The three cardinal signs of Parkinson’s disease are tremors, muscle stiffness, and slow movement (bradykinesia), but the disease can cause a wide variety of other signs and symptoms.

The signs and symptoms of Parkinson’s are divided into two categories: motor symptoms, which affect physical movement, and nonmotor symptoms, which can affect thinking, mood, sleep, sense of smell, and a variety of other body parts and functions.

While Parkinson’s affects each person somewhat differently, what’s true for most people is that the signs and symptoms tend to progress, or get worse over time.

There’s no single diagnostic test for Parkinson’s disease, and given the range of symptoms it can cause, as well as the number of other diseases that cause similar symptoms — called parkinsonism — it can take months or years to arrive at a diagnosis of Parkinson’s.

Motor Symptoms

Many of the motor symptoms of Parkinson’s are mild early in the course of the disease, and may initially affect only one side of the body.

In time, the symptoms tend to move to both sides of the body, but they often remain worse on the side where they started.

The three main motor symptoms of Parkinson’s are:

Bradykinesia A slowing of movement that affects everyone with Parkinson’s. It can make coordinated movement of your arms and hands difficult and lead to trouble with walking and standing.

Rigidity Many people with Parkinson’s experience stiffness in the arms, legs, or torso.

Tremor These shaking movements, which don’t occur in everyone with Parkinson’s, tend to be most noticeable when you’re at rest. They often affect just one hand, although tremor can also cause shaking of the chin, lips, face, and legs. When just the hands or fingers are affected, the movement is sometimes called “pillrolling” tremor, because the person appears to be rolling small objects or pills in their hand.

Other Parkinson’s motor symptoms include:

Postural Instability Loss of balance is often a problem in the later stages of Parkinson’s.

Loss of Automatic Movements Actions that may no longer happen include spontaneous smiling and swinging your arms when you walk. A decreased rate of blinking the eyes can also occur, sometimes leading to dry eyes.

Freezing This describes difficulty taking a step, usually the first step. You may feel like your feet are glued to the floor.

Micrographia Some people with Parkinson’s find that the size of their handwriting gets smaller over time.

Mask-Like Expression (Hypomimia) A decrease in the range of facial expressions is common in people with Parkinson’s.

Unwanted Accelerations You may experience sudden rapid speech, or an uncontrolled acceleration in your walking, known as festination.

Parkinsonian Gait This is a common way of walking stooped over, with a combination of freezing and festination.

Difficulty Speaking These problems may include an unusually soft voice or slurring of your words.

Difficulty Swallowing This can lead to drooling and an increased risk of choking. Drooling may also result from a reduction in automatic movements, including swallowing of saliva.

Nonmotor Symptoms

Nonmotor symptoms of Parkinson’s disease don’t affect movement, but rather your mood, senses, and ability to think.

Common nonmotor symptoms include:

Autonomic Dysfunction The autonomic nervous system controls automatic functions of the body, including heart rate, blood pressure, breathing, digestion, sweating, urination, and sexual arousal.

Any of these body functions can become abnormal in Parkinson’s disease, leading to issues like low blood pressure upon standing up (causing dizziness), constipation, urinary difficulties, abnormal sweating, and a decreased interest in sex.

Loss of Sense of Smell This is common with Parkinson’s, and losing your sense of smell — or your ability to distinguish one odor from another — can be one of the earliest symptoms of the disease.

Cognitive Problems and Dementia Problems with thinking, memory, multitasking, and judging distances are estimated to occur in 40 percent or more of people with Parkinson’s.

Psychosis and Hallucinations Psychosis — thoughts and beliefs that are out of touch with reality — may occur in 20 percent to 40 percent of people because of the disease itself and medication side effects.

Visual hallucinations — seeing things that aren’t real — are the most common psychotic symptom of Parkinson’s.

Hallucinations often become more frequent and severe as the disease progresses.

Some people with Parkinson’s also have delusions, including false beliefs that they’re in danger, being stolen from, or being cheated on by a spouse.

Mood Disorders Some people with Parkinson’s become depressed, anxious, or apathetic — lacking the motivation to walk, talk, or express emotion.

Sleep Disorders Difficulties falling asleep and staying asleep are common with Parkinson’s disease.

These problems may be caused or worsened by difficulty turning over in bed, muscle cramps or pain, a frequent need to urinate, or vivid dreams and nightmares.

Up to half of people with Parkinson’s disease may have REM sleep behavior disorder (RBD), in which a person physically acts out their dreams in their sleep. Dreams associated with RBD are often frightening, and the person may react by kicking, punching, or shouting. This can be dangerous for both the person experiencing the dream and their bed partner.

