A 62-year-old male notice...

A 62-year-old male noticed a subtle change in his handwriting 2 years before the presentation, which worsened gradually. He reported that when taking notes, “the hand cannot keep up … grinds to a halt” with micrographia. He also noticed that performing other tasks with the dominant right hand was more difficult, including brushing his teeth and buttoning the left cuff button. Several years before his handwriting changed, he started “flailing” during sleep. He reported that the flailing seemed connected to dreams of being chased and trying to get away. His wife reported that the flailing occurred 3 or 4 nights per week, typically several hours after falling asleep. Although he had never struck her during a dream, she avoided sleeping beside him. In addition, for many years, he had noticed a “terrible sense of smell.” He had no symptoms to suggest orthostatic hypotension or any change in bowel, bladder, or sexual functioning. Although he was frustrated by the difficulty of writing and worried about the diagnosis, he was not depressed or anxious. There was no family history of PD or exposure to dopamine-blocking medications.
On examination, there was mildly diminished voice volume and facial expression. He arose easily from a chair and walked well except absent right arm swing and a tendency to scuff the right shoe. Finger, heel, and toe-tapping on the right were all mildly slow with a decrement, meaning that the longer he did the task, the smaller the amplitude of the movement, with some brief arrests of movement. There was also subtle slowness of the left limbs and mild cogwheel rigidity of the right greater than the left limbs. The handwriting was micrographic. There was no resting tremor. Reflexes were normal, as were eye movements with no slowing of saccades which looks like the early stage of Parkinsonism. Does flailing in sleep have any connection with Parkinsonism? Can it serve as an early indicator of the condition?