Handwriting Changes in Neurodegenerative and Other Diseases

Neurodegenerative Causes

Micrographia, characterized by progressively smaller handwriting, is a hallmark feature of Parkinson's disease, representing cramped, small handwriting similar to what occurs in Parkinson disease, according to the American Association of Neurology 1, 2
Handwriting deterioration occurs as an early neurologic manifestation of Wilson disease, typically presenting in the third decade but can appear in childhood, as stated by the European Association for the Study of the Liver 1, 2
Wilson disease must be excluded in any patient aged 3-55 years with unexplained neurological symptoms, especially when combined with liver abnormalities, as recommended by the American Association for the Study of Liver Diseases 1, 2

Agraphia, or impaired writing, occurs as part of progressive aphasic syndromes, particularly in logopenic variant primary progressive aphasia due to Alzheimer's disease, according to the International Society for Frontotemporal Dementia 3
Agraphia develops with visuospatial dysfunction, alexia, acalculia, and limb apraxia in posterior cortical atrophy syndrome, usually caused by Alzheimer's disease, as stated by the Alzheimer's Association 3, 4
Writing difficulties can occur in behavioral variant frontotemporal dementia as part of executive dysfunction, as reported by the International Society for Frontotemporal Dementia 3

When evaluating handwriting changes, consider the age of onset, with Wilson disease typically presenting ages 3-55 years, Parkinson's disease usually later, and Alzheimer's disease typically after age 65, as recommended by the American Geriatrics Society 1, 2
The pattern of change, such as progressive micrographia suggesting Parkinson's or Wilson disease, and agraphia with language impairment suggesting Alzheimer's-related aphasic syndrome, should be considered, as stated by the American Academy of Neurology 1, 3
Associated features, such as tremor and rigidity pointing to Parkinson's, liver disease with neurologic symptoms mandating Wilson disease evaluation, and visuospatial problems suggesting posterior cortical atrophy, should be evaluated, as recommended by the European Association for the Study of the Liver 1, 2, 3