For many who have both RBD and Parkinson’s, the RBD came first. Several studies have shown that a high proportion of people with RBD go on to develop Parkinson’s disease or another neurodegenerative disease, such as Lewy body dementia or multiple system atrophy, both of which cause parkinsonian symptoms.

Daytime Sleepiness Excessive daytime sleepiness affects up to 75 percent of people with Parkinson’s. It may be worsened by medication for the disease.

Some people with Parkinson’s may fall asleep suddenly, which can be very dangerous if they drive a car.

Talk to your doctor about adjusting your medication if you experience this symptom.

Pain This is reported in more than 40 percent of people with Parkinson’s, often in the same areas of the body as motor symptoms. This pain is often described as burning, tingling, or stabbing.

How Is Parkinson’s Disease Diagnosed?

There’s no single diagnostic test for Parkinson’s disease, so it can be difficult to diagnose. Indeed, in some studies, up to a quarter of people who were thought to have Parkinson’s are found to have some other disorder at autopsy.

A diagnosis of Parkinson’s disease is therefore made with a combination of techniques.

Physical Exam and Medical History

As a first step, your doctor will observe and ask you about the signs and symptoms you’re experiencing.

Current diagnostic criteria define Parkinson’s disease as the presence of bradykinesia (slow movement) combined with either rest tremor, rigidity, or both.

If any of these symptoms began on one side of your body, or if you experience a tremor when your arm is at rest, Parkinson’s may be strongly suspected.

Most likely, your doctor will also ask you about any other symptoms you may have, even if they seem unrelated.

Nonmotor symptoms of Parkinson’s, such as a decreased sense of smell, constipation, REM sleep behavior disorder, and depression may occur years before the motor symptoms of the disease become apparent.

Elimination of Other Conditions

Although no test can diagnose Parkinson’s disease itself, your doctor may order blood tests or imaging studies to rule out other possible causes of your symptoms.

Your doctor will want to know about any medications or recreational drugs you take, since some drugs can cause symptoms similar to those of Parkinson’s.

Parkinson’s disease doesn’t show up on radiological studies like X-ray, MRI (magnetic resonance imaging), or CT (computed tomography) scans.

Doctors sometimes order dopamine transporter SPECT imaging (also known as DaTscan imaging) to differentiate between parkinsonian symptoms caused by either Parkinson’s disease or atypical parkinsonism on the one hand, or, on the other hand, parkinsonism due to other causes, such as vascular disease or drug use.

DaTscan imaging involves having a radioactive tracer infused via IV, then, several hours later, having images of your brain taken with a special camera. The scan itself takes about 30 minutes, during which you must remain still.

Levodopa Challenge

A combination of the drugs carbidopa and levodopa (Sinemet) — often referred to just as levodopa — is the most common and effective treatment of motor symptoms related to Parkinson’s disease. It works by increasing the amount of dopamine in the brain.

Sometimes doctors will administer a levodopa challenge, in which the drug is administered for a trial period, to assist in the diagnosis of Parkinson’s disease.

If your symptoms improve when you take levodopa, a diagnosis of Parkinson’s is likely.

One study found that the levodopa challenge predicted a Parkinson’s diagnosis in 70 percent to 81 percent of cases.

This technique is usually not useful for people with mild symptoms that don’t interfere with daily activities.

How Does Parkinson’s Disease Progress?

The progression of Parkinson’s disease varies widely from person to person. Some people respond well to treatment for many years, while in other people, the disease progresses more rapidly, and the drugs used to control symptoms work less well over time.

When drug treatment intensifies to improve symptom control, the risk of drug side effects, in particular dyskinesia, rises. Dyskinesia is an involuntary, uncontrolled movement that can look like fidgeting, writhing, head bobbing, or body swaying.

People who respond less well to drug treatment also tend to develop additional Parkinson’s symptoms, often including various nonmotor symptoms.

As symptoms advance, people with Parkinson’s increasingly need assistance carrying out activities of daily living.

What Are the Stages of Parkinson’s?

Neurologists use several rating scales to describe the progression of Parkinson’s symptoms. One that’s widely used is called the Hoehn and Yahr scale, which uses a system of stages.

Stage 1 Symptoms are seen on one side of the body only.
Stage 2 Symptoms are seen on both sides of the body. There’s no impairment of balance.
Stage 3 Balance impairment has begun. In this mild to moderate stage of the disease, the person is still physically independent.
Stage 4 This stage is marked by severe disability. The person is still able to walk or stand unassisted but may need a walker to get around.
Stage 5 The person requires a wheelchair or is bedridden unless assisted in standing and walking.

Additional reporting by Ingrid Strauch.

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