A standardized version [ Molloy et al.
The practical use of these scales in clinical practice and in research is discussed. Dementia is a term for a clinical syndrome characterized by progressive acquired global impairments of cognitive skills and ability to function independently.
Many patients show varying levels of behaviour disturbance at some point in the illness. Incidence and prevalence of dementia are strongly age dependent. With global aging of populations, dementia prevalence is rising and is projected to continue to do so for much of the present century.
The collateral damage in dementia is vast. Carer burden in terms of physical work, psychological distress and financial obligations is great. Many nonspecialist branches of medicine now operate some system for screening for and diagnosing dementia — for example, primary care, neurology or general hospital inpatient services. Rating scales are often advocated for use in influential guidelines [ NICE, ]. Many scales have been devised just in the field of dementia [ Burns et al.
The purpose of an assessment scale is to increase the precision of a decision by reducing subjectivity and increasing objectivity; for example, using a cognitive screening test score to screen for underlying dementia, to distinguish impairment due to dementia from normal age-related cognitive change or to monitor the effects of treatment of dementia in a clinic or controlled trial.
The properties of an ideal assessment scale would be that it is valid, that is, it has face validity experts like clinicians, patients and carers would agree that the questions are relevant and important , that it has construct validity it measures the construct it was designed to measure , concurrent validity when used alongside a gold standard assessment like a very well validated scale or an expert clinical assessment, it performs well , that it shows reliability — typically inter-rater reliability two or more raters using the scale in the same subjects and conditions come up with the same result and test—retest reliability the same rater using the scale on another occasion in the same subject comes up with the same result.
Importantly, it should be practical to use — in practice, this often depends on it being short so it can be used in busy clinical practice or as an outcome measure in a trial such that participants are not overburdened by long interviews and acceptable — so it does not upset, exhaust or embarrass the patient or assessor. The key task in using assessment scales in dementia as in any field is clarifying what they are to be used for, and by whom.
Another aspect of dementia which distinguishes it from other progressive neurological disorders is the increased reliance on others to assess clinical and practical problems. Dementia may from its earliest stages affect judgement, speech and memory, making patient judgements less reliable. This is directly relevant to the choice of assessment scales to be used in dementia care and research. In particular, judgements about functional impairment, quality of life and behaviour problems may have to be mainly, or entirely, derived from proxy reports.
In clinical practice and in research, cognition is considered the key change we want to observe in people with dementia. Diagnostic criteria for dementia depend on the presence of cognitive impairment [ APA, ], and other aspects of the clinical picture in dementia behaviour, impairment in function, increased costs, carer stress ultimately derive from impaired cognition.
Function refers to abilities to carry out activities of daily living, a direct consideration at the point of diagnosis of dementia [ APA, ] and also in assessing change and planning care interventions.
Behaviour changes seen in dementia, often referred to as Behavioural and Psychological Symptoms in Dementia BPSD are of special importance in influencing prescribing often hazardous , institutionalization of patients and carer stress. Proper evaluation of interventions for BPSD can only be carried out using reliable scales. Measurement of QOL is increasingly popular. In dementia, subjective evaluations are frequently impossible, and patients and carers have very different ratings of QOL.
Scales for measuring QOL include patient and proxy versions, and generic and dementia-specific scales. Depression is common in dementia; rating this fundamentally subjective experience is especially challenging in patients with cognitive impairment. Carer burden is a major issue in dementia; service- and research-level interventions may look to measure effects on carers using generic measures of psychological distress or measures designed specifically to measure carer burden.
This paper considers scales used for each of these areas. Scales in this section are included as they are used in clinical or research settings to screen for dementia, are brief under 30 min , involve professionals interacting with patients and have been either recommended in reviews or guidelines [ Brodaty et al.
Psychometric properties for each scale are summarized in Table 1. It should be noted that single cutoffs are never clearly best on any screening scale — those quoted have good combinations of sensitivity and specificity.
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. 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. The Mini-Cog [ Borson et al.
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 Test Your Memory [ Brown et al. 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.
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, ].
The Montreal Cognitive Assessment [Nasreddine et al. 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.
The ACE [ Mathuranth et al. 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.
Certain Prescription Drugs- Researchers believe that certain medications interfere with the brain's ability to clean out the harmful proteins related to Alzheimer's.
We discuss these risk factors and others as well as risk management strategies on our Alzheimer's Risk Factor Page. Individuals with a family history of Alzheimer's have a higher chance of carrying the ApoE gene and should consider genetic testing. Examples of Prevention Techniques Include: Daily cardiovascular exercise has been shown to increase blood flow to the brain and decrease the amount of Alzheimer's-causing proteins.
Regular mental stimulation results in a more active mind and a lower chance of developing the disease. Fortunately, studies have shown that individuals beginning to experience memory loss are able. The current scientific and medical body does not have a complete understanding of Alzheimer's or the human brain. While we know that Alzheimer's disease leads to the death of the brain's nerve cells, but we are not completely certain how the disease forms or what causes it.
As we have stated above, there is no cure for Alzheimer's. Fortunately, studies have shown that once the disease has developed its progress can slowed and in some cases stopped or even reversed.
The "B" refers to observed behavior, and "C" refers to the consequence, or the event that immediately follows a response.
For example, a student who is drawing pictures instead of working on his class assignment may react by cursing or throwing his pencil when his teacher tells him to finish the task. The teacher may discover verbal requests to work and other demands are antecedents that trigger problem behavior.
Common antecedents include critical feedback from others, absence of attention, and specific tasks or activities. The consequence may be that the teacher sends the student to the office every time he curses and throws his pencil. Over several observation sessions, it may become clear that the student is engaging in problem behavior to escape from his class assignment. An ABC Chart is used to organize information over several observation sessions by recording the types of behaviors observed and the events that precede and follow the behavior.
Observing and recording ABC data assists the team in forming a hypothesis statement and gathering evidence that the function maintaining a problem behavior has been identified. Click here for an example of a completed ABC Chart. Click here for a blank ABC Chart. An ABC Chart can also be used to identify antecedent events that are associated with the nonoccurrence of problem behavior.
Some intervention strategies involve modifying a student's environment by introducing antecedents and consequences that are associated with desirable behavior in other situations. For instance, a student may raise his hand and participate in class discussions when his teacher frequently reminds students to raise their hands and provides high levels of positive attention throughout the class antecedent events.
This teacher provides positive feedback for hand raising and participation consequence. However, in another setting, the teacher does not respond to the student when he raises his hand and provides low levels of positive attention to the student throughout the class period antecedent events. In this class, the student does not raise his hand, yells his teacher's name out loud when he needs assistance, and wanders out of his seat, all of which attract the teacher's attention.
He or she then reprimands the student for misbehaving consequence. Understanding the antecedent events that are associated with both the occurrence and nonoccurrence of problem behavior can help you modify the characteristics of a difficult situation.