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ALISTAIR BURNS, BRIAN LAWLOR, and
SARAH CRAIG
Rating scales in old age psychiatry
Br. J. Psychiatry, Feb 2002; 180: 161 - 167. [Abstract]
[Full
text] [PDF]
DEPRESSION
Geriatric
Depression Scale
The Geriatric Depression Scale (GDS) is a self-report
scale
designed to be simple to administer and not to
require the skills of a trained interviewer (Yesavage
et al, 1983). Each of the 30
questions has a yes/no answer, with the scoring
dependent
on the answer given. A sensitivity of 84% and
specificity of 95% have been documented with a cut-off
score of 11/12; a cut-off of 14/15 decreased
the sensitivity rate to 80% but increased
specificity to 100%. A 15-item version of the GDS has
been devised by Shiekh & Yesavage (1986),
and is probably the most common version currently used.
The shortened version has a cut-off score of
6/7 and correlates significantly with the
parent scale. Logistic regression analysis has been used
to derive a four-item version which has a
specificity of 88% with
a cut-off of 1/2, and sensitivity of 93% with a
cut-off of 0/1 (Katona, 1994). For
the assessment of depression in older people,
it is the scale against which others should be rated.
Brief Assessment
Schedule Depression Cards
The Brief Assessment Schedule Depression Cards (BASDEC)
system is based on the Brief Assessment
Schedule with the novel development that,
because of the difficulties of questions being overheard
on geriatric wards, patients choose answers from a deck
of
cards (Adshead et al, 1992).
The scale is administered by an interviewer
and takes 2-8 minutes to complete. The pack is
made up of 19 cards with enlarged black print on a white
background
and are presented one at a time. Both the GDS and
the BASDEC performed identically well in the
original study with a sensitivity of 71% and
negative predictive value of 86% against a psychiatric
diagnosis, using a BASDEC cut-off score of 6/7.
Cornell Scale for
Depression in Dementia
The Cornell Scale (Alexopoulos et al,
1988) is specifically for the assessment
of depression in dementia and is administered
by a clinician. It takes 20 minutes with the carer and
10 minutes with the patient.
It differs from other
depression scales in the method of administration rather
than in analysis of any different symptom profile seen
in depression with dementia compared with depression
alone
(Purandara et al, 2001). The 19-item scale is
rated on a three-point score of ‘absent’,
‘mild or intermittent’ and ‘severe’ symptoms,
with a note when the score is unevaluable. A
score of 8 or more suggests significant depressive
symptoms. It is the best scale available to assess mood
in the presence of cognitive impairment.
Geriatric Mental
State Schedule
The Geriatric Mental State Schedule (GMSS) is one of the
most widely used instruments for measuring a
wide range of psychopathology in older people
in all settings, but most importantly in community
surveys (Copeland et al,
1976). Literature on the GMSS is
extensive, and a number of different factors can be
derived from the results. There is a
computerised algorithm of proven
reliability and validity, AGECAT, which provides
standardised
diagnoses. The GMSS can be administered via a
laptop computer, has been translated into a number of
different languages, has to be administered
by a trained interviewer, and takes about 45
minutes to deliver. The use of the GMSS is limited to
research, where it represents the gold
standard.
Centre for
Epidemiological Studies — Depression scale
The Centre for Epidemiological Studies — Depression
(CES—D) scale is a self-administered scale, taking 5
minutes to complete. Originally developed for
a general population study (Radloff,
1977),
the instrument has been found to be particularly
useful
in older people. The scale consists of 20 items
and the scoring range is from 0 to 60. A
cut-off score of 16 has been suggested to
differentiate patients with mild depression from normal
subjects, with a score of 23 and over indicating
significant depression.
Hamilton Rating
Scale for Depression
The Hamilton Rating Scale for Depression (Hamilton,
1960) is the gold standard of
observer-rated depression rating scales. It
is a semi-structured interview, requires training to
complete, and takes 20-30 minutes to
administer. It is used to assess
in all age groups, both for clinical and research
purposes, the severity of depression rather
than as a diagnostic tool. A cut-off score of
10/11 is generally regarded as appropriate
for the diagnosis of depression.
