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Early symptoms of Parkinson's Disease
Early symptoms of Parkinson's disease are subtle and occur gradually. Patients may be tired or notice a general malaise. Some may feel a little shaky or have difficulty getting out of a chair. They may notice that they speak too softly or that their handwriting looks cramped and spidery. They may lose track of a word or thought, or they may feel irritable or depressed for no apparent reason. This very early period may last a long time before the more classic and obvious symptoms appear.
Friends or family members may be the first to notice changes. They may see that the person's face lacks expression and animation (known as "masked face") or that the person remains in a certain position for a long time or does not move an arm or leg normally. Perhaps they see that the person seems stiff, unsteady, and unusually slow.
As the disease progresses, the shaking, or tremor, that affects the majority of Parkinson's patients may begin to interfere with daily activities. Patients may not be able to hold utensils steady or may find that the shaking makes reading a newspaper difficult. Parkinson's tremor may become worse when the patient is relaxed. A few seconds after the hands are rested on a table, for instance, the shaking is most pronounced. For most patients, tremor is usually the symptom that causes them to seek medical help.
Major Symptoms of the Disease
Parkinson's disease does not affect everyone the same way. In some people the disease progresses quickly, in others it does not. Although some people become severely disabled, others experience only minor motor disruptions. Tremor is the major symptom for some patients, while for others tremor is only a minor complaint and different symptoms are more troublesome.
The tremor associated with Parkinson's disease has a characteristic appearance. Typically, the tremor takes the form of a rhythmic back-and-forth motion of the thumb and forefinger at three beats per second. This is sometimes called "pill rolling." Tremor usually begins in a hand, although sometimes a foot or the jaw is affected first. It is most obvious when the hand is at rest or when a person is under stress. In three out of four patients, the tremor may affect only one part or side of the body, especially during the early stages of the disease. Later it may become more general. Tremor is rarely disabling and it usually disappears during sleep or improves with intentional movement.
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Rigidity, or a resistance to movement, affects most parkinsonian patients. A major principle of body movement is that all muscles have an opposing muscle. Movement is possible not just because one muscle becomes more active, but because the opposing muscle relaxes. In Parkinson's disease, rigidity comes about when, in response to signals from the brain, the delicate balance of opposing muscles is disturbed. The muscles remain constantly tensed and contracted so that the person aches or feels stiff or weak. The rigidity becomes obvious when another person tries to move the patient's arm, which will move only in ratchet-like or short, jerky movements known as "cogwheel" rigidity.
Bradykinesia, or the slowing down and loss of spontaneous and automatic movement, is particularly frustrating because it is unpredictable. One moment the patient can move easily. The next moment he or she may need help. This may well be the most disabling and distressing symptom of the disease because the patient cannot rapidly perform routine movements. Activities once performed quickly and easily -- such as washing or dressing -- may take several hours.
Postural instability, or impaired balance and coordination, causes patients to develop a forward or backward lean and to fall easily. When bumped from the front or when starting to walk, patients with a backward lean have a tendency to step backwards, which is known as retropulsion. Postural instability can cause patients to have a stooped posture in which the head is bowed and the shoulders are drooped.
As the disease progresses, walking may be affected. Patients may halt in mid-stride and "freeze" in place, possibly even toppling over. Or patients may walk with a series of quick, small steps as if hurrying forward to keep balance. This is known as festination.
Symptoms often start with an occasional tremor in one finger that spreads over time to involve the whole arm. The tremor is often rhythmic -- 4 to 5 cycles per second -- and frequently causes an action of the thumb and fingers known as the pill-rolling tremor. Tremor is present when the limb is at rest or held up in a stiff unsupported position and usually disappears briefly during movement. Tremors can also occur in the head, lips, tongue, and feet, although they do not occur during sleep. In one study, 44% of patients reported experiencing internal tremors lasting less than half an hour, but occurring several times a week. Symptoms can occur on one or both sides of the body.
Motion and Motor Impairment
Slowness of motion (bradykinesia) is one of the classic symptoms of Parkinson's disease. Patients may eventually develop a stooped posture and a slow, shuffling walk. The gait can be erratic and unsteady and cause a person to fall. After a number of years, muscles may freeze up or stall, usually when a patient is making a turn or passing through narrow spaces, such as a doorway. Intestinal motility -- e.g., swallowing, digestion, and elimination -- may also slow down, causing eating problems and constipation. The muscle rigidity (akinesia) experienced in Parkinson's disease often begins in the legs and neck. Muscle rigidity in the face can produce a mask-like, staring appearance. Hand deformities may develop in late stages, causing severe discomfort and limitation. Handwriting, for instance, often becomes diminutive. Normally spontaneous muscle movements, such as blinking, may need to be done consciously.
