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DOI:
10.4103/AOMD.AOMD_33_19
Received : 25 Nov, 2019
Revised : 02 Jan, 2020
Accepted : 13 Jan, 2020
Published : 01 Apr, 2020
ORCID number
https://orcid.
org/0000-0001-6179-2177
Departments of 1Neurology
and 2Medicine, Federal
University of Santa Maria,
Santa Maria, Brazil
Address for
correspondence:
Dr. Jamir Pitton Rissardo,
Rua Roraima, Santa
Maria, Rio Grande do
Sul, Brazil.
E-mail: jamirrissardo@
gmail.com
© 2020 Annals of Movement Disorders | Published by Wolters Kluwer - Medknow 3
Review Article
Parkinson’s disease rating scales: a
literature review
Jamir Pitton Rissardo1,2, Ana L. Fornari Caprara1,2
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.
Key words:
Parkinson’s disease, rating, review, scale
Key Messages:
(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) Some of the scales need a lot of training before the application.
(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 on a variety of domains. In addition, the
increasing awareness for nonmotor issues of
A scale is critical for an objective and
standardized process in which the
purpose involves measuring differences
PD has prompted a search for instruments
capable of covering a range of symptoms
from neuropsychiatric and autonomic
between various individuals and determining dysfunction to sleep disturbance and other
priorities such as primary treatment goals.[1] nonmotor aspects.[2] It is worth mentioning
In this context, valid and reliable scales are that the nonmotor assessment is even more
needed to monitor, evaluate, and detect difficult to give a clear clinical description
the impact of Parkinson’s disease (PD) than the motor issues as it involves a
subjective evaluation and the patient’s
cooperation, which sometimes are difficult
This is an open access journal, and articles are distributed under to obtain.
the terms of the Creative Commons Attribution-NonCommercial-
ShareAlike 4.0 License, which allows others to remix, tweak, and
build upon the work non-commercially, as long as appropriate credit
How to cite this article: Pitton Rissardo J,
is given and the new creations are licensed under the identical terms.
Fornari Caprara AL. Parkinson’s disease rating scales:
For reprints contact: reprints@medknow.com a literature review. Ann Mov Disord 2020;3:3-22.
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Pitton Rissardo and Fornari Caprara: Parkinson’s disease rating scales
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
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
4 Annals of Movement Disorders - Volume 3, Issue 1, January-April 2020
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:
(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
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Pitton Rissardo and Fornari Caprara: Parkinson’s disease rating scales
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.
(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.
(c) Reference number.
(d) Acronym: The acronyms provided are those provided by
the clinimetric articles of the scale.
(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.
(f) The time required (minutes): The time was obtained from
the review and original articles.
(g) The advantage of the scale was compared with other scales.
(h) The disadvantage of the scale was compared with other
scales.
(i) Considerations/recommendations already published by
some group in task forces or other reviews.
Discussion
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[8-10] 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 (30 min). It is worth mentioning that PLQ can
be used only in the German population.[12-22]
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
Annals of Movement Disorders - Volume 3, Issue 1, January-April 2020 5
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.[24-27]
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.[28-35]
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).[36-50]
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).[51-64]
6
Table  1: Parkinson’s disease rating scales
Types and Scale Reference Acronym Number of Time Advantage Disadvantage Considerations/
Subtypes items (items required recommendations
or cognitive (min)
domains)
(I) Staging (a) Hoehn and Yahr 6,7 HY 1 1 Specific, traditional, simple, and Low sensitivity for early -Used to a
quick stages of the disease demographic
presentation of
patients -Useful for
defining inclusion/
exclusion criteria
(II) Health- (a) Parkinson's Disease 8,9,10 PDQ-39 39 15–20 Specific and validated for many Areas that do not measure: Sensitive to
related quality Questionnaire languages self-image and sexual changes that really
of life (HRQoL) function matter for the
patients, but this
is not the primary
issue in the clinical
evaluation that
focuses primarily
on functionality, so
most appropriate is
HRQoL
(b) Parkinson's Disease 8,9,10 PDQL 37 15–20 Specific and simple Areas that do not measure: Reflects the impact
Quality of Life Questionnaire eating and role function of PD by the own
patient's perspective
(c) Parkinson Impact Scale 8,11 PIMS 10 (two 10 Specific and includes universal Low degree of sensitivity Considered only
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optional precautions in an individual with as a means of

