A Comparison of the Severe Cognitive Impairment Rating Scale With the Mini-Mental State Examination and Delirium Rating Scale-Revised-98 for Delirium: A Cross-sectional Study

Author’s Accepted Manuscript A comparison of the Severe Cognitive Impairment Rating Scale with the Mini-Mental State Examination and Delirium Rating Scale-Revised98 for delirium: A cross-sectional study Jeong Lan Kim, Jin-Hoon Choi, Chae-Sung Im, Tae-Sung Kim, So-Hyun Ahn www.elsevier.com/locate/psym

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S0033-3182(17)30178-0 http://dx.doi.org/10.1016/j.psym.2017.08.002 PSYM805

To appear in: Psychosomatics Cite this article as: Jeong Lan Kim, Jin-Hoon Choi, Chae-Sung Im, Tae-Sung Kim and So-Hyun Ahn, A comparison of the Severe Cognitive Impairment Rating Scale with the Mini-Mental State Examination and Delirium Rating ScaleRevised-98 for delirium: A cross-sectional study, Psychosomatics, http://dx.doi.org/10.1016/j.psym.2017.08.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

A comparison of the Severe Cognitive Impairment Rating Scale with the Mini-Mental State Examination and Delirium Rating Scale-Revised-98 for delirium: A cross-sectional study Jeong Lan Kimª, Jin-Hoon Choiª, Chae-Sung Imª, Tae-Sung Kimª, So-Hyun Ahnª ª Department of Psychiatry, Chungnam National University Hospital, Daejeon, Korea

Corresponding Author So-Hyun Ahn, M.D., Department of Psychiatry, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea Tel: +82 42 280 7280, Fax: +82 42 280 7886, E-mail: [email protected]

Abstract Background: Cognitive impairment including attention deficits, disorientation, memory impairment, language disturbance, and impaired visuospatial ability, are core symptoms of delirium. The Severe Cognitive Impairment Rating Scale (SCIRS) was developed to assess cognition in patients with severe dementia, but may also be useful in elderly people with delirium. Objective: We investigated the use of the SCIRS to assess cognition in elderly patients with delirium. Methods: We recruited 147 participants, aged ™65 years, referred for psychiatric consultation at a tertiary-care university hospital. The diagnosis and severity of delirium were assessed using the Korean version of the Delirium Rating Scale-Revised-98 (K-DRS-98). Cognitive function was assessed using the SCIRS and the MiniMental State Examination (MMSE) in the Korean version of the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) Assessment Packet (MMSE-KC). Results: There was a strong correlation of SCIRS scores with K-DRS-98 cognition domain (r = -.796), severity scores (r = -.742), total scores (r = -.734), and the MMSE-KC (r = .905). Analysis of variance incorporating the severity of delirium suggested that while the MMSE showed a floor effect, the SCIRS could discriminate between moderate and severe delirium. Conclusion: The SCIRS is a useful instrument to assess

 

cognitive function in elderly patients with moderate to severe delirium.

Keywords: delirium, old age, cognitive impairment, rating scale

Introduction Delirium is an acute neuropsychiatric syndrome characterized by attentional impairment and cognitive dysfunction, including memory deficits, disorientation, language disturbances, and visuospatial disability. Delirium is more common among the elderly,(1) with a prevalence among elderly hospitalized patients of 11–30%.(2-5) Delirium is independently associated with various adverse outcomes, including an increased length of hospital stay, higher mortality, increased rates of institutionalization, accelerated cognitive decline and functional impairment, elevated healthcare costs, and increased distress experienced by the patient and family.(6-9) Despite its serious consequences, delirium is often underdiagnosed in hospital settings, with hypoactive delirium often mistaken for depression and hyperactive delirium misattributed as psychosis. Previous research reports no significant differences in cognitive symptoms seen across the hyperactive, hypoactive, and mixed types,(10) suggesting that cognitive function remains a core symptom of delirium, regardless of the motoric subtype. Many tools have been developed to assess various aspects of delirium. Commonly used measures for screening and determining delirium severity are the Confusion Assessment Method (CAM),(11) the CAM for the Intensive Care Unit (CAM-ICU),(12) the Delirium Rating Scale-Revised-98 (DRS-R-98),(13) and the Memorial Delirium Assessment Scale (MDAS).(14) These approaches include cognitive dysfunction as one of several assessment domains, but do not comprehensively assess cognition.

