Global assessments are Food and Drug Administration-required primary outcome measures in trials of putative antidementia drugs. Global ratings are intended to provide an index of clinical importance of change that cannot be obtained from quantitative assessment measures such as mental status examinations. Initially there were placebo patients, of whom completed the week study. Descriptive statistics, correlations with changes on other assessment instruments, and test-retest reliability were determined for the CIBI. The CIBI ratings were weakly but significantly correlated, in the expected direction, with change scores on the quantitative cognitive assessments. The CIBI was modestly reliable on test-retest at weeks 22 and 24 but less reliable compared with other quantitative outcome measures.
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Open in a separate window Bold text indicates scoring direction of positive screen for dementia. Any clinician can use this, and it takes only 3—4 min. It assesses orientation, registration, recall and concentration, and scores of 6 or below from maximum of 10 have been shown to screen effectively for dementia, though as with many brief screens, low positive predictive values mean a second-stage assessment is always necessary [ Antonelli Incalze et al.
Its brevity and ease of use have made it popular as a screening test in primary and secondary care nonspecialist settings. Clock drawing Numerous versions of the clock-drawing test have been devised, with many scoring algorithms [ Brodaty and Moore, ].
Patients are typically asked to draw a clock face with numbers and hands indicating a dictated time. It was designed as a quick and acceptable screening test for dementia.
It is fast, requires no training and most scoring methods are fairly simple. It shows fairly good sensitivity and specificity as a screening test. It assesses only a very narrow part of cognitive dysfunction seen in dementia, and many other conditions e. It incorporates the clock-drawing test, adding a three-item delayed word recall task. It is easy to administer, though scoring is less intuitive than AMTS.
The maximum score is 50; at a score of 30 or below, the test has good specificity and sensitivity [comparable to MMSE and Addenbrookes Cognitive Assessment — Revised ACE-R ] in distinguishing dementia from nondementia cases [ Hancock and Larner, ].
This form of test may be attractive for time-limited clinicians wanting to screen for dementia, especially in primary care. In total, it takes about 6 min. It has strong performance on sensitivity and specificity versus MMSE in detecting dementia in a typical primary care population [ Ismail et al. Memory Impairment Screen The Memory Impairment Screen is a very brief four-item scale taking under 5 min to administer, and showing good sensitivity and specificity in classifying dementia [ Buschke et al.
It lacks executive function or visuospatial items. This scale can be easily administered by clinicians or researchers with minimal training, takes around 10 min and assesses cognitive function in the areas of orientation, memory, attention and calculation, language and visual construction. It is widely translated and used. A standardized version [ Molloy et al. The MMSE is unfortunately sometimes misunderstood as a diagnostic test, when it is in fact a screening test with relatively modest sensitivity.
It has floor and ceiling effects and limited sensitivity to change. This in theory should limit its wider use in detecting change in clinical work and in research studies, though in these contexts it is still widely used, and even advocated [ NICE, ]. It takes minimal training and can be used in about 10 min by any clinician.
A score of 25 or lower from maximum of 30 is considered significant cognitive impairment. It performs at least as well as MMSE, including in screening for dementia. It has been widely translated. As it assesses executive function, it is particularly useful for patients with vascular impairment, including vascular dementia. It takes 15—20 min to administer and includes the items which lead to a MMSE score. It has been shown to have very high reliability and excellent diagnostic accuracy, and it is a practical option for clinical services intent on precision in diagnoses.
It covers all cognitive areas in dementia and has good sensitivity to change. The length of the assessment makes it generally unsuitable for clinical settings, but it is included as it is the leading assessment of cognitive change in drug trials in dementia, with a four-point difference between treatment groups considered clinically important [ Rockwood et al. It covers a range of cognitive functions, including orientation, language, memory, attention, praxis, calculation, abstract thinking and perception.
It takes around 25—40 min for a clinician to administer and requires a modest degree of training. Its combination of breadth and relative brevity make it suitable for clinical use, particularly new assessments of patients in memory clinics.
It has the added advantage of including questions to generate an MMSE score. It takes a carer professional or family 15 min to administer. It is sensitive to change in dementia and short enough to use in clinical practice carers may fill it in while clinicians are performing direct assessment of patients. It is regularly used as an outcome measure in clinical trials, where it is world leading as a dementia-specific measure. This outcome is among those recommended by a consensus recommendation of outcome scales for nondrug interventional studies in dementia [ Moniz-Cook et al.
Barthel Index The Barthel index [ Mahoney and Barthel, ] is probably the best known assessment of functional ability for older people. It focuses on physical disability in 10 domains and should not be used other than to assess physical functional deficits in people with dementia, among whom cognitive deficits tend to confound assessment.
It is observer rated and covers multiple important domains, including self-care, sphincters, mobility, communication, psychosocial function and cognition. Some training is required for its use. A UK version is available and it has been used in repeated observations of inpatients in general hospital [ Zekry et al.
It is therefore an example of a scale which addresses cognitive as well as physical function, and is likely to be especially useful in inpatient or rehabilitation settings. Instrumental Activities of Daily Living The Instrumental Activities of Daily Living scale [ Lawton and Brody, ] takes 5 min for a basically trained interviewer to assess ability in eight complex daily living tasks such as telephone use, shopping, housekeeping and finances. These abilities are more complex than the more basic abilities assessed by the Barthel scale, and therefore more sensitive to the cognitive changes seen in dementia.
It is very commonly used in European memory clinics [Ramirez-Diaz et al. It takes about 10 min to administer, and is conventionally used at the assessment stage in diagnosing dementia, usually combined with a direct cognitive assessment of the patient.