about sexual chronic disease identifying areas of
and financial potential problems
issues)
(d) Parkinson Lebensqualität 11 PLQ 44 15–20 Specific Only for the German Considered as an
population; validity and alternative in areas
sensitivity lower involving German-
speaking patients
(e) EuroQol 12-13 EQ-5D 5 (+visual 4 Generic, brief, simple, and Difficult to get a clear picture
Pitton Rissardo and Fornari Caprara: Parkinson’s disease rating scales

analog scale) attractive to applicate, available of overall health and how it

in many languages has changed within individual
patients
(f) 36-Item Short-Form 14,15 SF-36 36 5 Generic (PD and other
diseases) and multidimensional,
of easy application and
understanding
(g) Nottingham Health Profile 16,17,18 NHP 38 5 Generic and for a patient with Needs further study
chronic diseases in the initial stage of
the PD

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 Table  1: Continued
Types and Scale Reference Acronym Number of Time Advantage Disadvantage Considerations/
Subtypes items (items required recommendations
or cognitive (min)
domains)
(h) World Health Organization 19,20,21 WHOQOL-100 100 25 Generic and favors the opinion – –
Quality of Life Questionnaire of the patient
with 100 items
World Health Organization WHOQOL-BREF 26 8 Generic and favors the opinion – –
Quality of Life-BREF of the patient
(i) Sickness Impact Profile 22 SIP 136 30 A broad measure of functional Lengthy-time to applicate The most important
status. questions are about
writing and sexual
dysfunction
(III) Evaluation (a) Schwab and England 23,24 Schwab and 1 1 Easy and simple The clinometric properties of Same researchers
of the impact Activities of Daily Living England ADL this scale have never been are used in the
on activities of Scale established patient and the
daily living caregiver
(b) Northwestern University 24 NUDS or 6 6 – No information about –
Disability Scale NWUDS autonomic dysfunctions,
mental troubles, cognitive
impairment, and social
discomfort
(c) Intermediate Scale for 24 ISAPD x x It has already been
Assessment of PD described

Annals of Movement Disorders - Volume 3, Issue 1, January-April 2020

(d) Extensive Disability Scale 24 EDS 21 15–20 In a clinimetric study, it was It is a modified
considered the best for the version of the
functional status as compared Minimal Record of
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to HY and NUDS Disability

(IV) Loss of (a) Columbia University 24,25 CURS 25 5–10 Good reproducibility with the Early clinical trials
functionality Rating Scale exception of rigidity of L-DOPA
aimed at
evaluation of
the signs and
symptoms of
the disease
Pitton Rissardo and Fornari Caprara: Parkinson’s disease rating scales

(b) Webster Scale 24,26 – 10 – Evaluates better functionality Scarce data on its validity
than disability
(c) Parkinson’s Disease 24 PDIS 10 – Questionable validity It has only one
Impairment Scale study
(d) Unified Parkinson’s 27 UPDRS 42 10–20 A compound scale used to Has absence of screening
Disease Rating Scale capture multiple aspects of questions on several
PD (motor and nonmotor important nonmotor aspects
symptoms) of PD, ambiguities in the
written text, and inadequate
instructions for raters
(V) Evaluation (a) Short Parkinson’s 24 SPES 25 7–10 Short and easy Few studies
of functioning Evaluation Scale
and disability

