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A new rating scale for dementia syndromes
Arch. GerontoL Geriatr., 1 (1982) 311-330 Elsevier Biomedical Press
311
A new rating scale for dementia syndromes C.-G. Gottfries l, G. Brine 1, B. Gullberg 2 and G. Steen 3 I Department of Psychiatry, St. JOrgen's Hospital, University of GOteborg, 422 03 Hisings-Backa. 2 Department of Statistics, Land University, 220 05 Lund, and 3 Department of Community Health Sciences, Section of Geriatric Medicine, Lund University, Bangatan 5, 214 Ol MalmO, Sweden
(Received 24 March 1982; accepted in revised form 24 July 1982)
Summary A new scale, the GBS-scale, is constructed for rating dementia syndromes. The scale is divided into four subscales measuring motor, intellectual and emotional functions and different symptoms characteristic for dementia. The scale can be used by physicians, psychologists and registered nurses. The reliability of the scale is tested by rating 100 patients in somatic and psychogeriatric long-term care. The raters worked independently of each other and were recommended to confer with the staff about the status of the patient. The agreement between the raters was good. The validity of the scale was tested by comparing it with another geriatric rating scale. High correlations between the two scales were seen and indicated that the new scale measures dementia syndromes. The new scale measures degree of dementia and profiles of dementia syndromes. It is constructed in such a way that it can measure changes in dementia symptoms over a certain amount of time. Thus, it can be used in evaluating effect of treatment. It is not, however, meant to be a diagnostic scale. rating scale; dementia; motor impairment; intellectual impairment; emotional impairment; symptoms of dementia
Introduction In s t u d y i n g elderly p a t i e n t s w i t h d e m e n t i a valid m e t h o d s are n e c e s s a r y to rate the d e g r e e of i m p a i r m e n t of m e n t a l f u n c t i o n . T h i s m a y b e d i f f i c u l t since this g r o u p o f p a t i e n t s is h e t e r o g e n i c r e g a r d i n g m e n t a l as well as s o m a t i c illness. F u r t h e r m o r e , such p a t i e n t s o f t e n b e l o n g to d i f f e r e n t types of care, e.g. l o n g - t e r m c a r e m e d i c i n e a n d p s y c h i a t r y . A r a t i n g scale should, t h e r e f o r e , b e d e s i g n e d to e s t i m a t e b o t h d i f f e r e n t types and degree of dementia. T h e r e are scales c o n s t r u c t e d to m e a s u r e the d e g r e e o f c o n f u s i o n a n d g e r i a t r i c b e h a v i o u r , e.g. K a h n et al. (1960), R o b i n s o n (1961), P l u t c h i c k et al. ( 1971), G o t t f r i e s a n d C r o n h o l m (1974), S h a d e r et al. (1974), .~sberg et al. (1978), a n d Berg et al. (1980). T h e scale of G o t t f r i e s a n d G o t t f r i e s (1968) c o m p r i s e s 143 d e t a i l e d q u e s t i o n s 0167-4943/82/0000-0000/$02.75 © 1982 Elsevier Biomedical Press
312 regarding intellectual, emotional, social and motor functions. This scale was designed for patients with severe dementia syndromes and has previously been used in studies of multiinfarction and dementia of Alzheimer type (Adolfsson et al., 1981). Some existing rating scales give too brief an estimation of the type and degree of dementia, while other more detailed scales often give an undifferentiated picture because incomparable items are being brought together in an inappropriate way. The aim of the present work is to produce a concrete rating scale - easy to administer - to estimate the degree of dementia in geriatric patients. The scale is meant to judge physical inactivity, impairment of intellectual and emotional capacities and mental symptoms common in dementia. Furthermore, it is meant to be used at single estimations to get not only a quantitative measure of dementia but also a 'dementia profile', represented by the three subscales and the six mental symptoms rated. The scale is not, however, meant to be a diagnostic scale. It is to be used at repeated measurements and at evaluation of drug treatments. The scale can also be handled by other staff groups than psychiatrists. Not many technical words have been used and the formulation is as concrete as possible. The scale is named the ' G B S scale' after the authors Gottfries, Brhne and Steen. Items from The Comprehensive Psychopathological Rating Scale (CPRS, ~,sberg et al., 1978), have been used to produce subscales, e.g. a depression scale and a scale for measuring schizophrenic syndromes. Relevant items from CPRS were chosen to try to design a dementia scale. However, we were not satisfied by a dementia scale formed in this way, because it did not give a differentiated picture of the dementia. To construct the GBS scale we used, as starting points, the CPRS, Sandoz Clinical Assessment Geriatric and The Geriatric Rating Scale of Gottfries and Gottfries. The model of CPRS - dividing items in observed and reported - was not chosen, as patients with dementia too often fail to report symptoms or to participate in an active way. As in CPRS seven scale steps were used, in which the scale steps 0, 2, 4 and 6 were clearly defined (see Appendix). Zero was equivalent to normal function or absence of symptoms, while 6 meant maximal disturbance or presence of symptoms. The definitions of the scale steps were so formulated that they could be understood by most of the hospital workers. Under some circumstances, for instance at dysphasia, some items were not possible to rate, namely impaired orientation in time, long-windedness and emotional lability. If rating was not possible, this item was scored as 9. In this investigation a psychiatrist, a psychologist and registered nurses operated the scale. The scale is supposed to be used by staff who are well informed of the status of the patient. The amount of time which the rater has cared for the patient should be recorded in the scale. The scale is divided into four subscales which are supposed to estimate the motor, intellectual and emotional functions and symptoms characteristic for dementia syndromes (see Appendix). The motor section is composed of six items, which concern the motor inactivity and inability in activities of daily life (ADL). To the motor function also inability to control bladder and bowel is counted. T h e other items of the first section are motor insufficiency in undressing and dressing, motor insufficiency in taking food, impaired physical activity, deficiency of
313
spontaneous activity and motor insufficiency in managing personal hygiene. The second subscale is meant to estimate intellectual disturbances and comprises 11 variables, namely impairment orientation in space, impaired orientation in time, impaired personal orientation, impaired recent memory, impaired distant memory, impaired wakefulness, impaired concentration, inability to increase tempo, absentmindedness, long-windedness and distractability. The third subscale measures emotional disturbances and has three variables, namely emotional blunting, emotional lability and reduced motivation. The fourth subscale is meant to judge different symptoms characteristic for dementia syndromes and is heterogenically constructed. The variables in this section are confusion, irritability, anxiety, agony, reduced mood and restlessness.
