Table 1.

Supportive criteria, absolute exclusion criteria, and red flags for the diagnosis of Parkinson’s disease, according to the revised International Parkinson and Movement Disorder Society (MDS-PD) diagnostic criteria [Postuma et al. (21)].

Supportive criteria
Clear and dramatic beneficial response to dopaminergic therapy. During initial treatment, patient returned to normal or near-normal level of function. In the absence of clear documentation of initial response a dramatic response can be classified as: (a) marked improvement with dose increases or marked worsening with dose decreases. Mild changes do not qualify. Document this either objectively (>30% in UPDRS III with change in treatment), or subjectively (clearly documented history of marked changes from a reliable patient or caregiver) (b) unequivocal and marked on/off fluctuations, which must have at some point included predictable end-of-dose wearing off Presence of levodopa-induced dyskinesia Rest tremor of a limb, documented on clinical examination (in past, or on current examination) The presence of either olfactory loss or cardiac sympathetic denervation on MIBG scintigraphy
Absolute exclusion criteria: the presence of any of these features rules out PD
Unequivocal cerebellar abnormalities, such as cerebellar gait, limb ataxia, or cerebellar oculomotor abnormalities (e.g., sustained gaze evoked nystagmus, macro square wave jerks, hypermetric saccades)
Downward vertical supranuclear gaze palsy or selective slowing of downward vertical saccades
Diagnosis of probable behavioral variant frontotemporal dementia or primary progressive aphasia, defined according to consensus criteria within the first 5 years of disease
Parkinsonian features restricted to the lower limbs for more than 3 years
Treatment with a dopamine receptor blocker or a dopamine-depleting agent in a dose/time-course consistent with drug-induced parkinsonism
Absence of observable response to high-dose levodopa despite at least moderate severity of disease
Unequivocal cortical sensory loss (graphesthesia, stereognosis with intact primary sensory modalities), clear limb ideomotor apraxia, or progressive aphasia
Normal functional neuroimaging of the presynaptic dopaminergic system
Documentation of an alternative condition known to produce parkinsonism and plausibly connected to the patient’s symptoms, or, the expert evaluating physician, based on the full diagnostic assessment feels that an alternative syndrome is more likely than PD
Red flags
Rapid progression of gait impairment requiring regular use of wheelchair within 5 years of onset
A complete absence of progression of motor symptoms or signs over 5 or more years unless stability is related to treatment
Early bulbar dysfunction: severe dysphonia or dysarthria (speech unintelligible most of the time) or severe dysphagia (requiring soft food, NG tube, or gastrostomy) within first 5 years
Inspiratory respiratory dysfunction: either diurnal or nocturnal inspiratory stridor or frequent inspiratory sighs
Severe autonomic failure in the first 5 years of disease. This can include: (a)orthostatic hypotension—orthostatic decrease of blood pressure within 3 min of standing by at least 30 mmHg systolic or 15 mmHg diastolic, in the absence of dehydration, medication, or other diseases that could plausibly explain autonomic dysfunction, or (b)severe urinary retention or urinary incontinence in the first 5 years of disease (excluding long-standing or small amount stress incontinence in women), that is not simply functional incontinence. In men, urinary retention must not be attributable to prostate disease, and must be associated with erectile dysfunction
Red flags
Recurrent (>1/year) falls because of impaired balance within 3 years of onset
Disproportionate anterocollis (dystonic) or contractures of hand or feet within the first 10 years
Absence of any of the common non-motor features of disease despite 5 years disease duration. These include sleep dysfunction (sleep-maintenance insomnia, excessive daytime somnolence, symptoms of REM sleep behavior disorder), autonomic dysfunction (constipation, daytime urinary urgency, symptomatic orthostasis), hyposmia, or psychiatric dysfunction (depression, anxiety, or hallucinations)
Otherwise-unexplained pyramidal tract signs, defined as pyramidal weakness or clear pathologic hyperreflexia (excluding mild reflex asymmetry and isolated extensor plantar response)
Bilateral symmetric parkinsonism. The patient or caregiver reports bilateral symptom onset with no side predominance, and no side predominance is observed on objective examination

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