Parkinson's disease history and symptoms

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Common symptoms of Parkinson disease includes: Tremor, rigidity, bradykinesia, Cognitive dysfunction and dementia, psychosis and hallucinations, mood disorders including depression, anxiety, and apathy/abulia, sleep disturbances, fatigue, olfactory dysfunction, pain and autonomic dysfunction.

History and Symptoms

history

The most common symptoms that a PD patient complains in his/her history are slowness of movement (bradykinesia), shaking hands while they are at rest (resting tremor) and muscle stiffness (rigidity).[1] It’s in the favor of PD diagnosis if the presenting symptoms start unilaterally and the severity of them remains higher in the side of onset.[2] In their history they may mention some of the risk factors of Parkinson disease such as:

Common symptoms

The main clinical manifestations of Parkinson disease include tremor, rigidity and bradykinesia. Later in the course of the disease patient can have postural instability.[15][2][2] Some studies suggest that there can be three clinical subtypes for Parkinson disease: Tremor dominant, akinetic-rigid and postural instability and gait difficulty[16][17] but other studies demonstrate that clinical course of the disease can be variable and this subtypes can switch to each other through time.[17][18]

Motor symptoms

  • Tremor: Tremor is the most common symptom in Parkinson disease and can be the presenting sign in 70 to 80 percent of patients.[19][1] This symptom starts unilaterally mostly in hand and then progress to the other side of the body. It can also involve legs, jaw, lips and tongue.[20][21][22] PD tremor frequency is 3 to 7 Hz.[20] There is a symptom called re-emergent tremor in some of the PD patients. It manifests by postural tremor that starts after several seconds and can make it difficult to differentiate PD from essential tremor.[23][24]
  • Rigidity: Rigidity in PD in very common and can be seen in 75 to 90 percent of patients.[19][1][25] It commonly starts in the same side as the tremor. PD patients have increased resistance to passive movement of their joint and sometimes it’s known as cogwheel rigidity because of the ratchety pattern of resistance and relaxation. Some evidences suggest that superimposition of tremor on increased muscle tone creates this kind of rigidity.[26][27]
  • Bradykinesia: Bradykinesia or slowness of movement, is seen in 80 percent of PD patients.[1]
  • Postural instability: Gait and postural problems can be the main cause of disability in PD patients and commonly doesn’t response well to dopaminergic treatment.[28][29]

Nonmotor symptoms

  1. Depression: Mild to moderate depression is very common in PD and can be seen in 50 percent of PD patients.[45][46][47] these patients can present with anhedonia, sadness, guilt and feeling of worthlessness.[48]
  2. Anxiety: Anxiety, especially generalized anxiety disorder and social phobia is common in PD and can be seen in more than 30 percent of patients.[45][49] Anxiety is usually combined by depression.[50]
  3. Apathy and abulia: Apathy and abulia are characterized by lack of motivation, speech, emotional and motor function. The pathophysiology behind this symptom is involvement of frontal lobe in PD patients.[51][52]
  • Sleep disturbances: Sleep disorders is seen in 55 to 80 percent of PD patients in early or late stages of the disease.[53][54] approximately 40 percent of PD patients take medicine for sleep cause insomnia is as common as 60 percent in them.[53][54][55] the most common cause of insomnia and frequent awakening during sleep include nocturia, cramp, pain, nightmares and tremor.[55][56][57][58][59] another sleep disorder which can be seen in these patients is REM sleep behavior disorder (RBD), characterized by vigorous movement because of increased muscle tone[60][61]
  • Fatigue: The prevalence of fatigue in PD patients is 33 to 58 percent[62][63][64] it’s mostly associated with depression and excessive day time somnolence but can occur as an isolate problem too.[64][63][65]
  • Olfactory dysfunction: Deficits in odor identification and discrimination are common in PD[66] and can happen even before the motor symptoms of the disease.[67][68]
  • Pain: 46 percent of PD patients experience pain as a sense of lancinating, burning or tingling. The pain can be generalized or localized and can happen in different body areas like face, joints and genitals.[69][70][71]