Material and method
Investigation of reliability One-hundred patients were chosen for testing the reliability. Seventy patients (26 males and 44 females) were cared for in two wards in a nursing home for somatic long-term care. The patients therefore had somatic diseases, but most of them had symptoms of dementia. The average age was 81 + 9.0 (SD) yr (range 57-100). The remaining 30 patients lived in two psychogeriatric wards and they were often 'somatically healthy'. They had a continuously progressing dementia, usually dementia of Alzheimer type or multi-infarct dementia. This group consisted of 11 men and 17 women with an average age of 78 + 6.2 (SD) yr (range 64-89). In the latter group there was a drop-out of 2 women because of acute somatic illness, which made rating impossible. All patients had been in hospital for at least 1 mth and were well known by the staff. In the nursing home for somatic long-term care the ratings were performed by two registered nurses in each ward, independent of each other. In the two psychogeriatric wards the ratings were made by a physician, a psychologist and a registered nurse. The physician and the psychologist rated all the patients (n = 28), and the registered nurse rated the patients in one ward (n = 17). The ratings were performed on different occasions, but were coordinated in time, only two or three days being allowed to pass between the ratings of one patient. Thus, the raters worked independently of each other, and were recommended to confer with the staff about the status of the patients. The following ratings were performed: Registered nurse versus registered nurse (long-term care medicine); (Material I, n = 35). Registered nurse versus registered nurse (long-term care medicine); (Material II, n = 35). Registered nurse versus psychologist (psychogeriatric medicine); (Material III, n = 17).
314 Registered nurse versus physician (psychogeriatric medicine); (Material III, n = 17). Psychologist versus physician (psychogeriatric medicine); (Material I I I + IV, n = 28). The raters were not trained together before the reliability test. After the test was carried through some variables were reformulated, and then another reliability test for the reformulated variables and for the emotional subscale was performed by a physician, a psychologist and a registered nurse in a psychogeriatric ward (n = 20). This time the raters were trained together once. The ratings were performed on different occasions but were coordinated as regards time. The nurse was working in the ward and knew the patients well. The physician and the psychologist did not know the patients very well and conferred with the staff about the status of the patients.
Investigation of validity The patients included in Material I and II were also rated with another geriatric rating scale (Gottfries and Gottfries, 1968) by one of the registered nurses participating in the study. Results
In Table I the mean values of the ratings and the exact + 1 score point agreement percent (EA%) are given for the materials. As is evident from the table the patients in the nursing home for somatic long-term care had high means regarding items measuring reduced motor functions. Among the psychogeriatric patients the intellectual and emotional reduction dominated while motor disturbances were less pronounced. In the two materials there was sufficient severity of symptoms for testing the reliability and validity of the scale.
Reliability In Table I the correlation coefficients between two independent raters are given. As is evident from the table there was a high agreement for most of the items at the ratings in the nursing home (Material I and II). There were only three items which did not reach a significant level ( P < 0.05), namely wakefulness (Material I), distractability (Material II), and anxiety (Material I). In the psychogeriatric group there was also a high agreement between the raters regarding most of the items, but the reliability coefficients did not reach a significant level regarding speech disturbances (Material III), discomfort-irritability (Material II1), anxiety (Material I I I + IV), and reduced mood (Material I I I + IV). The items distractability and discomfort-irritability were reformulated in a more concrete way to be understood properly. The item speech disturbances which also had low correlation coefficients was omitted in the final scale, and the item anxiety was divided into two items anxiety and agony. , If six motor items were gathered to a motor syndrome, the agreement between the raters was high, the correlation coefficient varied between 0.83 and 0.93 (Table II and Fig. 1).
