455733

2012
TAN561756285612455733Therapeutic Advances in Neurological DisordersB Sheehan

Therapeutic Advances in Neurological Disorders Review

Assessment scales in dementia Ther Adv Neurol Disord

(2012) 5(6) 349­–358

DOI: 10.1177/
1756285612455733
Bart Sheehan
© The Author(s), 2012.
Reprints and permissions:
http://www.sagepub.co.uk/
Abstract:  Dementia involves progressive and often remorseless decline in cognition, function, journalsPermissions.nav
behaviour and care needs. Assessment in dementia relies on collateral as well as patient-
derived information. Many assessment scales have been developed over decades for use
in dementia research and care. These scales are used to reduce uncertainty in decision
making, for example in screening for cognitive impairment, making diagnoses of dementia
and monitoring change. Ideal scales used in dementia should demonstrate face validity and
concurrent validity against gold standard assessments, should be reliable, practical, and
should rely on objective rather than subjective information. Assessment scales in the domains
of cognition, function, behaviour, quality of life, depression in dementia, carer burden and
overall dementia severity are reviewed in this article. The practical use of these scales in
clinical practice and in research is discussed.

Keywords:  Assessment, dementia, scales

Introduction most branches of medicine, including dementia, Correspondence to:

Bart Sheehan,
Dementia is a term for a clinical syndrome charac- has emerged. Many scales have been devised just MRCPsych, MD
terized by progressive acquired global impair- in the field of dementia [Burns et al. 2002]. The Medical School Building,
University of Warwick,
ments of cognitive skills and ability to function purpose of an assessment scale is to increase Coventry CV4 7AL, UK
independently. Many patients show varying levels the precision of a decision by reducing subjectiv- b.sheehan@warwick.ac.uk

of behaviour disturbance at some point in the ity and increasing objectivity; for example, using
illness. Care burden, for family carers as well as a cognitive screening test score to screen for
state/other care funders, increases as the condition underlying dementia, to distinguish impairment
progresses. The syndrome is caused by many dis- due to dementia from normal age-related cogni-
eases, with Alzheimer’s disease, vascular dementia tive change or to monitor the effects of treatment
and dementia with Lewy bodies together account- of dementia in a clinic or controlled trial. The
ing for around 90% of cases. Incidence and preva- properties of an ideal assessment scale would be
lence of dementia are strongly age dependent. With that it is valid, that is, it has face validity (experts
global aging of populations, dementia prevalence is like clinicians, patients and carers would agree
rising and is projected to continue to do so for that the questions are relevant and important),
much of the present century. The collateral dam- that it has construct validity (it measures the con-
age in dementia is vast. Carer burden in terms of struct it was designed to measure), concurrent
physical work, psychological distress and financial validity (when used alongside a gold standard
obligations is great. Many nonspecialist branches assessment like a very well validated scale or an
of medicine now operate some system for screen- expert clinical assessment, it performs well), that
ing for and diagnosing dementia – for example, it shows reliability – typically inter-rater reliability
primary care, neurology or general hospital inpa- (two or more raters using the scale in the same
tient services. Rating scales are often advocated for subjects and conditions come up with the same
use in influential guidelines [NICE, 2006]. result) and test–retest reliability (the same rater
using the scale on another occasion in the same
subject comes up with the same result). Impor­
Assessment scales in dementia tantly, it should be practical to use – in practice,
A vast industry in generation, validation and this often depends on it being short (so it can be
reporting of properties/utility of rating scales in used in busy clinical practice or as an outcome

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Therapeutic Advances in Neurological Disorders 5 (6)