References

  1. ↑ 1.0 1.1 1.2 1.3 Pagano G, Ferrara N, Brooks DJ, Pavese N (April 2016). "Age at onset and Parkinson disease phenotype". Neurology. 86 (15): 1400–7. doi:10.1212/WNL.0000000000002461. PMC 4831034. PMID 26865518.
  2. ↑ 2.0 2.1 2.2 Hughes AJ, Daniel SE, Kilford L, Lees AJ (March 1992). "Accuracy of clinical diagnosis of idiopathic Parkinson's disease: a clinico-pathological study of 100 cases". J. Neurol. Neurosurg. Psychiatry. 55 (3): 181–4. PMC 1014720. PMID 1564476.
  3. ↑ 3.0 3.1 Noyce AJ, Bestwick JP, Silveira-Moriyama L, Hawkes CH, Giovannoni G, Lees AJ, Schrag A (December 2012). "Meta-analysis of early nonmotor features and risk factors for Parkinson disease". Ann. Neurol. 72 (6): 893–901. doi:10.1002/ana.23687. PMC 3556649. PMID 23071076.
  4. ↑ Gustafsson H, Nordström A, Nordström P (June 2015). "Depression and subsequent risk of Parkinson disease: A nationwide cohort study". Neurology. 84 (24): 2422–9. doi:10.1212/WNL.0000000000001684. PMC 4478031. PMID 25995056.
  5. ↑ Jiang W, Ju C, Jiang H, Zhang D (September 2014). "Dairy foods intake and risk of Parkinson's disease: a dose-response meta-analysis of prospective cohort studies". Eur. J. Epidemiol. 29 (9): 613–9. doi:10.1007/s10654-014-9921-4. PMID 24894826.
  6. ↑ Lv Z, Qi H, Wang L, Fan X, Han F, Wang H, Bi S (November 2014). "Vitamin D status and Parkinson's disease: a systematic review and meta-analysis". Neurol. Sci. 35 (11): 1723–30. doi:10.1007/s10072-014-1821-6. PMID 24847960.
  7. ↑ Jafari S, Etminan M, Aminzadeh F, Samii A (August 2013). "Head injury and risk of Parkinson disease: a systematic review and meta-analysis". Mov. Disord. 28 (9): 1222–9. doi:10.1002/mds.25458. PMID 23609436.
  8. ↑ Scher AI, Ross GW, Sigurdsson S, Garcia M, Gudmundsson LS, Sveinbjörnsdóttir S, Wagner AK, Gudnason V, Launer LJ (September 2014). "Midlife migraine and late-life parkinsonism: AGES-Reykjavik study". Neurology. 83 (14): 1246–52. doi:10.1212/WNL.0000000000000840. PMC 4180488. PMID 25230997.
  9. ↑ Savica R, Grossardt BR, Carlin JM, Icen M, Bower JH, Ahlskog JE, Maraganore DM, Steensma DP, Rocca WA (October 2009). "Anemia or low hemoglobin levels preceding Parkinson disease: a case-control study". Neurology. 73 (17): 1381–7. doi:10.1212/WNL.0b013e3181bd80c1. PMC 2769554. PMID 19858460.
  10. ↑ Petrovitch H, Ross GW, Abbott RD, Sanderson WT, Sharp DS, Tanner CM, Masaki KH, Blanchette PL, Popper JS, Foley D, Launer L, White LR (November 2002). "Plantation work and risk of Parkinson disease in a population-based longitudinal study". Arch. Neurol. 59 (11): 1787–92. PMID 12433267.
  11. ↑ Powers KM, Smith-Weller T, Franklin GM, Longstreth WT, Swanson PD, Checkoway H (June 2003). "Parkinson's disease risks associated with dietary iron, manganese, and other nutrient intakes". Neurology. 60 (11): 1761–6. PMID 12796527.
  12. ↑ Hu G, Jousilahti P, Nissinen A, Antikainen R, Kivipelto M, Tuomilehto J (December 2006). "Body mass index and the risk of Parkinson disease". Neurology. 67 (11): 1955–9. doi:10.1212/01.wnl.0000247052.18422.e5. PMID 17159100.
  13. ↑ Goldman SM, Quinlan PJ, Ross GW, Marras C, Meng C, Bhudhikanok GS, Comyns K, Korell M, Chade AR, Kasten M, Priestley B, Chou KL, Fernandez HH, Cambi F, Langston JW, Tanner CM (June 2012). "Solvent exposures and Parkinson disease risk in twins". Ann. Neurol. 71 (6): 776–84. doi:10.1002/ana.22629. PMC 3366287. PMID 22083847.
