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Four motor symptoms are considered cardinal in PD: tremor, rigidity, bradykinesia and postural instability. Tremor is the most apparent and well-known symptom. It is most commonly a rest tremor: maximal when the limb is at rest and disappearing with voluntary movement and sleep. It affects to a greater extent the most distal part of the extremity and is typically unilateral at onset. Though around 30% of PD sufferers do not have tremor at disease onset most of them would develop it along the course of the disease. Rigidity is due to joint stiffness and increased muscle tone, which combined with a resting tremor produce a ratchety, "cogwheel rigidity" when the limb is passively moved. Rigidity may be associated with joint pain, such pain being a frequent initial manifestation of the disease. Bradykinesia (slowness of movement) is the most characteristic clinical feature of PD and it produces difficulties not only with the execution of a movement but also with its planning and initiation. The performance of sequential and simultaneous movements is also hindered. In the late stages of the disease postural instability is typical, which leads to impaired balance and falls.
PD motor symptomatology is not limited to these four symptoms. Gait and posture disturbances such as decreased arm swing, a forward-flexed posture and the use of small steps when walking; speech and swallowing disturbances; and other symptoms such as a mask-like face expression or a small handwriting are only examples of the ample range of common motor problems that can appear with the disease.
Parkinson's disease causes neuropsychiatric disturbances, which include mainly cognition, mood and behavior problems and can be as disabling as motor symptoms.
Cognitive disturbances occur even in the initial stages of the disease in some cases. A very high proportion of sufferers will have mild cognitive impairment as the disease advances. Most common cognitive deficits in non-demented patients are executive dysfunction, which translates into impaired set shifting, poor problem solving, and fluctuations in attention among other difficulties; Slowed cognitive speed, memory problems; specifically in recalling learned information, with an important improvement with cues; and visuospatial skills difficulties, which are seen when the person with PD is for example asked to perform tests of facial recognition and perception of line orientation.
Deficits tend to aggravate with time, developing in many cases into dementia. A person with PD has a sixfold increased risk of suffering it, and the overall rate in people with the disease is around 30%. Moreover, prevalence of dementia increases in relation to disease duration, going up to 80%. Dementia has been associated with a reduced quality of life in disease sufferers and caregivers, increased mortality and a higher probability of attending a nursing home.
Cognitive problems and dementia are usually accompanied by behavior and mood alterations, although these kind of changes are also more common in those patients without cognitive impairment than in the general population. Most frequent mood difficulties include depression, apathy and anxiety. Obsessive-compulsive behaviors such as craving, binge eating, hypersexuality, pathological gambling, or other, can also appear in PD, and have been related to a dopamine dysregulation syndrome associated with the medications for the disease.
In addition to cognitive and motor symptoms PD can impair other body functions. Sleep problems can be worsened by medications for PD, but they are a core feature of the disease. They can manifest as excessive daytime somnolence, disturbances in REM sleep or insomnia. The autonomic system is altered which can lead for example to orthostatic hypotension, oily skin and seborrheic dermatitis, excessive sweating, urinary incontinence and altered sexual function. Constipation and gastric dysmotility can be severe enough to endanger comfort and health. PD is also related to different ophthalmological abnormalities such as decreased blink rate and alteration in the tear film, leading to irritation of the eye surface, abnormalities in ocular pursuit and saccadic movements and limitations in the upward gaze. Changes in perception include reduced sense of smell and sensation of pain and paresthesias.
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