Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-8448b6f56d-tj2md Total loading time: 0 Render date: 2024-04-24T14:31:08.068Z Has data issue: false hasContentIssue false

Chapter 1 - Parkinson’s Disease: An Overview of the Non-Motor Symptomatology

Published online by Cambridge University Press:  05 March 2022

By
Daniel van Wamelen ,
Valentina Leta  and
K. Ray Chaudhuri
Edited by
Néstor Gálvez-Jiménez ,
Amos D. Korczyn  and
Ramón Lugo-Sanchez
Néstor Gálvez-Jiménez
Affiliation:
Florida International University
Amos D. Korczyn
Affiliation:
Tel-Aviv University
Ramón Lugo-Sanchez
Affiliation:
Cleveland Clinic
Get access

Summary

Non-motor symptoms (NMS) are a crucial component of Parkinson’s disease (PD) and the burden of the range of NMS that occurs in PD is one of the main determinants of quality of life [1]. In 1817, Dr. James Parkinson already described several NMS in his “shaking palsy,” the condition that would later be named after him, including pain, constipation, and sleep disturbances [2]. Nonetheless, after a long period of inertia, over the last 20 to 25 years, the interest in NMS has increased and evidence suggests that the overall burden of NMS dominates and can influence the risk of developing motor parkinsonism in the premotor stage of PD while being a driving factor for quality of life [3]. The identification of NMS in PD has been greatly aided by the development of specific tools, such as the NMS questionnaire (NMSQ) in 2006 [4] and the NMS Scale (NMSS) in 2007 [5].

Type
Chapter
Information
Non-motor Parkinson's Disease , pp. 3 - 17
Publisher: Cambridge University Press
Print publication year: 2022

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Politis, M, Wu, K, Molloy, S, et al. Parkinson’s disease symptoms: the patient’s perspective. Mov Disord 2010; 25: 1646–1651.CrossRefGoogle ScholarPubMed
Parkinson, J. An essay on the shaking palsy. 1817. J Neuropsychiatry Clin Neurosci 2002; 14: 223–236; discussion 222.Google Scholar
Titova, N, Padmakumar, C, Lewis, SJG, Chaudhuri, KR. Parkinson’s: a syndrome rather than a disease? J Neural Transm 2017; 124: 907–914.CrossRefGoogle Scholar
Chaudhuri, KR, Martinez‐Martin, P, Schapira, AH, et al. International multicenter pilot study of the first comprehensive self‐completed nonmotor symptoms questionnaire for Parkinson’s disease: the NMSQuest study. Mov Disord 2006; 21: 916–923.CrossRefGoogle ScholarPubMed
Chaudhuri, KR, Martinez-Martin, P, Brown, RG, et al. The metric properties of a novel non-motor symptoms scale for Parkinson’s disease: results from an international pilot study. Mov Disord 2007; 22: 1901–1911.Google Scholar
Martinez-Martin, P, Schrag, A, Weintraub, D, et al. Pilot Study of the International Parkinson and Movement Disorder Society-sponsored Non-motor Rating Scale (MDS-NMS). Mov Disord Clin Pract 2019; 6: 227–234.Google Scholar
Zis, P, Martinez-Martin, P, Sauerbier, A, et al. Non-motor symptoms burden in treated and untreated early Parkinson’s disease patients: argument for non-motor subtypes. Eur J Neurol 2015; 22: 1145–1150.Google Scholar
Carod-Artal, FJ, Mesquita, HM, Ziomkowski, S, Martinez-Martin, P. Burden and health-related quality of life among caregivers of Brazilian Parkinson’s disease patients. Parkinsonism Relat Disord 2013; 19: 943–948.CrossRefGoogle ScholarPubMed
Goetz, CG, Tilley, BC, Shaftman, SR, et al. Movement Disorder Society-sponsored revision of the Unified Parkinson’s Disease Rating Scale (MDS-UPDRS): scale presentation and clinimetric testing results. Mov Disord 2008; 23: 2129–2170.Google Scholar