  14. ↑ Gustafsson H, Aasly J, Stråhle S, Nordström A, Nordström P (May 2015). "Low muscle strength in late adolescence and Parkinson disease later in life". Neurology. 84 (18): 1862–9. doi:10.1212/WNL.0000000000001534. PMC 4433465. PMID 25841033.
  15. ↑ Gelb DJ, Oliver E, Gilman S (January 1999). "Diagnostic criteria for Parkinson disease". Arch. Neurol. 56 (1): 33–9. PMID 9923759.
  16. ↑ Marras C, Lang A (April 2013). "Parkinson's disease subtypes: lost in translation?". J. Neurol. Neurosurg. Psychiatry. 84 (4): 409–15. doi:10.1136/jnnp-2012-303455. PMID 22952329.
  17. ↑ 17.0 17.1 Thenganatt MA, Jankovic J (April 2014). "Parkinson disease subtypes". JAMA Neurol. 71 (4): 499–504. doi:10.1001/jamaneurol.2013.6233. PMID 24514863.
  18. ↑ Alves G, Larsen JP, Emre M, Wentzel-Larsen T, Aarsland D (August 2006). "Changes in motor subtype and risk for incident dementia in Parkinson's disease". Mov. Disord. 21 (8): 1123–30. doi:10.1002/mds.20897. PMID 16637023.
  19. ↑ 19.0 19.1 Hoehn MM, Yahr MD (May 1967). "Parkinsonism: onset, progression and mortality". Neurology. 17 (5): 427–42. PMID 6067254.
  20. ↑ 20.0 20.1 Findley LJ, Gresty MA, Halmagyi GM (June 1981). "Tremor, the cogwheel phenomenon and clonus in Parkinson's disease". J. Neurol. Neurosurg. Psychiatry. 44 (6): 534–46. PMC 491035. PMID 7276968.
  21. ↑ Scott RM, Brody JA, Schwab RS, Cooper IS (July 1970). "Progression of unilateral tremor and rigidity in Parkinson's disease". Neurology. 20 (7): 710–4. PMID 5463541.
  22. ↑ Hunker CJ, Abbs JH (1990). "Uniform frequency of parkinsonian resting tremor in the lips, jaw, tongue, and index finger". Mov. Disord. 5 (1): 71–7. doi:10.1002/mds.870050117. PMID 2296262.
  23. ↑ Jankovic J, Schwartz KS, Ondo W (November 1999). "Re-emergent tremor of Parkinson's disease". J. Neurol. Neurosurg. Psychiatry. 67 (5): 646–50. PMC 1736624. PMID 10519872.
  24. ↑ Louis ED, Levy G, Côte LJ, Mejia H, Fahn S, Marder K (October 2001). "Clinical correlates of action tremor in Parkinson disease". Arch. Neurol. 58 (10): 1630–4. PMID 11594921.
  25. ↑ Hughes AJ, Daniel SE, Lees AJ (1993). "The clinical features of Parkinson's disease in 100 histologically proven cases". Adv Neurol. 60: 595–9. PMID 8420197.
  26. ↑ Deuschl G, Bain P, Brin M (1998). "Consensus statement of the Movement Disorder Society on Tremor. Ad Hoc Scientific Committee". Mov. Disord. 13 Suppl 3: 2–23. PMID 9827589.
  27. ↑ LANCE JW, SCHWAB RS, PETERSON EA (March 1963). "Action tremor and the cogwheel phenomenon in Parkinson's disease". Brain. 86: 95–110. PMID 13928399.
  28. ↑ Koller WC, Glatt S, Vetere-Overfield B, Hassanein R (April 1989). "Falls and Parkinson's disease". Clin Neuropharmacol. 12 (2): 98–105. PMID 2720700.
  29. ↑ Muslimovic D, Post B, Speelman JD, Schmand B, de Haan RJ (June 2008). "Determinants of disability and quality of life in mild to moderate Parkinson disease". Neurology. 70 (23): 2241–7. doi:10.1212/01.wnl.0000313835.33830.80. PMID 18519873.
  30. ↑ Svenningsson P, Westman E, Ballard C, Aarsland D (August 2012). "Cognitive impairment in patients with Parkinson's disease: diagnosis, biomarkers, and treatment". Lancet Neurol. 11 (8): 697–707. doi:10.1016/S1474-4422(12)70152-7. PMID 22814541.
  31. ↑ Muslimovic D, Post B, Speelman JD, Schmand B (October 2005). "Cognitive profile of patients with newly diagnosed Parkinson disease". Neurology. 65 (8): 1239–45. doi:10.1212/01.wnl.0000180516.69442.95. PMID 16247051.