315
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Fig. 1. Motor impairment rated by independent raters. * = Patients from long-term care medicine (raters: registered nurses; n = 70). O = Patients from psychogeriatric medicine (raters: physician, psychologist;
n = 28).
When the 12 intellectual items were gathered to an intellectual syndrome, the agreement between the raters was also high (r = 0.81 - 0 . 9 7 ) (Table II and Fig. 2). When three items were gathered to an emotional syndrome the agreement between the raters was somewhat lower, the correlations varied between coefficient 0.57 and 0.87 (Table II and Fig. 3). The renewed reliability testing after the reformulations of some of the items gave improved reliability values (see Table I). The renewed reliability testing of the emotional functions after training gave improved reliability values only between physician and psychologist (see Table II).
Validity Parallel to the use of the GBS scale another geriatric rating scale was used (Gottfries and Gottfries, 1968). This scale includes two subscales measuring motor impairment, two subscales measuring intellectual impairment and one subscale measuring emotional bluntness. When studying the relationship between motor impairment rated with the GBS scale and the Gottfries-Gottfries subscales 1 and 2 (Material I and II) the correla-
Motor functions Motor insufficiency in undressing and dressing Motor insufficiency in taking food Impaired physical activity Deficiency of spontaneous activity Motor insufficiency in managing personal hygiene Inability to control bladder and bowel Intellectual functions Impaired orientation in space
Material
74 81 81 57 76 76
73
4.0 1.2 3.8 2.4 3.9 3.0
2.0
0.84
0.89
0.86
0.48
0.99
0.89
0.69
rs (N vs. N)
M
EA%
I
(n = 35)
I+II
(n = 70)
Long-term care medicine
0.83
0.89
0.83
0.71
0.61
0.66
0.87
rs (N vs. N)
II (n = 35)
5.3
4.4
5.3
2.7
2.1
2.2
4.7
M
I11 + IV (n = 28)
86
75
82
71
93
71
71
EA%
0.91
0.80
0.55
0.75
0.98
0.88
0.63
rs (N vs. Ps)
II1 (n = 17)
Psychogeriatric medicine
0.89
0.78
0.82
0.55
0.75
0.90
0.72
r, (N vs. Ph)
Ili (n = 17)
0.76
0.73
0.62
0.78
0.84
0.74
0.67
r~ (Ps vs. Ph)
(n - 28)
I l l + IV
Mean value ( M ) of the scores from all items, exact_+ 1 score point agreement (%) between two raters (EA%) and Spearman rank correlations coefficients (r,) between ratings by registered nurses (N), psychologist (Ps) and physician (Ph) in the wards of long-term care and psychogeriatric medicine, respectively.
TABLE I
0.74 0.66 0.42 0.64 0.24 0.62 0.34 0.67 0.72 0.73 0.82 0.59 0.67 0.64 0.69 0.59 0.16 0.39 0.78
59 70 60 73 66 77 51 59 59 46 79 59 66 59 67 64 59 61 83
5.4 3.7 5.3 4.6 0.8 4.8 4.4 4.9 4.5 4.0 2.9 3.0 4.2 4.9 4.0 2.0 1.3 1.6 1.9
0.82 0.74 0.81 0.60 0.65 0.80 0.53 0.67 0.58 0.13 0.86 0.65 0.60 0.71 0.75 0.61 0.30 0.61 0.70 61
64 71 54
61 43 71
36 82 82 54 61
82 50 78 67 75 75
Figures within parentheses are correlation coefficients from the renewed reliability testing (n = 20). a Excluded in the final scale. b Modified in the final scale. ¢ Included in the final scale.
Impaired orientation in time 2.9 Impaired personal orientation 1.1 Impaired recent memory 2.7 Impaired distant memory 1.5 Impaired wakefulness 0.8 Impaired concentration 2.1 Inability to increase tempo 2.6 Absentmindedness 2.7 Long-windedness 2.0 Distractability 1.9 Speech disturbances a 1.5 Emotional functions Emotional blunting 1.6 Emotional lability 1.8 Reduced motivation 3.1 Symptoms common in dementia syndromes Confusion 2.3 Irritability b 1.9 Anxiety b 2.3 Agony ¢ Reduced mood 2.1 Restlessness 1.3 0.61 (0.45) 0.68 (0.34) 0.74 (0.52)
0.74 (0.47) 0.76 (0.48) 0.76 (0.76) 0.85 0.56 (0.66) 0.81 (0.58) (0.65) 0.63 0.59
0.51 0.05 (0.50) 0.57 (0.44) (0.65) 0.29 0.83
0.47 0.56 0.66 0.62 (0.88) 0.36
0.84 0.86 0.52 0.58 (0.75) 0.15
0.74 0.89 0.70 0.68 (O.83) 0.56
0.69 0.32 (0.86) 0.29 (0.87) (0.94) 0.22 0.61
0.63 (0.75) 0.44 (0.82) o.35 (o.82)
0.51 0.74 0.54 0.74 0.61 0.73
0.99 0.80 0.72 0.90 0.19 0.74
0.72 0.82 0.98 0.78 0.59 0.64
318 TABLE II Correlation coefficients (Spearman Rank correlation) between ratings by registered nurses (N), psychologist (Ps) and physician (Ph), in the wards of long-term care and psychogeriatric medicine, respectively. Six items were gathered to a syndrome of motor impairment, twelve items to a syndrome of intellectual impairment and three items to a syndrome of emotional impairment. Variable
Syndrome of motor impairment Syndrome of intellectual impairment Syndrome of emotional impairment
Long-term care medicine
Psychogeriatric medicine
N vs. N Material
N vs. N Material
N vs. Ps Material
N vs. Ph Material
I (n = 35)
1I (n = 35)
III (n = 17)
IV (n = 17)
Ps vs. Ph Material V (n = 28)
0.90
0.93
0.91
0.83
0.83
0.82
0.86
0.97
0.86
0.81
0.70
0.74
0.87
0.65
0.57
66
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Fig. 2. Intellectual impairment rated by independent raters. * = Patients from long-term care medicine (raters registered nurses; n = 70). O = Patients from psychogeriatric medicine (raters physician and psychologist; n = 26).
