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Table of Contents
REVIEW ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 3-22

Parkinson’s disease rating scales: a literature review


Department of Neurology, Federal University of Santa Maria, Santa Maria, Brazil; Department of Medicine, Federal University of Santa Maria, Santa Maria, Brazil

Date of Submission25-Nov-2019
Date of Decision10-Jan-2020
Date of Acceptance13-Jan-2020
Date of Web Publication01-Apr-2020

Correspondence Address:
Dr. Jamir Pitton Rissardo
Rua Roraima, Santa Maria, Rio Grande do Sul.
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AOMD.AOMD_33_19

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  Abstract 

A scale is critical for an objective and standardized process in which the purpose involves measuring differences between various individuals and determining priorities such as primary treatment goals. The aim of this study was to describe and analyze the most common Parkinson’s disease (PD) scales already used for research and clinical practice. We searched three databases in an attempt to locate existing scales about PD published until 2017 in electronic form, only the articles in English, Spanish, and Portuguese were reviewed. In sum, 114 scales were evaluated and divided into 6 types representing a general evaluation, such as staging, health-related quality of life, evaluation of the impact on activities of daily living, loss of functionality aimed at evaluation of the signs and symptoms of the disease, evaluation of functioning and disability loss, and other specific evaluations. Other specific evaluations include the following: fear of falling, depression, psychosis, sleep, apathy and anhedonia, anxiety, dysautonomia, dyskinesia, fatigue, motor fluctuations, psychosocial problems, secondary levodopa effects, Scales for Outcomes in Parkinson’s disease (SCOPA) studies, and cognitive impairment screening. When required, more specific characteristics of each scale were included: time to apply, the number of items, advantage, and disadvantage. In the literature, there are a large number of scales, but the majority of them were created for other diseases and only later studied for PD. Also, more than half have only a small number of studies with psychometric evaluation and others can be used for only a specific portion of the general population due to their specific feature assessment or language availability.

Keywords: Parkinson’s disease, rating, review, scale


How to cite this article:
Pitton Rissardo J, Fornari Caprara AL. Parkinson’s disease rating scales: a literature review. Ann Mov Disord 2020;3:3-22

How to cite this URL:
Pitton Rissardo J, Fornari Caprara AL. Parkinson’s disease rating scales: a literature review. Ann Mov Disord [serial online] 2020 [cited 2020 Jun 5];3:3-22. Available from: http://www.aomd.in/text.asp?2020/3/1/3/281747




  Key messages: Top


  1. (1) In the literature, there are a large number of scales, but the majority of them were created for other diseases with later study in Parkinson’s disease.


  2. (2) Some of the scales need a lot of training before the application.


  3. (3) None of the scales is perfect, and it would probably be better to use combined scales even though we know that they overlap in some aspects.



  Introduction Top


A scale is critical for an objective and standardized process in which the purpose involves measuring differences between various individuals and determining priorities such as primary treatment goals.[1] In this context, valid and reliable scales are needed to monitor, evaluate, and detect the impact of Parkinson’s disease (PD) on a variety of domains. In addition, the increasing awareness for nonmotor issues of PD has prompted a search for instruments capable of covering a range of symptoms from neuropsychiatric and autonomic dysfunction to sleep disturbance and other nonmotor aspects.[2] It is worth mentioning that the nonmotor assessment is even more difficult to give a clear clinical description than the motor issues as it involves a subjective evaluation and the patient’s cooperation, which sometimes are difficult to obtain.

PD is a progressive neurological disorder that gradually results in accumulating disabilities. New finds about pathophysiology and levodopa-induced motor complications have stimulated the development of new drugs and surgical techniques that have changed, in many cases, clinical outcomes throughout the last decades. In this way, the present therapeutic interventions demand valid instruments for research and clinical uses, and these, on their turn, should be effective enough to assess all the clinical systems of the patient with PD.[3] Thus, it was probably the discovery of new techniques in the management of PD that boosted the designing of new scales focusing on specific points of PD based on the needing evaluation. However, at the same time that the focus on certain characteristics of PD increased, fewer patients were evaluated, leading many scales to only extremely specific studies.

