Image used for illustrative purpose. Photo: File

From anxiety to loss of smell, subtle symptoms are frequently misdiagnosed before motor signs appear

When a young, physically active patient in his 30s began noticing subtle changes in his movement, Parkinson’s disease was the last thing on his mind. At Cleveland Clinic Abu Dhabi, neurologists say such cases are becoming increasingly familiar — with some patients diagnosed as young as 18, and many initially misdiagnosed for years.

“Young-onset Parkinson’s disease, defined as diagnosis before the age of 50, accounts for approximately 5 to 10 per cent of all Parkinson’s cases worldwide,” said Dr Yasmin Abdelmajid, Associate Staff Physician at the hospital’s Neurological Institute.

“Interestingly, this region appears to have a higher prevalence compared to global figures since we encounter such patients more frequently compared to other regions worldwide.” At the centre’s Parkinson’s Disease and Research programme, patients span the full spectrum of the condition, from early onset to advanced stages, including individuals in their late teens.

Often missed, often misunderstood

For younger patients, the disease rarely presents in the way most people expect. “Younger patients tend to present differently from the classic picture most people associate with Parkinson’s disease,” Dr Abdelmajid explained. “Motor fluctuations, dyskinesias and dystonia are more prominent early features in this age group.”

Dyskinesia causes involuntary, erratic dance-like movements, while dystonia involves sustained, often painful muscle contractions that twist the body into rigid, unnatural postures. Because of these atypical symptoms, and limited awareness, diagnosis is frequently delayed.

“And this is more the rule than the exception in young-onset cases,” she said. “We have seen patients who spent years being treated for primary depression, anxiety disorders, or orthopaedic shoulder pathology before the neurological picture became clear.”

Several early warning signs are often overlooked or treated in isolation. Depression and anxiety, she noted, can precede motor symptoms by up to a decade. Loss of smell is commonly dismissed as sinus-related, while a “frozen shoulder” on one side may in fact be an early neurological sign.

Other under-recognised indicators include REM sleep behaviour disorder, where patients act out their dreams, as well as constipation and urinary issues, which can appear years before a formal diagnosis. “This is one of the most important awareness messages we try to convey,” she said, stressing the need for earlier neurological evaluation when such symptoms appear together.

When fitness masks the signs

In some cases, high levels of physical fitness can actually delay diagnosis. “Some of the most diagnostically challenging and personally moving cases we have managed involve patients in their late 20s and 30s, including individuals who were athletically very active,” Dr Abdelmajid said. “High physical fitness can mask early motor signs, as compensatory movement strategies delay the emergence of classical features like rigidity or slowness.”

Instead, early clues may be subtle; a golfer noticing a change in their swing, or a swimmer experiencing loss of coordination on one side, long before any visible tremor appears.

Smart devices prompting early checks

Doctors are also beginning to see patients seeking medical advice after noticing irregularities flagged by wearable devices. “We are beginning to see patients who come to clinic having noticed something on their smartwatch or fitness tracker,” Dr Abdelmajid said, citing examples such as irregular gait patterns, reduced arm swing, or tremor alerts.

While consumer devices are not diagnostic, they are playing a role in prompting earlier consultations. “Research-grade wearables and digital biomarker platforms are actively being studied, and we believe in the next decade they will play a meaningful role in earlier, objective detection of Parkinson’s, particularly in the prodromal phase,” she added.

A life regained

For some patients, the impact of delayed diagnosis can be profound — but so too can the results of the right treatment. Dr Abdelmajid recalled the case of a 59-year-old man who had been misdiagnosed for years and left severely disabled by uncontrolled tremors affecting his head, arms and legs.

“Because of his age, his condition had been misdiagnosed as essential tremor for years, and he had been managed incorrectly throughout that time,” she said. “His quality of life continued to deteriorate, and the prolonged uncertainty and disability took a significant toll on his mental health.”

After finally receiving the correct diagnosis, he was evaluated for deep brain stimulation (DBS), a surgical treatment used in advanced cases. “The transformation that followed was nothing short of extraordinary.” Within months, his symptoms were significantly controlled. He returned to walking up to five kilometres a day, reconnected with friends, and resumed attending prayers at the mosque — something he had stopped due to embarrassment over his tremors.

“These are not small things. For this man, they were everything,” Dr Abdelmajid said. “This is what happens when the right patient is matched with the right advanced therapy at the right time. These outcomes are not miracles; they are what precise, multidisciplinary, expert care can achieve.”

With earlier diagnosis and the right support, many younger patients can continue to lead active lives, doctors say. But awareness, among both the public and healthcare providers remains key. “Any patient with asymmetric or atypical motor symptoms, unexplained mood changes, or a constellation of non-motor features should be referred for specialist evaluation,” Dr Abdelmajid concluded. “Because the earlier we recognise it, the more we can do.”