7
loss
8
Table  1: Continue
Types and Scale Reference Acronym Number of Time Advantage Disadvantage Considerations/
Subtypes items (items required recommendations
or cognitive (min)
domains)
(b) University of California 24 UCLA 21 10–15 Moderate-to-good inter-rater No evidence published, few
Los Angeles Scale reliability studies
(c) New York University 24 NYU 6 7–10 Low validity, few studies
Parkinson’s Disease
Evaluation
(VI) Other
specific
evaluations:
(1) Fear of (a) Falls Efficacy Scale- 28-30 FES-I 16 10 Several languages Evaluates concerns
falling International about falling,
favored the choice
(b) Swedish FES 28,31-32 FES(S) 13 3–5 Used to Swedish people Further studies are needed to Evaluates fall-
verify the validity related self-efficacy;
it is an FES
translated into
Swedish
(c) Activities-Specific Balance 28,33-34 ABC 16 5–10 Wider continuum of activity Ceiling and floor effects in Evaluates balance
Confidence Scale difficulty and more detailed item some reports confidence
descriptors than FES-I
(d) Modified Survey of 28,35 mSAFFE 17 A better choice for active and Less established than FES-I Evaluates activity
Activities and Fear of falling independent community- avoidance due
in the Elderly dwelling older adults to risk of falling,
favored the choice
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(2) Depression (a) Beck Depression 36,46,47 BDI 21 5–10 Assesses the intensity of Does not reflect a particular Designed to be
Inventory depression, today theory of depression administered by
trained interviewers;
it is most often self-
administered.
(b) Center for Epidemiological 37,46,47 CESD-R 20 3 In the past week Few data need more studies
Studies Depression Rating
Scale – Revised
Pitton Rissardo and Fornari Caprara: Parkinson’s disease rating scales

(c) 30-Item Geriatric
Depression Scale
40,46,47 GDS-30 30 3 Simple and fast, the most Only elderly people, limited Designed to
efficient depression screening content validity, and appears identify depression
scale to use in PD and no insensitive at the end of the in the elderly by
copyright restriction depression severity spectrum distinguishing
symptoms of
depression and
dementia. -Not used
in severe cognitive
impairment

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 Table  1: Continue
Types and Scale Reference Acronym Number of Time Advantage Disadvantage Considerations/
Subtypes items (items required recommendations
or cognitive (min)
domains)
(d) Inventory of Depressive 38,39,46 IDS-SR 30 10–15 Patients may have difficulty To assess the
Symptoms – Patient comprehending severity of,
and change
in, depressive
symptoms
(e) Inventory of Depressive 38,39,46 IDS-C 30 15–20 To assess the
Symptoms Clinician severity of,
and change
in, depressive
symptoms
(f) Patient Health 40,46,50 PHQ-9 9 3 Easy and fast, excellent to use Low sensitive to detect a An algorithm based
Questionnaire-9 in primary care to measuring major depressive disorder on Diagnostic
depression (severity and and Statistical
responsiveness to treatment) Manual Of Mental
Disorders, Fourth
Edition criteria
(g) 17-Item Hamilton 41,46,47 HAM-D-17 17 15–20 Measures the severity of The construction of
Depression Rating Scale depressive symptoms a depression rating
scale designed
to be particularly
sensitive to

Annals of Movement Disorders - Volume 3, Issue 1, January-April 2020

treatment effects is
described.
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(h) Montgomery–Asberg
Depression Rating Scale
(i) Zung Self-Rating
Depression Scale
(j) Hospital Anxiety and
Depression Scale
41,46,47 MADRS 10 15 Measures the of severity of Further studies are required More etiological
depressive symptoms approach
44,45,47 SDS 20 10 Short and more easily More confusing than GDS-30,
comprehended few studies confirm validity
to PD, and a large number
of somatic items are likely to
infiltrate depression rates
40,47 HADS 14 1–2 Easy and fast, excellent to use Has large effect sizes as Evaluates 7-item
in primary care to measuring compared to others and depression and
Pitton Rissardo and Fornari Caprara: Parkinson’s disease rating scales

depression (severity and measures depression 7-item anxiety

(k) Cornell Scale for the
Assessment of Depression in
Dementia
responsiveness to treatment)
43,47 CSDD 19 20–30 It is used with moderate-to- Further studies are required Uses information
severely impaired elders with from an interview
dementia and shows the with the patient and
effectiveness of interventions, caregiver
especially antidepressant
treatment