Montgomery— sberg
Depression Rating Scale
The Montgomery—sberg
Depression Rating Scale (MADRS) is administered by a
trained interviewer, takes 20 minutes to
complete and was designed as a measure of change
in studies of the treatment of depression (Montgomery
&
sberg,
1979). It was developed by taking items
from a longer scale. It is widely used in treatment
trials,
in both young and older patients. Specific
instructions are given regarding the ratings
and there is a comparative lack of emphasis
on somatic symptoms, making it useful for the assessment
of depression in people with physical illness. Cut-off
scores
have been suggested by Snaith et al (1986):
0-6 indicates the absence of depression (or recovery in
the setting of a clinical trial); 7-19, mild
depression; 20-34, moderate depression; and
35 and above, severe depression.
DEMENTIA:
COGNITIVE IMPAIRMENT
Mini-Mental State
Examination
The Mini-Mental State Examination (MMSE) is a rating of
cognitive function and takes 10 minutes to
administer by a trained interviewer (Folstein
et al, 1975). It is the most widely used measure
of cognitive function, and users need some
training and familiarisation with the
instrument. Much has been written about the MMSE and
amendments have been suggested such as the Standardised
Mini-Mental
State Examination (Molloy et
al, 1991) and the Modified Mini-Mental
State (Teng et al, 1987).
The original validity and reliability of the
MMSE were based on 206 patients with a variety of
psychiatric
disorders, the scale successfully separating those with
dementia, depression, or a combination of the
two. Details of extensive subsequent validity
and reliability studies are described by
Tombaugh & McIntyre (1992). A
cut-off score of 23 for the presence of
cognitive impairment has been suggested, with
variations depending on lack of education.
Mental Test Score
and Abbreviated Mental Test Score
The Mental Test Score (MTS) and its abbreviated version
are brief questionnaires to assess the degree
of cognitive function, particularly memory
and orientation; the MTS takes 10 minutes to
administer, and the abbreviated form 3 minutes (Hodkinson,
1972). The MTS was developed from the
Blessed Dementia Scale and was used in a
study of over 700 patients carried out under
the auspices of the Royal College of Physicians in the
1970s.
A score of 25 and above (out of 34) is within normal
range.
From it, the Abbreviated Mental Test Score (AMTS)
was developed, scored out of 9 or 10
(depending on whether the optional recognition
questionnaire is completed). A cut-off score of 7/8 out
of 10
(or 6/7 out of 9) is suggested to discriminate
between cognitive impairment and normality.
Qureshi & Hodkinson (1974) further
validated the shorter questionnaire.
Clock drawing
test
The clock drawing test takes only 2 minutes to
administer and reflects frontal and
temporoparietal functioning (Brodaty &
Moore, 1997;
Shulman et al, 1986). The
main advantages are its simplicity of
administration and the non-threatening nature
of the task. The patient is asked to draw a clock face
marking the hours and then draw the hands to indicate a
particular
time (e.g. 10 minutes to 2). Standardised methods
of scoring have been described with
sensitivities of up to 86% and specificity of
up to 96% compared with diagnosis using the MMSE. This
test is particularly useful in the general
practice setting.
Seven-minute
neurocognitive screening battery
The 7-minute neurocognitive screening battery is a test
for cognitive impairment which aims to
distinguish patients with dementia and normal
controls (Solomon
et al, 1998). It takes a mean of 7
minutes 42 seconds (range 6-11 minutes) to administer
by a trained interviewer. The 7-minute screen
consists of four tests representing four
cognitive areas affected in Alzheimer's disease: memory,
verbal fluency, visuoconstruction and orientation
for time. The screening instrument was designed so that
it
could be rapidly administered by a technician, requiring
no clinical judgement or training. It
distinguishes patients with early Alzheimer's
disease from those with normal ageing. It is
a relatively new instrument and its exact use has still
to be established.