319 0
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RATER X Fig. 3. Emotional bluntness rated by independent raters. * = Patients from long-term care medicine (raters registered nurses; n = 70). O = Patients from psychogeriatric medicine (raters physician and psychologist; n = 26).
tion coefficient varied between 0.53 and 0.92 (Table III). Regarding intellectual impairment the corresponding figures were between 0.83 and 0.92. The correlation coefficients regarding emotional bluntness were 0.42 and 0.47, respectively. The high T A B L E I11 Correlation coefficient between rated dementia syndromes according to the Gottfries-Gottfries scale and to the new rating scale for dementia syndromes (GBS-scale).
Motor impairment 1 Motor impairment 2 Intellectual impairment 1 Intellectual impairment 2 Emotional bluntness
Syndrome of motor impairment
Syndrome of intellectual impairment
Syndrome of emotional bluntness
Material
Material
Material
Material
Material
Material
I
II
I
II
I
II
0.92 0.53
0.86 0.81 0.86 0.83
0.92 0.88 0.42
0.47
320 correlation between the two scales indicates that the new scale measures the dementia syndromes similar to syndromes measured by the Gottfries-Gottfries scale. The Gottfries-Gottfries scale consists of simple items with 'yes' or ' n o ' answers. It is supposed to be used by the staff on the ward and the scale cannot be used at repeated measurements. The GBS scale is meant to measure with higher accuracy and is therefore possible to use at repeated investigations as when evaluating drug effects.
Discussion When constructing the scale the aim was to divide the scale into different subscales, e.g. motor, intellectual and emotional functions, to describe, if possible, a dementia profile. The scale also includes symptoms common in dementia syndromes. To study the reliability of the scale it was used by different observers, who rated the patients independently of each other. The raters were not trained before the first set of ratings and the interviews were made on different occasions although close to each other in time. Owing to this we can expect lower agreement between raters than at joint ratings. The scale is meant to be used by physicians, psychologists and registered nurses. The statistical analysis showed that these categories of staff groups can use the scale in a sufficient way. As mentioned above the scale was constructed so that different dementia syndromes could be measured. The statistical analysis showed that syndromes of motor impairment, intellectual impairment and, to a greater or lesser extent, emotional bluntness can be delimited. In the patient materials from the somatic wards we found a dementia profile dominated by motor impairment, while in the psychogeriatric materials the intellectual impairment dominated (Figs. 1 and 2). However, there was an overlapping between the subscales, the correlation coefficient for motor impairment/intellectual impairment being 0.60 and for motor i m p a i r m e n t / e m o tional bluntness 0.60. The correlation coefficient for intellectual i m p a i r m e n t / e m o tional bluntness was 0.82. The motor impairment can be due to central as well as peripheral disturbances. This may explain the somewhat lower correlation between motor impairment and other dementia variables. The scale does not discriminate motor deficits due to 'somatic' diseases. If the patient material includes patients with somatic diseases such as polyarthritis, this has to be considered. The reliability coefficients for the emotional subscale were somewhat lower than for the other subscales. We therefore made another reliability test after co-training the raters once. The reliability coefficients improved between physician and psychologist but were still low when nurses took part in the rating. Thus, this subscale seems to give the most reliable results when used by physicians and psychologists. When testing the scale patient materials from long-term care medicine and psychogeriatric medicine were used. It could be expected that the patients from the
321 somatic hospital should have m o r e p r o n o u n c e d m o t o r i m p a i r m e n t while .the patients from the psychogeriatric wards should have intellectual i m p a i r m e n t . The result of the ratings c o n f i r m e d this, which suggests a clinical validity of the scale. S u b g r o u p s from the m a t e r i a l were also rated with a n o t h e r rating scale for geriatric patients. The agreement between the scales was acceptable. Thus, also interscale validity seemed acceptable. In the original scale there was an item - speech d i s t u r b a n c e s - which was excluded later on since this item was far too b r o a d as it covered stammering, dysarthria, d y s p h o n i a a n d dysphasia. W h e n rating wakefulness the reliability was low, but this can p a r t l y be explained b y the low occurrence of this s y m p t o m in the samples. Owing to acceptable validity and reliability a n d due to its easiness to handle the G B S scale m a y in our o p i n i o n be useful in clinical work with geriatric patients with d e m e n t i a syndromes.
