Presenting Symptoms

PD has both motor and non-motor features. Some of the non-motor features are actually first present before the motor features in many patients, although they are not recognized as such. Here is the list of most common symptoms. Additional details are described under each category in the “Symptoms” section.

 

Motor Symptoms

PD is usually an asymmetric condition and motor symptoms are usually worse on the side where the symptoms first appeared; however, one out of five patients will not remember that their symptoms first started on a particular side of their body. The main motor symptoms are:

Bradykinesia

  • Be aware that many patients who have been diagnosed and operated on for “frozen shoulderi” may actually have early bradykinesia 

Muscular rigidity

  • Muscular rigidity can be seen unilateral or bilateral
  • Slow movements can make Activities of Daily Living (ADL) take longer

Resting tremor

  • The most common region for tremor is the hands but you can also see it in other parts of the body including the lower lip, jaw, or leg 
  • Patients will sometimes report a feeling of “internal tremor” preceding appearance of a visible resting tremor  

Postural instability

  • May not be prominent in early stages

Non–Motor Symptoms

Although motor symptoms are the ones used to make the diagnosis, it is important to note that non-motor symptoms can equally affect the quality of life of those affected by Parkinson’s. Non-motor symptoms are not exclusive of Parkinson but they should be addressed when treating a PD diagnosed patient. Here is the list of the most common non-motor symptoms:

Cognitive impairment

  • Cognitive symptoms can range from isolated memory and thinking problems to severe dementia
  • Over 50% of people with PD experience some form of cognitive impairment

Psychosis

  • Most commonly related to medication with advanced age as a risk factor due to sensitivity
  • Can occur in conjunction dementia

Depression

  • Many PD patients report onset of depression or depressive symptoms that may pre-date the diagnosis of PD
  • Early stage patients may struggle with diagnosis, and this may contribute to symptoms of depression
  • It is estimated that up to 50% of patients with PD may experience some form of depression during the course of their illness

Anxiety

  • About 40% of PD patients experience anxiety including panic attacks particularly in the off state
  • Off state anxiety may be associated with under-medication
  • PD related anxiety may also present as social phobia, although this should be distinguished from embarrassment regarding public display of symptoms

Compulsive and Impulsive Behavior

  • Loss of impulse control or disinhibition, has been reported in PD
  • This can be present at the time of diagnosis and can get worse with PD medications such us levodopa and dopamine agonist

Orthostatic Hypotension

  • Affects 20% to 50% of PD patients
  • Can occur at any stage, but usually most bothersome in moderate to advanced patients

Sexual Dysfunction

  • Sexual dysfunction is common among patients with PD and represents one of the disabling features of the disease
  • The most common sexual dysfunctions affecting mostly men with PD are:
    • Decreased desire
    • Erectile dysfunction (ED)
    • Hypersexuality

Urinary Problems

  • Urinary complaints in PD are very common, and may be present from early on in the disease
  • Symptoms are caused by PD and not linked to anti-PD medications
  • Urinary urgency and frequency (especially nocturnal) are the most common manifestations

Hyposmia

  • Olfactory loss precedes motor signs by years and is often insidious for patients 
  • At presentation their olfactory deficits are significant and this can be measured using bedside clinical tests such as the UPSITi (University of Pennsylvania Smell Identification Test) 
  • Some authors have identified banana, licorice and dill pickle as smells that may be more predictive of PD if the patient is impaired

Pain

  • Pain in PD can occur for a variety of reasons
  • Typically individualized, it does not always correlate to stage
  • Referral to Physical Therapist may be appropriate after evaluation

Sleep Disorders

  • Insomnia
  • REM sleep behavior disorder (RBDi): Active dreams state when normally paralyzed, characterized by talking, moving limbs or grabbing partner
  • Sleep apnea

Other Typical Motor and Non-Motor Features

  • Micrographia
  • Asymmetrical arm swing
  • Masked face
  • Hypophonia
  • Dysphagia
  • Constipation

Clinical Best Practices

  • Rule out other causes of presenting symptoms
  • Symmetry of symptoms (Parkinson’s plus syndromes including MSA, PSP, etc.), dementia at onset of parkinsonism with hallucinations (dementia with Lewy bodies (DLB)), lack of response, and rapidly progressive symptoms and signs would certainly raise the question as to the diagnosis
References: 

Bohnen NI, Gedela S, Kuwabara H, et al.  Selective hyposmia and nigrostriatal dopaminergic denervation in Parkinson’s disease.  J Neurol 2007;254:84-90.