Alzheimer's
Disease Assessment Scale
The Alzheimer's Disease Assessment Scale (ADAS) takes 45
minutes administered by a trained observer and is a
standardised assessment of cognitive function
and non-cognitive features (Rosen et
al, 1984). The cognitive section of the scale
(ADAS-Cog) is the gold standard for measuring
change in cognitive function in drug trials.
Deterioration of about 10% per year in cognitive
tests in patients with Alzheimer's disease is regarded
as average.
The cognitive domains include components of
memory, language and praxis, while the
non-cognitive features include mood state and
behavioural changes. There are 11 main sections testing
cognitive function and 10 assessing non-cognitive
features.
GLOBAL
ASSESSMENTS
Clinical Dementia
Rating
The Clinical Dementia Rating (CDR)
scale is used as a global measure of dementia
(Hughes
et al, 1982; Berg, 1984)
and is usually completed by a clinician in
the setting of detailed knowledge of the
individual patient. Much of the information
will therefore already have been gathered, either as
part of
normal clinical practice or as part of a research study.
If a specific interview is carried out, about
40 minutes is needed to gather the relevant
information. The CDR has become one of
the main methods by which the degree of dementia is
quantified
into stages. Six domains are assessed: memory;
orientation;
judgement and problem-solving; community affairs;
home and hobbies; and personal care. Ratings
are 0 for healthy people, 0.5 for
questionable dementia and 1, 2 and 3 for mild, moderate
and severe dementia as defined in the CDR
scale.
Clinicians'
Global Impression of Change
The Clinicians' Global Impression of Change scale is
administered
by a trained rater and takes 10-40 minutes (Guy,
1976). The ratings depend on the ability
of the clinician to detect change, and any
change that is clinically detectable is significant.
By definition, these measures are global ratings of a
patient's
clinical condition, and inevitably draw
information from a wide variety of sources.
The scale has been used extensively in
clinical trials of antidementia drugs where a global
assessment of the degree of dementia is required, and
can usefully assess change from a specified
baseline (Knopman et al, 1994;
Schneider & Olin, 1996).
BEHAVIOURAL AND
PSYCHOLOGICAL SYMPTOMS
Neuropsychiatric
Inventory
The Neuropsychiatric Inventory (NPI) evaluates a wider
range
of psychopathology than comparable instruments (Cummings
et al, 1994). It may help
distinguish between different causes of
dementia, records severity and frequency separately, and
takes 10 minutes to administer. The NPI assesses ten
domains:
delusions; hallucinations; dysphoria; anxiety;
agitation/aggression;
euphoria; disinhibition; irritability/lability;
apathy; and aberrant motor behaviour. A
screening strategy is used to cut down the
length of time the instrument takes to administer,
but obviously it takes longer if replies are positive.
It is scored from 1 to 144 and severity and frequency
are independently assessed. The NPI has been
translated into a number of languages
and it is now used widely in drug trials.
BEHAVE—AD
The BEHAVE—AD (Reisberg et al,
1987) takes 20 minutes to administer by a
clinician and was designed particularly to be
useful in prospective studies of behavioural symptoms
and in pharmacological trials to document behavioural
symptoms
in patients with Alzheimer's disease. The
BEHAVE—AD is the original behaviour rating
scale in Alzheimer's disease. It is in two
parts: the first part concentrates on symptomatology,
and the second requires a global rating of the symptoms,
on a four-point scale of severity. The
domains covered are paranoid
and delusional ideation; hallucinations; activity
disturbances; aggression; diurnal variation; mood; and
anxieties and phobias.
MOUSEPAD
The Manchester and Oxford Universities Scale for the
Psychopathological Assessment of Dementia (MOUSEPAD) is
administered to carers
by an experienced clinician, and takes 15-30
minutes, most items being given a three-point
severity score (Allen et al, 1996).
The main indication for use of the scale is the
measurement of psychiatric symptoms and behavioural
changes in patients
with dementia.
The MOUSEPAD is based on
the longer Present Behavioural Examination (Hope
& Fairburn, 1992), and was developed as a shorter
instrument and one with an equal emphasis on
psychiatric symptomatology and behavioural
changes.
