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Identifying prodromal Parkinson's disease: Pre-Motor disorders in Parkinson's disease


  • Ronald B. Postuma MD, MSc,

    Corresponding author
    1. Department of Neurology, McGill University, Montreal General Hospital, Montreal, Quebec, Canada
    2. Centre d'Études Avancées en Médecine du Sommeil, Hopital du Sacre-Coeur, Montreal, Canada
    • Department of Neurology, L7-312 Montreal General Hospital, 1650 Cedar Ave., Montreal, Quebec, Canada H3G 1A4
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  • Dag Aarsland MD, PhD,

    1. Department of Old Age Psychiatry, Psychiatric Clinic, Stavanger University Hospital, Stavanger, Norway
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  • Paolo Barone MD, PhD,

    1. Centro per le Malattie Neurodegenerative, University of Salerno, Salerno, Italy
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  • David J. Burn MD, FRCP,

    1. Institute for Ageing and Health, Newcastle University, Newcastle upon Tyne, United Kingdom
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  • Christopher H. Hawkes MD, FRCP,

    1. Neuroscience Centre, Institute of Cell and Molecular Science, Barts and The London School of Medicine and Dentistry, London, United Kingdom
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  • Wolfgang Oertel MD, PhD,

    1. Department of Neurology, Philipps-Universität, Marburg, Germany
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  • Tjalf Ziemssen MD

    1. Autonomes und neuroendokrinologisches Funktionslabor, Neurologische Klinik und Poliklinik, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Germany
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  • Relevant conflicts of interest/financial disclosures: Ronald B. Postuma received research funds from the Weston Foundation, the Webster Foundation, the Fonds de la Recherche en Sante Quebec, the Canadian Institute of Health Research, and the Parkinson Society of Canada. Dag Aarsland received research support from Novartis, Merck Serono, and Lundbeck.

  • Full financial disclosures and author roles may be found in the online version of this article.


Increasing recognition that Parkinson's disease (PD) may start outside of the substantia nigra has led to a rapidly expanding effort to define prodromal stages of PD, before motor signs permit classical diagnosis. Many of these efforts center around the identification of clinical non-motor symptoms and signs of disease. There is now direct evidence that olfaction, rapid eye movement (REM) sleep behavior disorder (RBD), constipation, and depression can be present in prodromal PD. In addition, there is suggestive evidence that visual changes, other autonomic symptoms, and subtle cognitive changes may also be present at prodromal stages. A critical issue in utility of these prodromal markers will be assessment of sensitivity, specificity, and positive and negative predictive values. Although these have yet to be fully defined, olfactory deficits, some visual changes, and autonomic symptoms occur in the majority of PD patients at diagnosis, suggesting good potential sensitivity. However, with the exception of RBD and perhaps some specific autonomic measures, specificity, and positive predictive value of these markers may be insufficient to be used alone as identifiers of prodromal disease. The evidence for the utility of olfaction, RBD, autonomic markers, visual changes, mood disorders, and cognitive loss as markers of prodromal PD and the potential sensitivity and specificity of these markers are summarized. © 2012 Movement Disorder Society