Primary and Secondary Symptoms
This article is excerpted from the APDA's booklet, Coping With Parkinson's Disease
The earliest symptoms of PD may be nonspecific and include weakness, tiredness, and fatigue. Thus. the disease may go unrecognized for some time. More specific symptoms may include: tremor of the resting hands (common in up to 75 percent of patients), a change in speech, difficulty in turning while in bed or walking. and a decreased arm swing while walking. Other early symptoms may be: difficulty in starting to walk; difficulty in getting into and out of a chair or car: a change in handwriting, where the script becomes smaller (micrographia): depression: and drooling, especially at night. Patients with moderate disease experience increased difficulty with balance and walking.
The primary symptoms of PD (stiffness, tremor, slowness and poverty of movement. difficulty with balance. and difficulty in walking) are the most disabling. In some patients. secondary symptoms appear. Some of these may result from the effects of one. or more. of the primary symptoms on a specific group of muscles. For example. the speech difficulty (a secondary symptom) that many patients experience arises from the effects of rigidity, tremor, and bradykinesia (primary symptoms) on the muscles of the throat that are used in speech.
Some secondary symptoms result from involvement of other parts of the nervous system (other than the extrapyramidal system). Sometimes, the secondary symptoms may become more disabling than the primary ones.
Rigidity is an increased tone in the muscles and is present when the limbs are still. It increases when the limbs are moving. Rigidity is related to an overactivity of certain cells in the spiral cord which regulate muscle tone. Rigidity is often confused with spasticity. another condition of increased muscle tone. Spasticity does not occur in PD and differs from rigidity in several ways. Spasticity increases during movement of the limbs. and then suddenly gives way. Spasticity, not rigidity, follows the paralysis of a stroke. Rigidity is, by itself, not disabling. However, rigidity is often incorrectly used to describe bradykinesia (slowness and poverty of movement), another primary symptom which is disabling.
Tremor, absent in up to 25 percent of patients. appears in the hands- and sometimes the feet-of non-moving limbs. The tremor may be worse on one side of the body than on the other: and it may involve the head. neck, face, and jaw.
Tremors usually decrease when the hands are stretched out in front of the patient or when the hands are moving.. In some patients, however, the tremor may increase when the hands are in this position (sustention or postural tremor).
In others. the tremor increases when the hands are moving (action tremor). The sustention and action tremors may indicate involvement of structures in the nervous system. such as the cerebellum which coordinates movements. The resting tremor usually responds to some of the antiparkinsonian drugs. The sustention and action tremors usually do not respond to these drugs.
Bradykiniesia is one of the more disabling symptoms of PD. It is characterized by a delay in starting all movements. slowness and poverty of all movements, and the arrest of ongoing movements. It may contribute to some of the other parkinsonian symptoms. such as difficulty with balance and walking.
Difficulty with Balance refers to the inability to maintain equilibrium or to react to abrupt changes in position. This problem contributes to the falls that many patients suffer-falls that may result in injuries.
Difficulty in Walking includes problems in starting to walk: a decrease in the natural arm swing: short, shuffling steps destination). difficulty in turning: and sudden. abrupt freezing spells. The difficulty in walking may be complicated by bradykinesia and difficulty with balance. A parkinsonian patient who experiences difficulty in walking and balance may at times resemble a moving car without brakes.
Depression occurs in as many as one-half of patients with PD. Although depression is usually considered to be an appropriate reaction to a disabling illness, patients with PD experience depression more than patients wits other similarly disabling illnesses. In some patients, the depression occurs before PD begins, and may be more disabling than the disease.
In some patients. the depression may be associated with anxiety and agitation ("agitated depression''). In a few patients, the depression may become so severe that treatment of the depression may become more important than the treatment of PD Treatment of a severe depression is best accomplished by a psychiatrist who may prescribe drugs to help alleviate the depression. Treatment of the depression often leads to an improvement in parkinsonian symptoms.
Sleep Disturbances are a common complaint of PD patients. They include an inability to fall asleep or an inability to remain asleep. with frequent nighttime awakenings (the patient is exhausted in the morning). Some patients experience a reversal of their sleep patterns; they sleep during the day. taking several naps. and are awake at night. Patients may also have vivid dreams, and, rarely, nightmares. Bed partners often report that the patients speak in their sleep and have jerking, involuntary movements of their limbs (myoclonus). For some patients, difficulty in sleeping is related to their depression.
Some sleeping difficulties. especially vivid dreaming or myoclonus. are related to levodopa. Readjustment of the dose of levodopa, and eliminating the evening dose (if possible). may improve the patient's sleep. On the other hand. some patients require levodopa to sleep because a lack of medication makes them so rigid that they cannot turn in bed. Standard sleeping preparations are occasionally helpful, but must be used with caution-particularly for depressed patients.