Cohen-Mansfield
Agitation Inventory
The seven-point rating system of the Cohen-Mansfield
Agitation
Inventory (CMAI) assesses 29 different agitated
behaviours
in patients with cognitive impairment (Cohen-Mansfield,
1989). It takes 10-15 minutes and is
carried out by carers. Training is essential.
The agitated behaviours include wandering, aggression,
inappropriate vocalisation, hoarding items, sexual
disinhibition
and negativism, and are rated on a seven-point
scale of frequency. The CMAI is useful for
the assessment of agitation in residents of
nursing and residential homes.
Revised Memory
and Behaviour Problems Checklist
The Revised Memory and Behaviour Problems Checklist
assesses
behavioural problems in dementia, taken from
caregiver reports (Teri et al,
1992). It is a 24-item list that provides one
total score and three subscores for memory-related
problems,
depression and disruptive behaviours, assessing
both the frequency of the behaviour and the
caregiver's reaction.
ACTIVITIES OF
DAILY LIVING
Bristol
Activities of Daily Living Scale
The Bristol Activities of Daily Living Scale was
designed specifically for use in patients
with dementia (Bucks et al, 1996).
The
scale assesses 20 daily living abilities. Face
validity was measured by way of carer
agreement that the items were important, construct
validity was confirmed by principal components analysis
and concurrent validity by assessment with observed
performance,
and there is good test—retest reliability. Three
phases
in the design of the scale are described, and
researchers designing their own scale should
read the account of this development, which
is a model of clarity.
Alzheimer's
Disease Functional Assessment and Change Scale
The Alzheimer's Disease Functional Assessment and Change
Scale (ADFACS) is used for the assessment of
activities of daily living in patients with
Alzheimer's disease with particular reference
to outcomes in clinical trials (Galasko
et al, 1997). It is informant-based
and takes 20 minutes. The scale has been used
in drug trials, and consists of ten items for
instrumental activities of daily living: ability to use
the telephone; performing
household tasks; using household appliances;
handling money; shopping; preparing food;
ability to get around both inside and outside
the home; pursuing hobbies and leisure activities;
handling personal mail; and grasping situations or
explanations.
These are rated from no impairment to severe
impairment.
Basic activities of daily
living are assessed on a six-point scale (an
additional rating, very severe impairment, is included).
These are: toileting, dressing, personal hygiene
and grooming, physical ambulation and
bathing. The scale was developed from 45
activities of daily living items, with the chosen items
having been shown to be sensitive to change over 12
months,
to correlate with the MMSE and to have good
test—retest
reliability (Galasko et al,
1997).
Interview for
Deterioration in Daily Living Activities in Dementia
The Interview for Deterioration in Daily Living
Activities in Dementia (IDDD) assesses
activities of daily living, taking 15 minutes
to administer with a caregiver (Teunisse
et al, 1991). The scale covers 33 self-care
activities such as washing, dressing and eating, as well
as more complex activities such as shopping,
writing and answering the telephone, tasks performed
equally by men and women (earlier scales of activities
of daily living tended to rely more heavily
on female-dominated and less complex tasks).
Both the initiative to perform activities
and the performance itself are evaluated.
Disability
Assessment for Dementia
The Disability Assessment for Dementia (DAD) scale (Gelinas
et al, 1999) is rated by a trained
observer and takes 20 minutes. It is a new
functional scale specifically developed for patients
with Alzheimer's disease and assesses basic and
instrumental
activities of daily living.
GLOBAL MEASURES
OF PSYCHIATRIC SYMPTOMATOLOGY
Psychogeriatric
Assessment Scale
The Psychogeriatric Assessment Scale (PAS) provides an
assessment
of the clinical changes of dementia and depression
(Jorm et al, 1995).
The package is easy to administer and score, and
can be used by lay interviewers. It is intended
for use both in research and service
evaluation, taking about 10 minutes to
administer by a trained lay interviewer or clinician.
There are three scales derived from an
interview with the subject (cognitive impairment,
depression, stroke) and three derived
from an interview with an informant (cognitive
decline, behavioural change, stroke).
