); poor nutrition (vitamins and minerals are vital for the synthesis of red blood cells); alcoholism (implies a decrease in the number of vitamins and minerals). Other, less common causes are: liver disease, bleeding disorders, thalassemia, infections, cancer, arthritis, enzyme deficiency, toxins or hereditary disorders4.

Methods

In this pilot study, 4 patients with stage III Parkinson’s disease were observed. The patients were diagnosed in doctor’s Docu Axelerad Any private clinic and treated from the disease’s debut. The selection criteria followed: no clear signs of dementia (Mini Mental State Examination Score, MMSE>18). All patients signed the informed consent. Patients were evaluated using the motor part of the UPDRS (UPDRS III), Parkinson’s Disease Fatigue Scale and several blood tests were indicated to be done that elucidated the diagnose.

The first patient, M.D., male, 63 years, diagnosed with Parkinson’s disease 11 years ago and had a gastric resection 2 years ago.The patient had akinesia, bradikinesia and hipokinesia. Also, the patient had balance impaimets but without falls. The patient didn’t have a caregiver, being independent in his daily living activities. The patient had tremor of his all four limbs, being more increased on the left side. The patient had rigidity.

The non-motor symptoms of the patient have aggravated in the last year and consisted in: fatigue, difficulties in cognition, reasoning and concentration, insomnia, apathy and depression and usual general pain. At the part III of UPDRS Scale test the patient obtained 32 points. At the Parkinson’s Disease Fatigue Scale test, the patient had 64 points, being in the level of moderate fatigue. His blood test results were: Haemoglobin level = 120 g/L, The mean cell volume = 75 fL,  Hematocrit= 30%, serum ferritin = 10 g/dL, serum iron= 65 g/dL, transferrin saturation= 10%, Mean corpuscular hemoglobin concentration= 30 g/dL, reticulocytes= 2%. His anemia was hypochromic microcytic.

The patient was referred to an internal disease department to diagnose and treat the cause of anemia, and after 6 months of following the treatment, he returned to the routine neurological consultation. After the 6 months, the non-motor symptoms of the patient have improved: fatigue disspaeared, the difficulties in cognition were soften, the reasoning and concentration improved, insomnia, apathy, depression and usual general pain became almost absent. At the part III of UPDRS Scale test the patient obtained 32 points. At the Parkinson’s Disease Fatigue Scale test, the patient had 58 points, being in the level of mild fatigue.

The second patient N.N., female, 57 years, diagnosed with Parkinson’s disease 10 years ago and had a jejunal resection 1 year ago. The patient had akinesia, bradikinesia and hipokinesia. Also, the patient had balance impaimets but without falls. The patient didn’t have a caregiver, being independent in her daily living activities. The patient had tremor of her all four limbs, being more increased on the rigth side. The patient had rigidity too.

The non-motor symptoms of the patient have aggravated in the last year and consisted in: fatigue, memory loss, poor concentration, shortness of breath and diarrhea. At the part III of UPDRS Scale test the patient obtained 30 points. At the Parkinson’s Disease Fatigue Scale test, the patient had 69 points, being in the level of moderate fatigue. Her blood test results were: Erytrocytes: 3.500.000/mm3, Haemoglobin level = 129 g/L, The mean cell volume = 105 fL,  Hematocrit= 30%, Mean corpuscular hemoglobin concentration= 29 g/dL, reticulocytes=0,8%, Leucocytes= 5.500/mm3, Thrombocytes= 400.000/mm3. Her anemia was hyperchromic macrocytic.

The patient was referred to an internal disease department to diagnose and treat the cause of anemia, and after 6 months of following the treatment, she returned to the routine neurological consultation. After the 6 months, the non-motor symptoms of the patient have improved: the fatigue has decreased, memory losses were rarely present, the concentration ability was better, the shortness of breath and diarrhea were cured. At the part III of UPDRS Scale test the patient obtained 30 points. At the Parkinson’s Disease Fatigue Scale test, the patient had 60 points, being in the level of mild fatigue.