For the assessment of PD, there are many different scales that propose to evaluate diverse fields of PD. This evaluation includes the analysis of disease staging, quality of life, activities of daily living, impairment, disability, and other specific aspects. However, there is still little evidence on the psychometric characteristics of most of these instruments used for this disease, and some are beneficial only for a specific group of individuals.[4] This is supported, for example, by the fact that many scales are not appropriated for both research and clinical practice. Also, a significant amount of scales have no validity in most of the countries where they are applied, for they were not adequately adapted to the reality of a foreign population, but instead, only translated from their original language.[5] Furthermore, it is known that many instruments destined to evaluate specific aspects of the disease, such as cognitive impairment, are not able to do this in a non-biased manner. The aim of this study was to describe and analyze the most common PD scales used for research and clinical practice.


  Methods Top


Search strategy

We searched three databases, Google Scholar, Health Sciences Literature (LILACS), and MEDLINE, in an attempt to locate existing scales about PD published until 2017 in electronic form.. Search terms were “scale, evaluation instruments, outcome measures, rating scales, validation studies, questionnaire, clinimetric, reliability, and validity.” These terms were combined with “Parkinson and Parkinson’s disease.”

Inclusion and exclusion criteria

Original articles, case reports, case series, letters to the editor, task forces, and poster presentations published until 2017 were included in this review in English, Spanish, and Portuguese. The two authors independently screened the titles and abstracts of all papers found from the initial search. Disagreements between the authors were resolved through discussion.

Due to a large number of published scales in the literature, we prioritized the description of only some scales in this review. This selection was based on the number of citations, reviews’ evaluation that compared different scales, and task forces by the “The Movement Disorder Society” assessing the recommendations of scales for PD.

We excluded scales not related to PD, scales that were applied only in a small group of individuals, and scales without at least one article showing the clinimetric. Also, cases that were not accessible by electronic methods, including after a request to the authors of the study by email, were excluded.

Data extraction

When provided, we extracted the author’s name, year of publication, and country of occurrence, and the scales’ characteristics assessed were type/subtype, time to applicate, number of items, advantages, and disadvantages. The majority of the reports did not provide sufficient information about the statistical methods to assess the predictive values of the scales. The data were extracted by two independent authors, double-checked to ensure matching, and organized.

Definition

The scales are divided into two groups by their methods: qualitative and quantitative methods.[6] This study focused only on qualitative methods. These methods involve subjective evaluations to inventory the symptoms, signs, and functional loss.

In [Table 1], PD scales are organized and are divided into nine columns:
Table 1: Parkinson’s disease rating scales

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  1. (a)Type (I, II, III, …)/subtype (1, 2, 3, …) of the scale, that is: staging (I); health-related quality of life (HRQoL) (II); evaluation of the impact on activities of daily living (III); loss of functionality aimed at evaluation of the signs and symptoms of the disease (IV); evaluation of functioning and disability loss (V); and other specific evaluations. Specific evaluations include the following: fear of falling (1); depression (2); psychosis (3); sleep (4); apathy and anhedonia (5); anxiety (6); dysautonomia (7); dyskinesia (8); fatigue (9); motor fluctuations (10); psychosocial problems (11); secondary levodopa effects (12); Scales for Outcomes in Parkinson’s disease (SCOPA) studies (13); and cognitive impairment screening (14).

    These types and subtypes were proposed by the authors of this review for better comprehension and understanding of the differences of the scales. They represent the main characteristic of the scales and their use. Even though some scales were not aimed for that subtype, the majority of the studies, including the task forces published by the “The Movement Disorder Society,” evaluated the scale in that manner. We tried to organize the scales proposed by other articles, but most of them evaluated only a small number of scales that were chosen selectively. Also, in an attempt to use these published organizations, many scales described in this article are likely to have more than one classification.


  2. (b) Scale: Sometimes the name was not provided by the authors of the article. Therefore, we named according to the reviews cited or as was commonly named in the literature.


  3. (c) Reference number.


  4. (d) Acronym: The acronyms provided are those provided by the clinimetric articles of the scale.


  5. (e) The number of items (items or cognitive domains): Some scales when used for PD did not assess all the items that the scale has. Thus, we included only the number of items that were evaluated in PD.


  6. (f) The time required (minutes): The time was obtained from the review and original articles.


