Identification of Advanced Parkinson's Disease in North Africa: Calibrating the 5–2–1 Criteria Threshold

Accurate identification of advanced Parkinson's disease (APD) remains a challenge in routine practice, as it guides referral for device-aided therapies.The 5-2-1 composite criteria-derived from a Delphi consensus-define APD by ≥5 daily levodopa doses, ≥2 hours of "off" time, or ≥1 hour of troublesome dyskinesia, with fulfillment of any single criterion considered sufficient for APD classification. 1 However, the current threshold may reduce specificity and result in overclassification in populations with distinct genetic profile.North Africa represents such a setting, with frequencies of the LRRK2-G2019S mutation reaching 30-42%. 2 This mutation increases the risk of levodopa-induced dyskinesia and motor fluctuations despite slower overall disease progression.2,3 As a result, levodopa-related motor manifestations may appear earlier and reflect mutation-related susceptibility rather than true disease advancement, potentially leading a single 5-2-1 criterion to overestimate APD in some patients.Any APD overestimation may be especially consequential in North Africa, where specialized movement disorder services remain limited.In this context, an insufficiently specific screening strategy may overload referral pathways and delay access for patients genuinely eligible for advanced therapies.