Stages
of Parkinson's Disease
This
article is excerpted from the APDA's booklet, Coping With Parkinson's Disease
The
following scale, developed by Hoehn and Yahr, is the most widely used one
to describe PD:
- Stage One
- Signs and
symptoms on one side only
- Symptoms
mild
- Symptoms
inconvenient but not disabling
- Usually presents
with tremor of one limb
- Friends have
noticed changes in posture, locomotion and facial expression
- Stage Two
- Symptoms
are bilateral
- Minimal disability
- Posture and
gait affected
- Stage Three
- Significant
slowing of body movements
- Early impairment
of equilibrium on walking or standing
- Generalized
dysfunction that is moderately severe
- Stage Four
- Severe symptoms
- Can still
walk to a limited extent
- Rigidity
and bradykinesia
- No longer
able to live alone
- Tremor may
be less than earlier stages
- Stage Five
- Cachectic
stage
- Invalidism
complete
- Cannot stand
or walk
- Requires
constant nursing care
This rating
system has been largely supplanted by the Unified Parkinson's Disease Rating
Scale, which is much more complicated.
Unified Parkinson
Disease Rating Scale (UPDRS)
The UPDRS
is a rating tool to follow the longitudinal course of Parkinson's Disease.
It is made up of the 1) Mentation, Behavior, and Mood, 2) ADL and 3) Motor
sections. These are evaluated by interview. Some sections require multiple
grades assigned to each extremity. A total of 199 points are possible.
199 represents the worst (total) disability), 0--no disability.
- Mentation,
Behavior, Mood
- Intellectual
Impairment
- 0-none
- 1-mild (consistent
forgetfulness with partial recollection of events with no other difficulties)
- 2-moderate
memory loss with disorientation and moderate difficulty handling complex
problems
- 3-severe
memory loss with disorientation to time and often place, severe impairment
with problems
- 4-severe
memory loss with orientation only to person, unable to make judgments or
solve problems
- Thought Disorder
- 0-none
- 1-vivid dreaming
- 2-"benign"
hallucination with insight retained
- 3-occasional
to frequent hallucination or delusions without insight, could interfere
with daily activities
- 4-persistent
hallucination, delusions, or florid psychosis.
- Depression
- 0-not present
- 1-periods
of sadness or guilt greater than normal, never sustained for more than
a few days or a week
- 2-sustained
depression for >1 week
- 3-vegetative
symptoms (insomnia, anorexia, abulia, weight loss)
- 4-vegetative
symptoms with suicidality
- Motivation/Initiative
- 0-normal
- 1-less of
assertive, more passive
- 2-loss of
initiative or disinterest in elective activities
- 3-loss of
initiative or disinterest in day to say (routine) activities
- 4-withdrawn,
complete loss of motivation
- Activities
of Daily Living
- Speech
- 0-normal
- 1-mildly
affected, no difficulty being understood
- 2-moderately
affected, may be asked to repeat
- 3-severely
affected, frequently asked to repeat
- 4-unintelligible
most of time
- Salivation
- 0-normal
- 1-slight
but noticeable increase, may have nighttime drooling
- 2-moderately
excessive saliva, hay minimal drooling
- 3-marked
drooling
- Swallowing
- 0-normal
- 1-rare choking
- 2-occasional
choking
- 3-requires
soft food
- 4-requires
NG tube or G-tube
- Handwriting
- 0-normal
- 1-slightly
small or slow
- 2-all words
small but legible
- 3-severely
affected, not all words legible
- 4-majority
illegible
- Cutting Food/Handing
Utensils
- 0-normal
- 1-somewhat
slow and clumsy but no help needed
- 2-can cut
most foods, some help needed
- 3-food must
be cut, but can feed self
- 4-needs to
be fed
- Dressing
- 0-normal
- 1-somewhat
slow, no help needed
- 2-occasional
help with buttons or arms in sleeves
- 3-considerable
help required but can do something alone
- 4-helpless
- Hygiene
- 0-normal
- 1-somewhat
slow but no help needed
- 2-needs help
