A left-handed 79-year-old man presents with a troublesome resting tremor of his left hand. The tremor is evident in his writing. He has also noticed his writing is smaller than it used to be. He complains he has difficulty turning in bed to get comfortable and his wife complains that he sometimes kicks her in the middle of the night. When he gets out of bed in the morning he feels a little woozy, but this resolves after a while. On examination, he blinks about three times a minute and his face does not show much emotion. Glabelar tap is positive. He has a slow, shuffling gait. He has difficulty stopping, starting and turning. He holds his feet slightly apart to steady himself. When you pull him backwards, he is unable to right himself and stumbles back. Which of the signs and symptoms is not commonly associated with parkinsonism?
A. Postural instability
B. Rapid eye movement (REM) sleep disturbance
D. Broad-based gait
E. Autonomic instability
Ans: D This man presents with many symptoms of parkinsonism. However, the parkinsonian gait is typically narrow-based, not broad (D). Parkinson’s is a disease of dopaminergic neurone loss in the nigrostriatal pathways and results in the triad of bradykinesia, rigidity and tremor. A fourth sign to look out for is postural instability (A). This can be elicited by asking the patient to steady himself and pulling him backwards. During REM sleep (B), the brain is active but muscles are paralysed (thus associated with dreaming). In Parkinson’s disease (PD), muscles may be active allowing patients to act out their dreams, resulting in kicking, yelling, etc. Hypomimia (C) is the technical term for mask-like facies or reduced facial expression. Symptoms of autonomic dysfunction (E) are common and include constipation, postural hypotension and sexual dysfunction. Very prominent autonomic symptoms may suggest Shy–Drager’s, a type of multiple system atrophy (which in turn is one of the Parkinson’s plus syndromes).