Wu, JQ, Li, P, Stavitsky Gilbert, K, et al. Circadian rest-activity rhythms predict cognitive function in early Parkinson’s disease independently of sleep. Mov Disord Clin Pract 2018; 5: 614–619.Google Scholar
Klingelhoefer, L, Rizos, A, Sauerbier, A, et al. Night-time sleep in Parkinson’s disease – the potential use of Parkinson’s KinetiGraph: a prospective comparative study. Eur J Neurol 2016; 23: 1275–1288.CrossRefGoogle ScholarPubMed
van Wamelen, DJ, Hota, S, Podlewska, A, et al. Non-motor correlates of wrist-worn wearable sensor use in Parkinson’s disease: an exploratory analysis. NPJ Parkinsons Dis 2019; 5: 22.Google Scholar
Titova, N, Chaudhuri, KR. Non-motor Parkinson disease: new concepts and personalised management. Med J Aust 2018; 208: 404–409.CrossRefGoogle ScholarPubMed
Schrag, A, Zhelev, SS, Hotham, S, et al. Heterogeneity in progression of prodromal features in Parkinson’s disease. Parkinsonism Relat Disord 2019; 64: 275–279.CrossRefGoogle ScholarPubMed
Fereshtehnejad, SM, Zeighami, Y, Dagher, A, Postuma, RB. Clinical criteria for subtyping Parkinson’s disease: biomarkers and longitudinal progression. Brain 2017; 140: 1959–1976.Google Scholar
Guo, X, Song, W, Chen, K, et al. Disease duration-related differences in non-motor symptoms: a study of 616 Chinese Parkinson’s disease patients. J Neurol Sci 2013; 330: 32–37.Google Scholar
Ou, R, Yang, J, Cao, B, et al. Progression of non-motor symptoms in Parkinson’s disease among different age populations: a two-year follow-up study. J Neurol Sci 2016; 360: 72–77.CrossRefGoogle ScholarPubMed
Simuni, T, Caspell-Garcia, C, Coffey, CS, et al. Baseline prevalence and longitudinal evolution of non-motor symptoms in early Parkinson’s disease: the PPMI cohort. J Neurol Neurosurg Psychiatry 2018; 89: 78–88.Google Scholar
Aleksovski, D, Miljkovic, D, Bravi, D, Antonini, A. Disease progression in Parkinson subtypes: the PPMI dataset. Neurol Sci 2018; 39: 1971–1976.CrossRefGoogle ScholarPubMed
Holden, SK, Finseth, T, Sillau, SH, Berman, BD. Progression of MDS-UPDRS scores over five years in de novo Parkinson disease from the Parkinson’s progression markers initiative cohort. Mov Disord Clin Pract 2018; 5: 47–53.Google Scholar
Erro, R, Picillo, M, Vitale, C, et al. The non-motor side of the honeymoon period of Parkinson’s disease and its relationship with quality of life: a 4-year longitudinal study. Eur J Neurol 2016; 23: 1673–1679.Google Scholar
Antonini, A, Barone, P, Marconi, R, et al. The progression of non-motor symptoms in Parkinson’s disease and their contribution to motor disability and quality of life. J Neurol 2012; 259: 2621–2631.CrossRefGoogle ScholarPubMed
Picillo, M, Erro, R, Amboni, M, et al. Gender differences in non-motor symptoms in early Parkinson’s disease: a 2-year follow-up study on previously untreated patients. Parkinsonism Relat Disord 2014; 20: 850–854.Google Scholar
Picillo, M, Amboni, M, Erro, R, et al. Gender differences in non-motor symptoms in early, drug naive Parkinson’s disease. J Neurol 2013; 260: 2849–2855.Google Scholar
Picillo, M, Palladino, R, Moccia, M, et al. Gender and non-motor fluctuations in Parkinson’s disease: a prospective study. Parkinsonism Relat Disord 2016; 27: 89–92.CrossRefGoogle ScholarPubMed
Miyasaki, JM, Long, J, Mancini, D, et al. Palliative care for advanced Parkinson disease: an interdisciplinary clinic and new scale, the ESAS-PD. Parkinsonism Relat Disord 2012; 18 Suppl 3: S6–9.Google Scholar