measure in a trial such that participants are not and carers have very different ratings of QOL.
overburdened by long interviews) and accepta- Scales for measuring QOL include patient and
ble – so it does not upset, exhaust or embarrass proxy versions, and generic and dementia-specific
the patient or assessor. The key task in using scales. Depression is common in dementia; rating
assessment scales in dementia (as in any field) is this fundamentally subjective experience is espe-
clarifying what they are to be used for, and by cially challenging in patients with cognitive impair-
whom. Scales are frequently misunderstood and ment. Carer burden is a major issue in dementia;
misused, wasting patients’, carers’ and assessors’ service- and research-level interventions may look
time. Another aspect of dementia which distin- to measure effects on carers using generic meas-
guishes it from other progressive neurological dis- ures of psychological distress or measures desig­
orders is the increased reliance on others to assess ned specifically to measure carer burden. Overall
clinical and practical problems. Dementia may dementia severity assessments are designed to assign
from its earliest stages affect judgement, speech a level of severity to a patient’s condition, and are
and memory, making patient judgements less reli- especially useful in assorting cases in research or
able. Proxies such as family or professional carers service development. This paper considers scales
need to be consulted at all stages in the care jour- used for each of these areas.
ney, altering the traditional assessment method to
a shared patient/carer encounter (for example, the
combination of a patient-facing cognitive assess- Cognition: screening for dementia
ment with a structured or unstructured informant Scales in this section are included as they are
interview in diagnosing dementia). This is directly used in clinical or research settings to screen for
relevant to the choice of assessment scales to be dementia, are brief (under 30 min), involve pro-
used in dementia care and research. In particular, fessionals interacting with patients and have been
judgements about functional impairment, quality either recommended in reviews or guidelines
of life and behaviour problems may have to be [Brodaty et al. 2006; Holsinger et al. 2007; Milne
mainly, or entirely, derived from proxy reports. et al. 2008; Appels and Scherder, 2010], or widely
reported. Psychometric properties for each scale
are summarized in Table 1. It should be noted
An overview of assessment scales that single cutoffs are never clearly best on any
in dementia screening scale – those quoted have good combi-
In clinical practice and in research, cognition is nations of sensitivity and specificity.
considered the key change we want to observe
in people with dementia. Diagnostic criteria for Abbreviated Mental Test Score
dementia depend on the presence of cognitive The Abbreviated Mental Test Score (AMTS)
impairment [APA, 2000], and other aspects of [Qureshi and Hodkinson, 1974] is a 10-item scale
the clinical picture in dementia (behaviour, derived from a longer scale introduced previously
impairment in function, increased costs, carer [Hodkinson, 1972]. Any clinician can use this,
stress) ultimately derive from impaired cognition. and it takes only 3–4 min. It assesses orientation,
Function refers to abilities to carry out activities of registration, recall and concentration, and scores
daily living, a direct consideration at the point of of 6 or below (from maximum of 10) have been
diagnosis of dementia [APA, 2000] and also in shown to screen effectively for dementia, though
assessing change and planning care interventions. as with many brief screens, low positive predictive
Behaviour changes seen in dementia, often referred values mean a second-stage assessment is always
to as Behavioural and Psychological Symptoms in necessary [Antonelli Incalze et al. 2003]. Its brev-
Dementia (BPSD) are of special importance in ity and ease of use have made it popular as a
influencing prescribing (often hazardous), institu- screening test in primary and secondary care
tionalization of patients and carer stress. Proper nonspecialist settings.
evaluation of interventions for BPSD can only be
carried out using reliable scales. Quality of life Clock drawing
(QOL) is a multidimensional concept which Numerous versions of the clock-drawing test have
reflects the patient’s perception of the effect of been devised, with many scoring algorithms
their illness on their everyday physical and [Brodaty and Moore, 1997]. Patients are typically
emotional functioning. Measurement of QOL is asked to draw a clock face with numbers and
increasingly popular. In dementia, subjective eval- hands (indicating a dictated time). It was designed
uations are frequently impossible, and patients as a quick and acceptable screening test for

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 B Sheehan

Table 1.  Short dementia screening tests suitable for primary and secondary care.

