Department of Old Age Psychiatry, University of Manchester, UK
St Patrick's Hospital, Dublin, Ireland
Royal Bolton Hospitals NHS Trust, Bolton, UK
Correspondence: Professor Alistair Burns, Department of Old Age Psychiatry, Education and Research Centre, Wythenshawe Hospital, Southmoor Road, Manchester M23 9LT, UK. Tel: +44 (0) 161 291 3310; Fax: +44 (0) 161 291 5862; e-mail: a_burns{at}fsl.with.man.ac.uk
Declaration of interest The authors have received honoraria and hospitality from pharmaceutical companies working in old age psychiatry.
See editorial, pp.
9798, this issue.
ABSTRACT
Background There is a vast array of scales available to assess all aspects of mental and physical health in older people which may be of relevance to the work of old age psychiatrists.
Aims To summarise some of the scales that may be commonly used in clinical and research practice and to give the reader guidelines as to where further information can be obtained.
Method The scales were selected on the basis of the authors' own clinical and research knowledge and information was gathered from a comprehensive text on assessment scales in old age psychiatry.
Results The selected scales are described in brief and a table outlines the purposes for which they are most suitable.
Conclusions Although many scales are available, the choice of the individual scale relies specifically on the question that is to be asked. The ideal scale does not exist.
INTRODUCTION
A multitude of scales are available to assess the effects of mental and physical problems in older people. A recent compendium of scales (Burns et al, 1999b) contained 162, all of which are available to the old age psychiatrist interested in applying them in a clinical setting. This wide choice presents a formidable challenge to the clinician or researcher in deciding which scale is the most appropriate to use. The purpose of this paper is to help readers sift through the plethora of published scales and enable them to move towards making an informed choice of what to use and when.
What is the purpose of applying the rating scale?
Determining which scale should be selected must always follow an analysis
of the underlying purpose. It is remarkable how often this simple step is
ignored and this frequently leads to the wrong choice. Is the scale to be used
to screen a population, to assess severity of symptoms, to help with diagnosis
or to monitor change?
What is to be measured?
There are five major clinical domains that are relevant to the old age
psychiatrist: mood; behaviour; functioning; cognition; and quality of life and
carer burden. Each can be measured separately using a specific scale, or
alternatively can be assessed as part of a multi-dimensional instrument.
Who is to carry out the rating?
Ratings can be self-reported, observerrated, or based on information from
an informant. The choice of instrument is often based on a combination of the
user's familiarity with the scale, the time available for its application, and
the presence and reliability of an informant. Subjective ratings are highly
dependent on the cooperation of patients and their ability to understand
either written or verbal instructions. Observer-based ratings can be
time-consuming, and can misinterpret the severity and impact of the illness
because they reflect a snapshot rather than a
video of the patient's illness. Informant-based ratings are
commonly used for patients with dementia, who may not be reliable observers of
their own functioning or behaviour; such ratings may be subject to bias,
influenced by the informant's mood state or perceptions. Often, a combination
of proxy reporting followed by direct patient interview gives the best
result.
What resources are available?
The time available and the person who is to carry out the rating are key
factors in determining choice of scale. For a scale to be used as part of
routine clinical practice it has to be brief and easy to administer. Many
instruments require specific training although, generally speaking, scales can
be completed by any competent clinician. There is rarely a need for
independent assessment of interrater and testretest reliability, unless
the scale is being applied to a population different from that in the original
description.
Which scale to use?
A brief description of the scales most frequently used in old age
psychiatry is provided below and is summarised in
Table 1, which also lists the
time needed for the rating procedure, and whether it is to be done by an
observer, the caregiver or the patient. Some instruments have been developed
specifically for elderly patients, whereas others have been adapted for use in
the elderly. For example, the Brief Psychiatric Rating Scale was developed for
use in young patients with schizophrenia but is often used to measure
agitation in elderly patients with dementia. Scales developed specifically
for, and standardised in, older people are preferable to scales developed for
younger people, which may not translate well to older populations. The
Hamilton Rating Scale for Depression may underestimate depression in older
patients because of the atypical nature of depressive symptoms in the elderly.
Even where scales are designed for the elderly population, some have been
developed with a specific disease entity in mind and may not be appropriate
for use in all situations. The Geriatric Depression Scale is a self-report
rating scale for depression in older people, but may not be useful following
stroke, or in patients with dementia and depression.
|
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 (CESD)
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.
Montgomerysberg Depression
Rating Scale
The Montgomerysberg 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.
BEHAVEAD
The BEHAVEAD (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 BEHAVEAD 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
testretest 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 testretest 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
(QoLAD) 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 DSMIIIR
(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.
RATING SCALES AND THE ART OF ASSESSMENT
In old age psychiatry, as in general psychiatry, the art of practice involves making judgements about the presence or absence of psychiatric illness and the assessment of its impact and severity. A good psychiatrist may make these judgements automatically, but a better psychiatrist supplements clinical judgement by making sure all the right questions have been asked and by rating the severity of the illness or impairment. The use of rating scales helps formalise the assessment approach, ensures thoroughness, may clarify the presence or absence of mental illness, gives an index of severity, and facilitates the determination of response to treatment and disease course over time.
The use of rating scales in old age psychiatry has to a large extent been restricted to the academic and research arenas. Although there are many complex and unwieldy scales that could only be used in research settings, the majority of the scales described here are suitable for clinical use to complement and improve our assessment of patients. Old age psychiatrists should become more comfortable with routine use of such scales, and training in and exposure to the various rating scales that can be used in elderly people should be incorporated into undergraduate, postgraduate and specialist training programmes. Rating scales can be as useful a clinical tool to the old age psychiatrist as the stethoscope and patella hammer are to the physician.
Clinical Implications and Limitations
CLINICAL IMPLICATIONS
LIMITATIONS
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Received for publication November 7, 2000. Revision received February 9, 2001. Accepted for publication May 23, 2001.
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