Higginson, IJ, Gao, W, Saleem, TZ, et al. Symptoms and quality of life in late-stage Parkinson syndromes: a longitudinal community study of predictive factors. PLoS One 2012; 7: e46327.CrossRefGoogle ScholarPubMed
Saleem, TZ, Higginson, IJ, Chaudhuri, KR, et al. Symptom prevalence, severity and palliative care needs assessment using the Palliative Outcome Scale: a cross-sectional study of patients with Parkinson’s disease and related neurological conditions. Palliat Med 2013; 27: 722–731.Google Scholar
Chesselet, MF, Richter, F, Zhu, C, et al. A progressive mouse model of Parkinson’s disease: the Thy1-aSyn (“Line 61”) mice. Neurotherapeutics 2012; 9: 297–314.Google Scholar
Bichler, Z, Lim, HC, Zeng, L, Tan, EK. Non-motor and motor features in LRRK2 transgenic mice. PLoS One 2013; 8: e70249.Google Scholar
Sardi, SP, Clarke, J, Kinnecom, C, et al. CNS expression of glucocerebrosidase corrects alpha-synuclein pathology and memory in a mouse model of Gaucher-related synucleinopathy. Proc Natl Acad Sci USA 2011; 108: 12101–12106.Google Scholar
Zhu, XR, Maskri, L, Herold, C, et al. Non-motor behavioural impairments in parkin-deficient mice. Eur J Neurosci 2007; 26: 1902–1911.CrossRefGoogle ScholarPubMed
Taylor, TN, Caudle, WM, Shepherd, KR, et al. Nonmotor symptoms of Parkinson’s disease revealed in an animal model with reduced monoamine storage capacity. J Neurosci 2009; 29: 8103–8113.CrossRefGoogle Scholar
Duty, S, Jenner, P. Animal models of Parkinson’s disease: a source of novel treatments and clues to the cause of the disease. Br J Pharmacol 2011; 164: 1357–1391.Google Scholar
Jellinger, KA. Neuropathobiology of non-motor symptoms in Parkinson disease. J Neural Transm 2015; 122: 1429–1440.Google Scholar
Quinn, NP. Classification of fluctuations in patients with Parkinson’s disease. Neurology 1998; 51: S25–29.CrossRefGoogle ScholarPubMed
Rodriguez-Violante, M, Ospina-Garcia, N, Davila-Avila, NM, et al. Motor and non-motor wearing-off and its impact in the quality of life of patients with Parkinson’s disease. Arq Neuropsiquiatr 2018; 76: 517–521.Google Scholar
Rahmani, M, Benabdeljlil, M, Bellakhdar, F, et al. Deep brain stimulation in Moroccan patients with Parkinson’s disease: the experience of the Neurology Department of Rabat. Front Neurol 2018; 9: 532.CrossRefGoogle ScholarPubMed
Witjas, T, Kaphan, E, Azulay, JP, et al. Nonmotor fluctuations in Parkinson’s disease: frequent and disabling. Neurology 2002; 59: 408–413.CrossRefGoogle ScholarPubMed
Storch, A, Schneider, CB, Wolz, M, et al. Nonmotor fluctuations in Parkinson disease: severity and correlation with motor complications. Neurology 2013; 80: 800–809.Google Scholar
Lohle, M, Hermann, W, Hausbrand, D, et al. Putaminal dopamine turnover in de novo Parkinson’s disease predicts later neuropsychiatric fluctuations but not other major health outcomes. J Parkinsons Dis 2019; 9(4): 1–12.Google Scholar
Hillen, ME, Sage, JI. Nonmotor fluctuations in patients with Parkinson’s disease. Neurology 1996; 47: 1180–1183.CrossRefGoogle ScholarPubMed
Gunal, DI, Nurichalichi, K, Tuncer, N, et al. The clinical profile of nonmotor fluctuations in Parkinson’s disease patients. Can J Neurol Sci 2002; 29: 61–64.Google Scholar
Brun, L, Lefaucheur, R, Fetter, D, et al. Non-motor fluctuations in Parkinson’s disease: prevalence, characteristics and management in a large cohort of parkinsonian outpatients. Clin Neurol Neurosurg 2014; 127: 93–96.Google Scholar