  32. ↑ Levin BE, Llabre MM, Reisman S, Weiner WJ, Sanchez-Ramos J, Singer C, Brown MC (March 1991). "Visuospatial impairment in Parkinson's disease". Neurology. 41 (3): 365–9. PMID 2006002.
  33. ↑ Stern Y, Richards M, Sano M, Mayeux R (October 1993). "Comparison of cognitive changes in patients with Alzheimer's and Parkinson's disease". Arch. Neurol. 50 (10): 1040–5. PMID 8215961.
  34. ↑ Emre M, Aarsland D, Brown R, Burn DJ, Duyckaerts C, Mizuno Y, Broe GA, Cummings J, Dickson DW, Gauthier S, Goldman J, Goetz C, Korczyn A, Lees A, Levy R, Litvan I, McKeith I, Olanow W, Poewe W, Quinn N, Sampaio C, Tolosa E, Dubois B (September 2007). "Clinical diagnostic criteria for dementia associated with Parkinson's disease". Mov. Disord. 22 (12): 1689–707, quiz 1837. doi:10.1002/mds.21507. PMID 17542011.
  35. ↑ Hobson P, Meara J (September 2004). "Risk and incidence of dementia in a cohort of older subjects with Parkinson's disease in the United Kingdom". Mov. Disord. 19 (9): 1043–9. doi:10.1002/mds.20216. PMID 15372593.
  36. ↑ Aarsland D, Andersen K, Larsen JP, Lolk A, Nielsen H, Kragh-Sørensen P (March 2001). "Risk of dementia in Parkinson's disease: a community-based, prospective study". Neurology. 56 (6): 730–6. PMID 11274306.
  37. ↑ Aarsland D, Bronnick K, Williams-Gray C, Weintraub D, Marder K, Kulisevsky J, Burn D, Barone P, Pagonabarraga J, Allcock L, Santangelo G, Foltynie T, Janvin C, Larsen JP, Barker RA, Emre M (September 2010). "Mild cognitive impairment in Parkinson disease: a multicenter pooled analysis". Neurology. 75 (12): 1062–9. doi:10.1212/WNL.0b013e3181f39d0e. PMC 2942065. PMID 20855849.
  38. ↑ Emre M (August 2004). "Dementia in Parkinson's disease: cause and treatment". Curr. Opin. Neurol. 17 (4): 399–404. PMID 15247534.
  39. ↑ "Hallucinations in Parkinson's disease. prevalence, phenomenology and risk factors. Fenelon G* mahieux F, huon R, Ziegler M. Brain 2000;123:733-745". Am. J. Ophthalmol. 130 (2): 261–2. August 2000. PMID 11004314.
  40. ↑ Sanchez-Ramos JR, Ortoll R, Paulson GW (December 1996). "Visual hallucinations associated with Parkinson disease". Arch. Neurol. 53 (12): 1265–8. PMID 8970453.
  41. ↑ Lee AH, Weintraub D (June 2012). "Psychosis in Parkinson's disease without dementia: common and comorbid with other non-motor symptoms". Mov. Disord. 27 (7): 858–63. doi:10.1002/mds.25003. PMC 3511789. PMID 22674352.
  42. ↑ Cummings JL (July 1991). "Behavioral complications of drug treatment of Parkinson's disease". J Am Geriatr Soc. 39 (7): 708–16. PMID 2061539.
  43. ↑ Goetz CG, Wuu J, Curgian LM, Leurgans S (January 2005). "Hallucinations and sleep disorders in PD: six-year prospective longitudinal study". Neurology. 64 (1): 81–6. doi:10.1212/01.WNL.0000148479.10865.FE. PMID 15642908.
  44. ↑ Friedman JH (May 1985). "'Drug holidays' in the treatment of Parkinson's disease. A brief review". Arch. Intern. Med. 145 (5): 913–5. PMID 3888135.
  45. ↑ 45.0 45.1 Aarsland D, Larsen JP, Lim NG, Janvin C, Karlsen K, Tandberg E, Cummings JL (October 1999). "Range of neuropsychiatric disturbances in patients with Parkinson's disease". J. Neurol. Neurosurg. Psychiatry. 67 (4): 492–6. PMC 1736593. PMID 10486397.
  46. ↑ Ravina B, Camicioli R, Como PG, Marsh L, Jankovic J, Weintraub D, Elm J (July 2007). "The impact of depressive symptoms in early Parkinson disease". Neurology. 69 (4): 342–7. doi:10.1212/01.wnl.0000268695.63392.10. PMC 2031220. PMID 17581943.