 

Few studies have quantified severe cognitive dysfunction in older patients with delirium. Early recognition of cognitive changes consistent with delirium would presumably lead to an earlier diagnosis and treatment for specific conditions.(15) Various instruments and scales are available for such cognitive assessment but may not be suitable to assess delirium in elderly patients. The MiniMental State Examination (MMSE)(16) is the most popular tool for assessing cognitive impairment, but was not specifically designed for assessing delirium. The Clock Drawing Test (CDT) is sensitive to general cognitive impairment, but lacks specificity for delirium.(17) Finally, although the Cognitive Test for Delirium (CTD) was designed to assess patients with delirium and cognitive impairment,(15) it was developed specifically for ICU patients with delirium, particularly those who are intubated or unable to speak or write. The Severe Cognitive Impairment Rating Scale (SCIRS) was originally developed to assess cognition in patients with severe dementia.(18) It is a valid and reliable test for evaluating cognitive function in patients with advanced dementia. It takes less time and is easier to administer than other scales, and avoids the floor effect in advanced dementia. Therefore, in this study we evaluated the usefulness of the SCIRS to assess cognition in elderly patients with delirium. Material and Methods Participants This was a cross-sectional study of cognitive function tests for delirium in consecutive inpatient referrals to an old age psychiatry consultation-liaison service at a tertiary university hospital (Chungnam National University Hospital, Daejeon, Korea). Patients had been referred for psychiatric consultation following an acute onset of fluctuating cognitive impairment and consciousness disturbance, between May 2011 and July 2012. All participants were aged >65 years. The study

 

involved the assessment of 155 patients, of which 8 were excluded because they did not fulfill the inclusion and/or exclusion criteria for the study. Accordingly, 147 participants were included. Informed consent was obtained from all patients prior to participation. For patients unable to provide consent, legal proxies provided substituted consent. The institutional review board of the Ethics Committee of Chungnam National University Hospital approved the study (2011-05-086), which conformed to the tenets of the Declaration of Helsinki. Data collection Two experienced psychiatrists (TS or CS) made the diagnoses according to the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV-TR) (19) based on a complete clinical assessment at the time of consultation and independent of the K-DRS-98, MMSEKC and SCIRS. The diagnosis and severity of delirium were scored using the Korean version of the Delirium Rating Scale-Revised-98 (K-DRS-98).(20) To assess cognitive function, the same psychiatrist administered the SCIRS and the MMSE using the Korean version of the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) Assessment Packet (MMSE-KC) (21) to each patient. K-DRS-98 provided ratings of the preceding 24 h period whereas the MMSE-KC and SCIRS measured cognition at the time of its administration. K-DRS-98 and MMSE-KC responses were not used to rate the SCIRS items. Instruments K-DRS-98 The DRS-R-98 is a useful diagnostic and assessment tool for delirium severity, detecting a broad range of symptoms.(13) The standardized Korean version, K-DRS-98, is a valid and reliable delirium measure with high inter-rater reliability and internal consistency among delirium and other neuropsychiatric conditions including dementia, schizophrenia etc.(20) It demonstrated an inter-rater

 

reliability of 0.893 for the severity items and 0.969 for the diagnosis items. Internal consistency was two 0.867 and 0.858. It has 16 items, 13 of which assess symptom severity including memory, orientation, attention, language, and visuospatial function. Three items are of diagnostic significance. Severity ratings range from 0 (no impairment) to 3 (severe impairment). The maximum severity and total scores are 39 and 46 points, and the optimal cut-off severity and total scores for the K-DRS-98 are 16 and 21.5, respectively. The test has a sensitivity of 92% and specificity of 78% for K-DRS-98 severity, and a sensitivity of 92% and specificity of 96% for K-DRS-98 total. MMSE-KC Developed by Folstein and colleagues,(16) the MMSE is one of the most frequently used cognitive screening tools. The MMSE-KC has 19 items, scored between 0 and 30, with a low score indicating poor cognitive function. The MMSE-KC assesses orientation, memory, attention/concentration, language, and visuospatial function. It also includes two items not included in the MMSE, focusing on judgment, instead of reading and writing, to facilitate administration to illiterate individuals. Normative values for the MMSE-KC were reported in a sample of elderly Korean people.(22) Scores of 19 and below indicate severe cognitive impairment, scores of 20–23 indicate MCI, and scores of 24 and greater represent normal ability. At the time of development, this scale yielded a reliability of 0.92; in the present study, it had a Cronbach's alpha of 0.73.(21) SCIRS The SCIRS is a quick and easy cognitive function test specifically designed to assess cognition in patients with moderate to severe dementia.(18) Conventional neuropsychological measurements, show a floor effect. Moreover, only a few tests specifically evaluate cognition such as Severe Impairment Battery (SIB), the Test for Severe Impairment, the Hierarchic Dementia Scale (HDS), Severe Mini-Mental State Examination (SMMSE). Of these, SIB has been most validated on various populations, but shows some limitations such as specialized training, specialized equipment, long

