Editing Progressive supranuclear palsy (section)

=== Signs and Symptoms of PSP-RS Subtype ===
PSP-RS is characterized by a combination of motor, ocular, cognitive, and speech-related impairments, that typically emerge in early stages of the disease. Symptoms of PSP-RS usually begin after 60 and steadily progress over time.<ref name=":0" /> Clinical symptoms of PSP-RS often include unexplained falls, unsteady gait, bradykinesia, apathy, disinhibition, cognitive dysfunction, difficulty planning or multitasking, slow speech, and impaired ocular movement.<ref name=":0" /><ref name=":3" /><ref name=":4">{{Cite journal |last1=Krzosek |first1=Patrycja |last2=Madetko |first2=Natalia |last3=Migda |first3=Anna |last4=Migda |first4=Bartosz |last5=Jaguś |first5=Dominika |last6=Alster |first6=Piotr |date=2022-02-09 |title=Differential Diagnosis of Rare Subtypes of Progressive Supranuclear Palsy and PSP-Like Syndromes—Infrequent Manifestations of the Most Common Form of Atypical Parkinsonism |journal=Frontiers in Aging Neuroscience |volume=14 |doi=10.3389/fnagi.2022.804385 |doi-access=free |pmid=35221993 |pmc=8864174 |issn=1663-4365}}</ref> PSP-RS is also characterized by unresponsiveness to dopamine therapies often prescribed for those with [[Parkinson's disease]].<ref name=":5">{{Cite journal |last=Armstrong |first=Melissa J. |date=March 2018 |title=Progressive Supranuclear Palsy: an Update |url=http://link.springer.com/10.1007/s11910-018-0819-5 |journal=Current Neurology and Neuroscience Reports |language=en |volume=18 |issue=3 |page=12 |doi=10.1007/s11910-018-0819-5 |pmid=29455271 |issn=1528-4042|url-access=subscription }}</ref> Patients can present initially with symptoms more characteristic of the PSP-Parkinson (PSP-P) subtype which is characterized by asymmetric rigidity, resting tremor, and are more responsive to dopamine therapies such as [[Levodopa|levadopa]] compared to PSP-RS.<ref>{{Cite journal |last1=Coughlin |first1=David G. |last2=Litvan |first2=Irene |date=April 2020 |title=Progressive supranuclear palsy: Advances in diagnosis and management |journal=Parkinsonism & Related Disorders |language=en |volume=73 |pages=105–116 |doi=10.1016/j.parkreldis.2020.04.014|pmid=32487421 |pmc=7462164 }}</ref> Clinical and pathological differences between PSP-P and PRSP-RS occur within the first year of the disease, with individuals with PSP-RS exhibiting faster progression of symptoms and lower survival rates after diagnosis. Diagnostic criteria distinguish between '''probable''' and '''possible''' PSP-RS, as definitive diagnosis requires post-mortem neuropathological confirmation.<ref name=":5" /> The NINDS-SPSP criteria define probable PSP-RS as requiring both vertical supranuclear gaze palsy and early postural instability with falls, while possible PSP-RS requires either vertical gaze palsy or slowed vertical saccades combined with early falls.<ref name=":5" /><ref name=":4" /> PSP-RS effects more Males than Females, with a Male to Female ratio of 1.8:1.<ref name=":3" /> Symptom progression tends to occur more quickly in PSP-RS than other sub-types with the average disease duration being 5.9 years and an average age of death of 72.1 years.<ref name=":3" /><ref name=":7" />

==== Motor Symptoms in PSP-RS ====
One of the key features of PSP-RS that occurs within the first year of symptom onset, is early postural instability which often leads to unexplained falls.<ref name=":6" /><ref name=":5" /><ref name=":8">{{Cite journal |last1=Alster |first1=Piotr |last2=Madetko |first2=Natalia |last3=Koziorowski |first3=Dariusz |last4=Friedman |first4=Andrzej |date=2020-03-10 |title=Progressive Supranuclear Palsy—Parkinsonism Predominant (PSP-P)—A Clinical Challenge at the Boundaries of PSP and Parkinson's Disease (PD) |journal=Frontiers in Neurology |volume=11 |page=180 |doi=10.3389/fneur.2020.00180 |doi-access=free |pmid=32218768 |pmc=7078665 |issn=1664-2295}}</ref> Additionally, patients present with axial rigidity, which is characterized by stiffness in the neck and body.<ref name=":5" /> This is often accompanied with [[bradykinesia]] which is slowness of movement. Although PSP-RS is often misdiagnosed as Parkinson's disease, tremors are uncommon in PSP-RS.<ref name=":3" /> Motor symptoms are often symmetrical in PSP-RS with both sides of the body being affected.<ref name=":10">{{Cite journal |last1=Chunowski |first1=Patryk |last2=Madetko-Alster |first2=Natalia |last3=Alster |first3=Piotr |date=2024-09-28 |title=Asymmetry in Atypical Parkinsonian Syndromes-A Review |journal=Journal of Clinical Medicine |volume=13 |issue=19 |pages=5798 |doi=10.3390/jcm13195798 |issn=2077-0383 |pmc=11477316 |pmid=39407856 |doi-access=free}}</ref>

===== Ocular Symptoms in PSP-RS =====
A defining feature of PSP-RS is vertical supranuclear gaze palsy, which is difficulty with voluntary downward gaze.<ref name=":9">{{Cite journal |last1=Krzosek |first1=Patrycja |last2=Madetko |first2=Natalia |last3=Migda |first3=Anna |last4=Migda |first4=Bartosz |last5=Jaguś |first5=Dominika |last6=Alster |first6=Piotr |date=2022-02-09 |title=Differential Diagnosis of Rare Subtypes of Progressive Supranuclear Palsy and PSP-Like Syndromes—Infrequent Manifestations of the Most Common Form of Atypical Parkinsonism |journal=Frontiers in Aging Neuroscience |volume=14 |doi=10.3389/fnagi.2022.804385 |doi-access=free |pmid=35221993 |pmc=8864174 |issn=1663-4365}}</ref> Vertical supranuclear gaze palsy, a symptom characterized by decreased velocity and amplitude of vertical eye movements (saccades) is often the prominent diagnostic feature of PSP-RS. Approximately 40% of patients with PSP-RS experiencing supranuclear gaze palsy, but it may not present until 3–4 years after disease onset.<ref name=":0" /><ref name=":9" /> Individuals with PSP-RS also display other ocular motor symptoms such as dry, red and sore eyes, blurred vision, and difficulty focusing.<ref name=":7" /> They may also experience spontaneuous and involuntary eye-lid closure or apraxia of the eyelid opening.<ref name=":7" />

===== Cognitive and Behavioral Symptoms in PSP-RS =====
Cognitive changes are frequent in PSP-RS compared to other PSP subtypes and include slowed thinking (bradyphrenia), executive dysfunction, and difficulty with planning or problem-solving.<ref name=":5" /><ref name=":8" /> Some patients exhibit apathy, emotional blunting, or involuntary episodes of laughing or crying unrelated to mood.<ref name=":7" /> Some studies report that around half the individuals with PSP-RS develop these personality changes within 2-years of diagnosis.<ref name=":7" /> Dementia is not typically a dominant feature early on but may develop in later stages.