The physician explains that past researchers lumped Parkinson’s disease was into two types; rigid akinetic or tremor dominant. In the days before levodopa patients evolved into a fixed dystonic posture. In fact, the PD is really a gradually progressive dystonic illness with or without tremors. Dytonia is an abnormal posture of a limb or other body part due to sustained contraction of muscles. The patient has had the disease for more than twenty years and today she sits in a wheelchair, her daughter by her side. She wears functional black sneakers though the dystonia is still evident in the position her left foot takes. The muscle spasm makes her left foot curl to the outside. Attempting to transfer to the toilet with one functional foot is difficult.
When the doctor recommended they increase the dosage of levodopa, in an effort to counter the dystonia, hallucinations became more frequent and she spent some time in a nursing home. With Seroquel the anxiety attacks have stopped, she sleeps well and is less agitated during the day. Though the patient may be faring better, her daughter’s expression is drawn tight. The physician complements the patient, telling her she looks well. The others in the room agree. At eighty three her complexion is smooth. Her skin is tightly pored, her white hair thick and styled. She has her own teeth and they are white. Though she has trouble raising her arms, her blouse is attractive and feminine.
On physical exam, the doctor notes he feels some rigidity in her left wrist, and it’s evident by the staccato way he flexes the joint. He conducts a modified Luria test, to assess her mental function and asks her to remember three numbers, after he she has said them three times. She has trouble imitating a movement the doctor performs, and he notes she suffers from a motor apraxia. The daughter notes her mother and father used to play Scrabble together, but those days are gone.
The visit progresses and the physician prints out the patient’s prescriptions , including one that may help her memory, begins explaining that the same kinds of chemical structures that are used to kill insects and as chemical weapons (acetyl cholinesterase inhibitors) have been modified to a safe medication (eg Aricept) that may improve the memory of patients with Alzheimer’s disease. The difference between a poison and a medicaton often revolves potency (or strength) and the formulation of the medicine. He expands on this, commenting the very popular notion that school children are taught to say no to drugs is deeply flawed, and that he would advocate the idea to Say Know to Drugs. He catches himself then, commenting he has had too much coffee, and that he looks forward to their next visit in six months. The daughter reaches over and shakes his hand before she unlocks the brakes of the wheelchair.
The coffee and perhaps the two other medical students have caused him to overlook the dissonance obvious in daughter’s mood. She is the soul caregiver for her mother, now. Her mother’s well- cared for appearance probably comes from her efforts, and she probably has little time for herself. She wears the strain of care giving, and it is not pretty.