<P> PD invariably progresses with time . A severity rating method known as the Unified Parkinson's disease rating scale (UPDRS) is the most commonly used metric for clinical study . A modified version known as the MDS - UPDRS is also sometimes used . An older scaling method known as the Hoehn and Yahr scale (originally published in 1967), and a similar scale known as the Modified Hoehn and Yahr scale, have also been commonly used . The Hoehn and Yahr scale defines five basic stages of progression . </P> <P> Motor symptoms, if not treated, advance aggressively in the early stages of the disease and more slowly later . Untreated, individuals are expected to lose independent ambulation after an average of eight years and be bedridden after ten years . However, it is uncommon to find untreated people nowadays . Medication has improved the prognosis of motor symptoms, while at the same time it is a new source of disability, because of the undesired effects of levodopa after years of use . In people taking levodopa, the progression time of symptoms to a stage of high dependency from caregivers may be over 15 years . However, it is hard to predict what course the disease will take for a given individual . Age is the best predictor of disease progression . The rate of motor decline is greater in those with less impairment at the time of diagnosis, while cognitive impairment is more frequent in those who are over 70 years of age at symptom onset . </P> <P> Since current therapies improve motor symptoms, disability at present is mainly related to non-motor features of the disease . Nevertheless, the relationship between disease progression and disability is not linear . Disability is initially related to motor symptoms . As the disease advances, disability is more related to motor symptoms that do not respond adequately to medication, such as swallowing / speech difficulties, and gait / balance problems; and also to levodopa - induced complications, which appear in up to 50% of individuals after 5 years of levodopa usage . Finally, after ten years most people with the disease have autonomic disturbances, sleep problems, mood alterations and cognitive decline . All of these symptoms, especially cognitive decline, greatly increase disability . </P> <P> The life expectancy of people with PD is reduced . Mortality ratios are around twice those of unaffected people . Cognitive decline and dementia, old age at onset, a more advanced disease state and presence of swallowing problems are all mortality risk factors . On the other hand, a disease pattern mainly characterized by tremor as opposed to rigidity predicts an improved survival . Death from aspiration pneumonia is twice as common in individuals with PD as in the healthy population . </P>

Which of the following is associated with parkinson's disease