  47. ↑ Tandberg E, Larsen JP, Aarsland D, Cummings JL (February 1996). "The occurrence of depression in Parkinson's disease. A community-based study". Arch. Neurol. 53 (2): 175–9. PMID 8639068.
  48. ↑ Gotham AM, Brown RG, Marsden CD (April 1986). "Depression in Parkinson's disease: a quantitative and qualitative analysis". J. Neurol. Neurosurg. Psychiatry. 49 (4): 381–9. PMC 1028762. PMID 3701347.
  49. ↑ Broen MP, Narayen NE, Kuijf ML, Dissanayaka NN, Leentjens AF (August 2016). "Prevalence of anxiety in Parkinson's disease: A systematic review and meta-analysis". Mov. Disord. 31 (8): 1125–33. doi:10.1002/mds.26643. PMID 27125963.
  50. ↑ Wee N, Kandiah N, Acharyya S, Chander RJ, Ng A, Au WL, Tan LC (February 2016). "Depression and anxiety are co-morbid but dissociable in mild Parkinson's disease: A prospective longitudinal study of patterns and predictors". Parkinsonism Relat. Disord. 23: 50–6. doi:10.1016/j.parkreldis.2015.12.001. PMID 26711668.
  51. ↑ Reijnders JS, Scholtissen B, Weber WE, Aalten P, Verhey FR, Leentjens AF (October 2010). "Neuroanatomical correlates of apathy in Parkinson's disease: A magnetic resonance imaging study using voxel-based morphometry". Mov. Disord. 25 (14): 2318–25. doi:10.1002/mds.23268. PMID 20669264.
  52. ↑ Robert G, Le Jeune F, Lozachmeur C, Drapier S, Dondaine T, Péron J, Travers D, Sauleau P, Millet B, Vérin M, Drapier D (September 2012). "Apathy in patients with Parkinson disease without dementia or depression: a PET study". Neurology. 79 (11): 1155–60. doi:10.1212/WNL.0b013e3182698c75. PMID 22895582.
  53. ↑ 53.0 53.1 Tandberg E, Larsen JP, Karlsen K (November 1998). "A community-based study of sleep disorders in patients with Parkinson's disease". Mov. Disord. 13 (6): 895–9. doi:10.1002/mds.870130606. PMID 9827612.
  54. ↑ 54.0 54.1 Oerlemans WG, de Weerd AW (March 2002). "The prevalence of sleep disorders in patients with Parkinson's disease. A self-reported, community-based survey". Sleep Med. 3 (2): 147–9. PMID 14592234.
  55. ↑ 55.0 55.1 Gjerstad MD, Wentzel-Larsen T, Aarsland D, Larsen JP (May 2007). "Insomnia in Parkinson's disease: frequency and progression over time". J. Neurol. Neurosurg. Psychiatry. 78 (5): 476–9. doi:10.1136/jnnp.2006.100370. PMC 2117851. PMID 17098844.
  56. ↑ Kumar S, Bhatia M, Behari M (July 2002). "Sleep disorders in Parkinson's disease". Mov. Disord. 17 (4): 775–81. doi:10.1002/mds.10167. PMID 12210875.
  57. ↑ Lees AJ, Blackburn NA, Campbell VL (December 1988). "The nighttime problems of Parkinson's disease". Clin Neuropharmacol. 11 (6): 512–9. PMID 3233589.
  58. ↑ Schrempf W, Brandt MD, Storch A, Reichmann H (2014). "Sleep disorders in Parkinson's disease". J Parkinsons Dis. 4 (2): 211–21. doi:10.3233/JPD-130301. PMID 24796235.
  59. ↑ Askenasy JJ, Yahr MD (September 1990). "Parkinsonian tremor loses its alternating aspect during non-REM sleep and is inhibited by REM sleep". J. Neurol. Neurosurg. Psychiatry. 53 (9): 749–53. PMC 1014251. PMID 2246656.
  60. ↑ Sixel-Döring F, Trautmann E, Mollenhauer B, Trenkwalder C (September 2011). "Associated factors for REM sleep behavior disorder in Parkinson disease". Neurology. 77 (11): 1048–54. doi:10.1212/WNL.0b013e31822e560e. PMID 21832215.
  61. ↑ Schenck CH, Mahowald MW (March 2002). "REM sleep behavior disorder: clinical, developmental, and neuroscience perspectives 16 years after its formal identification in SLEEP". Sleep. 25 (2): 120–38. PMID 11902423.