with shower or bath or very slow in hygienic care
- 3-requires
assistance for washing, brushing teeth, going to bathroom
- 4-helpless
- Turning in
Bed/ Adjusting Bed Clothes
- 0-normal
- 1-somewhat
slow no help needed
- 2-can turn
alone or adjust sheets but with great difficulty
- 3-san initiate
but not turn or adjust alone
- 4-helpless
- Falling-Unrelated
to Freezing
- 0-none
- 1-rare falls
- 2-occasional,
less than one per day
- 3-average
of once per day
- 4->1 per
day
- Freezing
When Walking
- 0-normal
- 1-rare, may
have start hesitation
- 2-occasional
falls from freezing,
- 3-frequent
freezing, occasional falls
- 4-frequent
falls from freezin
- Walking
- 0-normal
- 1-mild difficulty,
day drag legs or decrease arm swing
- 2-moderate
difficultly requires no assist
- 3-severe
disturbance requires assistance
- 4-cannot
walk at all even with assist
- Tremor
- 0-absent
- 1-slight
and infrequent, not bothersome to patient
- 2-moderate,
bothersome to patient
- 3-severe,
interfere with many activities
- 4-marked,
interferes with many activities
- Sensory Complaints
Related to Parkinsonism
- 0-none
- 1-occasionally
has numbness, tingling, and mild aching
- 2-frequent,
but not distressing
- 3-frequent
painful sensation
- 4-excruciating
pain
- Motor Exam
- Speech
- 0-normal
- 1-slight
loss of expression, diction,volume
- 2-monotone,
slurred but understandable, mod. impaired
- 3-marked
impairment, difficult to understand
- 4-unintelligible
- Facial Expression
- 0-Normal
- 1-slight
hypomymia, could be poker face
- 2-slight
but definite abnormal diminution in expression
- 3-mod. hypomimia,
lips parted some of time
- 4-masked
or fixed face, lips parted 1/4 of inch or more with complete loss of expression
- Tremor at
Rest
- Face
- 0-absent
- 1-slight
and infrequent
- 2-mild and
present most of time
- 3-moderate
and present most of time
- 4-marked
and present most of time
- Right Upper
Extremity (RUE)
- 0-absent
- 1-slight
and infrequent
- 2-mild and
present most of time
- 3-moderate
and present most of time
- 4-marked
and present most of time
- LUE
- 0-absent
- 1-slight
and infrequent
- 2-mild and
present most of time
- 3-moderate
and present most of time
- 4-marked
and present most of time
- RLE
- 0-absent
- 1-slight
and infrequent
- 2-mild and
present most of time
- 3-moderate
and present most of time
- 4-marked
and present most of time
- LLE
- 0-absent
- 1-slight
and infrequent
- 2-mild and
present most of time
- 3-moderate
and present most of time
- 4-marked
and present most of time
- Action or
Postural Tremor
- RUE
- 0-absent
- 1-slight,
present with action
- 2-moderate,
present with action
- 3-moderate
present with action and posture holding
- 4-marked,
interferes with feeding
- LUE
- 0-absent
- 1-slight,
present with action
- 2-moderate,
present with action
- 3-moderate
present with action and posture holding
- 4-marked,
interferes with feeding
- Rigidity
- Neck
- 0-absent
- 1-slight
or only with activation
- 2-mild/moderate
- 3-marked,
full range of motion
- 4-severe
- RUE
- 0-absent
- 1-slight
or only with activation
- 2-mild/moderate
- 3-marked,
full range of motion
- 4-severe
- LUE
- 0-absent
- 1-slight
or only with activation
- 2-mild/moderate
- 3-marked,
full range of motion
- 4-severe
- RLE
- 0-absent
- 1-slight
or only with activation
- 2-mild/moderate
- 3-marked,
full range of motion
- 4-severe
- LLE
- 0-absent
- 1-slight
or only with activation
- 2-mild/moderate
- 3-marked,
full range of motion
- 4-severe
- Finger taps
- Right
- 0-normal
- 1-mild slowing,
and/or reduction in amp.
- 2-moderate
impaired. Definite and early fatiguing, may have occasional arrests
- 3-severely
impaired. Frequent hesitations and arrests.
- 4-can barely
perform
- Left
- 0-normal
- 1-mild slowing,
and/or reduction in amp.
- 2-moderate
impaired. Definite and early fatiguing, may have occasional arrests
- 3-severely
impaired. Frequent hesitations and arrests.