Seki, M, Takahashi, K, Uematsu, D, et al. Clinical features and varieties of non-motor fluctuations in Parkinson’s disease: a Japanese multicenter study. Parkinsonism Relat Disord 2013; 19: 104–108.Google Scholar
Storch, A, Rosqvist, K, Ebersbach, G, Odin, P. Disease stage dependency of motor and non-motor fluctuations in Parkinson’s disease. J Neural Transm 2019; 126: 841–851.CrossRefGoogle ScholarPubMed
Rieu, I, Houeto, JL, Pereira, B, et al. Impact of mood and behavioral disorders on quality of life in Parkinson’s disease. J Parkinsons Dis 2016; 6: 267–277.Google Scholar
Muller, B, Assmus, J, Herlofson, K, et al. Importance of motor vs. non-motor symptoms for health-related quality of life in early Parkinson’s disease. Parkinsonism Relat Disord 2013; 19: 1027–1032.CrossRefGoogle ScholarPubMed
Martinez-Fernandez, R, Schmitt, E, Martinez-Martin, P, Krack, P. The hidden sister of motor fluctuations in Parkinson’s disease: a review on nonmotor fluctuations. Mov Disord 2016; 31: 1080–1094.Google Scholar
Nissenbaum, H, Quinn, NP, Brown, RG, et al. Mood swings associated with the ‘on-off’ phenomenon in Parkinson’s disease. Psychol Med 1987; 17: 899–904.Google Scholar
Racette, BA, Hartlein, JM, Hershey, T, et al. Clinical features and comorbidity of mood fluctuations in Parkinson’s disease. J Neuropsychiatry Clin Neurosci 2002; 14: 438–442.Google Scholar
Richard, IH, Justus, AW, Kurlan, R. Relationship between mood and motor fluctuations in Parkinson’s disease. J Neuropsychiatry Clin Neurosci 2001; 13: 35–41.CrossRefGoogle ScholarPubMed
Friedenberg, DL, Cummings, JL. Parkinson’s disease, depression, and the on-off phenomenon. Psychosomatics 1989; 30: 94–99.Google Scholar
Sierra, M, Carnicella, S, Strafella, AP, et al. Apathy and impulse control disorders: yin & yang of dopamine dependent behaviors. J Parkinsons Dis 2015; 5: 625–636.CrossRefGoogle ScholarPubMed
Pagonabarraga, J, Martinez-Horta, S, Fernandez de Bobadilla, R, et al. Minor hallucinations occur in drug-naive Parkinson’s disease patients, even from the premotor phase. Mov Disord 2016; 31: 45–52.CrossRefGoogle ScholarPubMed
Stacy, M, Bowron, A, Guttman, M, et al. Identification of motor and nonmotor wearing-off in Parkinson’s disease: comparison of a patient questionnaire versus a clinician assessment. Mov Disord 2005; 20: 726–733.Google Scholar
Goetz, CG, Lutge, W, Tanner, CM. Autonomic dysfunction in Parkinson’s disease. Neurology 1986; 36: 73–75.Google Scholar
Pursiainen, V, Korpelainen, JT, Haapaniemi, TH, et al. Blood pressure and heart rate in parkinsonian patients with and without wearing-off. Eur J Neurol 2007; 14: 373–378.Google Scholar
Leta, V, van Wamelen, DJ, Rukavina, K, et al. Sweating and other thermoregulatory abnormalities in Parkinson’s disease: a review. Mov Disord 2019; 2: 39.Google Scholar
Juri, C, Rodriguez-Oroz, M, Obeso, JA. The pathophysiological basis of sensory disturbances in Parkinson’s disease. J Neurol Sci 2010; 289: 60–65.Google Scholar
Tinazzi, M, Recchia, S, Simonetto, S, et al. Muscular pain in Parkinson’s disease and nociceptive processing assessed with CO2 laser-evoked potentials. Mov Disord 2010; 25: 213–220.Google Scholar
Rukavina, K, Leta, V, Sportelli, C, et al. Pain in Parkinson’s disease: new concepts in pathogenesis and treatment. Curr Opin Neurol 2019; 32: 579–588.Google Scholar
Ford, B. Pain in Parkinson’s disease. Mov Disord 2010; 25 Suppl1: S98–103.Google Scholar
Park, A, Stacy, M. Dopamine-induced nonmotor symptoms of Parkinson’s disease. Parkinsons Dis 2011; 2011: 485063.Google Scholar