Instrument Time to Gold standard Cutoff Sensitivity Specificity Reference

use (min)
MMSE 5–10 DSM-IV diagnosis 23/24 0.79 0.95 Hancock and Larner [2011]
AMTS 3–4 Clinical diagnosis 6/7 0.81 0.84 Antonelli Incalze et al. [2003]
Clock- 3 DSM III-R dementia Shulman method, 0.86 0.96 Brodaty and Moore [1997]
drawing test score 2/3
6-CIT 3–4 Clinical diagnosis 7/8 0.90 1.00 Brooke and Bullock [1999]
of dementia
GPCOG 6 DSM-IV dementia 10/11 on total 0.82 0.83 Brodaty et al. [2002]
score
Mini-Cog 3 Independent Probably normal/ 0.76 0.89 Borson et al. [2003]
clinical diagnosis possibly impaired
of dementia
TYM 5–10 DSM-IV dementia 30/31 0.73 0.88 Hancock and Larner [2011]
MoCA 10 Clinical diagnosis 25/26 1.00 0.87 Nasreddine et al. [2005]
of Alzheimer’s
disease
ACE-R 15–20 DSM-IV dementia 73/74 0.90 0.93 Hancock and Larner [2011]
MIS Under 5 Clinical diagnosis 5/6 0.86 0.91 Buschke et al. [1999]
of dementia
Bold text indicates scoring direction of positive screen for dementia.
ACE-R, Addenbrookes Cognitive Assessment – Revised; AMTS, Abbreviated Mental Test Score; DSM, Diagnostic and Statistical Manual of Mental
Disorder; GPCOG, General Practitioner assessment of Cognition; MIS, Memory Impairment Screen; MMSE, Mini-Mental State Examination; MoCA,
Montreal Cognitive Assessment; TYM, Test Your Memory.

dementia. It is fast, requires no training and most designed to be self-administered under medical
scoring methods are fairly simple. It shows fairly supervision. The maximum score is 50; at a score
good sensitivity and specificity as a screening test. of 30 or below, the test has good specificity and
It assesses only a very narrow part of cognitive sensitivity [comparable to MMSE and Adden­
dysfunction seen in dementia, and many other brookes Cognitive Assessment – Revised (ACE-
conditions (e.g. stroke) will affect it directly. R)] in distinguishing dementia from nondementia
cases [Hancock and Larner, 2011]. This form of
Mini-Cog test may be attractive for time-limited clinicians
The Mini-Cog [Borson et al. 2000] is a very short wanting to screen for dementia, especially in
test (3 min) suitable for primary care screening primary care.
for dementia. It incorporates the clock-drawing
test, adding a three-item delayed word recall General Practitioner assessment of Cognition
task. It showed comparable sensitivity and speci- The General Practitioner assessment of Cognition
ficity to the Mini-Mental State Examination (GPCOG) [Brodaty et al. 2002] was designed for
(MMSE) in classifying community cases of demen- use in primary care and includes nine direct patient
tia [Borson et al. 2003]. cognitive items, and six informant questions assess-
ing change over several years. In total, it takes about
6-CIT 6 min. It has strong performance on sensitivity and
The 6-CIT [Brooke and Bullock, 1999] was specificity versus MMSE in detecting dementia in a
designed for screening in a primary care setting. It typical primary care population [Ismail et al. 2009].
takes 3–4 min to administer, and scoring is between
0 and 28, with cutoffs of 7/8 showing good screen- Memory Impairment Screen
ing sensitivity and specificity. It is easy to adminis- The Memory Impairment Screen is a very brief
ter, though scoring is less intuitive than AMTS. four-item scale taking under 5 min to administer,
and showing good sensitivity and specificity in
Test Your Memory classifying dementia [Buschke et al. 1999]. It
The Test Your Memory [Brown et al. 2009] test lacks executive function or visuospatial items. Its
is a recently developed 10-item cognitive test use is likely to be confined to primary care, as an

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Therapeutic Advances in Neurological Disorders 5 (6)