- 4-can barely
perform
- Hand Movements
(open and close hands in rapid succession)
- Right
- 0-normal
- 1-mild slowing,
and/or reduction in amp.
- 2-moderate
impaired. Definite and early fatiguing, may have occasional arrests
- 3-severely
impaired. Frequent hesitations and arrests.
- 4-can barely
perform
- Left
- 0-normal
- 1-mild slowing,
and/or reduction in amp.
- 2-moderate
impaired. Definite and early fatiguing, may have occasional arrests
- 3-severely
impaired. Frequent hesitations and arrests.
- 4-can barely
perform
- Rapid Alternating
Movements (pronate and supinate hands)
- Right
- 0-normal
- 1-mild slowing,
and/or reduction in amp.
- 2-moderate
impaired. Definite and early fatiguing, may have occasional arrests
- 3-severely
impaired. Frequent hesitations and arrests.
- 4-can barely
perform
- Left
- 0-normal
- 1-mild slowing,
and/or reduction in amp.
- 2-moderate
impaired. Definite and early fatiguing, may have occasional arrests
- 3-severely
impaired. Frequent hesitations and arrests.
- 4-can barely
perform
- Leg Agility
(tap heel on ground, amp should be 3 inches)
- Right
- 0-normal
- 1-mild slowing,
and/or reduction in amp.
- 2-moderate
impaired. Definite and early fatiguing, may have occasional arrests
- 3-severely
impaired. Frequent hesitations and arrests.
- 4-can barely
perform
- Left
- 0-normal
- 1-mild slowing,
and/or reduction in amp.
- 2-moderate
impaired. Definite and early fatiguing, may have occasional arrests
- 3-severely
impaired. Frequent hesitations and arrests.
- 4-can barely
perform
- Arising From
Chair (pt. arises with arms folded across chest)
- 0-normal
- 1-slow, may
need more than one attempt
- 2-pushes
self up from arms or seat
- 3-tends to
fall back, may need multiple tries but can arise without assistance
- 4-unable
to arise without help
- Posture
- 0-normal
erect
- 1-slightly
stooped, could be normal for older person
- 2-definitely
abnormal, mod. stooped, may lean to one side
- 3-severely
stooped with kyphosis
- 4-marked
flexion with extreme abnormality of posture
- Gait
- 0-normal
- 1-walks slowly,
may shuffle with short steps, no festination or propulsion
- 2-walks with
difficulty, little or no assistance, some festination, short steps or propulsion
- 3-severe
disturbance, frequent assistance
- 4-cannot
walk
- Postural
Stability (retropulsion test)
- 0-normal
- 1-recovers
unaided
- 2-would fall
if not caught
- 3-falls spontaneously
- 4-unable
to stand
- Body Bradykinesia/
Hypokinesia
- 0-none
- 1-minimal
slowness, could be normal, deliberate character
- 2-mild slowness
and poverty of movement, definitely abnormal, or dec. amp. of movement
- 3-moderate
slowness, poverty, or small amplitude
- 4-marked
slowness, poverty, or amplitude
Schwab and
England Activities of Daily Living
Gillingham
FJ, Donaldson MC, eds., Third Symp. of Parkinson's Disease, Edinburgh,
Scotland, E&S Livingstone, 1969, pp.152-7.
Rating can
be assigned by rater or by patient.
- 100%-Completely
independent. Able to do all chores w/o slowness, difficulty, or impairment.
- 90%-Completely
independent. Able to do all chores with some slowness, difficulty, or impairment.
May take twice as long.
- 80%-Independent
in most chores. Takes twice as long. Conscious of difficulty and slowing
- 70%-Not completely
independent. More difficulty with chores. 3 to 4 X along on chores for
some. May take large part of day for chores.
- 60%-Some
dependency. Can do most chores, but very slowly and with much effort. Errors,
some impossible
- 50%-More
dependant. Help with 1/2 of chores. Difficulty with everything
- 40%-Very
dependant. Can assist with all chores but few alone
- 30%-With
effort, now and then does a few chores alone of begins alone. Much help
needed
- 20%-Nothing
alone. Can do some slight help with some chores. Severe invalid
- 10%-Totally
dependant, helpless
0%-Vegetative
functions such as swallowing, bladder and bowel function are not functioning.
Bedridden.
Next
Back
to Parkinson's Directory