Acknowledgements This s t u d y was s u p p o r t e d b y grants from The Swedish M e d i c a l Research Council (B82-21X-05002-06A); Stiftelsen H a n d l a n d e n H j a l m a r Svenssons F o r s k n i n g s f o n d ; F o n d e n F r e d r i k och Ingrid Thurings Stiftelse; G u n a n d Bertil Stohnes Stiftelse f6r M e d i c i n s k F o r s k n i n g and K o n u n g G u s t a v V:s och D r o t t n i n g Victorias Stiftelse.
References Adolfsson, R., Gottfries, C.G., Nystr6m, L. and Winblad, B. (1981): Prevalence of dementia disorders in institutionalized Swedish old people. The work imposed by caring for these patients. Acta Psychiatr. Scand., 63, 225-244. ,~sberg, M., Montgomery, S.A., Perris, C., Schalling, D. and Sedvall, G. (1978): A comprehensive psychopathological rating scale. Acta Psychiatr. Scand., 271, 5-27. Berg, S. and Svensson, T. (1980): An orientation scale for geriatric patients. Age Ageing, 9, 215-219. Gottfries, C.G. and Gottfries, 1. (1968): Geriatriskt skattningsschema, Stencil St. Lars Sjukhus, Lund, Sweden. Kahn, R.L., Goldfarb, A.I., Pollak, M. and Peck, A. (1969): Brief objective measure for the determination of mental status in the aged. Am. J. Psychiatry, 117, 326. Plutchik, R., Conte, H., Lieverman, M., Bakur, M., Grossman, J. and Lehrman, N. (1976): Plutchick geriatric rating scale. In: ECDEU Assessment Manual for Psychopharmacology, pp. 275-281. Editor: W. Guy. Rockville, Maryland. Robinson, R.A. (1961): Some problems of clinical trials in elderly people. Gerontol. Clin., 3, 247-251. Shader, R.J., Harmatz, J.S. and Salzman, C. (1974): A new scale for clinical assessment in geriatric populations: Sandoz Clinical Assessment Geriatric (SCAG). J. Am. Geriatr. Soc., 22, 107.
311
A new rating scale for dementia syndromes C.-G. Gottfries l, G. Brine 1, B. Gullberg 2 and G. Steen 3 I Department of Psychiatry, St. JOrgen's Hospital, University of GOteborg, 422 03 Hisings-Backa. 2 Department of Statistics, Land University, 220 05 Lund, and 3 Department of Community Health Sciences, Section of Geriatric Medicine, Lund University, Bangatan 5, 214 Ol MalmO, Sweden
(Received 24 March 1982; accepted in revised form 24 July 1982)
Summary A new scale, the GBS-scale, is constructed for rating dementia syndromes. The scale is divided into four subscales measuring motor, intellectual and emotional functions and different symptoms characteristic for dementia. The scale can be used by physicians, psychologists and registered nurses. The reliability of the scale is tested by rating 100 patients in somatic and psychogeriatric long-term care. The raters worked independently of each other and were recommended to confer with the staff about the status of the patient. The agreement between the raters was good. The validity of the scale was tested by comparing it with another geriatric rating scale. High correlations between the two scales were seen and indicated that the new scale measures dementia syndromes. The new scale measures degree of dementia and profiles of dementia syndromes. It is constructed in such a way that it can measure changes in dementia symptoms over a certain amount of time. Thus, it can be used in evaluating effect of treatment. It is not, however, meant to be a diagnostic scale. rating scale; dementia; motor impairment; intellectual impairment; emotional impairment; symptoms of dementia
Introduction In s t u d y i n g elderly p a t i e n t s w i t h d e m e n t i a valid m e t h o d s are n e c e s s a r y to rate the d e g r e e of i m p a i r m e n t of m e n t a l f u n c t i o n . T h i s m a y b e d i f f i c u l t since this g r o u p o f p a t i e n t s is h e t e r o g e n i c r e g a r d i n g m e n t a l as well as s o m a t i c illness. F u r t h e r m o r e , such p a t i e n t s o f t e n b e l o n g to d i f f e r e n t types of care, e.g. l o n g - t e r m c a r e m e d i c i n e a n d p s y c h i a t r y . A r a t i n g scale should, t h e r e f o r e , b e d e s i g n e d to e s t i m a t e b o t h d i f f e r e n t types and degree of dementia. T h e r e are scales c o n s t r u c t e d to m e a s u r e the d e g r e e o f c o n f u s i o n a n d g e r i a t r i c b e h a v i o u r , e.g. K a h n et al. (1960), R o b i n s o n (1961), P l u t c h i c k et al. ( 1971), G o t t f r i e s a n d C r o n h o l m (1974), S h a d e r et al. (1974), .~sberg et al. (1978), a n d Berg et al. (1980). T h e scale of G o t t f r i e s a n d G o t t f r i e s (1968) c o m p r i s e s 143 d e t a i l e d q u e s t i o n s 0167-4943/82/0000-0000/$02.75 © 1982 Elsevier Biomedical Press
312 regarding intellectual, emotional, social and motor functions. This scale was designed for patients with severe dementia syndromes and has previously been used in studies of multiinfarction and dementia of Alzheimer type (Adolfsson et al., 1981). Some existing rating scales give too brief an estimation of the type and degree of dementia, while other more detailed scales often give an undifferentiated picture because incomparable items are being brought together in an inappropriate way. The aim of the present work is to produce a concrete rating scale - easy to administer - to estimate the degree of dementia in geriatric patients. The scale is meant to judge physical inactivity, impairment of intellectual and emotional capacities and mental symptoms common in dementia. Furthermore, it is meant to be used at single