Signs and symptoms of Parkinson's disease: Wikis

  

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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

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

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

  • Tremor normally has a frequency between 4 and 6 Hz (cycles per second) and is the most apparent and well-known symptom.[1] It is most commonly a rest tremor: maximal when the limb is at rest and disappearing with voluntary movement and sleep; it is a pronation-supination tremor that is described as "pill-rolling".[1] Tremor affects to a greater extent the most distal part of the extremity and is typically unilateral at onset.[1] Though around 30% of PD sufferers do not have tremor at disease onset most of them would develop it along the course of the disease.[1]
  • Rigidity: defined as joint stiffness and increased muscle tone. In combination with a resting tremor, this produces a ratchety, "cogwheel rigidity" when the limb is passively moved.[1] It may be associated with joint pain, such pain being a frequent initial manifestation of the disease.[1]
  • Bradykinesia and akinesia: the former refers to slowness of movement while the latter to the absence of it.[1] It is the most characteristic clinical feature of PD and it produces difficulties not only with the execution of a movement but also with its planning and initiation.[1] The performance of sequential and simultaneous movements is also hindered.[1] Rapid, repetitive movements produce a dysrhythmic and decremental loss of amplitude.
  • Postural instability: failure of postural reflexes, along other disease related factors such as orthostatic hypotension or cognitive and sensory changes, which lead to impaired balance and falls.[1] It usually appears in the late stages of PD.[1]

Other motor symptoms include:

  • Gait and posture disturbances:
    • Shuffling gait:[1] gait is characterized by short steps, with feet barely leaving the ground. Small obstacles tend to cause the patient to trip.
    • Decreased arm-swing.[1]
    • Turning "en bloc": rather than the usual twisting of the neck and trunk and pivoting on the toes, PD patients keep their neck and trunk rigid, requiring multiple small steps to accomplish a turn.
    • Camptocormia:[1] stooped, forward-flexed posture. In severe forms, the head and upper shoulders may be bent at a right angle relative to the trunk.[2]
    • Festination:[1] a combination of stooped posture, imbalance, and short steps. It leads to a gait that gets progressively faster and faster, often ending in a fall.
    • Gait freezing: also called motor blocks, is a manifestation of akinesia.[1] Gait freezing is characterized by a sudden inability to move the lower extremities which usually lasts less than 10 seconds.[1] It may worsen in tight, cluttered spaces, when attempting to initiate gait or turning around, or when approaching a destination.[1] Freezing improves with treatment and also with behavioral techniques such as marching to command or following a given rhythm.[1]
    • Dystonia:[1] abnormal, sustained, painful twisting muscle contractions, often affecting the foot and ankle (mainly toe flexion and foot inversion) which often interferes with gait.
    • Scoliosis[1]
  • Speech and swallowing disturbances.
    • Hypophonia:[1] soft speech.
    • Monotonic speech: Speech quality tends to be soft, hoarse, and monotonous.[1]
    • Festinating speech: excessively rapid, soft, poorly-intelligible speech.
    • Drooling: most likely caused by a weak, infrequent swallow.[1]
    • Dysphagia: impaired ability to swallow; which in the case of PD is probably related to an inability to initiate the swallowing reflex or by a too long laryngeal or oesophageal movement.[1] Can lead to aspiration pneumonia.
    • Dysarthria[1]
  • Other motor symptoms:

Neuropsychiatric

Example of reported prevalences of mood problems in PD patients with dementia[1][3]
Mood problem Prevalence
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.[4] A very high proportion of sufferers will have mild cognitive impairment as the disease advances.[1] Most common deficits in non-demented patients are:

  • Executive dysfunction, which translates into impaired set shifting, poor problem solving, and fluctuations in attention among other difficulties.[4]
  • Slowed cognitive speed (Bradyphrenia).[4]
  • Memory problems; specifically in recalling learned information, with an important improvement with cues. Recognition is less impaired than free recall pointing towards a retrieving more than to an encoding problem.[4]
  • Regarding language, patients are found to have problems in verbal fluency tests.[4]
  • Visuospatial skills difficulties, which are seen when the person with PD is for example asked to perform tests of facial recognition and perception of line orientation.[4]

Deficits tend to aggravate with time, developing in many cases into dementia. A person with PD has a six-fold increased risk of suffering it,[1] and the overall rate in people with the disease is around 30%.[4] Moreover, prevalence of dementia increases in relation to disease duration, going up to 80%.[4] 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.[4]

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]

  • Depression:[1] Depression is well recognized in PD, having been identified as "melancholia" by James Parkinson in his original report of the disease in 1817. Estimated prevalence rates of depression vary widely according to the population sampled and methodology used although prevalence at a given time is most probably around 31%; which doubles the numbers in the general population.[5] There is an increased risk for any individual with depression to go on to develop Parkinson's disease at a later date.[5][6] It is increasingly thought to be a consequence of the disease rather than an emotional reaction to disability.[7]
  • Apathy[1]
  • Anxiety:[1] Seventy percent of individuals with Parkinson's disease diagnosed with pre-existing depression go on to develop anxiety. Ninety percent of Parkinson's disease patients with pre-existing anxiety subsequently develop depression; apathy or abulia.

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]

Hallucinations are not rare.[1] 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:

  • Excessive daytime somnolence.[1]
  • Insomnia, characterized mostly by sleep fragmentation.[1]
  • Disturbances in REM sleep: disturbingly vivid dreams, and rapid eye movement behavior disorder, characterized by acting out of dream content.[1] It appears in a third of the patients and it is a risk factor for Parkinson's disease in the overall population.[1]

Perception

  • Impaired proprioception (the awareness of bodily position in three-dimensional space).
  • Reduction or loss of sense of smell (hyposmia or anosmia).[1] It may be an early marker of the disease.[1]
  • Pain:[1] neuropathic, muscle, joints, and tendons, attributable to tension, dystonia, rigidity, joint stiffness, and injuries associated with attempts at accommodation.
  • Paresthesias.[1]

Autonomic

Gastrointestinal

Parkinson' disease causes constipation and gastric dysmotility that is severe enough to endanger comfort and even health.[9] 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.[10]

Neuro-ophthalmological

PD is related to different ophthalmological abnormalities produced by the neurological changes.[1] 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 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. 
  2. ^ 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. PMID 16735399. 
  3. ^ 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. PMID 16820421. 
  4. ^ 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. 
  5. ^ 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. 
  6. ^ 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. 
  7. ^ McDonald W (2003). "Prevalence, Etiology, and Treatment of Depression in Parkinson’s Disease". Biol Psychiatry 54: 363–375. doi:10.1016/S0006-3223(03)00530-4. PMID 12893111. 
  8. ^ 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. 
  9. ^ 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. 
  10. ^ 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. 
  11. ^ Uc EY (2006). "Impaired visual search in drivers with Parkinson's disease". Annals of Neurology 6: EPub ahead of print. doi:10.1002/ana.20958. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&dopt=Abstract&db=PubMed&list_uids=16969860. 







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