9
 Table  1: Continue

10
Types and Scale Reference Acronym Number of Time Advantage Disadvantage Considerations/
Subtypes items (items required recommendations
or cognitive (min)
domains)
(l) Major Depression 42,48 MDI 10 5–10 Better than SDS to measure the Emphasizes the intensity of Diagnosis of
Inventory ICD-10 severity of the depression mood symptoms rather than major depression,
its frequency according to either
the DSM-IV criteria
or the ICD-10
criteria.
(3) Psychosis (a) Parkinson Psychosis 50 PPRS 7 5–15 Specifically to assess psychosis Fails to capture Suggested
Rating Scale in PD, short heterogeneous psychosis
in PD
(b) Parkinson Psychosis 50 PPQ 14 5–15 Specifically to PD, cataloging Does not include all Suggested
Questionnaire discrete psychotic phenomena hallucination phenomena;
delusions are more detailed
than hallucinations, although
they are less common in PD
(c) Rush Hallucination 50 – 53 >30 Covers the past 1 month Severity is based on Listed
Inventory emotional association;
delusions are not included
(d) Baylor Parkinson’s 50 – 6 5–15 Easy and quick Rate symptom’s frequency Listed
Disease Hallucination seems disproportionate
Questionnaire
(e) Neuropsychiatric 50 NPI 12 15–30 Many strengths: efficient Its development as an Recommended
Inventory administration, separating instrument to evaluate
symptom’s frequency, some patients with dementia limits
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questions to specific psychotic its application to patients with

phenomena PD who are not demented
(f) Behavioral Pathology in 50 Behave-AD 25 15–30 The delusions and Constructed to Alzheimer’s Suggested
Alzheimer’s Disease Rating hallucinations items detailed disease
Scale rating to the PD
(g) Brief Psychiatric Rating 50 BPRS 18 15–30 It is the most widely used scale Does not provide a detailed Recommended
Scale characterization of the
psychotic phenomena that
occur in PD
Pitton Rissardo and Fornari Caprara: Parkinson’s disease rating scales

(h) Positive and Negative 50 PANSS 30 >30 Detailed definitions, the positive Constructed specifically to Recommended
Syndrome Scale scale also includes behavioral schizophrenia, long and
phenomena complex
(i) Schedule Assessment of 50 SAPS 34 >30 Easy and clear Developed to patients with Recommended
Positive Symptoms schizophrenia
(j) Nurses’ Observation Scale 51 NOSIE-30 30 5–15 Brief and simple, largely used Described to schizophrenic; Listed
for Inpatient Evaluation studies some of the items can be
confounded

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 Table  1: Continue
Types and Scale Reference Acronym Number of Time Advantage Disadvantage Considerations/
Subtypes items (items required recommendations
or cognitive (min)
domains)
(l) Clinical Global Impression 51 CGIS 3 <5 A few seconds to complete, Assessment of single items Suggested
Scale maybe be a useful addition to can be confusing
the more sophisticated scales.
(4) Sleep (a) Parkinson’s Disease 54,60,62 PDSS 15 (more an 5 Good to assess potential Insufficient to screen for Focus in nocturnal
Sleep Scale analog scale) causes of “bad-sleep” to specific sleep disorders sleep
differentiate in early and
advanced stages
(b) Pittsburg Sleep Quality 55,61,62 PSQI 19 5–10 More closely related to Is not likely to be useful as To assess sleep
Index psychological symptom ratings screening measures for habits and
and sleep diary measures than polysomnographic sleep disturbances during
the ESS abnormalities; some items are the previous month.
ambiguous and confusing
(c) Stanford Sleepiness Scale 51,56,62 SSS 1 1–2 Simple and quick Never been properly validated The measure of
alertness at the time
of administration.
(d) Karolinska Sleepiness 51,57,63,64 KSS 1 5 Simple and quick Problems with validity and The measure of
Scale too short to assess sleep sleepiness at a
problems specific point in
time.
(e) Epworth Sleepiness Scale 51,58 ESS 8 2–5 Many publications Unsuitable for screening for A measure of how

