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Casebook: Parkinson’s disease

Dr Peter Bagshaw discusses diagnosis, treatment options and management of Parkinson’s disease

Case 1

An 80-year-old man has been puzzling you for some time with his complaint of profound tiredness – corroborated by his wife, who has repeatedly confirmed ‘he’s not the man he used to be’. There is no obvious abnormality on examination and bloods are normal. You refer him to the local care for the elderly consultant and are surprised to receive a letter, a few weeks later, suggesting Parkinson’s disease.

Q1 How does Parkinson’s disease most commonly present in primary care – and, in particular, what are the more subtle presentations we should be aware of?

The cardinal symptoms of Parkinson’s disease are tremor, rigidity and slowness of movement (bradykinesia). The rigidity can be of two types: ‘cogwheel’ or ‘lead-pipe’. In addition, several other symptoms can point to the disease: small, spidery handwriting (micrographia), expressionless face and a shuffling gait are well known, but less well-known symptoms include loss of sense of smell, thrashing around in one’s sleep, constipation and a soft or low voice. In the early stages the symptoms and signs can be subtle and are worth seeking out. 

The current theory (part of the so-called Braak’s hypothesis) is that the earliest signs of Parkinson’s are found in the enteric nervous system, the medulla and the olfactory bulb. Under this theory, Parkinson’s only progresses to the substantia nigra and cortex over time, meaning that that non-motor symptoms, such as a loss of sense of smell (hyposmia), sleep disorders and constipation may precede the motor features of the disease by several years.

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