 

administration time, and a ceiling effect. Hence Choe et at. developed the SCIRS. It has been validated and is reliable for advanced Alzheimer’s disease patients. The internal consistency was 0.93 and inter-rater reliability and test-retest reliability was 0.99 and 0.90 for moderate to severe subjects. Moreover, it strongly correlated with MMSE. It consists of 11 items representing five cognitive domains: memory, orientation, language, frontal lobe function (comparison, concept shift, and attention), and visuospatial function. Some items were specifically created for the SCIRS, while others were selected and modified from the SIB,(23) SMMSE,(24) HDS,(25) and the Hasegawa Dementia Scale.(26) The maximum total score is 30 points, with lower scores denoting worse cognitive function. Statistical Analyses We investigated correlations of total SCIRS scores with MMSE-KC, K-DRS-98 total scores, and KDRS-98 severity scores using Pearson’s correlation coefficient (r). We categorized 3 factor analyses domains and 5 subscales and analyzed correlations for each instrument. To examine the ability of the SCIRS to distinguish delirium severity, mean SCIRS scores were compared among four delirium severity groups, classified using K-DRS-98 severity scores (Group 1: 0–15, Group 2: 16–20, Group 3: 21–24, and Group 4: 25–39), with consideration of the cut-off score and tertiles, using one-way analysis of variance (ANOVA) and Scheffe’s post-hoc test. Statistical significance was set at p <.05. All statistical analyses were performed using SPSS version 21.0 (SPSS Inc., Chicago, IL).

 

Results We included 147 participants (men: N = 98, 66.7%; women: N = 49, 33.3%), with an average age of 76.1 ±6.5 years (range: 64–96 years). Patients had a mean K-DRS-98 total score of 27.3 ± 7.1 (range 13–43) and severity scores of 21.7 ± 6.6 (range 9–37). The SCIRS mean scores were 16.0 ± 11.2 (range 0–30) and MMSE-KC were 9.7 ± 7.4 (range 0–26). The percentage of total possible points for patients with delirium varied considerably on the different tests. The average SCIRS score was 53% (16 points) of the possible points, whereas the same patients scored only a mean of 32% (9.7 points) of the possible points on the MMSE-KC. Correlation analysis Construct validity was evaluated by comparing scores on the SCIRS with those on the K-DRS-98 and MMSE-KC. SCIRS scores were strongly negatively correlated with those on the K-DRS-98 for total (r = -.734) and severity scores (r = -.742, Fig. 1). The SCIRS and MMSE-KC were most strongly correlated (r = .905, Fig. 1). (Table 1) The SCIRS and K-DRS-98, MMSE-KC and K-DRS-98 were strongly correlated for the cognitive and high order thinking domains and moderately correlated for the circadian domain. (Table 1) We categorized 5 domains; the SCIRS was better correlated with K-DRS-98 for frontal lobe function and visuospatial function than the MMSE-KC was with K-DRS-98. All the correlations were statistically significant (*p <0.05, **p <0.001). (Table 2) Assessment of delirium severity using the SCIRS To examine the ability of the SCIRS and MMSE-KC to assess delirium severity, we divided the participants into four groups based on their K-DRS-98 severity scores. Table 3 shows the mean total and subscale scores for the SCIRS and MMSE-KC in each group. One-way ANOVA revealed that the