Annals of Movement Disorders - Volume 3, Issue 1, January-April 2020

episodes of sudden sleep likely the subject
onset in patients with PD. is to a dozen off in
eight situations
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(f) Inappropriate Sleep 62 ISCS 12 2–5 The ISCS is used to capture The clinimetric properties of Identifies patients at
Composite Score excessive daytime sleepiness the ISCS are unknown and risk of sudden onset
appearing even in active it has not been used in a of sleep (SOS)
situations non-PD population, restricted while driving
to evaluating severe daytime
sleepiness.
(5) Apathy and (a) Apathy Evaluation Scale 66,67 AES 18 10–20 Assesses the severity of Problems with validation Suggested
anhedonia apathetic symptoms and may due to lack of consensus on
also be used to follow changes diagnostic criteria
Pitton Rissardo and Fornari Caprara: Parkinson’s disease rating scales

in apathy during treatment

(b) Apathy Inventory 66 AI 3 Undefined Assesses the severity and quick Problems with validation Listed
due to lack of consensus on
diagnostic criteria
(c) Apathy Scale 66 AS 14 Undefined It was developed specifically for Problems with validation Recommended
patients with PD due to lack of consensus on
diagnostic criteria
(d) Lille Apathy Rating Scale 66,68 LARS 33 10 Specifically designed for Longest scale to apathy Suggested
patients with PD

11
 Table  1: Continue

12
Types and Scale Reference Acronym Number of Time Advantage Disadvantage Considerations/
Subtypes items (items required recommendations
or cognitive (min)
domains)
(e) Chapman Scales 65,66 – 61 Undefined Most widely used instrument to Problems with validation Listed
for Physical and Social measure anhedonia in patients due to lack of consensus on
Anhedonia with psychiatric diseases diagnostic criteria. The single
study that used the scales in
PD patients concluded that
the scale was not useful
(f) Snaith–Hamilton Pleasure 66 SHAPS 14 Undefined Shorter and simple Problems with validation Suggested
Scale due to lack of consensus on
diagnostic criteria
(6) Anxiety (a) Anxiety Status Inventory 69 ASI 20 Undefined More commonly used in Poorly clinimetric properties Suggested
epidemiological studies of recording the
anxiety in PD presence of anxiety
(b) Zung Self-Rated Anxiety 69,71 SAS 20 5–10 Poorly clinimetric properties Suggested
Scale recording the
presence of anxiety
(c) Beck Anxiety Inventory 69 BAI 21 5–10 Used to screening for symptoms Less suitable to screen for Suggested
of panic attacks in patients with other anxiety disorders
PD
(d) Spielberger State-Trait 69,70 STAI 40 10 Brief and easy No validation for PD and does Suggested
Anxiety Inventory not cover all symptoms of
GAD and panic disorder
(e) Hamilton Anxiety Rating 69,71 HAS It has already been
Scale described
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(f) Hospital Anxiety and 69,70 HADS It has already been

Depression Scale described
(7) (a) Autonomic Dysfunction in 72 – 29 Undefined Specifically to PD This questionnaire has not yet Listed; a global
Dysautonomia Parkinson’s Disease been used in other studies survey of autonomic
and validation is needed symptoms in PD
(b) Composite Autonomic 72 COMPASS 73 20–30 High accuracy in the definition Complex and large Recommended
Symptoms Scale of autonomic symptoms. (with some
limitations)
Pitton Rissardo and Fornari Caprara: Parkinson’s disease rating scales

