Modes of presentation

Doctor checking elderly man's knee reflex


  • 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.




This website uses cookies to ensure you get the best experience, please accept these so we can deliver a more reliable service.

Manage preferences