• Sequential reduction amplitude and frequency
  • Slowing down, difficulty turning in bed, getting out of the bath 8


  • 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.