Hoehn And Yahr Staging Of Parkinsons Disease In Relation To Neuropsychological Measures
DOI: 10.2741/4649Cite This Paper
Parkinsons disease is primarily considered to be a progressive degenerative motor disease associated with the degeneration of striatal dopamine neurons. However, increasing evidence has suggested progressive cognitive and psychiatric changes as well. Forty-six patients with PD, ranging in severity from Hoehn and Yahr score of 1:4, were recruited from a clinic specializing in PD. Various cognitive and neuropsychological measures were used to discover if there were indeed differences due to the progression of PD. As H-Y stage significantly increased, so did age and levodopa equivalency dose of medications, both independent of one another. Years of education had a significant negative relationship with H-Y score. Measures of general cognition divulged a significant decrease as H-Y score increased. Finally, as H-Y score increased, magical ideation decreased, and religious group social support increased. Mechanistically, the significant cognitive decline occurring with H-Y staging may be linked to a reduced dopaminergic function. Significant cognitive and neuropsychological changes are associated with the progression of PD and its possible relationship to Reward Deficiency Syndrome .
Parkinsons disease, Hoehn and Yahr, Cognitive, Neuropsychology, Reward Deficiency Syndrome
Confinement To Bed Or Wheelchair Unless Aided
The patient may exhibit: inability to arise from a chair or get out of bed without help a tendency to fall when standing or turning freezing, stumbling or pulsion when walking. Without someone immediately present to provide assistance, the patient is in danger of falling.A typical example of diagnosis using this method of staging would be: a 64 year old with Stage III PD, more marked on the left than the right, of seven years duration. Another would be: A 55 year old with severe fluctuations in response to Sinemet, with PD of Stages II/IV, of ten years duration. The second example indicates that the patient is at Stage II when at his best or on and at stage 3 IV when at his worst or off. This gives the reader a succinct description of the progression of the disease and the current status of the patient.This method of grading severity is rather a potpourri, combining the symptoms of the patient, the physical signs as observed by the physician and the patients functional ability. In some instances, it is not applicable. For example, while general experience has been that is the onset of disturbances of balance that heralds future disability, some patients may have such severe tremor that they are incapacitated even though balance in intact. Others may have mild disturbance of balance for many years without losing independence. There are occasional patients who are more incapacitated by severe unilateral disease than are others by milder bilateral disease.
Clinical Stages Of Pd
Although clinical experts describe the symptoms and stages of PD differently, it is sometimes classified based on the daily-life disabilities with three stages as early, moderate, or advanced: Early represents the stage when a person has a mild tremor or stiffness but is able to continue work or other normal daily activities. This often refers to a person who has been newly diagnosed with PD Moderate refers to the stage when a person begins to experience limited movement. A person with moderate PD may have a mild to moderate tremor with slow movement Advanced refers to the stage when a person is significantly limited in his or her activity, despite treatment. Daily changes in symptoms, medicinal side effects that limit treatment, and loss of independence in the activities of daily living are common. A person with advanced PD may have significant and frequent changes in posture and movement with speech difficulties.
Tobias Warnecke MD, Rainer Dziewas MD, in, 2015
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What Are The Stages Of Parkinson’s Disease
Parkinsons disease is a neurodegenerative disorder that causes difficulty with walking and coordination. It occurs when the brain can no longer produce enough dopamine, one type of chemical in the brain. A progressive disease, Parkinson’s starts gradually and gets worse with time.
The most common symptoms of Parkinson’s disease are stiffness in different parts of the body, shaking , difficulty with balance and coordination, difficulty walking and slow movements. As the disease advances, muscle pain and cramps, problems with sleep, memory impairment, depression, and behavioral changes may set in, too.
The Hoehn and Yahr scale is used to stage Parkinsons disease according to the order in which symptoms appear and gradually worsen. There were previously five stages in the Hoehn and Yahr scale, but over time it was modifiedstages 1.5 and 2.5 were added to it.
Hoehn And Yahr Scale Wikipedia
An important clarifying factor of stage three is that the patient is still fully independent diseaxe their daily living activities, such as dressing, hygiene, and eating.
