2. Non motor manifestations
• Cognitive dysfunction and dementia
• Psychosis and hallucinations
• Mood disorders including depression, anxiety, and apathy/abulia
• Sleep disturbances
• Fatigue
• Autonomic dysfunction
• Olfactory dysfunction
• Gastrointestinal dysfunction
• Pain and sensory disturbances
• Dermatologic findings
3. “
”
In a multicenter survey of over 1000 patients
with PD, virtually all (97 percent) patients
reported nonmotor symptoms, with each patient
experiencing an average of approximately eight
nonmotor symptoms [].
Nonmotor symptoms in the psychiatric domain
occurred most frequently.
The PRIAMO study: A multicenter assessment of nonmotor symptoms and their impact on
quality of life in Parkinson's disease
Paolo Barone et al. Mov Disord. 2009.
https://pubmed.ncbi.nlm.nih.gov/19514014/
4. • In some patients, certain nonmotor features of PD :
- olfactory dysfunction
- constipation
- depression
- rapid eye movement [REM] sleep behavior
disorder [RBD])
may present before the motor ones
The Parkinson's complex: parkinsonism is just the tip of
the iceberg
J William Langston. Ann Neurol. 2006 Apr.
https://pubmed.ncbi.nlm.nih.gov/16566021/
5. Most troublesome nonmotor symptoms
occurring in both early- and late-stage PD
1 - pain
2 - mood disorders
3 - sleep problems
Parkinson's disease symptoms: the patient's perspective
Marios Politis et al. Mov Disord. 2010.
https://pubmed.ncbi.nlm.nih.gov/20629164/
6. Cognitive dysfunction and dementia
• 40 to 80 % of cases of PD
• Occurs late , usually 1 yr after onset of motor
symptoms
• risk factors for dementia in a Parkinson patient
1. Later age of onset of PD
2. Longer duration of PD symptoms
3. The presence of hallucinations
4. Depressive symptoms
5. Family history of dementia
1
7. Cognitive dysfunction and dementia
• psychomotor retardation (slowed speech, decreased movement,
and impaired cognitive function)
• memory difficulty
• altered personality
• problems with executive function (decision-making or
multitasking)
• memory retrieval problems
• Visuospatial misperception
1
8. • patients with PD and dementia have a mixture
of cortical neuronal Lewy inclusion bodies
filled with alpha-synuclein and the signature
amyloid plaques and neurofibrillary tangles of
AD
Cognitive dysfunction and dementia 1
9. Psychosis and hallucinations
• Occurs in 20 – 40 % of patients
• Most common - > Visual hallucinations
• Prevalence & Severity increases over time
• Occurs d2 lewy bodies or antiparkinsonian drugs esp.
Dopamine agonistis
2
10. • risk factors for psychosis in PD
1. use of high doses of antiparkinson drugs
2. presence of dementia
3. advancing age
4. impaired vision
5. depression
6. presence of sleep disorders
7. high comorbid disease burden
8. Longer disease duration
Psychosis and hallucinations 2
11. Mood disorders
• Depression — the most common psychiatric disturbance seen in
PD ( up to 50 % )
• Anxiety — Anxiety is the next most frequent psychiatric disturbance
in PD ( 30 – 40 % )
• Apathy : defined as a primary loss of motivation, characterized by
diminished speech, motor activity, and emotional expression
• most commonly related to frontal lobe and limbic system dysfunction
3
12. Sleep disorders
• In 55 – 80 % of patients
• most common sleep disturbances - > sleep fragmentation
(frequent awakening throughout the night) and early morning
awakening.
( nocturia, difficulty turning over in bed, cramps, vivid dreams or nightmares , pain
and tremors )
• Other sleep disorders :
• insomnia, daytime sleepiness with sleep attacks, restless legs
syndrome (RLS), and REM sleep behavior disorder
4
13. Fatigue
• In 30 % - 60 % of patients
• significantly related to
1. PD progression
2. Depression
3. Excessive daytime sleepiness
5
14. Autonomic dysfunction
• orthostasis, constipation, dysphagia, diaphoresis,
urinary difficulties, and sexual dysfunction
• May also be present in MSA ( more severe , less
respnosive to levo dopa , cerebellar and pyramidal
affection )
• Risk factors
1. older age
2. Cognitive dysfunction
3. Longer disease duration
6
15. • Orthostatic hypotension ( 60 % of patients ) - > very
common , occur early , may be aggravated by anti parkinsonian
drugs
• Urinary Symptoms - > Freuency , urgency , incontinence
• reduced bladder capacity because of involuntary detrusor muscle contractions at early
stages of bladder filling
• Sexual dysfunction ( 25 % of patients ) -> range from
underactivity to hypersexuality
Autonomic dysfunction 6
16. Olfactory dysfunction
• may precede motor symptoms or occur relatively
early in the course of PD
• Very common
• manifest as deficits in odor identification,
discrimination, and detection
7
17. Pain
• In up to 46 % of patients
• Can be stabbing , burning Or tingling
• Can be generalized or localized
• tend to correlate with motor fluctuations
8
18. Dermatologic findings
• Seborrheic dermatitis in 20 – 60 % ( scally erythematous patches in
area of skin rich in sebaceous glands eg. Scalp , face and chest
9
19. • Melanoma may also occur (type of skin cancer that develops
from the pigment-producing cells known as melanocytes )
Dermatologic findings 9
