Signs and symptoms of Parkinson's disease

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Illustration of the Parkinson disease by Sir William Richard Gowers from A Manual of Diseases of the Nervous System in 1886 showing the characteristic posture of PD patients

Signs and symptoms of Parkinson's disease are varied. Parkinson's disease affects movement, producing motor symptoms.[1] Non-motor symptoms, which include autonomic dysfunction, cognitive and neurobehavioral problems, and sensory and sleep difficulties, are also common.[1]

Contents

Motor symptoms

Parkinson's disease patient showing a flexed walking posture pictured in 1892. Photo appeared in Nouvelle Iconographie de la Salpètrière, vol. 5.
Frontal view.
Side view.
Woman suffering from paralysis agitans showing a characteristic type of extension. Photos were taken in 1889 and appeared in Nouvelle Iconographie de la Salpètrière, vol. 2.

Four motor symptoms are considered cardinal in PD: tremor, rigidity, slowness of movement, and postural instability.[1] Other motor symptoms include gait and posture disturbances such as decreased arm swing, a forward-flexed posture and the use of small steps when walking; speech and swallowing disturbances; and other symptoms such as a mask-like face expression or small handwriting are examples of the range of common motor problems that can appear.[1]

Cardinal symptoms

Four symptoms are considered cardinal in PD: tremor, rigidity, bradykinesia and postural instability.[1]

... immobile patients who become excited may be able to make quick movements such as catching a ball (or may be able to suddenly run if someone screams "fire"). This phenomenon (kinesia paradoxica) suggests that patients with PD have intact motor programmes but have difficulties accessing them without an external trigger, such as a loud noise, marching music or a visual cue requiring them to step over an obstacle.[1]

Other motor symptoms

Drawing of a Parkinson's disease patient face showing hypomimia. Depiction appeared in Nouvelle iconographie de la Salpétrière, vol 1 (1888)
Example of writing by a patient with Parkinson's disease; possibly showing micrographia in addition to other abnormal characteristics. Published by Jean-Martin Charcot in 1879. Text accompanying image stated "The strokes forming the letters are very irregular and sinuous, whilst the irregularities and sinuosities are of a very limited width. On a careful examination of this specimen of writing it will be perceived that the down-strokes are all, with the exception of the first letter, made with comparative firmness and are, in fact, nearly normal — the finer up-strokes, on the contrary, are all tremulous in appearance, and it is to the unsteadiness of these lines that the peculiar character of the writing here is principally due."

Other motor symptoms include:

Neuropsychiatric

Example of reported prevalences of mood problems in PD patients with dementia[1][8]
Mood problemPrevalence
Depression 58%
Apathy 54%
Anxiety 49%
Pathologic gambling can appear in PD patients as a manifestation of a dopamine dysregulation syndrome

Parkinson's disease causes neuropsychiatric disturbances, which include mainly cognition, mood and behavior problems and can be as disabling as motor symptoms.[1]

Cognitive disturbances occur even in the initial stages of the disease in some cases.[9] A very high proportion of sufferers will have mild cognitive impairment as the disease advances.[1] Most common deficits in non-demented patients are:

Deficits tend to aggravate with time, developing in many cases into dementia. A person with PD has a sixfold increased risk of suffering it,[1] and the overall rate in people with the disease is around 30%.[9] Moreover, prevalence of dementia increases in relation to disease duration, going up to 80%.[9] Dementia has been associated with a reduced quality of life in disease sufferers and caregivers, increased mortality and a higher probability of attending a nursing home.[9]

Cognitive problems and dementia are usually accompanied by behavior and mood alterations, although these kind of changes are also more common in those patients without cognitive impairment than in the general population. Most frequent mood difficulties include:[1]

Obsessive–compulsive behaviors such as craving, binge eating, hypersexuality, pathological gambling, or other, can also appear in PD, and have been related to a dopamine dysregulation syndrome associated with the medications for the disease.[1]

