Dr Obianozie, a consultant neurologist, discusses misconceptions and management of Parkinson’s Disease.
Mama Nneka was always dreaming. One dream was so vivid that, as her cowife and her son chased her away from her most lucrative palm-nut farm with a cutlass, she fell into a den of snakes.
Ojiugo had haunted her for years mentally, but when that was not enough, she attacked physically. Her right hand began to shake about two years ago, and soon after, her left hand. She found it harder and harder to till her small farm, which she loved, although her son, Ikenna, had told her to stop farming.
Mama refused to be consoled and asked to be taken away to her son’s family in Enugu. Ikenna lived in the city and had a good job in the government. There, maybe, the spirits and demons sent to haunt her would be far away. Ikenna noted Mama’s growing slowness and shaking, but chalked it up to her hard life in the village and her advancing age. When she fell for the first time, he decided to tackle it on the spiritual side, as Mama was convinced this had to be Ojiugo again. She pondered to herself what she had done to deserve this when she had shown this girl nothing but love despite having to share her beloved Osi with her.
Ikenna arranged for deliverance at his church in Enugu. The pastor had an active group ready to cast and bind all sorts of demons, and he had himself witnessed some dramatic deliverances from varied spirits.
“The spirit of shaking, I bind and cast you out, from wherever you came, back to sender! We are children of God, our portion is good health, no weapon fashioned against us shall prosper, I command you out of her, out of her, out of her” Mama Nneka felt the weight of the prophet’s hand on her head, and she tried to control her trembling as she stood in front of the altar. The congregation began to speak in tongues as she continued to stand.
As the voices of prayer grew louder and more intense, Mama Nneka began to feel dizzy. She had been standing for a long time waiting for this deliverance, but this was now the peak. She felt herself becoming more and more woozy and then nothing. Mama Nneka suddenly fell forward, hitting her head on the elaborate altar. She sustained a head injury and had to be rushed from the church to the teaching hospital nearby. While on admission for a concussion at the Teaching Hospital, the doctor noticed her shaking hands and masked face and asked for the Neurology team to review her.
She detailed how her farming practice had become more difficult in the last few years and how slow she had become in most of her activities. The tremor, which had started in her right hand, had progressed to the left and made farming even more difficult. The doctor asked her about her sleep. She initially refused to speak, and then Ikenna spoke up, “Mama has had spiritual attacks every night for years now. She talks and fights in her dreams, but doctor, we are tackling this spiritually.”
Parkinson’s Disease, the doctor told them, could explain all these. Ikenna was shocked. So there was a reason Mama had been shaking and having bad dreams? The doctor explained that those kinds of dreams were part of the Disease’s non-motor symptoms. He also explained that those dreams often came for many years before the actual slowness and shaking Mama had begun experiencing.
Parkinson’s Disease is the fastest-growing neurological Disease worldwide, currently affecting about 10 million people, with a projected figure of about 25.2 million people by 2050. Half of this figure lives in low-income countries, such as Nigeria. West Africa, Nigeria inclusive, is expected to see the world’s largest increase in PD cases, about 292%, by 2050.
Parkinson’s is a neurodegenerative disease characterised by the loss of neurons which produce a chemical in the brain called Dopamine. The brain needs Dopamine to help regulate movement, but it is also essential for mood and other brain functions. The core feature of Parkinson’s Disease is slow movements. This can be evident in how the patient walks, gets out of cars and out of bed and, in general, even his facial movements. It can be likened to watching a person in a slow-motion movie. Other features of Parkinson’s include hand and/or leg shaking (tremor) and joint stiffness.
Parkinson’s also has symptoms not related to movement like constipation, mood changes and sleep problems. The sleep problems range from difficulty falling asleep to sleeping too much to more dramatic ones, such as dream enactment behaviour, where people act out their dreams. There are also psychiatric and cognitive issues associated with Parkinson’s, but these tend to occur later in the disease course.
The main risk factor for Parkinson’s Disease is increasing age, although incidence is also affected by genetic predispositions and exposure to pesticides like paraquat. Parkinson’s has also been linked to exposure to chemicals like trichloroethylene (TCE), used in dry-cleaning industries, as a solvent for spray adhesives, and as a degreaser in automotive maintenance and in the plastic and textile industry. The widespread use of pesticides containing paraquat is associated with an increased risk of this condition among farmers.
Countries like Nigeria have low rates of diagnosis due to a lack of neurological services and experts to diagnose the condition. Stigma and lack of awareness also hamper early diagnosis and access to treatment. As was the case with Mama Nneka, who believed it was a spiritual attack and did not seek care for her symptoms.
Treatment exists for Parkinson’s Disease, and one of the most effective treatments is a synthetic form of the chemical missing called Levodopa. This helps to alleviate the symptoms but is not a cure for the Disease. Most patients respond excellently to the medications. However, Levodopa is often not available in some communities in Nigeria and other low-income countries. Okubadejo et al. surveyed pharmacies in the public and private sectors nationwide in 2018 and found that about 76% of private pharmacies and 20% of public pharmacies had formulations of this essential drug. Worse still, it costs about 41 days’ wages to buy a 30-day supply, well above the WHO recommendations.
Affordability, according to WHO, is expressed by calculating the number of days’ income a lowest-paid, unskilled worker needs to pay for a 30-day treatment. Ideally, it should cost less than 1 day’s wages for a 30-day supply. Other essential management components include neurorehabilitation, which is sadly lacking in most communities. Rehabilitation involves physical therapy, as well as occupational and speech therapy.
WHO has declared Parkinson’s Disease a disease of global health priority. The incorporation of diagnosis and early treatment at the primary care level would greatly improve access to care. Ensuring Levodopa is available at the community level and affordable by encouraging local pharmaceutical production would greatly improve access to this essential medication.
This April marks Parkinson’s disease awareness month in honour of the birth of James Parkinson, the London physician who first described the condition in 1817. Please join us to advocate for better diagnosis, early referral to neurologists, and access to Levodopa for all.
Nkechi Obianozie, a Consultant Neurologist, is a Fellow of the West African College of Physicians (FWACP)