  62. ↑ van Hilten JJ, Weggeman M, van der Velde EA, Kerkhof GA, van Dijk JG, Roos RA (1993). "Sleep, excessive daytime sleepiness and fatigue in Parkinson's disease". J Neural Transm Park Dis Dement Sect. 5 (3): 235–44. PMID 8369103.
  63. ↑ 63.0 63.1 Friedman J, Friedman H (October 1993). "Fatigue in Parkinson's disease". Neurology. 43 (10): 2016–8. PMID 8413960.
  64. ↑ 64.0 64.1 Karlsen K, Larsen JP, Tandberg E, Jørgensen K (March 1999). "Fatigue in patients with Parkinson's disease". Mov. Disord. 14 (2): 237–41. PMID 10091615.
  65. ↑ Alves G, Wentzel-Larsen T, Larsen JP (November 2004). "Is fatigue an independent and persistent symptom in patients with Parkinson disease?". Neurology. 63 (10): 1908–11. PMID 15557510.
  66. ↑ Tissingh G, Berendse HW, Bergmans P, DeWaard R, Drukarch B, Stoof JC, Wolters EC (January 2001). "Loss of olfaction in de novo and treated Parkinson's disease: possible implications for early diagnosis". Mov. Disord. 16 (1): 41–6. PMID 11215591.
  67. ↑ Ponsen MM, Stoffers D, Booij J, van Eck-Smit BL, Wolters E, Berendse HW (August 2004). "Idiopathic hyposmia as a preclinical sign of Parkinson's disease". Ann. Neurol. 56 (2): 173–81. doi:10.1002/ana.20160. PMID 15293269. Vancouver style error: initials (help)
  68. ↑ Ross GW, Petrovitch H, Abbott RD, Tanner CM, Popper J, Masaki K, Launer L, White LR (February 2008). "Association of olfactory dysfunction with risk for future Parkinson's disease". Ann. Neurol. 63 (2): 167–73. doi:10.1002/ana.21291. PMID 18067173.
  69. ↑ Goetz CG, Tanner CM, Levy M, Wilson RS, Garron DC (1986). "Pain in Parkinson's disease". Mov. Disord. 1 (1): 45–9. doi:10.1002/mds.870010106. PMID 3504231.
  70. ↑ Hillen ME, Sage JI (November 1996). "Nonmotor fluctuations in patients with Parkinson's disease". Neurology. 47 (5): 1180–3. PMID 8909426.
  71. ↑ Ford B, Louis ED, Greene P, Fahn S (July 1996). "Oral and genital pain syndromes in Parkinson's disease". Mov. Disord. 11 (4): 421–6. doi:10.1002/mds.870110411. PMID 8813222.
  72. ↑ Verbaan D, Marinus J, Visser M, van Rooden SM, Stiggelbout AM, van Hilten JJ (July 2007). "Patient-reported autonomic symptoms in Parkinson disease". Neurology. 69 (4): 333–41. doi:10.1212/01.wnl.0000266593.50534.e8. PMID 17646625.
  73. ↑ Asahina M, Vichayanrat E, Low DA, Iodice V, Mathias CJ (June 2013). "Autonomic dysfunction in parkinsonian disorders: assessment and pathophysiology". J. Neurol. Neurosurg. Psychiatry. 84 (6): 674–80. doi:10.1136/jnnp-2012-303135. PMID 22942216.
  74. ↑ Lemack GE, Dewey RB, Roehrborn CG, O'Suilleabhain PE, Zimmern PE (August 2000). "Questionnaire-based assessment of bladder dysfunction in patients with mild to moderate Parkinson's disease". Urology. 56 (2): 250–4. PMID 10925088.
  75. ↑ Araki I, Kitahara M, Oida T, Kuno S (November 2000). "Voiding dysfunction and Parkinson's disease: urodynamic abnormalities and urinary symptoms". J. Urol. 164 (5): 1640–3. PMID 11025724.
  76. ↑ Koller WC, Vetere-Overfield B, Williamson A, Busenbark K, Nash J, Parrish D (October 1990). "Sexual dysfunction in Parkinson's disease". Clin Neuropharmacol. 13 (5): 461–3. PMID 2272026.
  77. ↑ Singer C, Weiner WJ, Sanchez-Ramos JR (1992). "Autonomic dysfunction in men with Parkinson's disease". Eur. Neurol. 32 (3): 134–40. doi:10.1159/000116810. PMID 1592069.

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