Dementia (senility) consists of difficulty with memory. recognition! abstraction. and calculation. It may also be associated with confusion and disorientation. Senility, when present. occurs among elderly patients in the later stages of PD. However. it is erroneous to assume that senility is an inevitable outcome. Furthermore. in cases of PD with senility, the senility ranges from mild to a more marked decline.
Many physicians believe that the more common form of Parkinson's Disease (without senility) differs from those cases with senility. PD without senility usually begins in patients in their 40s, 50s, and 60s! runs a long course; and responds well to medications. PD with senility begins in older people and usually runs a shorter and more severe course. The senility of PD may resemble Alzheimer's Disease.
Medications, such as levodopa; and especially the anticholinergic drugs (Artane, Cogentin, Kemadrin. Akineton); amantadine (Symmetrel); and the dopamine agonists may. in some elderly patients, inadvertently result in such mental changes as delusions. confusion, paranoia. or hallucinations. These mental changes disappear when the offending drugs are stopped or doses of these medications are reduced; however, it may take several days to notice improvement. The appearance of drug-induced mental changes in a patient who is not senile does not mean that the patient will become senile. Every physician strives to maintain a balance between the beneficial and adverse effects of antiparkinsonian drugs. This objective is more difficult to achieve in patients who are senile.
Forced Eyelid Closure (blepharospasm) is the inability to open the eyelids-or once opened. to keep them open. Rarely, blepharospasm results in the inability to open the eyes at all. Such patients cannot read, watch television. or carry on many other daily activities.
Antiparkinsonian drugs alleviate the blepharospasm for some patients; though they may worsen this condition for others. Several drugs, not ordinarily used in PD, may be helpful in the treatment of blepharospasm. Other treatments may include: cutting some of the fibers of the facial nerves (a simple surgical procedure). or injecting very small amounts of a paralytic drug into the muscles that close the eyes.
Speech Problems may occur in PD. Frequently, the speech impairment is mild and consists of a change in voice volume, phonation, or articulation. Generally, the volume change is the first such symptom and the patient speaks "more softly.'' Usually. the patient's voice is loud at the beginning of a sentence and then fades. The voice may also become monotonous. lacking variation and feeling.
In addition to the decrease in volume, the voice may sound breathy, tremulous. high-pitched, hoarse, or strident. Words may become slurred and indistinct; word endings may be omitted; final consonant sounds, such as the "k'' in look, may be unclear; syllables and words may be crowded and run together words may be accelerated towards the end of a sentence. Occasionally. speech difficulties arise early in the disease. Initially, these problems may be evident only when the patient uses the telephone which filters out some of the normal frequencies. Specific measures such as speech therapy. amplification devices. and medications may be helpful.
Drooling (sialorrhea) usually results from the patient's inability to swallow saliva leading to its accumulation in the throat. This may be evident only at night when patients are reclining and lose gravity's assistance in swallowing. In a few patients. drooling may result from an overproduction of saliva. Drooling usually improves with the use of medications, especially the anticholinergic drugs which decrease the production of saliva.
Difficulty in Swallowing (dysphagia) usually occurs late in PD, and is rarely one of the early symptoms. Patients experience this difficulty with both solids and liquids.
Normally, swallowing begins when food is taken into the mouth. and is then forced down the throat by the tongue. The presence of food in the throat starts the voluntary muscles of the upper gullet (esophagus) contracting. these. in turn. start the involuntary muscles of the lower gullet contracting, which push the food from the throat through the gullet to the stomach. In some patients. the swallowing difficulty arises from an inability to force the food down the throat and an inability of the voluntary muscles of the throat and gullet to contract. This results in pooling of food in the throat. These patients complain of food getting stuck in their throat. To alleviate the problem, patients should place small portions of food in their mouth and chew and swallow slowly and carefully. They should always completely swallow one morsel before putting other food into the mouth.
When food is in the throat. the throat closes off from the air passages that lead to the nose. as well as those that lead to the lungs, thus preventing food from going into those areas. In some parkinsonian patients, pooling of food in the throat may cause food to go into the lungs (aspiration). Frequent episodes of food aspiration may appear as a cough or as pneumonia. Such pneumonias occur only in patients with advanced disease.
Other swallowing difficulties may result from a failure of a valve, that allows food to pass from the gullet into the stomach, to work properly. The patient may complain of fullness or burning in the throat or even in the chest. The burning sensation comes from the digestive juices of the stomach flowing into the gullet via the faulty valve resulting in inflammation of the gullet (esophagitis). Occasionally. these symptoms resemble those of heart disease. These symptoms should be evaluated by a physician. Sometimes patients are unable to swallow pills. This may not be reported by the patient. and only becomes apparent after other PD symptoms worsen. Rarely, the swallowing difficulty becomes so severe that intravenous feeding or feeding through a special tube, placed into the stomach usually via the nose (nasogastric tube), may be required.