alternative to GPCOG, 6-CIT, clock-drawing, Longer cognitive assessments

Mini-Cog or AMTS. Alzheimer’s Disease Assessment Scale – Cognitive
section.  The Alzheimer’s Disease Assessment
Mini-Mental State Examination Scale – Cognitive section (ADAS-Cog) [Rosen
The MMSE [Folstein et al. 1975] is by some way et al. 1984] is a detailed cognitive assessment
the best known and most widely used measure for dementia, and takes a trained interviewer
of cognition in clinical practice worldwide. This about 40 min to administer. It covers all cogni-
scale can be easily administered by clinicians or tive areas in dementia and has good sensitivity
researchers with minimal training, takes around to change.
10 min and assesses cognitive function in the
areas of orientation, memory, attention and calcu- The length of the assessment makes it generally
lation, language and visual construction. Patients unsuitable for clinical settings, but it is included
score between 0 and 30 points, and cutoffs of as it is the leading assessment of cognitive change
23/24 have typically been used to show signifi- in drug trials in dementia, with a four-point dif-
cant cognitive impairment. It is widely trans- ference between treatment groups considered
lated and used. A standardized version [Molloy clinically important [Rockwood et al. 2007].
et al. 1991] improves its reliability, and is probably
most important for research settings. The MMSE Cambridge Assessment of Memory and Cogni-
is unfortunately sometimes misunderstood as a tion.  The Cambridge Assessment of Memory
diagnostic test, when it is in fact a screening test and Cognition [Roth et al. 1986] is the cognitive
with relatively modest sensitivity. It has floor and section of the comprehensive CAMDEX assess-
ceiling effects and limited sensitivity to change. ment. It covers a range of cognitive functions,
This in theory should limit its wider use in including orientation, language, memory, atten-
detecting change in clinical work and in research tion, praxis, calculation, abstract thinking and
studies, though in these contexts it is still widely perception. It takes around 25–40 min for a clini-
used, and even advocated [NICE, 2006]. cian to administer and requires a modest degree
of training. It performs well against MMSE with
Montreal Cognitive Assessment no ceiling effects and conventional cutoffs of
The Montreal Cognitive Assessment [Nasred­ 79/80 have demonstrated excellent sensitivity and
dine et al. 2005] was originally developed to help specificity for dementia [Huppert et al. 1995]. Its
screen for mild cognitive impairment (MCI). combination of breadth and relative brevity make
It takes minimal training and can be used in it suitable for clinical use, particularly new assess-
about 10 min by any clinician. It assesses atten- ments of patients in memory clinics. It has the
tion/concentration, executive functions, concep- added advantage of including questions to gener-
tual thinking, memory, language, calculation and ate an MMSE score.
orientation. A score of 25 or lower (from maxi-
mum of 30) is considered significant cognitive
impairment. It performs at least as well as MMSE, Function
including in screening for dementia. It has been
widely translated. As it assesses executive func- Bristol Activities of Daily Living Scale
tion, it is particularly useful for patients with vas- The Bristol Activities of Daily Living Scale
cular impairment, including vascular dementia. (BADLS) [Bucks et al. 1996] was designed spe-
cifically for use in patients with dementia and cov-
Addenbrookes Cognitive Assessment ers 20 daily living activities. It takes a carer
The ACE [Mathuranth et al. 2000] and its com- (professional or family) 15 min to administer. It is
monly used revision the ACE-R [Mioshi et al. sensitive to change in dementia and short enough
2006] was originally developed as a screening to use in clinical practice (carers may fill it in
test for dementia which, unlike the MMSE, while clinicians are performing direct assessment
would rely less on verbal than on executive abili- of patients). It is regularly used as an outcome
ties. It takes 15–20 min to administer and includes measure in clinical trials, where it is world leading
the items which lead to a MMSE score. It has as a dementia-specific measure. This outcome is
been shown to have very high reliability and among those recommended by a consensus rec-
excellent diagnostic accuracy, and it is a practical ommendation of outcome scales for nondrug
option for clinical services intent on precision in interventional studies in dementia [Moniz-Cook
diagnoses. et al. 2008].