  7. (g) The advantage of the scale was compared with other scales.


  8. (h) The disadvantage of the scale was compared with other scales.


  9. (i) Considerations/recommendations already published by some group in task forces or other reviews.



  Discussion Top


The first type of scale is about the staging of PD; the only scale until the present moment is Hoehn and Yahr Scale that is simple and quick but has low sensitivity in early stages. These scales are recommended in demographic presentations of patients and are useful for defining inclusion and exclusion criteria. In this way, they are one of the fast and easy methods for separating the patients in subgroups, when a general analysis is required.[6],[7]

The second type is HRQoL, which has nine commonly used scales. They can be divided into specific and generic scales. The specific scales have problems with their restriction in some characteristics of PD as they superficially or not measure important areas such as self-image, sexual function, or the role functionality of the individual. To be more specific, we cannot take a clear picture of the patient’s overall health. However, the recommendations are using this type: if an initial evaluation, PDQ-39 and PDQL[8],[9],[10] are useful, but if the areas of potential problems need to be identified, PIMS should be used.[11] The SIP has the broadest measure among HRQoL. Also, it has important questions about writing and sexual dysfunction, but this will be time-consuming (30min). It is worth mentioning that PLQ can be used only in the German population.[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22]

The third type is an evaluation of the impact on the activity of daily living, which has four scales. They are easy and quick, but the clinimetric properties to PD have never been established. The most important use of these scales is when an evaluation of the patient and his/her caregiver is needed. In this way, when it is obtained by the clinical history that the patient needs his/her caregiver for all basic tasks or is noted a burnout of the caregiver, this scale could be useful.[23],[24]

The fourth type is about the loss of functionality aimed at the evaluation of the signs and symptoms of the disease, which has four scales. They have good reproducibility, but some drawbacks are that some symptoms could not be analyzed. The major sample of this type is UPDRS that captures multiple aspects of PD but fails in the evaluation of nonmotor symptoms and in the inadequate (ambiguities) instruction for application. Thus, before applying these scales, the researchers need to spend a significant quantity of time in the development of skills for a uniform and stable evaluation.[24],[25],[26],[27]

The fifth type is about functioning and disability, which has three scales. They are short and easy but only have few studies in the literature with this type.[24]

In the sixth type, we resume the scales related to specific analyses. This category was separated into 14 subtypes. The first subtype is about fear of falling, which has four scales. There are a small number of studies analyzing these scales together, but they have marked differences in language and some specific details. The articles suggest that FES-I and mSAFFE should be used for the evaluation of activity avoidance due to the risk of falling.[28],[29],[30],[31],[32],[33],[34],[35]

The second subtype is about depression, which has 12 scales. These scales are not specifically made to PD, but the majority of them are easy and quick. Probably, the best scale to use is the GDS-30 because it is simple, does not have copyright restriction, and is efficient in screening depression of PD. However, some have the most specific use: self-administered analysis (BDI), distinguish depression from dementia (GDS-30), the severity of depression (IDS-SR, IDS-C), treatment efficacy (HAM-D-17), and for more etiological approach (MADRS).[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50]

The third subtype is psychosis, which has 11 scales. These are divided into specific and generalized scales. The majority of these scales are classified as recommended or suggested for Parkinson’s psychosis. The most used scale is BPRS, but it has some drawbacks when the characterization of psychotic phenomena is needed.[50],[51]

The fourth subtype is about sleep, which has six scales. These scales are simple and quick. They distinguish in specific uses such as a focus in nocturnal sleep (PDSS), sleep habits (PSQI), alertness at time of administration (SSS), sleep at a specific point (KSS), sleep in the specific eight situations (ESS), and patients at risk of sudden sleep while driving (ISCS).[51],[52],[53],[54],[55],[56],[57],[58],[59],[60],[61],[62],[63],[64]

The fifth subtype is about apathy and anhedonia, which has six scales. These are divided into specific and generalized scales. The majority of the scales have problems with their validation and they have been used in a few studies. The only recommended scale is AS that also has problems with validation, but it is specifically developed for PD. The scales AES and AI are used to assess the severity, and the AES is used to follow the changes of apathy during treatment.[65],[66],[67]