Psychotic symptoms are common in PD, generally associated with dopamine therapy. Symptoms of psychosis, or impaired reality testing, are either hallucinations, typically visual, less commonly auditory, and rarely in other domains including tactile, gustatory or olafactory, or delusions, that is, irrational beliefs. Hallucinations are generally stereotyped and without emotional content. Initially patients usually have insight so that the hallucinations are benign in terms of their immediate impact but have poor prognostic implications, with increased risk of dementia, worsened psychotic symptoms and mortality. Delusions occur in about 5-10% of treated patients, and are considerably more disruptive, being paranoid in nature, of spousal infidelity or family abandonment. Psychosis is an independent risk factor for nursing home placement.[16]

Hallucinations can occur in Parkinsonian syndromes for a variety of reasons. There is an overlap between Parkinson's disease and Lewy body dementia, so that where Lewy bodies are present in the visual cortex, hallucinations may result. Hallucinations can also be brought about by excessive dopaminergic stimulation. Most hallucinations are visual in nature, often formed as familiar people or animals, and are generally non-threatening in nature. Some patients find them comforting; however their carers often find this part of the disease most disturbing and the occurrence of hallucinations is a major risk factor for hospitalisation. Treatment options consist of modifying the dosage of dopaminergic drugs taken each day, adding an antipsychotic drug like quetiapine, or offering carers a psychosocial intervention to help them cope with the hallucinations.

Sleep

Rapid eye movement sleep (REM) is altered in PD as opposed to the shown EEG polysomnographic record representing normal REM

Sleep problems can be worsened by medications for PD, but they are a core feature of the disease.[1] Some common symptoms are:

Perception

Autonomic

Gastrointestinal

Parkinson' disease causes constipation and gastric dysmotility that is severe enough to endanger comfort and even health.[18] A factor in this is the appearance of Lewy bodies and Lewy neurites even before these affect the functioning of the substantia nigra in the neurons in the enteric nervous system that control gut functions.[19]

Neuro-ophthalmological

PD is related to different ophthalmological abnormalities produced by the neurological changes.[1][20] Among them are:

