Stages of Parkinson's disease and related symptoms

By Cristiano Antonino On Nov 5, 2022

Is it possible to identify stages of Parkinson’s disease? Parkinson’s disease is a gradually progressive neurodegenerative disorder mainly characterised by two phases: a presymptomatic and a symptomatic one

The first is characterised by the loss by apoptosis of dopaminergic neurons in the substantia nigra, although it is not yet perfectly clear when this actually starts or what percentage of their loss is quantified.

Some theories postulate the existence of a time lag of at least five years between the initial depletion of dopaminergic neurons and the onset of the first symptoms; other researchers claim that the loss of neurons may even begin around forty years before clinical onset.

It is very difficult to determine the exact first symptoms of Parkinson’s disease, as the onset is gradual and insidious; some symptoms are so mild that it is difficult to recognise them early.

We can classify the symptomatic phase of Parkinson’s into two parts: the early and late phase

Early phase. This is characterised by the appearance of the first symptoms, which occurs when approximately 70% of the neurons in the substantia nigra have been lost.
Late Phase. The second phase, on the other hand, refers to the time span in which the progression of the disease takes place. When Parkinson’s disease is diagnosed, it can present various clinical pictures: 70% of cases present tremor at rest, rigidity affects 89-99% of patients, bradykinesia 77-98% of cases, and postural instability 37%. Finally, 72-75% of patients present with the typical asymmetrical onset. There are different forms of Parkinson’s disease, with some presenting all four cardinal symptoms, while in others it is mainly tremor or akinesia and rigidity.

The neurologists Hoehn and Yahr classified Parkinson’s disease into five stages

Stage I: mild and unilateral involvement; characterised by the appearance of tremor in the upper limbs at rest. Approximately one year earlier, other symptoms such as prodromal algia or pain sensation may occur. Use of the upper limb is reduced. Upon close examination of the individual, slight rigidity, the presence of akinesia and impairment of rapid reciprocating movements and finger dexterity are evident. A slowing of movements and worsening in repetition is observed.
Stage II: bilateral involvement with early alterations in posture that becomes fixed with trunk, hips, knees and ankles slightly flexed. In addition, all movements tend to slow down gradually, resulting in what is known as bradykinesia.
Stage III: there is a marked impairment of gait with the appearance of retropulsion or propulsion. There is increased impairment of postural reflexes, gait becomes hurried and short, with the trunk anteflexed. There is a significant slowing of gait and an increase in bradykinesia, while retropulsion and propulsion begin to cause falls. Occasionally, the patient may need help with certain tasks.
Stage IV: high disability. The patient requires more assistance in carrying out normal daily activities and is no longer able to live alone; falls are frequent and tasks requiring fine motor control are difficult or impossible.
Stage V: complete disability occurs. Walking is impossible as is maintaining an upright position; in bed, supine and immobile, with the head slightly flexed on the trunk the patient constantly has his mouth open due to dysphagia and reduced spontaneous swallowing. Obviously, this clinical picture refers to a patient not undergoing any drug treatment.

At what stage do the first symptoms appear in Parkinson’s disease?

There are small signs that appear even many years before the onset, which are difficult even for doctors to pinpoint.

A diagnostic suspicion of possible Parkinson’s disease generates fears; a survey by the National Parkinson’s Foundation revealed that people avoid seeing a doctor even when symptoms are present, delaying the start of effective and potentially neuroprotective therapy.

Early symptoms of Parkinson’s are:

Loss of the sense of smell, one of the lesser known senses, and often the first warning, but almost always recognised late. Loss of taste could be associated because the two senses overlap. Some researchers are working to develop a screening test for olfactory function.

Sleep disorders. There is a sleep disorder known RBD in which people act out their dreams during sleep: they may scream, kick, or grind their teeth. They may even attack their bed partners. About 40 per cent of people with RBD may develop Parkinson’s even ten years later. Two other sleep disorders commonly associated with Parkinson’s are restless leg syndrome (a tingling sensation in the legs and the feeling of having to move them) and sleep apnoea.

Constipation and other bowel and bladder problems. One of the most common and most neglected early signs, as it is non-specific, is constipation and meteorism, as Parkinson’s can affect the autonomic nervous system, slowing down the entire digestive process. One way to recognise the difference between ordinary constipation and constipation caused by Parkinson’s is that the latter is often accompanied by a feeling of fullness even after a small meal. When the urinary tract is also affected, some people have hesitation to urinate, while others begin to experience episodes of incontinence.

Lack of facial expression. Loss of dopamine can involve the facial muscles, making them stiff and sluggish, resulting in the characteristic lack of facial expression. Described as ‘stone face’ or ‘poker face’ Like all early symptoms, the changes are subtle: slowness in smiling, frowning, or looking into the distance, frequent blinking.

Persistent neck pain more common in women, related to spinal muscle involvement. Sometimes presents as a numbness or tingling that reaches the shoulder and arm.

Slow and tight writing. One of the symptoms of Parkinson’s, known as bradykinesia, is the slowing down and loss of spontaneous and routine movements. Slowing down of writing is one of the most common ways in which bradykinesia presents itself. Writing begins to become slower and more laboured, and often seems smaller and tighter than before.

Changes in tone of voice and speech. The voice of a person with Parkinson’s disease often becomes much more faint and monotone; researchers are working on a voice analysis technique as a possible early screening and diagnostic tool.

Reduced arm movement due to increased muscle tone In some patients, one arm will swing less than the other when walking.

Excessive sweating. When Parkinson’s affects the autonomic nervous system some patients experience increased sweating (hyperhidrosis) with associated excessively oily skin or scalp with dandruff. Many also have a problem with excess salivation, caused by difficulty swallowing rather than overproduction of saliva.

Mood and personality changes. Personality types related to Parkinson’s are described, such as the occurrence of anxiety in new situations, social withdrawal, and depression. Several studies show that depression is often the first sign, others also experience changes in their rational abilities, in particular concentration and so-called ‘executive functions (planning and execution of tasks) with early loss of the ability to multitask.

How much time elapses from the appearance of the first symptoms to the patient’s loss of autonomy?

As I mentioned earlier, it can take up to 10-15 years, but early diagnosis and the timely initiation of effective treatment could lengthen this time frame.

Today, we also have effective therapies for the more advanced stages of the disease (deep brain stimulation, duodenal infusion of Dopa, subcutaneous pumps of Apomorphine, etc.) that allow an acceptable quality of life in many cases.

Parkinson’s disease is often identified as a disease of old age.

Is there a preferred age at which it develops?

The average age of onset is around 58-60 years, but around 5 % of patients may present with a juvenile onset between the ages of 21 and 40 years, predominantly linked to specific genetic mutations (parkins).

Before the age of 20 it is extremely rare.

Over the age of 60 it affects 1-2% of the population, while the percentage rises to 3-5% when the age is over 85.

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