Brief Psychiatric
Rating Scale
The Brief Psychiatric Rating Scale (BPRS) takes about 20
minutes and is administered by a trained
interviewer. The BPRS is a 16-item,
seven-point ordered category rating scale which has
been developed through previous versions (Overall
& Gorham, 1962).
The domains assessed are somatic concern; anxiety;
emotional withdrawal; conceptual
disorganisation; guilt feelings; tension; mannerisms and
posturing; grandiosity; depressive mood; hostility;
suspiciousness; hallucinatory behaviour; motor
retardation; uncooperativeness; unusual
thought content; and blunted affect.
The questions are completed in 2-3 minutes following the
interview.
Health of the
Nation Outcome Scales 65+
The Health of the Nation Outcome Scales 65+ (HoNOS 65+)
are an adaptation of the equivalent scale for
younger people (Burns et
al, 1999a). It is a 12-item score dealing
with the following aspects of the mental state and
living situation: aggression; self-harm; drug
and alcohol use; cognitive problems; physical
illness and disability; hallucinations and delusions;
depression; other symptoms; relationships;
activities of daily living;
residential environment; and daytime activities.
Its main use is in the
provision of the global assessment of a
patient. Its administration takes about 10 minutes and
requires some training. The HoNOS 65+ is
becoming a useful tool in defining
the characteristics of populations of older people
with mental health problems.
Cambridge Mental
Disorders of the Elderly Examination
The Cambridge Mental Disorders of the Elderly
Examination (CAMDEX) is a structured
instrument made up of eight sections — an
interview with the subject, a cognitive section (the
CAMCOG), the interviewer's observations of
the subject, a physical examination,
results of investigations, a note of medication,
any additional information and an interview
with an informant (Roth et al,
1986). The resulting information provides a
formal diagnosis in a number of categories:
four types of dementia, delirium, depression,
anxiety, paranoid disorder, and other psychiatric
disorders. Interrater reliability is excellent and a
cut-off score of 79/80 gives a 92%
sensitivity and 96% specificity in relation to a
diagnosis of dementia. The CAMDEX has been used
extensively in research studies.
CARER BURDEN AND
QUALITY OF LIFE
General Health
Questionnaire
The General Health Questionnaire (GHQ) is a
self-administered
screening test used for detecting psychiatric
disorders in community settings and
non-psychiatric clinical settings (Goldberg
& Williams, 1988).
A number of versions are available; the
commonly used 12-item one takes 5 minutes. It is not
normally
used as a screening measure in older people, but
has been used as a measure of psychological
distress and psychiatric morbidity in carers
of patients with dementia (Marriott
et al, 2000)
and seems to be sensitive to change in that
situation.
Quality of Life
in Alzheimer's Disease Patient and Caregiver Report
The Quality of Life in Alzheimer's Disease Patient and
Caregiver
Report (QoL—AD) is used for the assessment of
quality
of life in dementia and is taken from self and
caregiver reports (Logsdon et al,
1999). This 13-item assessment relates to the
domains of mood, physical health, memory, relationships,
self-esteem
and current situation. Each is marked on a
four-point scale.
OTHER SCALES
Confusion
Assessment Method
The Confusion Assessment Method (CAM) instrument (Inouye
et al, 1990) consists of nine
operationalised criteria from DSM—III—R (American
Psychiatric Association, 1987) including the four
cardinal features of delirium: acute onset and
fluctuation,
inattention, disorganised thinking and altered
level of consciousness. Both the first and
second features, and either the third or fourth feature,
are required for the diagnosis. The results
have been validated against psychiatric diagnosis and
found to be valid.
Cognitive
Failures Questionnaire
The Cognitive Failures Questionnaire (CFQ) is used as a
measure of self-reported failures in
perception, memory and motor function (Broadbent
et al, 1982) and takes about 10 minutes to
complete.
This questionnaire may be of use in screening
different memory complaints in a population
or clinical sample. Its use has not been
validated against the presence or absence of dementia,
but it gives a useful overview of which aspects of
memory loss
are giving rise to problems.
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