Parkinson’s Disease: Symptoms, Complaints, Signs

The following symptoms and complaints may indicate PD:

Leading symptoms (Parkinson’s disease triad):

  • Akinesia (immobility, rigidity of movement).
  • Rigor (stiffness of the muscles as a result of an increase in muscle tone, which persists throughout passive movement, in contrast to spasticity; cogwheel phenomenon: jerky yielding of muscle tone during passive movement of an extremity).
  • Tremor – Parkinsonian tremor (mid-frequency: 4 – 7 Hz); occurs primarily at rest (resting tremor) and is unilateral; typical movement pattern (“pill-pulling tremor”) and slower than essential tremor; tremor in PD is historically divided into three types:
    • Type I: resting tremor or resting and holding/moving tremor of the same frequency.
    • Type II: resting and holding/movement tremor of different frequency.
    • Type III: pure holding/movement tremor.

Akinesia

  • Hypophonia – soft, monotone speech.
  • Bradykinesia – slowing of voluntary movements [central cardinal symptom of idiopathic Parkinson’s syndrome, IPS].
  • Hypokinesia – amplitude reduction of voluntary movements.
  • Hypomimia – decreased facial expression and infrequent blinking of the eyelids.
  • Marche a petit pas – small-step gait.
  • Micrography – writing becoming smaller during writing.
  • Movement disorders with a tendency to fall forward (propulsion), backward (retropulsion), or sideways (lateropulsion)

Rigor

  • Increase in tone that occurs throughout the range of motion and is independent of the speed of joint movement
  • Triggering or amplification by simultaneous activation of the contralateral side.
  • Tremor may be superimposed on rigor; then the so-called “cogwheel phenomenon” occurs

Tremor

  • Classic Parkinson’s tremor: appears with supported arms at rest with a frequency of about 4-6 Hz (higher frequencies possible in early stages of the disease); also called pill tremor; seminal is the decrease in amplitude at the onset of voluntary movements; can be activated by mental occupation or emotions.
  • Rarely occurring: holding tremor (mean frequency of 5-7 Hz, as in essential tremor). which can often coexist with rest tremor and action tremor (8-12 Hz).

Optional accompanying symptoms

  • Cognitive symptoms:
    • Bradyphrenia (slowed thinking).
    • Frontal disorders (damage to the anterior portions of the frontal brain).
    • In advanced stages dementia [probably partly a direct consequence of central dopamine deficiency)])
  • Mental symptoms:
    • Fatigue
    • Apathy (apathy)
    • Depression (occur as a sequelae in 35-45% of patients; in younger patients, depression occurs before the onset of motor signs of disease and may therefore be considered an early symptom; is probably in part a direct consequence of central dopamine deficiency)
    • Hallucinations, visual
    • Melancholia
    • Sleep disorders
    • Mood swings
    • Delusion
  • Sensory symptoms:
    • Dysesthesias (sensory disturbances).
    • Hyposmia (reduction in olfactory perception) – precedes diagnosis by up to 10 years
    • Pain
    • Loss of visual acuity, color vision problems and eye dryness.
  • Vegetative symptoms:
    • Disturbances of blood pressure/orthostatic hypotension and/or temperature regulation.
    • Disorders of bladder and bowel function – including constipation (obstruction)
    • Disorders of sexual functions
    • Dysphagia (swallowing disorder)
    • Hypersalivation (synonyms: sialorrhea, sialorrhea or ptyalism) – increased salivation.
    • Seborrhea (overproduction of skin oils by the sebaceous glands of the skin).
    • Daytime sleepiness / fatigue

The diagnosis is made on the basis of symptomatology:

  • Parkinsonian syndromes are defined by the presence of akinesia (immobility and rigidity) and one of the following cardinal symptoms occurring in varying degrees:
    • Rigor (stiffness of the muscles as a result of an increase in muscle tone, which remains throughout passive movement, unlike spasticity),
    • Rest tremor (tremor at rest; 4-6, rarely up to 9 Hz; onset at rest, decrease with movement) or a
    • Postural instability (postural instabilityt not primarily explained by visual, vestibular, cerebellar, or proprioceptive disturbances). [Occurring in the middle stages of the disease.]

    Presence of supporting criteria

    • Unilateral onset and persistent asymmetry in disease progression.
    • Classic rest tremor
    • Clear positive response (> 30% UPDRS (Unified Parkinson Disease Rating Scale) motor) to L-dopa.
    • Sustained L-dopa response for more than 5 years.
    • Occurrence of L-dopa-induced choreatic dyskinesias (involuntary, irregular, rapid, brief muscle contractions with a movement effect; not suppressible, or suppressible only for a very short time)
    • Slow clinical progression (progression) with disease progression over more than 10 years.
  • The hit rate can be improved if patients are screened for hyposmia using test. The olfactory disorders precede the motor disorders by about 4-6 years!
  • Possible additional tests are the L-dopa test or apomorphine test. Here, the patient is administered L-dopa and apomorphine, respectively. If an improvement in symptoms occurs in the course of these tests, then in most cases there is an idiopathic Parkinson’s disease.
  • In idiopathic Parkinson’s disease (IPS), olfactory disturbances are found as a prominent symptom in addition to tremor, rigor, and akinesia. Olfactory disturbances can be detected in over 95% of these patients.
  • 10 years before Parkinson’s diagnosis, tremor already occurred in 2% of cases (8 times less frequently in the control group) and constipation was found in one in five Parkinson’s patients at this time. Between 2 and 5 years before diagnosis, 7% of Parkinson’s patients already had tremor and one in four complained of constipation.

“Premotor” patients

There are patients in whom motor symptoms occur later, that is, their dopaminergic neurons are attacked later. In these so-called “premotor” patients, the serotonergic neurons are destroyed first. The failure of the serotonergic system leads to the following prodromal symptoms, which often precede motor symptoms by many years:

  • Dysosmia (olfactory dysfunction).
  • Constipation (constipation)
  • Depression
  • Insomnia (sleep disorders)

In premotor patients, extensive deficits were detected using the marker 11-DASB in single photon emission tomography (SPECT).Note: 11C-DASB binds to a serotonin transporter in the brain. Additional notes

  • See Subsequent disease/Predictive factors:Three factors determine Parkinson’s progression: orthostatic hypotension, rapid eye movement sleep behavior disorder (RBD), and mild cognitive impairment (MCI).
  • The lifetime prevalence (disease frequency over a lifetime) of psychotic symptoms and visual hallucinations in Parkinson’s disease patients is about 50%.