Weight loss, between 10-30 pounds, is another secondary symptom. It may be related to: difficulty in swallowing; the large amount of energy used up by the violent tremors or involuntary movements. or the disease's effect on the part of the brain that controls weight and appetite (hypothalamus).
Constipation is frequent among the elderly, including patients with PD. Constipation. by itself. is not a cause for concern. There is no medical need to move the bowels each day and there is no Self-poisoning" if the bowels are not moved for several days. PD can lead to constipation by slowing the activity of the intestines. This slowing may, at times, worsen as a result of medication. especially the anticholinergic drugs.
After an examination. including blood tests, stool analysis, and a sigmoidoscopy of the lower bowel. has ruled out other causes of constipation. there are several measures patients can take to ease bowel movements:
If these measures are not helpful. then glycerine suppositories, small doses of senna laxatives, or careful use oil Fleet's or saline enemas (under medical supervision) may be tried.
Breathing Problems, or shortness of breath after minimal physical activity, should be evaluated to rule out heart or lung disease. If the results are negative. shortness of breath may be due to rigidity, or bradykinesia of the chest wall muscles which prevents the lungs from expanding.
Some patients on levodopa. without rigid chest wall muscles or heart or lung disease, may experience shortness of breath and abnormal grunting respirations because levodopa may cause uncoordinated involuntary movements of the diaphragm, chest wall muscles. and upper throat muscles.
In patients whose shortness of breath comes from heart or lung disease. these conditions should be treated to improve breathing. When shortness of breath arises from rigidity or bradykinesia of the chest wall muscles, increasing the patient's antiparkinsonian medications will improve breathing. If the shortness of breath is a result of levodopa, decreasing the patient's medications will improve breathing.
Difficulty in Voiding is a problem which may consist of urgency (a strong desire to void). frequency, hesitancy in starting to void, difficulty in completing voiding, and incomplete voiding with dribbling. Rarely, a patient may be unable to void.
PD results in difficult voiding because the muscles of the bladder become rigid and bradykinetic. thus decreasing the ability of the bladder to contract and expel urine. Some antiparkinsonian drugs. such as the anticholinergics and Symmetrel, may increase the voiding difficulty.
In men, this difficulty may suggest prostate-gland trouble. For women. the problem may suggest laxness of the vagina or uterus with secondary pressure on the bladder Patients who experience difficulty in voiding should be checked for these conditions, as well as for infections and diabetes. Infections and diabetes may cause irritation of the bladder, resulting in voiding problems.
Dizziness upon standing is the result of a drop in blood pressure upon standing (orthostatic hypotension). In these patients. a careful search for the cause of this drop is required. Some antiparkinsonian drugs (levodopa and the dopamine agonists) may cause dizziness on standing. This will disappear once the body has adjusted to the drugs.
Dizziness may also be caused by other drugs which some patients take for different medical conditions (i.e., high blood pressure, heart failure. and depression). Dizziness may also result from dehydration. malnutrition. diabetes, or other illnesses.
Treatment of PD patients for dizziness on standing is complicated because many of the antiparkmsonian drugs increase the dizziness. These patients may require a decrease in the dose of antiparkinsonian drugs. stopping any water pills which the patient may take for other conditions. or placing the patient in elastic stockings The patient may also need drugs (florinef. Indocin) or common table salt which cause the body to retain fluid.
Stooped Posture and rounded shoulders develop in many PD patients. The stooped posture arises, in part, from rigidity of the neck and back muscles. It Is helpful for such patients to participate in exercises that are designed to lessen this rigidity of the back muscles. Occasionally, the stooped posture may respond to treatment with levodopa or one of the dopamine agonists.
Swelling of the Feet (edema) usually occurs toward the end of the day after a patient has been standing and disappears when the patient lies down. These patients should be evaluated for other causes, including heart failure, Swelling of the feet probably results from the inability of the rigid leg muscles to massage fluid from the feet back to the heart. Such fluid normally accumulates in the feet through the effects of gravity. Rarely, drugs such as Symmetrel and some of the dopamine agonists may result in swelling of the feet.
PD patients who develop this symptom may not require any treatment. However. if the swelling becomes very pronounced. then a number of measures may be used. including elevating the feet, elastic support stockings, and, less often water pills.
Sexual Problems A decrease in the desire for sex may result from the non-specific effects of a chronic illness: fear of being unable to perform satisfactorily; depression, and occasionally, medications.
Some men complain of the inability to achieve or maintain an erection (impotence). If this occurs, the patient should have a thorough examination to determine if there are other causes.
Shortly after the introduction of levodopa. a number of reports appeared about the drug's ability to increase sexual function. Initially, it could not be determined whether the increased sexual activity was a result of the patient's general improvement or whether levodopa was an aphrodisiac. Now the consensus is that increased sexual activity, when present, is directly related to the patient's general improvement.
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