neurologic disorders
Parkinson Disease
Symptoms and Signs of Parkinson Disease
In most patients, symptoms of Parkinson disease begin insidiously. Aresting tremorof one hand is often the first symptom. The tremor is characterized as follows: Slow and coarse Maximal at rest, lessening during movement, and absent during sleep Amplitude increased by emotional tension or fatigue Often involving the wrist and fingers, sometimes involving the thumb moving against the index finger (pill rolling), as when people roll a pill in their hand or handle a small object Usually, the hands or feet are affected first, most often asymmetrically. The jaw and tongue may also be affected, but not the voice. However, speech may become hypophonic, with characteristic monotonous, sometimes stuttering dysarthria.. Tremor may become less prominent as rigidity progresses. In predominantly rigid-akinetic forms of Parkinson disease, resting tremor is subtle or absent. Rigiditydevelops independently of tremor in many patients. When a clinician moves a rigid joint, semirhythmic jerks occur because the intensity of the rigidity varies, causing a ratchet-like effect (cogwheel rigidity). Slow movements(bradykinesia) are typical in Parkinson disease. Repetitive motor activity results in a progressive or sustained decrease in amplitude of movement (hypokinesia), and movement becomes hard to initiate (akinesia). Rigidity and hypokinesia may contribute to muscle aches and sensations of fatigue. The face becomes masklike (hypomimic), with an open mouth and reduced blinking. Excessive drooling (sialorrhea) may contribute to disability. Hypokinesia and impaired control of distal muscles cause micrographia (writing in very small letters) and make activities of daily living increasingly difficult. Postural instabilitymay develop later in Parkinson disease; if present at disease onset, alternative diagnoses should be suspected. Patients have difficulty starting to walk, turning, and stopping. They shuffle, taking short steps, holding their arms flexed to the waist, and swinging their arms little or not at all with each stride. Steps may inadvertently quicken, while stride length progressively shortens; this gait abnormality, called festination, is often a precursor to freezing of gait (when, without warning, walking and other voluntary movements may suddenly halt). A tendency to fall forward (propulsion) or backward (retropulsion) when the center of gravity is displaced results from loss of postural reflexes. Posture becomes stooped. Dementiadevelops in about one third of patients, usually late in Parkinson disease. Early predictors of its development are visuospatial impairment (eg, getting lost while driving) and decreased verbal fluency. are common. Insomnia may result from nocturia or from the inability to turn in bed. Sleep deprivation may exacerbate depression and cognitive impairment and contribute to excessive daytime sleepiness. Rapid eye movement (REM) sleep behavior disorder may develop; in this disorder, verbalization and uncontrollable, possibly violent limb movements occur during REM sleep because the paralysis that normally occurs during REM sleep is absent. Neurologic symptoms unrelated to parkinsonismcommonly develop because synucleinopathy occurs in other areas of the central, peripheral, and autonomic nervous systems. The following are examples: Almost universal sympathetic denervation of the heart, contributing to Orthostatic Hypotension None Esophageal dysmotility, contributing to Dysphagia and increased risk of aspiration Lower bowel dysmotility, contributing to Constipation None Urinary hesitancy and/or urgency, potentially leading to Urinary Incontinence in Adults (common) Anosmia (common) In some patients, some of these symptoms occur before the motor symptoms of Parkinson disease and frequently worsen over time. Seborrheic Dermatitis None 