The third patient S.M., male, 62 years, diagnosed with Parkinson’s disease 15 years ago and had chronic kidney disease stage III. The patient had akinesia, bradikinesia and hipokinesia. The patient presented balance impaimets with rare falls. The patient didn’t have a caregiver, being independent in his daily living activities. The patient had tremor of his all four limbs, being more increased on the left side. Also, the patient had rigidity.

The non-motor symptoms of the patient have aggravated in the last 2,5 years and consisted in: fatigue, memory loss, poor concentration, shortness of breath and insomnia. At the part III of UPDRS Scale test the patient obtained 33 points. At the Parkinson’s Disease Fatigue Scale test, the patient had 72 points, being in the level of moderate fatigue. His blood test results were: Erytrocytes: 3.200.000/mm3, Haemoglobin level = 6,5 g/dL, The mean cell volume = 69 fL,  Hematocrit= 20%, Mean corpuscular hemoglobin concentration= 24 g/dL, reticulocytes=0,8%, Leucocytes= 8.900/mm3, Thrombocytes= 500.000/mm3. His anemia was hypochromic microcytic.

The patient was referred to an internal disease department to diagnose and treat the cause of anemia, and after the 6 months of following the treatment, he returned to the routine neurological consultation. After the 6 months, the non-motor symptoms of the patient have improved: the fatigue was almost null, the memory capacity and the capacity to concentrate have restored, the shortness of breath disappeared and insomnia was still pendant, but now being mild. At the part III of UPDRS Scale test the patient obtained still 33 points. At the Parkinson’s Disease Fatigue Scale test, the patient had 60 points, being in the level of mild fatigue.

The fourth patient J.S., female, 60 years, diagnosed with Parkinson’s disease 12 years ago and didn’t have any subsidiary diseases. The patient had akinesia, bradikinesia and hipokinesia. The patient presented equlibrium impaimets. The patient didn’t have a caregiver, being independent in her daily living activities. The patient had tremor of his all four limbs, being more increased on the left side. Also, the patient presented rigidity.

The non-motor symptoms of the patient have aggravated in the last 1,5 years and consisted in: headache, pain, fatigue, memory loss, poor concentration, shortness of breath and insomnia. At the part III of UPDRS Scale test the patient obtained 31 points. At the Parkinson’s Disease Fatigue Scale test, the patient had 73 points, being in the level of moderate fatigue. Her blood test results were: Erytrocytes: 3.900.000/mm3, Haemoglobin level = 11 g/dL, The mean cell volume = 68 fL,  Hematocrit= 30%, Mean corpuscular hemoglobin concentration= 30 g/dL, reticulocytes= 2%, Leucocytes= 7.300/mm3, Thrombocytes= 300.000/mm3. Her anemia was hypochromic microcytic.

The patient was referred to an internal disease department to diagnose and treat the cause of anemia, and after 6 months she returned to the routine neurological consultation, without an apparent cause of anemia, she has been taking vitamins during the period. After the 6 months, the blood tests of the patient remained mainly the same, and non-motor symptoms of the patient were mostly unchanged.

Results

The results of the patients before and after the treatment of anemia, show an improvement of the mental state of the patients from the point of view of memory, concentration and cognition. From a physical point of view, patients experienced improvements in fatigue and fatigue, insomnia and breathing disorders.

Discussion

According to the results of the described cases, can be concluded that anemia produces changes in Parkinson’s patients and the treatment of anemia is a priority in these patients, improving the physical and mental state of these patients, altogether improving the quality of life and lowering the risks of development of other underlying diseases.

Conclusion

            In conclusion, in the cases studies, we observed the importance of blood test scans amongst the Parkinson’s disease patients both with and without subsequent diseases. Therefore, we advise a routine control consisting of complete blood count with red cell indices, iron indices and assessment of renal function, being part of an anemia evaluation.

Un articol semnat de : DOCU AXELERAD SILVIU, STROE ALINA ZORINA, DOCU AXELERAD ANY, DOCU AXELERAD DANIEL