If sought it is not uncommon that the physician is unable to make a diagnosis, either by the most assiduous and astute physical examination or by the most advanced technology. Similarly, many patients never reach Stage V. One yqhr or foot may parkinskn been clumsier than the other may have.
Unilateral and axial involvement. Since then, a modified Hoehn and Yahr scale was proposed with the addition of stages 1. This rating system has been largely supplanted by the Unified Parkinsons Disease Rating Scalewhich assesses limitation of daily activities hodhn non-motor symptoms in more detail.
Activities of daily living Speech: While the symptoms worsen over time, it is worth noting that some patients with PD never reach stage five. Clear Turn Off Turn On. Bilateral involvement without impairment of balance. In spite of these drawbacks, this method of grading severity has proved practical over many years. There are occasional patients who are more incapacitated by severe unilateral disease than are others by milder bilateral disease.
Health Technology Assessment, No.
As H-Y stage significantly increased, so did age and levodopa equivalency dose of medications, both independent of one another. This work was produced by Clarke et al.
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Tentative Protocol Of Clinical Trial
Once we confirm the safety and efficacy of the iPSC-derived DA progenitor cells manufactured by our protocol, we will make a formal request to the institutional and governmental committees about the clinical application of the cells. We, however, have not yet fixed the protocol of the clinical trial therefore, the tentative protocol below might be changed according to discussions with the committees.
Inclusion criteria: We will recruit PD patients with symptoms uncontrollable by medical treatment. The patients will be aged 5070 at the time of inclusion and be suffering from PD more than 5 years. The patients will be in the middle stage of their disease and show good response to l-dopa .
Exclusion criteria: Patients with significant cognitive impairment or severe disease histories including surgeries will be excluded.
Design: The study will be an open-labeled phase I or I/II study at a single institute . The number of the patients will be 510, with no control groups.
Fig. 3. A direct comparison of autologous and allogeneic transplantation of iPSC-derived neural cells in the brain of nonhuman primates. Autologous transplantation of iPSC-derived neurons elicited only a minimal immune response in the brain . In contrast, allografts caused an acquired immune response with the activation of microglia and the infiltration of leukocytes . Consequently, a higher number of DA neurons survived in the autografts.
Yunfeng Wu, Pinnan Chen, in, 2019
What You Can Do
As of 2021, there is no definite cure for Parkinsons disease. There is also no definite known cause. Its likely due to a combination of an individuals susceptibility and environmental factors. Most cases of Parkinsons disease happen without a genetic link.
According to research published in 2012, only report having a family member with the disease. Many toxins are suspected and have been studied, but no single substance can be reliably linked to Parkinsons.
However, research is ongoing. Its estimated that
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What Is The Hoehn And Yahr Scale In Parkinsons
Parkinsons is a degenerative condition that affects the central nervous system and the motor system. The symptoms experienced by any individual occur at a slow pace and turn to worse over a period of time. It is difficult to find the presence of the illness in the early stages, as the symptoms could be due to other health conditions. Hence, it is unpredictable and often makes it difficult for any physician to offer appropriate treatment at the right time.
The signs that an individual displays in the early stages of Parkinsons disease are stiffness of the muscles, difficulty in movement, shaking, and the beginning of the loss of memory. The slow progression of the Parkinsons disease further leads to the development of depression, changes in the behavior pattern, and occurrence of dementia. Other problems include emotional and sleep disturbances. Parkinsonism or Parkinsonian Syndrome is the term that addresses the collective symptoms that change the motor system of the individual.
The Hoehn And Yahr Scale For Parkinson’s
Two doctors named Dr. Hoehn and Dr. Yahr developed a scale that puts Parkinsons disease into five stages.The first stage is the mildest stage of the disease and stage five is the worst stage.
The symptoms may be mild or severe or happen a lot, or not as much. Also, the time spent at each stage of the disease varies, and the skippingof stages, from Stage 1 to Stage 3, for example, is not uncommon.