 

level of severity significantly affected performance on the SCIRS. With an increase in K-DRS-98 severity scores, there was a significant decrease in SCIRS total and subscales scores. Scheffe’s posthoc comparisons showed that the SCIRS scores of Groups 3 and 4 differed from those of Groups 1 and 2, as well as from each other. Thus, the SCIRS could discriminate among K-DRS-98 severity scores of 16–20, 21–24, and 25–39. Only those with K-DRS-98 severity scores of 16–20 could not be differentiated from those of 0–15. The MMSE yielded similar results for total scores. However, while the SCIRS results were similar for all subscales, the MMSE-KC was only useful for the memory and language subscales. Thus, a floor effect was observed for the MMSE-KC for orientation, attention, and visuospatial function domains, whereas the SCIRS was much more robust to the floor effect in all five domains. SCIRS performance in patients with very low cognitive function The efficacy of the SCIRS to measure cognitive function in patients with very low cognitive function was assessed by examining the performance of participants (N = 47) scoring between 0 and 4 points on the MMSE-KC (i.e., 13.3% of the whole scale; Table 4). In these participants, the corresponding SCIRS score was 0–10 points (i.e., 33.3% of the scale), thereby avoiding the floor effect (Fig. 1). Regarding the five subscales, the MMSE-KC offered only 0–50% of the possible ranges, whereas the SCIRS offered 28.6–75% of the possible points. Thus, the SCIRS was better able to test cognitive function among those with the lowest MMSE-KC scores. Discussion Our findings provide evidence that the SCIRS is a useful instrument to assess cognitive function in elderly individuals with moderate to severe delirium. Our study showed that SCIRS scores were highly correlated with K-DRS-98 cognition domain and MMSE-KC scores.

 

Cognitive disturbance is a core symptom of delirium. Factor analyses of delirium symptoms have revealed that the circadian, cognitive, and higher level thinking domains, with the highest loading values for cognitive domains.(27) According to Trzepacz, using a standardized cognitive test to address a particular cognitive function would enhance all diagnostic instruments currently used for assessing delirium.(28) Investigating cognitive disturbance in delirium may facilitate an understanding of its phenomenology and shed light on differences of phenomenology or recovery trajectories between delirium superimposed on dementia and delirium in the absence of dementia.(29, 30) The DRS-R-98 is a scale for a broad phenomenological assessment and severity rating of delirium. It is a well-validated instrument with high inter-rater reliability, sensitivity, and specificity. Discrimination of delirium from psychiatric illness is critical in a psychogeriatric population; the DRS-R-98 is useful. It includes the cognitive and neurobehavioral elements prevalent over the previous 24 h. However, with an assorted patient population in a hospital, the use of the DRS-R-98 in routine clinical practice may be limited owing to the training required to use the tool, time taken to administer, and essential basic knowledge of psychiatry.(31) Few have been specifically developed to test cognitive function in patients with delirium. To date, the MMSE is the most popular instrument used to assess cognitive impairment, and is most commonly used to screen for delirium. However, its utility in this regard remains uncertain. According to a metaanalysis of studies investigating the use of the MMSE as a diagnostic and screening test for delirium, it is not recommended as a case-finding confirmatory test, but may be used as an initial screen to rule out those with high scores who are unlikely to have delirium, with approximately 93% accuracy.(32) Low MMSE scores indicate the need to employ another mental-status examination, including a cognitive function test. Studies report lower MMSE scores in hospitalized patients with delirium superimposed on dementia than in those with delirium without dementia.(33, 34) In the present study,

 