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 B Sheehan

Barthel Index It is therefore suitable as a screening tool rather

The Barthel index [Mahoney and Barthel, 1965] than in assessing change in function.
is probably the best known assessment of func-
tional ability for older people. It takes 5 min of
informant’s time and has been widely translated Behaviour
and validated. It focuses on physical disability in
10 domains and should not be used other than to Neuropsychiatric Inventory
assess physical functional deficits in people with The Neuropsychiatric Inventory [Cummings
dementia, among whom cognitive deficits tend to et al. 1994] assesses a wide range of behaviours
confound assessment. seen in dementia for both frequency and severity.
These include delusions, agitation, depression,
The Functional Independence Measure irritability and apathy. The scale takes 10 min for
The Functional Independence Measure [Keith a clinician to administer to a carer. It has good
et al. 1987] measures overall disability. It is psychometric properties and is widely used in
observer rated and covers multiple important drug trials, while being short enough (especially
domains, including self-care, sphincters, mobil- with patients without a wide range of behavioural
ity, communication, psychosocial function and issues) to consider for use in clinical practice.
cognition. Some training is required for its
use. A UK version is available and it has been Cohen-Mansfield Agitation Inventory
used in repeated observations of inpatients in The Cohen-Mansfield Agitation Inventory
general hospital [Zekry et al. 2008]. It is there- [Cohen-Mansfield, 1986] takes 15 min for carers
fore an example of a scale which addresses cog- to rate, but requires some training. Up to
nitive as well as physical function, and is likely 29 behaviours seen in dementia are rated for fre-
to be especially useful in inpatient or rehabilita- quency – the lack of focus on severity is corrected
tion settings. by the breadth of behaviours covered. The behav-
iours covered include many of those found most
Instrumental Activities of Daily Living disruptive, including verbal aggression, repeti-
The Instrumental Activities of Daily Living scale tiveness, screaming, hitting, grabbing and sexual
[Lawton and Brody, 1969] takes 5 min for a basi- advances. It is most commonly used in research
cally trained interviewer to assess ability in eight settings.
complex daily living tasks such as telephone use,
shopping, housekeeping and finances. These abil- BEHAVE-AD
ities are more complex than the more basic abili- The BEHAVE-AD [Reisberg et al. 1987] takes
ties assessed by the Barthel scale, and therefore 20 min for a clinician to use, and is therefore
more sensitive to the cognitive changes seen in most commonly used in interventional research
dementia. It is very commonly used in European studies. It covers most of the important disrup-
memory clinics [Ramirez-Diaz et al. 2005]. tive behaviours, including aggression, overactiv-
ity, psychotic symptoms, mood disturbances,
The Informant Questionnaire on Cognitive anxiety and day/night disturbances. Respondents
Decline in the Elderly are asked about the presence of behaviours and
The Informant Questionnaire on Cognitive how troubling they are. It is reliable, sensitive to
Decline in the Elderly (IQCODE) [Jorm and change and to stage of disease.
Jacomb, 1989] is a questionnaire administered
to an informant outlining changes in everyday
cognitive function. It aims to establish cognitive Quality of life
decline independent of premorbid ability by con-
centrating on 16–26 (depending on version) func- Generic measures of quality of life
tional tasks, including recall of dates/conversations/ EuroQol. The EuroQol measure [EuroQol
whereabouts of objects, handling finances and Group, 1990] is a short, freely available generic
using gadgets. It takes about 10 min to adminis- measure of health-related quality of life. It can be
ter, and is conventionally used at the assessment simply administered to patients or carers in the
stage in diagnosing dementia, usually combined form of a very brief self-completed question-
with a direct cognitive assessment of the patient. naire. There are two core components to the
This combination increases accuracy of diagnoses instrument: a description of the respondent’s own
versus cognitive assessment alone [Jorm, 1994]. health using a health state classification system

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Therapeutic Advances in Neurological Disorders 5 (6)