estimations to get not only a quantitative measure of dementia but also a 'dementia profile', represented by the three subscales and the six mental symptoms rated. The scale is not, however, meant to be a diagnostic scale. It is to be used at repeated measurements and at evaluation of drug treatments. The scale can also be handled by other staff groups than psychiatrists. Not many technical words have been used and the formulation is as concrete as possible. The scale is named the ' G B S scale' after the authors Gottfries, Brhne and Steen. Items from The Comprehensive Psychopathological Rating Scale (CPRS, ~,sberg et al., 1978), have been used to produce subscales, e.g. a depression scale and a scale for measuring schizophrenic syndromes. Relevant items from CPRS were chosen to try to design a dementia scale. However, we were not satisfied by a dementia scale formed in this way, because it did not give a differentiated picture of the dementia. To construct the GBS scale we used, as starting points, the CPRS, Sandoz Clinical Assessment Geriatric and The Geriatric Rating Scale of Gottfries and Gottfries. The model of CPRS - dividing items in observed and reported - was not chosen, as patients with dementia too often fail to report symptoms or to participate in an active way. As in CPRS seven scale steps were used, in which the scale steps 0, 2, 4 and 6 were clearly defined (see Appendix). Zero was equivalent to normal function or absence of symptoms, while 6 meant maximal disturbance or presence of symptoms. The definitions of the scale steps were so formulated that they could be understood by most of the hospital workers. Under some circumstances, for instance at dysphasia, some items were not possible to rate, namely impaired orientation in time, long-windedness and emotional lability. If rating was not possible, this item was scored as 9. In this investigation a psychiatrist, a psychologist and registered nurses operated the scale. The scale is supposed to be used by staff who are well informed of the status of the patient. The amount of time which the rater has cared for the patient should be recorded in the scale. The scale is divided into four subscales which are supposed to estimate the motor, intellectual and emotional functions and symptoms characteristic for dementia syndromes (see Appendix). The motor section is composed of six items, which concern the motor inactivity and inability in activities of daily life (ADL). To the motor function also inability to control bladder and bowel is counted. T h e other items of the first section are motor insufficiency in undressing and dressing, motor insufficiency in taking food, impaired physical activity, deficiency of
313
spontaneous activity and motor insufficiency in managing personal hygiene. The second subscale is meant to estimate intellectual disturbances and comprises 11 variables, namely impairment orientation in space, impaired orientation in time, impaired personal orientation, impaired recent memory, impaired distant memory, impaired wakefulness, impaired concentration, inability to increase tempo, absentmindedness, long-windedness and distractability. The third subscale measures emotional disturbances and has three variables, namely emotional blunting, emotional lability and reduced motivation. The fourth subscale is meant to judge different symptoms characteristic for dementia syndromes and is heterogenically constructed. The variables in this section are confusion, irritability, anxiety, agony, reduced mood and restlessness.
Material and method
Investigation of reliability One-hundred patients were chosen for testing the reliability. Seventy patients (26 males and 44 females) were cared for in two wards in a nursing home for somatic long-term care. The patients therefore had somatic diseases, but most of them had symptoms of dementia. The average age was 81 + 9.0 (SD) yr (range 57-100). The remaining 30 patients lived in two psychogeriatric wards and they were often 'somatically healthy'. They had a continuously progressing dementia, usually dementia of Alzheimer type or multi-infarct dementia. This group consisted of 11 men and 17 women with an average age of 78 + 6.2 (SD) yr (range 64-89). In the latter group there was a drop-out of 2 women because of acute somatic illness, which made rating impossible. All patients had been in hospital for at least 1 mth and were well known by the staff. In the nursing home for somatic long-term care the ratings were performed by two registered nurses in each ward, independent of each other. In the two psychogeriatric wards the ratings were made by a physician, a psychologist and a registered nurse. The physician and the psychologist rated all the patients (n = 28), and the registered nurse rated the patients in one ward (n = 17). The ratings were performed on different occasions, but were coordinated in time, only two or three days being allowed to pass between the ratings of one patient. Thus, the raters worked independently of each other, and were recommended to confer with the staff about the status of the patients. The following ratings were performed: Registered nurse versus registered nurse (long-term care medicine); (Material I, n = 35). Registered nurse versus registered nurse (long-term care medicine); (Material II, n = 35). Registered nurse versus psychologist (psychogeriatric medicine); (Material III, n = 17).