About half of Parkinson's patients develop some speech difficulty caused by rigidity of the facial muscles, loss of motor control, and impaired breath control. Tone can become monotonous, words may be repeated over and over, or the rate of speech may even be very fast. Swallowing may be difficult.
Depression and Mental Problems
Depression is often present as one of the first symptoms and is probably partially caused by a chemical imbalance in the brain. Because depression is common in old age or can be caused by other factors, the patient often does not connect it with other early symptoms of Parkinson's. Defects in thinking, memory, language, and problem solving skills often occur later on. Dementia occurs in almost 30% of Parkinson's patients, who are usually older individuals who have had major depression.
Are There Other Symptoms?
The sense of smell is impaired in about 70% of patients. Vision is also effected, including color perception. The patient may experience changes in sensations of temperature, hot flashes, excessive sweating, and cramps and burning in the legs. Parkinson symptoms that may occur after encephalitis include greasy skin and hair, tics, spasms, rapid and repetitive speech, and oculogyric crises -- disturbances in which the eyes become fixed in one direction for minutes or even hours. In people with a history of migraine, the onset of Parkinson's is associated with change in migraine symptoms (most often improvement). Constipation is a major problem for Parkinson patients and occurs both as a result of the disease and a side effect of its treatment. Laxatives, stool softeners, and other medications may be prescribed. Bladder control and urinary incontinence are also problems, which can be helped by taking Sudafed.
Various other symptoms accompany Parkinson's disease; some are minor, others are more bothersome. Many can be treated with appropriate medication or physical therapy. No one can predict which symptoms will affect an individual patient, and the intensity of the symptoms also varies from person to person. None of these symptoms is fatal, although swallowing problems can cause choking.
Depression. This is a common problem and may appear early in the course of the disease, even before other symptoms are noticed. Depression may not be severe, but it may be intensified by the drugs used to treat other symptoms of Parkinson's disease. Fortunately, depression can be successfully treated with antidepressant medications.
Emotional changes. Some people with Parkinson's disease become fearful and insecure. Perhaps they fear they cannot cope with new situations. They may not want to travel, go to parties, or socialize with friends. Some lose their motivation and become dependent on family members. Others may become irritable or uncharacteristically pessimistic.
Memory loss and slow thinking may occur, although the ability to reason remains intact. Whether people actually suffer intellectual loss (also known as dementia) from Parkinson's disease is a controversial area still being studied.
Difficulty in swallowing and chewing. Muscles used in swallowing may work less efficiently in later stages of the disease. In these cases, food and saliva may collect in the mouth and back of the throat, which can result in choking or drooling. Medications can often alleviate these problems.
Speech changes. About half of all parkinsonian patients have problems with speech. They may speak too softly or in a monotone, hesitate before speaking, slur or repeat their words, or speak too fast. A speech therapist may be able to help patients reduce some of these problems.
Urinary problems or constipation. In some patients bladder and bowel problems can occur due to the improper functioning of the autonomic nervous system, which is responsible for regulating smooth muscle activity. Some people may become incontinent while others have trouble urinating. In others, constipation may occur because the intestinal tract operates more slowly. Constipation can also be caused by inactivity, eating a poor diet, or drinking too little fluid. It can be a persistent problem and, in rare cases, can be serious enough to require hospitalization. Patients should not let constipation last for more than several days before taking steps to alleviate it.
Skin problems. In Parkinson's disease, it is common for the skin on the face to become very oily, particularly on the forehead and at the sides of the nose. The scalp may become oily too, resulting in dandruff. In other cases, the skin can become very dry. These problems are also the result of an improperly functioning autonomic nervous system. Standard treatments for skin problems help. Excessive sweating, another common symptom, is usually controllable with medications used for Parkinson's disease.
Sleep problems. These include difficulty staying asleep at night, restless sleep, nightmares and emotional dreams, and drowsiness during the day. It is unclear if these symptoms are related to the disease or to the medications used to treat Parkinson's disease. Patients should never take over-the-counter sleep aids without consulting their physicians.
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