References

  1. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae af ag ah ai aj ak al am an ao ap aq ar as at au av aw ax ay az ba bb bc bd be bf bg bh bi bj bk bl bm bn bo bp bq br bs bt bu bv bw bx Jankovic J (April 2008). "Parkinson's disease: clinical features and diagnosis". J. Neurol. Neurosurg. Psychiatr. 79 (4): 368–76. doi:10.1136/jnnp.2007.131045. PMID 18344392. http://jnnp.bmj.com/content/79/4/368.full. 
  2. ^ a b Cooper G, Eichhorn G, Rodnitzky RL (2008). "Parkinson's disease". In Conn PM. Neuroscience in medicine. Totowa: Humana Press. pp. 508–512. ISBN [[Special:BookSources/978-1-60327-455-8|978-1-60327-455-8]]. 
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  4. ^ Banich MT, Compton RJ (2011). "Motor control". Cognitive neuroscience. Belmont, CA: Wadsworth, Cengage learning. pp. 108–44. ISBN 0-8400-3298-6. 
  5. ^ Fung VSC, Thompson PD (2007). "Rigidity and spasticity". In Tolosa E, Jankovic JJ. Parkinson's disease and movement disorders. Hagerstown, MD: Lippincott Williams & Wilkins. pp. 504–13. ISBN 0-7817-7881-6. 
  6. ^ Rodriguez-Oroz MC, Jahanshahi M, Krack P, et al. (December 2009). "Initial clinical manifestations of Parkinson's disease: features and pathophysiological mechanisms". Lancet Neurol 8 (12): 1128–39. doi:10.1016/S1474-4422(09)70293-5. PMID 19909911. 
  7. ^ Lepoutre A, Devos D, Blanchard-Dauphin A, et al (2006). "A specific clinical pattern of camptocormia in Parkinson's disease". J. Neurol. Neurosurg. Psychiatr. 77 (11): 1229–34. doi:10.1136/jnnp.2005.083998. PMC 2077366. PMID 16735399. //www.ncbi.nlm.nih.gov/pmc/articles/PMC2077366/. 
  8. ^ Aarsland D, Brønnick K, Ehrt U, et al. (January 2007). "Neuropsychiatric symptoms in patients with Parkinson's disease and dementia: frequency, profile and associated care giver stress". Journal of Neurology, Neurosurgery, and Psychiatry 78 (1): 36–42. doi:10.1136/jnnp.2005.083113. PMC 2117797. PMID 16820421. //www.ncbi.nlm.nih.gov/pmc/articles/PMC2117797/. 
  9. ^ a b c d e f g h i Caballol N, Martí MJ, Tolosa E (September 2007). "Cognitive dysfunction and dementia in Parkinson disease". Mov. Disord. 22 (Suppl 17): S358–66. doi:10.1002/mds.21677. PMID 18175397. 
  10. ^ a b Lieberman A (January 2006). "Depression in Parkinson's disease -- a review". Acta Neurologica Scandinavica 113 (1): 1–8. doi:10.1111/j.1600-0404.2006.00536.x. PMID 16367891. 
  11. ^ Ishihara L, Brayne C (April 2006). "A systematic review of depression and mental illness preceding Parkinson's disease". Acta Neurologica Scandinavica 113 (4): 211–20. doi:10.1111/j.1600-0404.2006.00579.x. PMID 16542159. 
  12. ^ McDonald W; Richard, IH; Delong, MR (2003). "Prevalence, Etiology, and Treatment of Depression in Parkinson's Disease". Biol Psychiatry 54 (3): 363–375. doi:10.1016/S0006-3223(03)00530-4. PMID 12893111. 
  13. ^ Menza, Matthew Combating Depression in Parkinson's Disease. Parkinson's Disease Foundation News & Review. Spring 2009.
  14. ^ Menza MA. Psychiatric symptoms associated with Parkinson disease. Drug Benefit Trends. 2010;22:58-60.
  15. ^ The National Collaborating Centre for Chronic Conditions, ed. (2006). "Non-motor features of Parkinson’s disease". Parkinson's Disease. London: Royal College of Physicians. pp. 113–33. ISBN 1-86016-283-5. http://guidance.nice.org.uk/CG35/Guidance/pdf/English. 
  16. ^ Friedman JH (June 2010). "Parkinson's disease psychosis 2010: A review article". Parkinsonism Relat Disord 16 (9): 553–60. doi:10.1016/j.parkreldis.2010.05.004. PMID 20538500. 
  17. ^ Gupta AK, Bluhm R (January 2004). "Seborrheic dermatitis". Journal of the European Academy of Dermatology and Venereology 18 (1): 13–26; quiz 19–20. doi:10.1111/j.1468-3083.2004.00693.x. PMID 14678527. 
  18. ^ Pfeiffer RF (February 2003). "Gastrointestinal dysfunction in Parkinson's disease". Lancet Neurology 2 (2): 107–16. doi:10.1016/S1474-4422(03)00307-7. PMID 12849267. 
  19. ^ Lebouvier T, Chaumette T, Paillusson S, et al. (September 2009). "The second brain and Parkinson's disease". The European Journal of Neuroscience 30 (5): 735–41. doi:10.1111/j.1460-9568.2009.06873.x. PMID 19712093. 
  20. ^ a b c Armstrong RA (March 2008). "Visual signs and symptoms of Parkinson's disease". Clin Exp Optom 91 (2): 129–38. doi:10.1111/j.1444-0938.2007.00211.x. PMID 18271776. 
  21. ^ Uc EY; Rizzo, M; Anderson, SW; Sparks, J; Rodnitzky, RL; Dawson, JD (2006). "Impaired visual search in drivers with Parkinson's disease". Annals of Neurology 6 (4): 407–13. doi:10.1002/ana.20958. PMID 16969860.