Parkinson's disease scales

Unified Parkinson's Disease Rating Scale (UPDRS)

Main reference: Fahn S, Elton RL, Members of the UPDRS Development Committee: Unified Parkinson's Disease Rating Scale. In: Fahn S, Marsden CD, Calne DB, Lieberman A, eds: Recent developments in Parkinson's disease. Florham Park, NJ: Macmillan Health Care Information 1987;153–163.

Type: Clinician-rated scale with structured interview and examination.

Main indications: Used to grade and monitor the severity of motor aspects of Parkinson’s disease in individual patients.

Rating performed by: Trained health professionals, usually a specialist nurse or neurologist.

Time period covered by scale: The present.

Time required to complete rating: 20 minutes for each state (on and off medication)

Remarks: Widely used rating scale for Parkinson’s disease that consists of four sections. The first section covers mentation, behaviour, and mood (intellectual impairment, thought disorder, depression, and motivation and initiative).

The second section covers the history of activities of daily living (speech, salivation, swallowing, handwriting, ability to cut up food and use utensils, dressing, self-hygiene, turning in bed and adjusting bed clothes, falling (unrelated to freezing), freezing when walking, ambulation, tremor, and sensory complaints related to parkinsonism.

The third section is a more formal motor examination (speech, facial expression, tremor at rest, action or postural tremor, rigidity, finger tapping, hand movements, rapid alternating movements, leg agility, getting up from a chair, posture, gait, postural stability, body bradykinesia or hypokinesia); where relevant these motor features are examined and recorded separately for each limb.

The fourth section details the history of complication of treatment (dyskinesia, on – off fluctuations and predictability) High scores indicate greater severity of disease.

The UPDRS has been shown to give a reliable indication of motor disability, although it does not adequately cover the non-motor symptoms of the disease, for which new scales are under development.

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Hoehn and Yahr Staging of Parkinson’s Disease

Main reference: Hoehn MH, Yahr MD. Parkinsonism. Onset, progression and mortality. Neurology 17:427–442, 1967.

Type: Simple Clinician-rated scale based on general findings of distribution of neurological examination relating to functional ability, balance, and independence.

Main indications: Used to categorise the degree of clinical disability in patients with Parkinson’s disease.

Rating performed by: Trained health professional.

Time period covered by scale: The present.

Time required to complete rating: 10 minutes.

Remarks: Five stages (I–V) are used:

• Stage I indicates unilateral involvement, usually with little or no functional impairment
• Stage II indicates bilateral or midline involvement without disturbance of balance
• Stage III indicates that the first signs of impaired righting reflexes are present – this usually correlates with some restrictions in activity and mild or moderate disability, although independence in activities of daily living is usually retained
• Stage IV indicates fully developed, disabling disease, although the ability to walk and to stand unassisted is retained
• Stage V indicates bed- or chairbound unless assisted

Stage I is not infrequently skipped, since the disease may have a bilateral presentation. (An unvalidated modified form exists in which stages 1.5 and 2.5 are added to indicate mild axial/midline disease is clinically useful).

This simple staging has been found to be reproducible and to correlate with the general functional level of the patient, especially since it is usually the onset of disturbance of balance and the righting reflexes that herald severe disability.

Useful for categorising patients, and samples of patients. However, probably too simplistic to be considered the sole measurement instrument for studies.