314 Registered nurse versus physician (psychogeriatric medicine); (Material III, n = 17). Psychologist versus physician (psychogeriatric medicine); (Material I I I + IV, n = 28). The raters were not trained together before the reliability test. After the test was carried through some variables were reformulated, and then another reliability test for the reformulated variables and for the emotional subscale was performed by a physician, a psychologist and a registered nurse in a psychogeriatric ward (n = 20). This time the raters were trained together once. The ratings were performed on different occasions but were coordinated as regards time. The nurse was working in the ward and knew the patients well. The physician and the psychologist did not know the patients very well and conferred with the staff about the status of the patients.
Investigation of validity The patients included in Material I and II were also rated with another geriatric rating scale (Gottfries and Gottfries, 1968) by one of the registered nurses participating in the study. Results
In Table I the mean values of the ratings and the exact + 1 score point agreement percent (EA%) are given for the materials. As is evident from the table the patients in the nursing home for somatic long-term care had high means regarding items measuring reduced motor functions. Among the psychogeriatric patients the intellectual and emotional reduction dominated while motor disturbances were less pronounced. In the two materials there was sufficient severity of symptoms for testing the reliability and validity of the scale.
Reliability In Table I the correlation coefficients between two independent raters are given. As is evident from the table there was a high agreement for most of the items at the ratings in the nursing home (Material I and II). There were only three items which did not reach a significant level ( P < 0.05), namely wakefulness (Material I), distractability (Material II), and anxiety (Material I). In the psychogeriatric group there was also a high agreement between the raters regarding most of the items, but the reliability coefficients did not reach a significant level regarding speech disturbances (Material III), discomfort-irritability (Material II1), anxiety (Material I I I + IV), and reduced mood (Material I I I + IV). The items distractability and discomfort-irritability were reformulated in a more concrete way to be understood properly. The item speech disturbances which also had low correlation coefficients was omitted in the final scale, and the item anxiety was divided into two items anxiety and agony. , If six motor items were gathered to a motor syndrome, the agreement between the raters was high, the correlation coefficient varied between 0.83 and 0.93 (Table II and Fig. 1).
315
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n = 28).
When the 12 intellectual items were gathered to an intellectual syndrome, the agreement between the raters was also high (r = 0.81 - 0 . 9 7 ) (Table II and Fig. 2). When three items were gathered to an emotional syndrome the agreement between the raters was somewhat lower, the correlations varied between coefficient 0.57 and 0.87 (Table II and Fig. 3). The renewed reliability testing after the reformulations of some of the items gave improved reliability values (see Table I). The renewed reliability testing of the emotional functions after training gave improved reliability values only between physician and psychologist (see Table II).
Validity Parallel to the use of the GBS scale another geriatric rating scale was used (Gottfries and Gottfries, 1968). This scale includes two subscales measuring motor impairment, two subscales measuring intellectual impairment and one subscale measuring emotional bluntness. When studying the relationship between motor impairment rated with the GBS scale and the Gottfries-Gottfries subscales 1 and 2 (Material I and II) the correla-
Motor functions Motor insufficiency in undressing and dressing Motor insufficiency in taking food Impaired physical activity Deficiency of spontaneous activity Motor insufficiency in managing personal hygiene Inability to control bladder and bowel Intellectual functions Impaired orientation in space
Material
74 81 81 57 76 76
73
4.0 1.2 3.8 2.4 3.9 3.0
2.0
0.84
0.89
0.86
0.48
0.99
0.89
0.69
rs (N vs. N)
M
EA%
I
(n = 35)
I+II
(n = 70)
Long-term care medicine
0.83
0.89
0.83
0.71
0.61
0.66
0.87
rs (N vs. N)
II (n = 35)
5.3
4.4
5.3
2.7
2.1
2.2
4.7
M
I11 + IV (n = 28)
86
75
82
71
93
71
71
EA%
0.91
0.80
0.55
0.75
0.98
0.88
0.63
rs (N vs. Ps)
II1 (n = 17)
Psychogeriatric medicine
0.89
0.78
0.82
0.55
0.75
0.90
0.72
r, (N vs. Ph)
Ili (n = 17)
0.76
0.73
0.62
0.78
0.84
0.74
0.67
r~ (Ps vs. Ph)
(n - 28)
I l l + IV
Mean value ( M ) of the scores from all items, exact_+ 1 score point agreement (%) between two raters (EA%) and Spearman rank correlations coefficients (r,) between ratings by registered nurses (N), psychologist (Ps) and physician (Ph) in the wards of long-term care and psychogeriatric medicine, respectively.