Stage 1 The main symptoms- tremor, muscle stiffness, slowness of movement and problems with posture- are only onone side of the body. Problems with balance might also appear.
Stage 2 The disease will be on both sides of the body now and minor symptoms like problems with swallowing,talking and something called facial masking may be noticed.
Stage 3 The same symptoms of Stage 2 are still there but may be worse now. Problems with balance will now benoticed for the first time. At this stage, the person with Parkinson’s is still independent.
Stage 4 The person with Parkinson’s will now be getting more and more disabled and will need help with some orall activities of daily living.
Stage 5 At this stage the person is confined to a wheelchair or bed and needs total assistance.
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Age Gender Disease Severity And Duration
Increasing age predisposes the population group more than 45 years not only to PD but also to OP. Indeed, a considerable number of individuals who experience PD may already have OP. The comparative risk of OP in males and females with PD has been disputed, but the prevailing consensus points to a higher risk for women, consistent with the overall predominance of OP in women in addition to overlying neurologic factors.
The relationship between PD severity and duration and the degree of OP has also been subject to varied interpretations. Lorefalt et al. and van den Bos found no correlation between disease severity and disease duration. Other studies revealed a direct correlation, but generally in association with confounding factors .
Table 41.1. Comparison of bone mineral density in Parkinsons disease patients at different stage of Hoehn and Yahr .
| H& amp Y I and II | H& amp Y III and IV | P |
|---|
Jiro Kasahara, … Masahiro Nomoto, in, 2013
First Signs Of Impaired Righting Reflexes This Is Evident As The Patient Turns Or Is Demonstrated When He Or She Is Pushed From Standing Equilibrium With The Feet Together And Eyes Closed
Loss of balance, with the inability to make the rapid, automatic and involuntary movements necessary to protect against falling, is one of the most troubling and dangerous aspects of Parkinsonism and one of the least easily treated. Even when manifested by only slight unsteadiness, it is the criterion separating Stage II and Stage III. All other aspects of Parkinsonism are evident and usually diagnosis is not in doubt.
However, the most important factor identifying Stage III is that the patient is still fully independent in all activities of daily living Although somewhat restricted, has work potential depending upon the type of employment. A normal life can be.
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Schwab And England Activites Of Daily Living Scale
The Schwab and England ADL Scale is a means of measuring a persons ability to perform daily activities in terms of speed and independence through a percentage figure. The rating may be made by a professional or by the person being tested. High percentages indicate a high level of independence while low percentages indicate dependence:
- 100% – Completely independent. Able to do all activities without slowness, difficulty or impairment
- 90% – Completely independent. Able to do all activities with some slowness, difficulty or impairment. Activities may take twice as long to complete
- 80% – Independent in most activities, but activities take twice as long. Conscious of difficulty and slowing
- 70% – Not completely independent. More difficulty with activities, which may take three to four times as long. May take large part of day for chores
- 60% – Some dependency. Can do most activities, but very slowly and with much effort, but some chores are impossible
- 50% – More dependent. Help required with half of chores. Difficulty with everything
- 40% – Very dependent. Can assist with all chores but can manage few alone
- 30% – With effort, now and then does a few chores alone or begins alone. Much help needed
- 20% – Cannot do anything alone. Can give some slight help with some chores. Severe invalid
- 10% – Totally dependent, helpless
- 0% – Vegetative functions such as swallowing
Fully Developed Severely Disabling Disease The Patient Is Still Able To Walk And Stand Unassisted But Is Markedly Incapacitated
The patient is unable to lead an independent life because of the need for help with some activities of daily living. It is this inability to live alone which marks the transition from Stage III to Stage IV. No matter how difficult it is for him/her, if the patient still is able to live alone, his/her disease is at Stage III not Stage IV. The patient at Stage IV however, does remain able to stand and walk unassisted.
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Nature Of Swallowing Impairment
Table 106.5. Studies Using Instrumental Assessment Tools to Characterize Swallowing Abnormalities in PSP Patients
| Reduction/absence of cricopharyngeal muscle activity early in the course of the disease | Not known |
This table gives information about the study populations, evaluation methods, and most frequent findings of studies that were performed to characterize swallowing abnormalities in PSP patients.