with five dimensions, and a rating on a visual ana- a popular 15-item version (GDS-15) [Sheikh and
logue thermometer scale. It takes 2 min to com- Yesavage, 1986]. GDS-15 is usually self rated
plete. Like many quality of life instruments, carer though can be rated by an assessor. It is sensitive to
and proxy ratings diverge widely, many patients change and is reliable in older people in institu-
with dementia cannot fill out the instrument, tional care. It takes about 5–10 min to administer.
and the chief use of EuroQoL in dementia is as Its major drawback in dementia is that it has been
a health utility measure for measuring the eco- validated for people with mild dementia, but not
nomic impact of interventions in trials. for those with moderate to severe dementia (among
whom completion rates may be low due to diffi-
Short Form-36.  The Short Form-36 (SF-36) culty comprehending questions).
[Ware and Sherbourne, 1992] and its shorter
descendant the SF-12 [Ware et al. 1996] are Cornell Scale for depression in dementia
examples of generic measures of quality of life The Cornell Scale [Alexopoulos et al. 1988a] is a
which use recall over particular periods of time 19-item scale in which questions are asked of the
(typically 1 or 4 weeks) and are used to estimate patient and the carer, meaning that the patient
health burden in large populations. These instru- does not need to be able to answer questions for it
ments have been shown to have high rates of non- to be used. The maximum score is 38. It has been
completion among frail older people and especially validated patients with and without dementia
among those with moderate to severe dementia. [Alexopoulos et al. 1988b]. In patients with
They may have limited use for carers of people dementia, it is considered the gold standard for
with dementia, but probably cannot routinely be quantifying depressive symptoms.
used in practice with patients.
The Montgomery Asberg Depression
Dementia-specific quality of life instruments Rating Scale
Alzheimer’s Disease-related Quality of Life scale.  The Montgomery Asberg Depression Rating
The Alzheimer’s Disease-related Quality of Life Scale (MADRS) [Montgomery and Asberg, 1979]
scale (QoL-AD) [Logsdon et al. 1999] is a 13-item takes about 15–20 min for a trained assessor to
scale which has been extensively validated, is dis- complete. It is useful among older patients in that
ease specific, can be completed by patient or carer mainly psychological rather than confounding
and is suitable for use across the range of severity physical symptoms are assessed. It is particularly
of dementia [Hoe et al. 2005]. It takes 10–15 min sensitive to change and often used in interven-
to administer. Patient and proxy versions are tional research but the same issues as with GDS
available. In a controversial area, its disease- will limit its usefulness outside mild dementia.
specific properties, along with those of the health-
related quality of life in dementia instrument The Hamilton Depression Rating Scale
(DEMQOL), make it a leading choice if quality of The Hamilton Depression Rating Scale [Hamilton,
life is to be assessed [Moniz-Cook et al. 2008]. 1960] is one of the most commonly used depres-
sion rating scales. It requires 20–30 min of ques-
DEMQOL.  DEMQOL [Smith et al. 2007] is a tions in a semi-structured interview by a trained
31-item, disease-specific instrument for evalu- interviewer, and is therefore unlikely to be used in
ating health-related quality of life in dementia, people with dementia. It is commonly used in
which shows comparable psychometric properties antidepressant drug trials, and like MADRS,
to the best available instruments and has been has a preponderance of psychological rather than
validated in a UK population. It has both patient- physical items.
completed and proxy forms. Like QoL-AD, it is
primarily likely to be used in research studies. The Hospital Anxiety and Depression Scale
The Hospital Anxiety and Depression Scale
[Zigmond and Snaith, 1983] is a popular screen-
Depression in dementia ing test for depression and anxiety which was
originally aimed at patients in hospital, though it
The Geriatric Depression Scale has been used much more widely in recent years.
The Geriatric Depression Scale (GDS) [Yesavage It takes 3–5 min and is self-reported. Though easy
et al. 1983] is the most commonly used assessment to use and accurate at detecting depression, it has
of depressed mood among older people, and has little practical use for older patients with signifi-
been shortened to numerous versions, including cant cognitive impairment.