most participants had low scores, with 98% scoring below 24. Therefore, another cognitive function test is necessary to discriminate the subgroups among those with low MMSE scores. The SCIRS can better distinguish the more severe end of cognitive dysfunction than can the MMSE. In the present study, 47 patients with severe delirium had total MMSE scores of 0–4 points, while their SCIRS scores ranged from 0–10 points. Thus, elderly patients with delirium who have very severe cognitive function impairments scored at or near the floor on the MMSE, but obtained meaningful total SCIRS scores. As intended, the SCIRS retained the ability to assess further cognitive decline at a point where the patients’ performances were approaching the floor on the MMSE-KC. The SCIRS also had greater ability to discriminate between different levels of severity for several cognitive domains than did the MMSE-KC. Similar to an earlier study of patients with dementia,(18) our findings showed that the SCIRS avoids the floor effect in patients with delirium in all domains. Conversely, using the MMSE, the floor effect was observed in orientation, attention, and visuospatial ability. The SCIRS is useful to assess attention for severe delirium than MMSE-KC. Attention deficit is a core symptom of delirium. Attention can help to distinguish between delirium and dementia.(35) The score for frontal lobe function (including attention) in the SCIRS began to decline earlier than those of the other subscales, and could be used to distinguish among all the delirium severity groups. For the SCIRS, a stimulation card was developed and used to test frontal lobe function, including attention and visuospatial ability. Some items were selected and modified from the Clock Reading Test and Right–Left Orientation Test, while other novel tests were created specifically for the SCIRS.(18) Several patients in the present study could not speak or easily use a pencil, rendering backward spelling and copying a design (as required in the MMSE) problematic, whereas the stimulation card employed in the SCIRS is easy to make and carry, and can be administered to those unable to speak or write.

 

We therefore suggest that the SCIRS may be more broadly useful for assessing cognitive function in delirium. If well validated K-DRS-98 can be applied to the diagnosis delirium phenomenology and severity, and if the severity is above moderate, SCIRS use is recommended, other than MMSE, to assess cognitive function. The SCIRS administration needed no special training and required only 216 ± 48 (148–330) s for the subjects with an MMSE score of ≥14 and showed no floor effect.(18) In severe delirium, it is useful to assess attention deficit. Some limitations should be considered while interpreting our results. We used a cross-sectional study design and only assessed each patient once, failing to account for the fluctuating symptoms of delirium. We also did not investigate the validity of the SCIRS for delirium. Further, we included a sample of etiologically heterogeneous participants and did not consider the presence of dementia. Future studies should conduct validation of the SCIRS for delirium, including longitudinal assessment of cognitive functions. Further evaluation could confirm whether our findings can be explained by differences between delirium and dementia, differences in assessment tools used, or whether they are due to the unique phenomenology of delirium.

Conclusion Our results show that the SCIRS is useful for assessing cognitive function in patients with moderate to severe delirium. It is a helpful supplemental instrument in patients with K-DRS-98 severity scores greater than 21 or low MMSE scores, particularly those with impaired frontal lobe functions and visuospatial ability. Larger prospective studies could establish whether the SCIRS is a superior cognitive test for delirium in typical clinical settings than other currently used assessments.

 

Funding: This work was supported by the Daejeon Geriatric Medical Center of Chungnam National University Hospital Research Fund 2011. Disclosure: The authors disclose no proprietary or commercial interest in any product mentioned or concept discussed in this article.

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Table 1. Correlation between SCIRS, MMSE-KC, and K-DRS-98 scores K-DRS98 Severity score -0.742**

K-DRS-98 Cognitive domain

SCIRS

K-DRS98 Total score -0.734**

MMSE-KC

-0.742**

K-DRS-98 0.760** Circadian domain K-DRS-98 0.830** High order thinking domain K-DRS-98 0.865** Cognitive domain K-DRS-98 0.987** Severity score K-DRS-98 1 Total score SCIRS: Severe Cognitive

K-DRS-98 Circadian domain

MMSEKC

SCIRS

-0.796**

K-DRS-98 High order thinking domain -0.605**

-0.502**

0.905**

1

-0.755**

-0.823**

-0.639**

-0.504**

1

0.752**

0.514**

0.651**

1

0.836**

0.716**

1

0.875**

1

1

Impairment Rating Scale; K-DRS-98: Korean version of the Delirium

 

Rating Scale-Revised-98; MMSE-KC: Mini-Mental State Examination-Korean version of the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) Assessment Packet. **p < 0.001

Table 2. Correlation between SCIRS, MMSE-KC, and K-DRS-98 scores for each subscales Subscales K-DRS-98 SCIRS MMSE-KC K-DRS-98 1 -.606** -.640** Orientation SCIRS 1 .644* MMSE-KC 1 K-DRS-98 SCIRS MMSE-KC K-DRS-98 1 -.499** -.646** Memory SCIRS 1 .753** MMSE-KC 1 K-DRS-98 SCIRS MMSE-KC K-DRS-98 1 -.714** -.432** Frontal function (attention) SCIRS 1 .414** MMSE-KC 1 K-DRS-98 SCIRS MMSE-KC K-DRS-98 1 -.741** -.238** Visuospatial ability SCIRS 1 .166* MMSE-KC 1 K-DRS-98 SCIRS MMSE-KC K-DRS-98 1 -.578** -.640** Language SCIRS 1 .910** MMSE-KC 1 SCIRS: Severe Cognitive Impairment Rating Scale; K-DRS-98: Korean version of the Delirium Rating Scale-Revised-98; MMSE-KC: Mini-Mental State Examination-Korean version of the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) Assessment Packet. *p < 0.05, **p < 0.001