Figure 106.1. Residue of white bread in the valleculae of a dysphagic PSP patient.
This figure shows residue of white bread left after the swallow in the valleculae of a dysphagic PSP patient as seen endoscopically.
Videofluoroscopic swallowing studies revealed impaired oral bolus control, reduced tongue mobility, poor mastication, reflux and diffuse esophageal spasm as additional signs of PSP-related dysphagia . Whereas dysfunction of the pharyngeal phase of swallowing did not differ between PD and PSP patients, VFSS detected significantly more oral-phase abnormalities in PSP patients . A study using esophageal manometry also found an inadequate relaxation of the upper esophageal sphincter during swallowing in some PSP patients . This finding was confirmed by another study, in which electromyography of different muscles of swallowing was performed. Thereby, it was shown that in contrast to patients with PD, PSP patients exhibit reduction or absence of the inhibition of cricopharyngeal muscle activity during swallowing .
Jun Takahashi, in, 2017
Unilateral Involvement Only Usually With Minimal Or No Functional Impairment
The patient has tremor, rigidity, slowness and paucity of movement, or poor condition in the arm and/or legs on one side of the body. Occasionally one side of the face is involved, producing an asymmetry of expression that may look very like the effects of a mild stroke or Bells palsy. This stage of Parkinsons is often missed entirely. For example when the diagnosis is made at a more advanced Stage, the patient may remember having noticed an intermittent tremor of one hand many years before. Old home movies may show that the patient didnt swing one arm as much as the other did while walking. One hand or foot may have been clumsier than the other may have. Often these symptoms are so mild that no formal medical attention is sought. If sought it is not uncommon that the physician is unable to make a diagnosis, either by the most assiduous and astute physical examination or by the most advanced technology. Sometimes the disease must evolve over many years before a diagnosis can be made with certainty.
Usually was inserted into the original definition to modify minimal or no functional impairment: because, very rarely, a patient presents with very severe and disabling unilateral symptoms: extreme and violent tremor or rigidity and akinesia in one limb so severe that the limb is virtually paralyzed. Most doctors worry about a stroke or tumor which they should. When all necessary tests show nothing, one must wait and observe. Eventually Stage II may emerge.
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Comparison Between Fallers And Nonfallers
Fallers were older and had longer disease duration and increased disease severity according to the UPDRS , Hoehn and Yahr and Schwab and England activities of daily living scores. In addition, fallers scored worse in the Mini-Mental State Examination and experienced a higher frequency of motor fluctuations, dyskinesia, and freezing of gait . Tremor as the initial predominant symptom was more frequent in nonfallers. Fallers were treated with higher doses of levodopa and more frequently received COMT inhibitors, central cholinesterase inhibitors, and atypical neuroleptics than nonfallers . Patients treated with central cholinesterase inhibitors had dementia associated with PD and those treated with quetiapine had hallucinations.
Bilateral Or Midline Involvement Without Impairment Of Balance
Months or years later similar symptoms and signs are noticed on the opposite side of the body, or other signs appear in midline what physicians call Axial signs. These may include: bilateral loss of facial expression decreased blinking speech abnormalities soft voice, monotony, fading volume after starting to speak loudly, slurring, stiffness of truncal muscles making the patient appear awkward and stiff or resulting in neck and back pain postural abnormalities causing stooping, generalized slowness in, but still capable of, carrying out all activities of daily living, sometimes an aggravation to those waiting for the patient to complete tasks.
Usually the diagnosis is easy at this Stage if it has been preceded by a clear cut tremor or other symptom on one side. But not all Parkinson’s patients have tremor or other definite signs of Stage I unilateral Parkinsonism. If Stage I was missed and the predominant symptoms at Stage II are only slowness and a lack of spontaneous movement, the diagnosis may still be in doubt. For example, even in Stage II, Parkinsonism may be interpreted as only advancing age.
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