Modes of presentation

Bradykinesia

Sequential reduction amplitude and frequency
Slowing down, difficulty turning in bed, getting out of the bath

Tremor

Coarse, often initially unilateral / asymmetrical
4-6 Hz- pill rolling
Differential diagnosis: essential tremor, vascular tremor

Rigidity

Cog wheeling
Stiffness
May be attributed to frozen shoulder etc.
Muscle aches / pains

Combination features

Festinant gait

There are non motor symptoms which are increasingly being recognised as part of the symptoms of PD. These are broken into three categories;

1. Cognitive & psychiatric

Depression (40%) - SSRI is first line (but rare interactions with selegeline/ rasegiline) also consider tricyclic antidepressants if the sleep pattern is disturbed. Nortriptyline has the lowest anticholinergic effects and so may have the fewest side-effects.

Psychosis - This may relate to medication- so avoid typical antipsychotics which can worsen the motor symptoms. Atypicals such as quetiapine and olanzapine can be tried.

Anxiety (20-40%)

Dementia – Can occur in late stages but drug side effects can cause similar problems. Sequentially withdraw tricyclics, anticholinergics, selegeline, dopamine agonists. Consider cholinesterase inhibitors- eg; Rivastigmine.

Apathy - SSRIs can help, but not with selegilne

Sleep disorders

Up to 98% of patients with Parkinson’s
Wake sleep cycle disrupted
Nocturia
Difficulty turning over in bed
Restless Legs Syndrome (RLS)
Insomnia
REM behavioural sleep disorder (RBSD)
Sleep attacks
Excessive daytime sleepiness

Sexual dysfunction

2. Dysautonomia

Urinary problems

Constipation (50 %)

Sweating excessively is typical and often associated with dyskinesias.

Orthostatic hypotension (48% of patients with PD) can treat with domperidone (10 mg tds) and/or Fludrocortisone-0.1 mg od.

Hot / cold sensation

Dysphagia/ drooling/ hypernasal speech as a result of the decreased ability of the soft palate to seal off the nasal cavity.

Nausea / weight loss

Anorectal Dysfunction

3. Pain and sensory

Olfactory loss

Pain - This can occur in up to 50 % of patients with PD. Patients may complain of sensory type pain or musculoskeletal pain secondary to parkinsonian rigidity or hypokinesia.

Paraesthesia