(c) Freiburg Questionnaire 72,76 – 5 Undefined Short and easy Was not used in other studies Listed
and not validated
(d) Hobson Scale 72,73 – 23 Undefined Designed to estimate the Listed
prevalence of bladder and
autonomic symptoms
(e) l-threo-3,4- 72,74 l-threo-DOPS 10 Undefined Has not yet been used by Listed
Dihydroxyphenylserine Scale other groups
(f) Non-Motor Symptoms 72 NMS-Quest 30 5–7 Easy to score It is not a rating scale It is the first
Questionnaire for Parkinson’s validated tool to
Disease screen for the
presence of NMS
in PD

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 Table  1: Continue
Types and Scale Reference Acronym Number of Time Advantage Disadvantage Considerations/
Subtypes items (items required recommendations
or cognitive (min)
domains)
(g) Non-Motor Symptoms 72 NMSS 30 10–15 Questionnaire to quantify NMS The NMSS has not yet been Suggested
Scale and easy to score used by groups other than the
developers
(h) Senard 72,75 – 8 Undefined Does not include frequency Prevalence of
and severity OH and nature of
postural events
related to a fall in
BP in patients with
PD
(i) Orthostatic Grading Scale 72 OGS 5 5 Short, frequency and severity of Has not yet been used Suggested
orthostatic symptoms specifically in patients with
PD
(8) Dyskinesia (a) Abnormal Involuntary 87,94 AIMS 10 14 Does not allow the impact of Clinimetric problems, score Recommended;
Movement Scale dyskinesia on the quality of life to designed other dyskinesia assesses the
besides PD severity of abnormal
movements in
different parts of the
body
(b) Clinical Dyskinesia Rating 87,92 CDRS 10 (five 10 Useful to clinician Has not been used outside of Suggested;
Scale hyperkinesia the developing group independently

Annals of Movement Disorders - Volume 3, Issue 1, January-April 2020

and five evaluates
dyskinesia) hyperkinesia and
dystonic posture
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(c) Lang-Fahn Activities of 87,93 LFADLDS 5 5 Brief and easy On the basis of retrospective Suggested
Day Living Dyskinesia Scale recall of patient, no quality of
life assessment of the impact
of dyskinesia is provided
(d) Obeso Dyskinesia Rating 87,90 CAPIT 3 2 Easy and clear Problems with time frame Suggested
Scale
(e) Parkinson Disease 87,91 PDYS-26 26 10 Specifically made for patients Potential redundancy on Suggested as
Dyskinesia Scale with PD and easy to use modalities of activity a measure for
assessing the
Pitton Rissardo and Fornari Caprara: Parkinson’s disease rating scales

patient’s perception
of functional impact
from dyskinesia
in PD
(f) Rush Dyskinesia Rating 87,88 RDRS 3 5 Assesses functional disability of Assessments are performed Recommended
Scale dyskinesia at the single time points and
the evaluation time point may
or may not reflect the rest, no
consideration made for pain
or discomfort of the day.
(g) Unified Dyskinesia Rating 87,89 UDysRS 26 15 Comprehensive rating tool Has not been studied by Suggested
Scale other groups

