Modes of presentation

Modes of presentation 1


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


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


  • 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.