Features of Parkinson’s disease:
- Hypokinesia (paucity of movement)
- Resting tremor
- Postural instability (usually the last of the cardinal signs)
Those are the cardinal signs.Tremor is typically made worse by stress, tiredness, or the feeling that other people are noticing.
Speech pattern can also be affected:
- Hypernasal speech (soft palate can’t block the back of the nose)
- Poor fluency of speech – ‘stuttering’ speech, frequent pauses, repetition of words/syllables
- ‘Flattening’ of speech – loss of ability to change pitch and volume, leading to a loss of natural rhythm.
- Difficulty turning (they tend to turn ‘en bloc’) either while standing/walking or in bed.
- Depression occurs in one in three Parkinson’s patients (over the course of their lifetime) and anxiety is also common and can predate the diagnosis.
- Excess sleepiness/daytime dozing occur in approximately half of Parkinson’s patients and can predate the diagnosis.
- Bladder dysfunction occurs in around 40% – nocturia is the most common symptom, but frequency, urgency and urge incontinence can also occur.
- Constipation occurs in around 50%.
- Sexual difficulties; ED in men and lack of arousal, difficulty in climaxing, dyspareunia and vaginismus in women.
- Orthostatic hypotension – in almost half
- Excessive salivation/drooling
- Excessive sweating
- Pain – in up to half- can be sensory-type pain or pain due to muscle rigidity.
Note that these symptoms are typically more of a problem than the cardinal Parkinson’s symptoms.
Things you wouldn’t expect to see in Parkinson’s disease:
- Frequent falls at an early stage
- Rapid progression/early loss of mobility
- Symmetrical symptoms initially
- Dementia as a prominent early feature
- Cerebellar signs
- Pyramidal signs
- Abnormalities of eye movements, or double vision
- Lack of tremor
- Lack of response to L-dopa
Any of these features would call the diagnosis into question; as would medications such as metoclopramide which could account for a Parkinsonian picture. If a patient with a diagnosis of Parkinson’s develops any of these, refer back to neurology (or, in our case, the geriatrician with a special interest in Parkinson’s who sees our patients with it) for a review of the diagnosis.
This is caused by a series of small strokes affecting the basal ganglia and creating a Parkinson’s-like picture. It typically presents with a shuffling gait and frequent falls in a patient with arteriopathic risk factors; it typically does not cause tremor.
Management of Parkinson’s
NICE guidelines advise referring to a specialist rather than starting treatment yourself. (This is what I would do anyway, so it’s good to know I’m right there.)
(BMJ Learning module)