13
 Table  1: Continue

14
Types and Scale Reference Acronym Number of Time Advantage Disadvantage Considerations/
Subtypes items (items required recommendations
or cognitive (min)
domains)
(9) Fatigue (a) Chalder Fatigue 77,81,86 CFQ 14 3–5 Rather than a measure of Few studies to Parkinson Developed to
Questionnaire impact or consequence, and assess disabling
has physical and mental fatigue severity
domains. in hospital and
community
populations
(b) Clinical Global Impression 78 CGIS x x It has already been
Scale described. Listed to
evaluate fatigue
(c) Fatigue Assessment 78,79 FAI 29 5–10 Various aspects of fatigue and Insufficient data to support Suggested,
Inventory allows comparison between the validity expanded version of
different disease groups the FSS
(d) Fatigue Impact Scale for 78,80 D-FIS 8 2–3 Emphasizes the impact of Little validation studies in PD D-FIS is a listed
Daily Use fatigue rather than the perceived scale for screening
severity for fatigue and
suggested a
measure for daily
assessment of
fatigue severity
(e) Fatigue Severity Inventory 78 FSI 33 5 Diversity of aspects related to Has not been formally Listed
fatigue validated and most of its
psychometric properties are
unknown.
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(f) Fatigue Severity Scale
(g) Functional Assessment
of Chronic Illness Therapy
Fatigue Scale
(h) Multidimensional Fatigue
78,82 FSS 9 2–3 Brief and easy to use, and Does not provide a definition Recommended
translates to various language of the underlying variable it scale for screening
intends to measure. and severity rating
78,85 FACIT-F 13 5–10 Brief and easy to use, and Does not provide a clear Recommended
translates to various language definition of the underlying scale for screening
variable it intends to measure and suggested
scale for severity
rating.
78 MFI 20 10 Short scale with good The proposed factor structure Suggested
Pitton Rissardo and Fornari Caprara: Parkinson’s disease rating scales

Inventory psychometric properties has not always been

confirmed in independent
studies and there are no data
on the reliability of the scale
in PD.
(i) Parkinson Fatigue Scale- 78,84 PFS-16 16 5 Brief and easy to use, Does not define fatigue Recommended
16 developed specifically for use in scale for screening
patients with PD and suggested
scale for severity
rating

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 Table  1: Continue
Types and Scale Reference Acronym Number of Time Advantage Disadvantage Considerations/
Subtypes items (items required recommendations
or cognitive (min)
domains)
(j) Visual Analog Scales 78 VSA Brief and easy to use, and PD has not been validated Listed
generally easy for the subject to
understand
(10) Motor (a) Assessment of Parkinson 97 APDS
fluctuations Disease Scale
(b) Core assessment 97,98 CAPSIT-PD diary Registry for patients with Needs continuum evaluation Recommended;
Program for Surgical PD subjected to functional and few studies it was published
Interventional Therapies in neurosurgery providing the
Parkinson's Disease minimum
requirements for
a common patient
evaluation protocol
(c) Hauser Parkinson’s 102 PD Home Diary Easy and simple Needs more studies Recommended
Disease Home Diary
(d) Intermediate Scale for 99 ISAPD 13 7 Easy to apply and valid Needs more studies
Assessment of PD
(e) Wearing-off 100,101 WOQ-19 19 5 Easy and brief Few studies Recommended
Questionnaire-19
(11) (a) Belastungsfragebogen 95 BELA-P-k 19 Undefined Useful for evaluation of Few studies
Psychosocial Parkinson Kurzversion psychosocial problems

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problems
(12) Secondary(a) Parkinson’s Disease 96 PDSI 51 Undefined Useful patient evaluation tool to Few studies Informative to
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levodopa Symptom Inventory help clinicians assess and track measure changes
effects the symptom-related disease in symptoms and
status of patients. side effects over
time as treatment
progresses.
(13) SCOPA (a) Scale for Outcome in 104 SCOPA-AUT 25 10 Focused on the content and
studies Parkinson's Disease – the clinical applicability of the
Autonomic Dysfunction questionnaire, specifically made
to PD
Pitton Rissardo and Fornari Caprara: Parkinson’s disease rating scales

(b) Scale for outcome in 105,109 SCOPA-COG 10 10–15 Short, reliable, and valid,
Parkinson's Disease – specifically to PD
Cognition
(c) Scale for Outcome in 108 SCOPA- Motor 21 8 Shorter as compared with
Parkinson’s Disease – Motor Scale UPDRS, specifically made to
Scale PD
(d) Scale for Outcome 108 SCOPA-PC 12 10 Shorter, specifically made to Although SCOPA-COG was
in Parkinson's Disease - PD, more likely to be sensitive developed specifically for
Psychiatric Complication to early cognitive changes in the a PD population, it has not
PD population than the MMSE been used extensively in PD.

