The primary clinical features of Parkinson’s disease include rigidity, bradykinesia (slowness of movement), postural instability (loss of balance) and tremor. Tremor can begin insidiously as a slight shaking in one hand. It can then spread to involve the arm and usually spreads to the opposite side. This may occur over months to years. The characteristic appearance of the tremor is that of a pill-rolling motion between the thumb, index and middle fingers. Parkinsonian tremor occurs at rest and stops with movement of the hand or arm. This is a different type of tremor from the usual essential (intention) tremor. Essential tremor is characteristically more prominent when affected individuals are doing activities with their hands. Interestingly, shoulder pain can occasionally be the first presenting symptom of early Parkinson’s disease. It is important to note that not all Parkinson patients have tremor. The reverse is also true: Not everything that shakes is Parkinson’s disease.
Parkinson patients frequently complain of feeling stiff and weak. This is the characteristic of rigidity. Muscles develop a plastic-like stiffness. Some patients may be more aware of this than others. They have difficulty getting out of bed, rolling over in bed or standing from a sitting position. Rigidity accompanies bradykinesia, which is another hallmark of Parkinson’s disease. Patients typically notice a slowing down of all their movements. There is a significant delay in their ability to complete routine tasks such as dressing, eating, standing and walking. It is the combination of bradykinesia and rigidity that make Parkinson’s disease functionally disabling.
Postural instability, a problem with balance, can be a significant clinical problem. Associated with this is the characteristic stooped posture of Parkinsonism. Patients routinely complain of feeling off balance or unsteady. Some patients suffer from frequent stumbling and falls. This is due to the patient’s inability to make the normal reflex adjustments to sudden changes in position that naturally occur when turning or walking. Patients may have difficulty with initiating walking or while walking, suddenly stop when going through a doorway. This is known as freezing. Once they start walking, they may assume a stooped posture and take a series of rapid, short shuffling steps as if they were running forward to keep themselves from falling. This is the typical Parkinsonian gait known as festination. Another balance problem that can affect Parkinson patients is the tendency to fall backward known as retropulsion. This is one of the most difficult Parkinson symptoms to treat as there is no effective therapy, walker or exercise to prevent it.
Other common features of Parkinson’s disease include a masked facial appearance. Patients lose the normal expressions of facial movement while at rest or when speaking. Their blink rate also diminishes and it may appear that they are staring. The voice is also affected and speech may become slowed, very soft, and at times hoarse. Patients may speak in a monotone due to loss of normal speech inflection. The facial skin can develop a form of seborrhea that leads to an oily, scaly appearance. Daytime drooling is another common problem. It is not due to the overproduction of saliva but rather impairment of the swallowing reflex that normally clears saliva from the mouth as it is produced.
Swallowing disorders are more commonly seen in the later stages of Parkinson’s disease. Choking while eating may become a major problem and patients should exercise care to eat smaller bites and chew their food thoroughly. A Parkinson patient’s writing typically deteriorates. Writing becomes progressively smaller (micrographia) and illegible.
The autonomic nervous system (ANS) is the part of our nervous system that regulates automatic functions of the body. These include blood pressure, stomach and intestinal function, sleeping, sweating, as well as some aspects of breathing, and urination. The ANS regulates body functions that we are normally not consciously aware of. A common problem among Parkinson patients is a sudden drop in blood pressure when they stand up. This can result in severe dizziness and even loss of consciousness. This condition is known as orthostatic hypotension. Constipation is seen in the majority of Parkinson patients. The normal intestinal motility slows down, much like the Parkinson patient’s other movements. This can lead to chronic, persistent constipation. If left untreated, it may lead to pathologic constipation (obstipation) and even bowel obstruction. The latter is a medical emergency and may be fatal if left untreated. For this reason, Parkinson patients should drink plenty of fluids and have a high bulk fiber diet.
Sleep abnormalities are not uncommon. Parkinson patients frequently have difficulty sleeping at night. This may be due to problems with daytime drowsiness and frequent naps. These naps should be avoided as much as possible. Sleep disorders may be associated with, or due to, breathing irregularities such as apnea, a recurrent temporary halting of normal breathing. Other breathing problems may occur such as rapid breathing or a feeling of shortness of breath. The latter is due to rigidity of the respiratory muscles in between the ribs. This problem is typically worse at night.
Decreased visual function can also occur. Patients will frequently say that their eye exams are normal and yet they have trouble focusing. This is due to the decrease in dopamine in the retinal cells in the eye. Dopamine is an important chemical involved in good visual functioning.
Urinary difficulties are common. Patients may have trouble starting urination due to difficulty in relaxing the bladder sphincter muscles. The opposite problem, urinary frequency, can also occur. Patients have a feeling of needing to void frequently, but only produce a small amount of urine. This can lead to incontinence.
Psychiatric symptoms: Nocturnal hallucinations, agitation, and wandering at night can be a significant patient management problem. Not only are these due to the disease process itself, but can also be caused by the medications used to treat Parkinson’s disease. Hallucinations are common. They are not always disturbing to the patient, but may be frightening at times. Frequently they are caused by medications, but can be related to the disease process itself. Sudden onset of paranoia or unwarranted suspiciousness can occur. Frequently this suspiciousness is directed toward the patient’s spouse. If severe enough, patients sometimes have to be admitted to the hospital to prevent injuries to themselves and others.
Dementia (memory loss) is a significant and far too common problem in patients with Parkinson’s disease. It is estimated that approximately fifty percent of all Parkinson patients will ultimately develop some degree of Parkinson associated dementia. This process starts slowly with mild degrees of memory loss. As it worsens, forgetfulness, asking the same questions repeatedly and bizarre behavior become all too noticeable. Patients affected with this typically have a worsening of their symptoms at night (sundowning phenomenon), frequently becoming psychotic or more agitated. They may get dressed some time after midnight claiming that they are going to work, on vacation, to someone’s house (typically the person is deceased) or to the theater. A patient may wander about, lost in his own house or neighborhood. When patients deteriorate to this point, serious consideration must be given to putting the patient in a more supervised living environment. The earlier treatment is started for Parkinson dementia, the better the long term prognosis is for these patients.
Depression occurs in many patients with Parkinson’s disease. This can range anywhere from mild depression to a severe, disabling major depression. It is important for family members, caregivers, and medical personnel to be aware of this serious problem. Symptoms include loss of interest in activities or socializing, excessive fatigue, poor sleep patterns and irritability. Early identification and treatment of depression can significantly improve the patient’s quality of life. Current therapies can provide rapid, excellent relief of this troubling problem.