This combination increases accuracy of diagnoses versus cognitive assessment alone [ Jorm, ]. It is therefore suitable as a screening tool rather than in assessing change in function. These include delusions, agitation, depression, irritability and apathy. The scale takes 10 min for a clinician to administer to a carer. It has good psychometric properties and is widely used in drug trials, while being short enough especially with patients without a wide range of behavioural issues to consider for use in clinical practice.
Up to 29 behaviours seen in dementia are rated for frequency — the lack of focus on severity is corrected by the breadth of behaviours covered. The behaviours covered include many of those found most disruptive, including verbal aggression, repetitiveness, screaming, hitting, grabbing and sexual advances.
It is most commonly used in research settings. Respondents are asked about the presence of behaviours and how troubling they are. It is reliable, sensitive to change and to stage of disease. Quality of life Generic measures of quality of life EuroQol The EuroQol measure [ EuroQol Group, ] is a short, freely available generic measure of health-related quality of life.
It can be simply administered to patients or carers in the form of a very brief self-completed questionnaire. It takes 2 min to complete. Like many quality of life instruments, carer and proxy ratings diverge widely, many patients with dementia cannot fill out the instrument, and the chief use of EuroQoL in dementia is as a health utility measure for measuring the economic impact of interventions in trials.
These instruments have been shown to have high rates of noncompletion among frail older people and especially among those with moderate to severe dementia.
They may have limited use for carers of people with dementia, but probably cannot routinely be used in practice with patients. It takes 10—15 min to administer. Patient and proxy versions are available. In a controversial area, its disease- specific properties, along with those of the health-related quality of life in dementia instrument DEMQOL , make it a leading choice if quality of life is to be assessed [ Moniz-Cook et al.
It has both patient-completed and proxy forms. Like QoL-AD, it is primarily likely to be used in research studies. GDS is usually self rated though can be rated by an assessor. It is sensitive to change and is reliable in older people in institutional care.
It takes about 5—10 min to administer. Its major drawback in dementia is that it has been validated for people with mild dementia, but not for those with moderate to severe dementia among whom completion rates may be low due to difficulty comprehending questions.
The maximum score is It has been validated patients with and without dementia [ Alexopoulos et al. In patients with dementia, it is considered the gold standard for quantifying depressive symptoms.
It is useful among older patients in that mainly psychological rather than confounding physical symptoms are assessed. It is particularly sensitive to change and often used in interventional research but the same issues as with GDS will limit its usefulness outside mild dementia. It requires 20—30 min of questions in a semi-structured interview by a trained interviewer, and is therefore unlikely to be used in people with dementia.
It is commonly used in antidepressant drug trials, and like MADRS, has a preponderance of psychological rather than physical items. The Hospital Anxiety and Depression Scale The Hospital Anxiety and Depression Scale [ Zigmond and Snaith, ] is a popular screening test for depression and anxiety which was originally aimed at patients in hospital, though it has been used much more widely in recent years. It takes 3—5 min and is self-reported. Though easy to use and accurate at detecting depression, it has little practical use for older patients with significant cognitive impairment.
Carer burden General Health Questionnaire The General Health Questionnaire, item version [ Goldberg and Williams ] is a short self-rated scale designed to screen for psychological distress in the community. It is probably the most widely used and validated self-rated instrument for detection of psychological morbidity.
It takes only a few minutes to administer. Being disease specific gives it primacy in the area. Overall dementia severity Clinical Dementia Rating The Clinical Dementia Rating scale [ Morriss, ] allows more reliable staging of dementia than MMSE, and is based on caregiver accounts of problems in daily functional and cognitive tasks.
It takes only a few minutes for clinicians already familiar with individual cases, and classifies people with dementia into questionable, mild, moderate and severe. It has been well validated and classifies cases into seven stages from no complaints through to very severe. Like CDR, it is mainly used to assort cases by severity in research or in service development, as in an individual case, more subtle changes which are important may not be picked up.
It is therefore conceptually attractive for assessing progression, but requires a trained clinician and 10—40 min of interview time so may be unsuited to routine clinical practice.
Discussion A key consideration in deciding what dementia assessment scales to choose is to clarify the question being asked. Consensus guidelines have been attempted [ Ramirez Diaz et al. Most of the brief screening instruments like 6-CIT, clock drawing and AMTS are probably psychometrically as good as a common instrument like MMSE in screening for significant cognitive impairment, and are a little shorter.
They lack the breadth of assessments in MMSE and are therefore to be used only in settings in which time or frailty make longer assessment impossible.
CIBIC Plus-J Assessment Using a Videotaped Method in Alzheimer's Disease Patients
Open in a separate window Bold text indicates scoring direction of positive screen for dementia. Any clinician can use this, and it takes only 3—4 min. It assesses orientation, registration, recall and concentration, and scores of 6 or below from maximum of 10 have been shown to screen effectively for dementia, though as with many brief screens, low positive predictive values mean a second-stage assessment is always necessary [ Antonelli Incalze et al. Its brevity and ease of use have made it popular as a screening test in primary and secondary care nonspecialist settings. Clock drawing Numerous versions of the clock-drawing test have been devised, with many scoring algorithms [ Brodaty and Moore, ]. Patients are typically asked to draw a clock face with numbers and hands indicating a dictated time. It was designed as a quick and acceptable screening test for dementia.
Assessment scales in dementia
Statistical Methods for Research Workers. We tested the efficacy and tolerability of one-year treatment with memantine 10 mg bid in behavioral variant frontotemporal dementia bvFTD. This wcale aimed to assess the clinically variable ChEI treatment effects in a group of patients with mild AD using a semantic association and an N-back light working memory activation paradigm. To highlight the utility of using an effect size analysis to communicate the effectiveness of treatment interventions.