Weintraub, D, Claassen, DO. Impulse control and related disorders in Parkinson’s disease. Int Rev Neurobiol 2017; 133: 679–717.Google Scholar
Gatto, EM, Aldinio, V. Impulse control disorders in Parkinson’s disease. A brief and comprehensive review. Front Neurol 2019; 10: 351.Google Scholar
Smith, KM, Xie, SX, Weintraub, D. Incident impulse control disorder symptoms and dopamine transporter imaging in Parkinson disease. J Neurol Neurosurg Psychiatry 2016; 87: 864–870.CrossRefGoogle ScholarPubMed
Eisinger, RS, Ramirez-Zamora, A, Carbunaru, S, et al. Medications, deep brain stimulation, and other factors influencing impulse control disorders in Parkinson’s disease. Front Neurol 2019; 10: 86.Google Scholar
Palma, JA, Kaufmann, H. Treatment of autonomic dysfunction in Parkinson disease and other synucleinopathies. Mov Disord 2018; 33: 372–390.Google Scholar
Frucht, S, Rogers, JD, Greene, PE, et al. Falling asleep at the wheel: motor vehicle mishaps in persons taking pramipexole and ropinirole. Neurology 1999; 52: 1908–1910.Google Scholar
Pagano, G, Molloy, S, Bain, PG, et al. Sleep problems and hypothalamic dopamine D3 receptor availability in Parkinson disease. Neurology 2016; 87: 2451–2456.Google Scholar
Schapira, AHV, Chaudhuri, KR, Jenner, P. Non-motor features of Parkinson disease. Nat Rev Neurosci 2017; 18: 509.Google Scholar
Parnetti, L, Gaetani, L, Eusebi, P, et al. CSF and blood biomarkers for Parkinson’s disease. Lancet Neurol 2019; 18(6): 573–586.Google Scholar
Brooks, DJ, Pavese, N. Imaging biomarkers in Parkinson’s disease. Prog Neurobiol 2011; 95: 614–628.CrossRefGoogle ScholarPubMed
Ryman, SG, Poston, KL. MRI biomarkers of motor and non-motor symptoms in Parkinson’s disease. Parkinsonism Relat Disord 2019; 73: 85–93.Google ScholarPubMed
Rinne, JO, Portin, R, Ruottinen, H, et al. Cognitive impairment and the brain dopaminergic system in Parkinson disease: [18 F]fluorodopa positron emission tomographic study. Arch Neurol 2000; 57: 470–475.Google Scholar
Weintraub, D. Dopamine and impulse control disorders in Parkinson’s disease. Ann Neurol 2008; 64: S93–S100.Google Scholar
Sakakibara, R, Shinotoh, H, Uchiyama, T, et al. SPECT imaging of the dopamine transporter with [(123)I]-beta-CIT reveals marked decline of nigrostriatal dopaminergic function in Parkinson’s disease with urinary dysfunction. J Neurol Sci 2001; 187: 55–59.Google Scholar
Eisensehr, I, Linke, R, Tatsch, K, et al. Increased muscle activity during rapid eye movement sleep correlates with decrease of striatal presynaptic dopamine transporters. IPT and IBZM SPECT imaging in subclinical and clinically manifest idiopathic REM sleep behavior disorder, Parkinson’s disease, and controls. Sleep 2003; 26: 507–512.Google Scholar
Bohnen, NI, Gedela, S, Kuwabara, H, et al. Selective hyposmia and nigrostriatal dopaminergic denervation in Parkinson’s disease. J Neurol 2007; 254: 84–90.Google Scholar
Moccia, M, Erro, R, Picillo, M, et al. A four-year longitudinal study on restless legs syndrome in Parkinson disease. Sleep 2016; 39: 405–412.Google Scholar
Lee, JJ, Oh, JS, Ham, JH, et al. Association of body mass index and the depletion of nigrostriatal dopamine in Parkinson’s disease. Neurobiol Aging 2016; 38: 197–204.Google Scholar
Filippi, M, Sarasso, E, Agosta, F. Resting-state functional MRI in Parkinsonian syndromes. Mov Disord Clin Pract 2019; 6: 104–117.Google Scholar
