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Postural instability. People with PSP tend to present early in their condition with postural instability and a tendency to fall and lose their balance. A lot of people present with falls backwards, and that is very characteristic for PSP. If you're physios, the health professionals, the ambulance service, who are going out to people who are having frequent falls, that is a key question to ask, "When you are falling, which direction are you falling in?" That is an early indicator. People with PSP will present with a lot of lacerations at the back of their head. They won't be aware that they are going to fall, they just suddenly go backwards.

Slowness of movement, or bradykinesia, may be one of the earliest symptoms that the family notice. Maybe going out on walks, when maybe the father used to be well ahead during walking, they will think, "Well, the pace is not so fluid as it was." So a general slowing down, slowing down in motor tasks. Motor recklessness is one of the key indicators in PSP when people may be having frequent falls and they are sitting in a chair, and suddenly they will get up, they will suddenly get up and do something. Although they may be aware that they are going to fall, they have little insight into the condition. So that is quite a danger. You need to be very aware if people have PSP and they are having impulsivity and motor recklessness, that that is one of the key areas where they are going to fall. They will just get up.

Eye problems and changes in vision are one of the early indicators of PSP. People will often present with double vision, blurred vision, or difficulty with eye-opening, which we call blepharospasm. We may think somebody is asleep, but in fact, they are awake but they are just having trouble opening their eyelids. Alternatively, people may be speaking to you or watching television, and their eyes will close, or they will have trouble keeping them open while they are doing a functional task. There is often a reduced eye blink, and so people will get dry eyes, and for that, we might use artificial tears. And the supranuclear gaze palsy is the biggest characteristic. When people have slowness of movement of their eyes, and then the movement becomes very restricted. So that is for the upwards, and more predominantly, the downward gaze.

People with PSP become very light sensitive, and this can cause a lot of problems, not only outside of the house but in the house. People often have to dim the lights down, you will find that they are pulling the blinds down, which is difficult for the rest of the family to cope with. People often initially start wearing sunglasses. And you can also get wraparound sunglasses, which really restricts the amount of light that is getting in, that people are still able to see. It is easily addressed using the sunglasses or the wrap around glasses, yes. And the optician will often put a prism lens in their normal glasses. However, the PSPA also supply prism glasses, which helps with their downward gaze.

Speech is often affected quite early on in the condition. People may present with, their speech gets quieter. A lot of people have quiet speech, which is very, very rapid. So it is very difficult in a consultation to follow what they are saying. Other people may have very strained speech, and other people's speech might be slurred. Different presentations, but speech will be an indicator that something is not quite right early on in the condition. I think a lot of it is working with the family and carers, to make them more aware of what difficulties the people are having, so that not to rush them, and not to anticipate what they have said, to actually listen to what they are saying. And with early referrals, the speech therapist is vital. The speech therapist helps with all sorts of communication.

But another area associated with speech is swallowing. People present early with swallowing difficulties. When they are eating and drinking they might think the food goes down the wrong way. People tend to aspirate a little bit, which can lead to chest infections, pneumonia, and a lot of hospital admissions are actually because of chest infections. That is because of the reduced swallow and a reduced cough reflex. Some people have excessive saliva, and for some people that is their... In the clinic, we say, "What is a symptom that is annoying you most?" And they will say that producing all this excess saliva. Some of it is very thick, so it is difficult to swallow. One of the things that we use is Atropine eye drops. A few drops of those under the tongue and it seems to help with the saliva.

People with PSP tend to overfill their mouths, which has a big impact on their swallow. Difficulty then, swallowing and leading to aspiration and choking. And people appear to develop a sweet tooth, so they are over for looking for biscuits and cakes and sweets, and overeating on the sugary things.

People with PSP, their intelligence remains largely intact, but you do have subtle changes, cognitive changes. People might become more aggressive than they used to be, more irritable than they used to be. Or a big symptom with PSP is people become quite apathetic. People who have had high-powered jobs and they are out there in the workplace, you think when they have had that diagnosis, they would be kind of riling against it all. But they seem very accepting of it, accepting of all the different carers and people coming in and out of their house. So apathy is quite a big symptom.

People may become emotionally labile, that they may cry or laugh inappropriately. Maybe they are watching television and they will cry easily at a film or something, o a symptom that was not in their previous personality. People with Parkinson's may have a tremor, not every person with Parkinson's has tremor. But people with PSP don't have tremor. So when people come to you and you are suspecting a diagnosis, if the tremor is absent and you have got some of these other symptoms, then that can point you in the direction of PSP.