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 B Sheehan

Carer burden Discussion

A key consideration in deciding what dementia
General Health Questionnaire assessment scales to choose is to clarify the ques-
The General Health Questionnaire, 12-item tion being asked. Consensus guidelines have been
version [Goldberg and Williams 1988] is a attempted [Ramirez Diaz et al. 2005; Moniz-
short self-rated scale designed to screen for Cook et al. 2008]. Most of the brief screening
psychological distress in the community. It is instruments like 6-CIT, clock drawing and AMTS
probably the most widely used and validated are probably psychometrically as good as a com-
self-rated instrument for detection of psycho- mon instrument like MMSE in screening for sig-
logical morbidity. It takes only a few minutes to nificant cognitive impairment, and are a little
administer. shorter. They lack the breadth of assessments in
MMSE and are therefore to be used only in set-
Zarit Burden Interview tings in which time or frailty make longer assess-
The Zarit Burden Interview [Zarit et al. 1980] is ment impossible. The diagnosis of dementia is
a 22-item self-report inventory of direct stress always based on a clear history and invariably
to carers in caring; it was designed for carers of involves collateral history from an informant
people with dementia and has demonstrated along with direct patient assessment. Some com-
sensitivity to change. Being disease specific gives prehensive instruments to aid this diagnosis have
it primacy in the area. been developed. In memory clinics, structured
neuropsychological assessment and the use of
IQCODE to detail cognitive change as observed
Overall dementia severity by a carer are often used to improve precision
of diagnostic decisions. In borderline or mild
Clinical Dementia Rating cases of dementia, assessments probably need to
The Clinical Dementia Rating scale [Morriss, include assessments of at least this complexity,
1993] allows more reliable staging of dementia with important guidelines explicitly recommend-
than MMSE, and is based on caregiver accounts ing this [NICE, 2006]. Such assessments will
of problems in daily functional and cognitive usually involve assessment of premorbid ability
tasks. It takes only a few minutes for clinicians and quantification of explicit cognitive deficits,
already familiar with individual cases, and classi- including, but not limited to, memory, and estab-
fies people with dementia into questionable, lishing deficits compared with expected norms.
mild, moderate and severe. Commonly, these specialist assessments involve a
specially trained neuropsychologist. Scales like
Global Deterioration Scale the ACE-R can easily be used in clinical settings
The Global Deterioration Scale [Reisberg et al. by clinicians other than neuropsychologists. In
1982] is essentially for staging dementia and takes monitoring progress over time, cognition (for
only 2 min once relevant clinical information has example with MMSE, though subject to ceiling/
been collated. It has been well validated and clas- floor effects and relatively insensitive to change),
sifies cases into seven stages from no complaints function (e.g. BADLS) or a generic measure of
through to very severe. Like CDR, it is mainly overall severity of dementia(e.g. Clinical Dementia
used to assort cases by severity in research or in Rating, Global Deterioration Scale, CIBIC) are
service development, as in an individual case, often used. If cognitive performance is of specific
more subtle changes which are important may interest, a well validated scale like ADAS-Cog is
not be picked up. preferred, despite its length. For clinical trials in
which cognition is of primary interest, a de facto
Clinicians Global Impression of Change gold standard of a four-point change on ADAS-
The Clinicians Global Impression of Change Cog has been established [Rockwood et al. 2007].
(CIBIC-Plus) [Schneider et al. 1997] is a com- In assessing depression in dementia (Cornell
prehensive global measure of detectable change in scale) and carer stress (Zarit Burden Inventory)
cognition, function and behaviour, usually requir- there are relatively clear leading assessment scales.
ing separate interviews with patients and carers. It Quality of life assessment in dementia is a mine-
is therefore conceptually attractive for assessing field due to the disparity between patient and
progression, but requires a trained clinician and proxy ratings, and poor completion rates with
10–40 min of interview time so may be unsuited more severe dementia. The recent introduction of
to routine clinical practice. dementia-specific scales for quality of life, which

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Therapeutic Advances in Neurological Disorders 5 (6)

allow proxy ratings, is at least a significant vital signs measure for dementia screening in
step forward. Assessing change in behavioural multi-lingual elderly. Int J Geriatr Psychiatry
symptoms in dementia is especially important in 15: 1021–1027
judging treatment effects (for example – has the Borson, S., Scanlan, S., Chen, P.and Ganguli, M.
patient improved during short-term treatment (2003) The Mini-Cog as a screen for dementia:
with antipsychotic medication enough to justify validation in a population-based sample. J Am Geriatr
risks of continued prescribing?). Well established Soc 51: 1451–1454.
scales are available for this purpose. A general
Brodaty, H., Low, L., Gibson, L. and Burns, K. (2006)
principle in dementia assessment is that disease- What is the best dementia screening instrument for
specific instruments are usually markedly supe- general practitioners to use? Am J Geriatr Psychiatry
rior in clarifying judgements made. Subject to 14: 391–400.
limitations on clinical and research resources,
these instruments should be considered first to Brodaty, H. and Moore, C. (1997) The Clock
Drawing Test for dementia of the Alzheimer’s type:
maximize clinical practice. A great deal of effort
a comparison of three scoring methods in a memory
goes into choosing and justifying primary out- disorders clinic. Int J Geriatr Psychiatry 12: 619–627.
come measures in research trials; as clarity about
intervention effects is so important, basic famili- Brodaty, H., Pond, D., Kemp, N., Luscombe, G.,
arity with the strengths and weaknesses of com- Harding, L., Berman, K. et al. (2002) The GPCOG:
monly used assessment scales in dementia can a new screening test for dementia designed for general
practice. J Am Geriatr Soc 50: 530–534.
help improve the rigour of clinical practice.
Brooke, P. and Bullock, R. (1999) Validation of a
Funding 6 item cognitive impairment test with a view to primary
This research received no specific grant from any care usage. Int J Geriatr Psychiatry 14: 936–940.
funding agency in the public, commercial, or not- Brown, J., Pengas, G., Dawson, K., Brown, L.A. and
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