The sixth subtype is about anxiety, which has six scales. These scales have poorly clinimetric properties. One of the most used scales is ASI that has 20 items and whose application time is undetermined. The BAI is more used to assess panic attacks in PD.[68],[69],[70],[71]

The seventh subtype is about dysautonomia, which has nine scales. These scales were used only in a few studies, so their clinimetric properties are not consolidated. The recommended (but with some limitations) scale to evaluate dysautonomia are COMPASS, because it has high accuracy in the definition of autonomic symptoms in PD but is much complex and large as compared to the other scales of evaluation of dysautonomia.[72],[73],[74],[75],[76]

The eighth subtype is dyskinesia, which has seven scales. All of them can assess dyskinesia and are useful to clinician, brief, and simple to apply. The problems with these scales are that these are used only in a few studies and their clinimetric properties are not consolidated. The recommended scales are AIMS and RDS. The AIMS is best to assess the severity of dyskinesia and the RDS to assess functional disability, but the time spent to apply the AIMS is about twice the RDS.[77],[78],[79],[80],[81],[82],[83],[84]

The ninth subtype is about fatigue, which has 10 scales. These scales are brief and easy, but have problems with clinimetric evaluation because of few studies and not clearly defining the variable that it intends to measure. The recommended scales to screening the fatigue are FSS, FACIT-F, and PFS-16 (made specific to PD); the only one scale recommended to evaluate the severity is FSS.[85],[86],[87],[88],[89],[90],[91],[92],[93],[94]

The 10th subtype is about psychosocial problems. This subtype has only one scale, the Belastungsfragebogen Parkinson Kurzversion (BELA-P-k). This scale has only a few studies and is in German.[95]

The 11th subtype is about levodopa secondary effects. This subtype has only one scale, the Parkinson’s Disease Symptom Inventory (PDSI). It is useful for helping clinicians to measure changes in symptoms and side effects over the treatment time, but it has few studies.[96]

The 12th subtype is about motor fluctuations, which has five scales. All of them have little evidence and need more studies. CAPSIT-PD diary has a registry for patients with PD subjected to functional neurosurgery; it is recommended and was published providing minimum requirements for a common patient evaluation control. The other two classified as recommended scales and easy to apply are HPDD and WOQ-19.[97],[98],[99],[100],[101],[102]

The 13th subtype is about SCOPA studies. SCOPA is a large research project on Scales for Outcomes in Parkinson’s disease. This study has five scales. SCOPA-AUT is an autonomic scale, which focuses on the clinical applicability of the questionnaire. SCOPA-COG is to evaluate cognition, which is short, reliable, and valid. SCOPA-Motor Scale is to evaluate motor symptoms and is quick compared with UPDRS. SCOPA-PC is to evaluate psychiatric complications; it is relatively short and is more likely to be sensitive to early cognitive changes in the PD population than the MMSE. SCOPA-Sleep assesses nocturnal sleep disorders and daytime somnolence.[60],[103],[104],[105],[106],[107],[108]

The 14th subtype is about cognitive impairment screening, which has 10 scales. These scales are easy and quick. The best scales are PDD-SS, mattis dementia rating scale (MDRS), and MMSE. The MMSE is the widely used screening measure for detecting dementia, but the clinimetric evaluation in PD to detect mild cognitive impairment has not been adequately stabilized. The MOCA has more adequate clinimetric properties, but a higher formal knowledge is required compared to the MMSE.[109],[110],[111],[112],[113],[114],[115],[116],[117],[118],[119],[120],[121],[122]


  Conclusion Top


In sum, 114 scales are evaluated in [Table 1] and divided into 6 types. In the literature, there are a large number of scales and every year more and more scales are published for the assessment of PD. However, the majority of them have only a small number of studies with psychometric evaluation, and others can be used for only a specific portion of the general population due to their characteristic features such as language availability. Also, some of the newly developed scales are incorporating part of other ratings instead of only citing them; this gives the medical literature a confusing assessment, when evaluating these grading systems, and turns them into long, confusing, and difficult to apply clinically. Therefore, we believe that instead of developing new scales, the studies should focus on the clinimetric evaluation, and assess these scales in different ethnic origins translating the scales and evaluating their quality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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