MDS Clinical Diagnostic Criteria for Parkinson's Disease
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(2) Diagnostic Criteria For PD.
(3) Diagnosis of clinically “ESTABLISHED” PD. At least 2 supportive criteria. Absence of absolute exclusion criteria No red flags.
(4) Diagnosis of clinically “PROBABLE” PD. Numbers of supportive criteria = red flags (but no more than 2 red flags) Absence of absolute exclusion criteria.
(5) Supportive Criteria.
(6) 1.. Clear and dramatic beneficial response to dopaminergic therapy Note Initial treatment: patient retuned to normal or near-normal function. Marked improvement with dose increases (>30% in UPDRS III 或 subjectively with a clear history） Marked on/off fluctuations + predictable end-of-dose wearing off Can be from retrospective history (不用再特地調整藥物讓病患fluctuations).
(7) 2.. Presence of levodopa-induced dyskinesia.
(8) 3.. Rest tremor of a limb Note Documented in the past, or on current examination Included because …… Less common in alternate conditions Rest tremor occasionally less responsive to therapy if so, criterion 1 may be harder to meet.
(9) 4.. At least one ancillary diagnostic test (specificity > 80%) Note Olfactory loss (anosmia by age and sex) Metaiodobenzylguanidine scintigraphy cardiac sympathetic denervation.
(10) Absolute Exclusion Criteria.
(11) For all other criteria with a time component. Waiting until the duration before the criterion is considered as not met is. necessary. not.
(12) 1.. Unequivocal cerebellar abnormalities on examination Note Cerebellar gait Limb ataxia Cerebellar oculomotor abnormalities (sustained gaze-evoked nystagmus, macro square wave jerks, hypermetric saccades).
(13) 2.. Downward vertical supranuclear gaze palsy Selective slowing of downward vertical saccades.
(14) 3.. Diagnosis of probable behavioral variant frontotemporal dementia 或 primary progressive aphasia. within the first 5 y of disease. Note Other forms of dementia are not exclusion.
(15) 4.. Parkinsonian features restricted to lower limbs for more than 3 y.
(16) 5.. Dopamine receptor blocker/ dopamine-depleting agent (dose and time course) consistent with drug-induced parkinsonism.
(17) 6. Absence of observable response to high-dose levodopa despite at least moderate severity of disease Note High dose of levodopa daily = 600 mg/d Moderate severity parkinsonism = MDS-UPDRS score >2 (one measure of rigidity or bradykinesia) Absence of response Reported by patient (or reliable witness) Sequential examinations = improvement ≦ 3 points on the MDS-UPDRS Part III.
(18) 7.. Unequivocal cortical sensory loss (ie, graphesthesia, stereognosis with intact primary sensory modalities), clear limb ideomotor apraxia, or progressive aphasia.
(19) 8.. Normal functional neuroimaging of the presynaptic dopaminergic system Note. NOT imply that dopaminergic functional imaging is required for diagnosis.
(20) 9.. Documentation of an alternative condition known to produce parkinsonism and plausibly connected to the patient’s symptoms Note Dementia with Lewy Bodies is not considered an alternative parkinsonian syndrome.
(21) Red Flags.
(22) 1.. Rapid progression of gait impairment requiring regular use of wheelchair within 5 y of onset.
(23) 2.. Complete absence of progression of motor s/s over 5 or more years (unless stability is related to treatment) Note Targeted at patients who may have been misdiagnosed with parkinsonism.
(24) 3.. Early bulbar dysfunction (within the first 5 y of disease) Severe dysphonia Dysarthria Severe dysphagia Note MDS-UPDRS: 4 for dysarthria, 3 for dysphagia.
(25) 4.. Inspiratory respiratory dysfunction Diurnal or nocturnal inspiratory stridor Frequent inspiratory sighs.
(26) 5. Severe autonomic failure in the first 5y of disease Orthostatic hypotension Decrease of BP within 3 min of standing (at least 30 mm Hg SBP or 15 mm Hg DBP) Absence of dehydration, medication, or other diseases. Severe urinary incontinence/ retention Excluding longstanding low-volume stress incontinence (in women). Must be associated with erectile dysfunction; Not be caused by prostate disease (in men) Not functional incontinence. Note To identify the severe autonomic dysfunction associated with MSA.
(27) 6.. Recurrent (>1/y) falls because of impaired balance within 3 y of. onset. Note Be attributable to impaired balance 暈厥，癲癇，正常人也會跌倒的活動不算.
(28) 7.. Disproportionate anterocollis (dystonic in nature) or contractures of hand or feet within the first 10 y.
(29) 8. Absence of common nonmotor features of disease despite 5 y. disease duration Sleep dysfunction. Autonomic dysfunction Hyposmia Psychiatric dysfunction Note To detect non-parkinsonian conditions mimicking PD (dystonic tremor, essential tremor).
(30) 9.. Unexplained pyramidal tract signs = pyramidal weakness 或 pathologic hyperreflexia. Note Mild reflex asymmetry is excluded (commonly be seen in PD) Isolated extensor plantar response is excluded (difficulty in differentiating from a “striatal toe”).
(31) 10.. Bilateral symmetric parkinsonism Bilateral symptom onset No side predominance.
(32) Conclusion.
(33) 要臨床確診 ＝ 至少兩個支持條件，不能有排除條件，不能亮紅旗 支持條件 藥物有明顯效果，或有明顯停電來電現象 藥物造成的異動 靜止性顫抖 嗅覺測試或MIBG有發現.
(34) 排除條件 中等嚴重症狀，但高劑量藥物無效 突觸前多巴胺功能性影像正常. 症狀局限於下肢超過三年 垂直眼球運動受限 小腦症狀 五年內出現額葉顳葉失智或漸進性失語症 皮質症狀 （皮質感覺缺損，失用，漸進失語） 藥物造成的的類巴金森症狀 有其他可能造成類巴金森症狀. ＋syndrome.
(35) 紅旗 進展太快，五年內很快坐輪椅 進展太慢，五年後動作症狀沒惡化. 一開始就是雙側性症狀 口咽五年內受影響 呼吸功能異常 無法解釋的錐體路徑症狀. 十年內太過度的頸項前屈，或肢體蜷曲 三年內平衡不好太常跌倒 五年內出現自主神經異常 五年後沒出現非運動症狀（睡眠，自主神經，嗅覺喪失，精神症狀）.
(36)
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