 

Table 3. Comparison of participant scores for the SCIRS and MMSE-KC components according to delirium severity Frontal Total

Orientation

Memory

Visuospatial

function

Language

ability

(attention) KDRS-

SCI

MMS

SCI

MMS

SCI

MMS

SCI

MMS

SCI

MMS

SCI

MMS

RS

E-KC

RS

E-KC

RS

E-KC

RS

E-KC

RS

E-KC

RS

E-KC

0–15

25.8

16.74

3.44

5.30

5.96

3.78

8.44

6.26

2.26

5.78

0.30

(N =

9±

±

±

±

±

±

±

±

±

±

±

98 severit y

a

a

4.23

0.93

a

a

a

2.51

1.53

27)

5.85

16–20

23.0

14.25

3.33

3.75

4.90

(N =

8±

±

±

±

±

40)

21–27 (N = 40)

6.83

a

13.7 1± 10.1 b

4

a

4.52

1.12

8.15 ± 6.93

b

a

b

a

0.97

a

3.10 ± 1.03a,

a

1.78

1.58

a

0.81

a

1.72a

7.90

6.15

1.68

±

±

±

a

b

2.21

1.66

a

0.86

b

2.26

2.06

2.09

1.76

3.00

2.26

5.06

3.62

1.00

±

±

±

±

±

±

±

b

c

1.56

2.39

2.45

b

1.76

b

1.11 ±

3.63

b

2.95

b

1.02

c

a

1.76

0.47a

0.88

5.28

0.38

±

±

±

1.14

a

0.44 ± 1.08a,

a

1.88

1.44a

2.56

0.06

±

± b

b

2.60

0.24a

28–39

5.72

2.80

1.07

1.05

1.39

0.80

2.07

1.33

0.30

0.09

0.89

0.00

(N =

±

±

±

±

±

±

+

±

±

±

±

±

40) ANO VA F (p)

c

3.83

1.20

54.4

60.27

4*

*

7.27

c

c

c

0.15

32.6 5*

c

1.82

1.15

c

36.46

37.8

*

0*

c

2.94

1.91

c

d

0.79

39.18

44.0

50.06

34.3

*

5*

*

4*

b

0.35

6.39*

c

1.68

50.9 6*

0.00a

2.07

SCIRS: Severe Cognitive Impairment Rating Scale; K-DRS-98: Korean version of the Delirium Rating Scale-Revised-98; MMSE-KC: Mini-Mental State Examination-Korean version of the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) Assessment Packet. Superscript letters (a, b, c, d) denote the groups classified by the Scheffe post-hoc tests (p < 0.05). *p < 0.001

 

Table 4. SCIRS scores in participants with low MMSE-KC scores (0–4) (N = 47) Mean (SD)

Observed range

Maximum total score

K-DRS-98 severity

28.40 (4.61)

20–37

39

MMSE-KC total

0.81 (1.28)

0–4

30

Orientation

0.19 (0.40)

0–1

10

Memory

0.23 (0.60)

0–3

6

Language

0.38 (0.90)

0–4

8

Frontal function

0

0

5

Visuospatial function

0

0

1

2.04 (3.09)

0–10

30

Orientation

0.53 (0.88)

0–3

4

Memory

0.62 (0.99)

0–3

7

Language

0.70 (1.41)

0–5

9

Frontal function

0.06 (0.32)

0–2

3

Visuospatial function

0.13 (0.45)

0–2

7

MMSE-KC subscales

SCIRS total SCIRS subscales

SCIRS: Severe Cognitive Impairment Rating Scale; K-DRS-98: Korean version of the Delirium Rating Scale-Revised-98; MMSE-KC: Mini-Mental State Examination-Korean version of the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) Assessment Packet