15
 Table  1: Continue

16
Types and Scale Reference Acronym Number of Time Advantage Disadvantage Considerations/
Subtypes items (items required recommendations
or cognitive (min)
domains)
(e) Scale for Outcome in 103 SCOPA-Sleep 11 8 A specific PD rating scale Without exploring potential Asses nocturnal
Parkinson's Disease – Sleep causes of sleep disorders and sleep disorders
Scale somnolence and daytime
somnolence
(14) Cognitive (a) Addenbrooke’s Cognitive 109,119 ACE 6 CD 15–20 Not specifically to PD
impairment Examination
screening
(b) Cambridge Cognitive 117,119 CAMCOG 8CD 25–30 Not specifically to PD, lengthy Assesses cognitive
Assessment function and
screening for
dementia
(c) Dementia Rating Scale 112,113,119 DRS 5CD 15–30 Available in many languages
(d) Mini-Mental Parkinson 118,119 MMP 7CD 10 Quick and useful in detecting an Heavy representation of the
early cognitive change orientation item, which is also
the item contributing least to
scale variance, and a lack
of cortical items, and needs
more studies
(e) Mini-Mental State 111,112,119 MMSE 11 10 Easy and clear, most widely Has not adequate
Examination used screening tool for psychometric to detect mild
detecting dementia cognitive impairment in PD
and does not measure some
cognitive functions that are
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commonly impaired in PD
(f) Montreal Cognitive 110,111,119 MOCA 1CD 10 Easy and clear, has adequate Needs a population with
Assessment psychometric to detect mild greater knowledge than for
cognitive impairment in PD, and the MMSE
available in many languages
(g) Parkinson 115,116,119 PANDA 5CD 8–10 Specifically made to PD, Needs more clinimetric
Neuropsychometric Dementia superiority to MMSE evaluation
Assessment
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 Table  1: Continue
Types and Scale Reference Acronym Number of Time Advantage Disadvantage Considerations/
Subtypes items (items required recommendations
or cognitive (min)
domains)
(h) Parkinson’s Disease 114,119 PD-CRS 2CD 15–30 Specifically made to PD Characterized by
Cognitive Rating Scale the addition of
cortical dysfunction
on a predominant
and progressive
fronto-subcortical
impairment recently
conducted a
systematic review
of cognitive scales
used in PD and
identified the
PD-Cognitive Rating
Scale (PD-CRS)
as the optimal
PD-specific scale
for detecting early
cognitive deficits
in PD and tracking
the transition to PD
dementia.

Annals of Movement Disorders - Volume 3, Issue 1, January-April 2020

(i) Parkinson’s Disease 120,122 PDD-SS 8CD 5–7 Specifically made to PD, Quick
Dementia – Short Screen and appears as the first brief
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screening tests for diagnosing

(j) Repeatable Battery
for the Assessment of
Neuropsychological Status
Parkinson’s disease with
dementia as compared MDRS
and MMSE
121,122 RBANS 5CD 20–30 These data suggest that the Not specifically to PD
RBANS is effective at both
detecting and characterizing
dementia of different etiologies
Pitton Rissardo and Fornari Caprara: Parkinson’s disease rating scales

CD = cognitive domains, I = items, min = minutes, MDRS = mattis dementia rating scale, PD = Parkinson’s disease

17
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Pitton Rissardo and Fornari Caprara: Parkinson’s disease rating scales
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.[65-67]
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.[68-71]
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.[72-76]
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.[77-84]
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.[85-94]
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
18 Annals of Movement Disorders - Volume 3, Issue 1, January-April 2020
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.[97-102]
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.[60,103-108]
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.[109-122]
Conclusion
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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Pitton Rissardo and Fornari Caprara: Parkinson’s disease rating scales
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