Wolters, AF, van de Weijer, SCF, Leentjens, AFG, et al. Resting-state fMRI in Parkinson’s disease patients with cognitive impairment: a meta-analysis. Parkinsonism Relat Disord 2019; 62: 16–27.CrossRefGoogle ScholarPubMed
Gallea, C, Ewenczyk, C, Degos, B, et al. Pedunculopontine network dysfunction in Parkinson’s disease with postural control and sleep disorders. Mov Disord 2017; 32: 693–704.Google Scholar
Su, M, Wang, S, Fang, W, et al. Alterations in the limbic/paralimbic cortices of Parkinson’s disease patients with hyposmia under resting-state functional MRI by regional homogeneity and functional connectivity analysis. Parkinsonism Relat Disord 2015; 21: 698–703.Google Scholar
Yoneyama, N, Watanabe, H, Kawabata, K, et al. Severe hyposmia and aberrant functional connectivity in cognitively normal Parkinson’s disease. PloS One 2018; 13: e0190072.Google Scholar
Sarkar, A, Rawat, N, Sachan, N, Singh, MP. Unequivocal biomarker for Parkinson’s disease: a hunt that remains a pester. Neurotox Res 2019; 36: 627–644.Google Scholar
Dong, MX, Feng, X, Xu, XM, et al. Integrated analysis reveals altered lipid and glucose metabolism and identifies NOTCH2 as a biomarker for Parkinson’s disease related depression. Front Mol Neurosci 2018; 11: 257.Google Scholar
Oeckl, P, Metzger, F, Nagl, M, et al. Alpha-, beta-, and gamma-synuclein quantification in cerebrospinal fluid by multiple reaction monitoring reveals increased concentrations in Alzheimer’s and Creutzfeldt-Jakob disease but no alteration in synucleinopathies. Mol Cell Proteomics 2016; 15: 3126–3138.Google Scholar
Donadio, V, Incensi, A, Leta, V, et al. Skin nerve α-synuclein deposits: a biomarker for idiopathic Parkinson disease. Neurology 2014; 82: 1362–1369.Google Scholar
Borghammer, P. Is constipation in Parkinson’s disease caused by gut or brain pathology? Parkinsonism Relat Disord 2018; 55: 6–7.Google Scholar
Beach, TG, Adler, CH, Dugger, BN, et al. Submandibular gland biopsy for the diagnosis of Parkinson disease. J Neuropathol Exp Neurol 2013; 72: 130–136.Google Scholar
Seppi, K, Ray Chaudhuri, K, Coelho, M, et al. Update on treatments for nonmotor symptoms of Parkinson’s disease: an evidence-based medicine review. Mov Disord 2019; 34: 180–198.Google Scholar
Goldman, JG, Guerra, CM. Treatment of nonmotor symptoms associated with Parkinson disease. Neurol Clin 2020; 38(2): 269–292.Google Scholar
Stacy, MA, Murck, H, Kroenke, K. Responsiveness of motor and nonmotor symptoms of Parkinson disease to dopaminergic therapy. Prog Neuropsychopharmacol Biol Psychiatry 2010; 34: 57–61.Google Scholar
Kassubek, J, Chaudhuri, KR, Zesiewicz, T, et al. Rotigotine transdermal system and evaluation of pain in patients with Parkinson’s disease: a post hoc analysis of the RECOVER study. BMC Neurol 2014; 14: 42.Google Scholar
Martinez-Martin, P, Reddy, P, Katzenschlager, R, et al. EuroInf: a multicenter comparative observational study of apomorphine and levodopa infusion in Parkinson’s disease. Mov Disord 2015; 30: 510–516.Google Scholar
Dafsari, HS, Martinez-Martin, P, Rizos, A, et al. EuroInf 2: Subthalamic stimulation, apomorphine, and levodopa infusion in Parkinson’s disease. Mov Disord 2019; 34: 353–365.Google Scholar
Antonini, A, Stoessl, AJ, Kleinman, LS, et al. Developing consensus among movement disorder specialists on clinical indicators for identification and management of advanced Parkinson’s disease: a multi-country Delphi-panel approach. Curr Med Res Opin 2018; 34: 2063–2073.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×