TABLE I
0.74 0.66 0.42 0.64 0.24 0.62 0.34 0.67 0.72 0.73 0.82 0.59 0.67 0.64 0.69 0.59 0.16 0.39 0.78
59 70 60 73 66 77 51 59 59 46 79 59 66 59 67 64 59 61 83
5.4 3.7 5.3 4.6 0.8 4.8 4.4 4.9 4.5 4.0 2.9 3.0 4.2 4.9 4.0 2.0 1.3 1.6 1.9
0.82 0.74 0.81 0.60 0.65 0.80 0.53 0.67 0.58 0.13 0.86 0.65 0.60 0.71 0.75 0.61 0.30 0.61 0.70 61
64 71 54
61 43 71
36 82 82 54 61
82 50 78 67 75 75
Figures within parentheses are correlation coefficients from the renewed reliability testing (n = 20). a Excluded in the final scale. b Modified in the final scale. ¢ Included in the final scale.
Impaired orientation in time 2.9 Impaired personal orientation 1.1 Impaired recent memory 2.7 Impaired distant memory 1.5 Impaired wakefulness 0.8 Impaired concentration 2.1 Inability to increase tempo 2.6 Absentmindedness 2.7 Long-windedness 2.0 Distractability 1.9 Speech disturbances a 1.5 Emotional functions Emotional blunting 1.6 Emotional lability 1.8 Reduced motivation 3.1 Symptoms common in dementia syndromes Confusion 2.3 Irritability b 1.9 Anxiety b 2.3 Agony ¢ Reduced mood 2.1 Restlessness 1.3 0.61 (0.45) 0.68 (0.34) 0.74 (0.52)
0.74 (0.47) 0.76 (0.48) 0.76 (0.76) 0.85 0.56 (0.66) 0.81 (0.58) (0.65) 0.63 0.59
0.51 0.05 (0.50) 0.57 (0.44) (0.65) 0.29 0.83
0.47 0.56 0.66 0.62 (0.88) 0.36
0.84 0.86 0.52 0.58 (0.75) 0.15
0.74 0.89 0.70 0.68 (O.83) 0.56
0.69 0.32 (0.86) 0.29 (0.87) (0.94) 0.22 0.61
0.63 (0.75) 0.44 (0.82) o.35 (o.82)
0.51 0.74 0.54 0.74 0.61 0.73
0.99 0.80 0.72 0.90 0.19 0.74
0.72 0.82 0.98 0.78 0.59 0.64
318 TABLE II Correlation coefficients (Spearman Rank correlation) between ratings by registered nurses (N), psychologist (Ps) and physician (Ph), in the wards of long-term care and psychogeriatric medicine, respectively. Six items were gathered to a syndrome of motor impairment, twelve items to a syndrome of intellectual impairment and three items to a syndrome of emotional impairment. Variable
Syndrome of motor impairment Syndrome of intellectual impairment Syndrome of emotional impairment
Long-term care medicine
Psychogeriatric medicine
N vs. N Material
N vs. N Material
N vs. Ps Material
N vs. Ph Material
I (n = 35)
1I (n = 35)
III (n = 17)
IV (n = 17)
Ps vs. Ph Material V (n = 28)
0.90
0.93
0.91
0.83
0.83
0.82
0.86
0.97
0.86
0.81
0.70
0.74
0.87
0.65
0.57
66
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Fig. 2. Intellectual impairment rated by independent raters. * = Patients from long-term care medicine (raters registered nurses; n = 70). O = Patients from psychogeriatric medicine (raters physician and psychologist; n = 26).
319 0
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tion coefficient varied between 0.53 and 0.92 (Table III). Regarding intellectual impairment the corresponding figures were between 0.83 and 0.92. The correlation coefficients regarding emotional bluntness were 0.42 and 0.47, respectively. The high T A B L E I11 Correlation coefficient between rated dementia syndromes according to the Gottfries-Gottfries scale and to the new rating scale for dementia syndromes (GBS-scale).
Motor impairment 1 Motor impairment 2 Intellectual impairment 1 Intellectual impairment 2 Emotional bluntness
Syndrome of motor impairment
Syndrome of intellectual impairment
Syndrome of emotional bluntness
Material
Material
Material
Material
Material
Material
I
II
I
II
I
II
0.92 0.53
0.86 0.81 0.86 0.83
0.92 0.88 0.42
0.47
320 correlation between the two scales indicates that the new scale measures the dementia syndromes similar to syndromes measured by the Gottfries-Gottfries scale. The Gottfries-Gottfries scale consists of simple items with 'yes' or ' n o ' answers. It is supposed to be used by the staff on the ward and the scale cannot be used at repeated measurements. The GBS scale is meant to measure with higher accuracy and is therefore possible to use at repeated investigations as when evaluating drug effects.
Discussion When constructing the scale the aim was to divide the scale into different subscales, e.g. motor, intellectual and emotional functions, to describe, if possible, a dementia profile. The scale also includes symptoms common in dementia syndromes. To study the reliability of the scale it was used by different observers, who rated the patients independently of each other. The raters were not trained before the first set of ratings and the interviews were made on different occasions although close to each other in time. Owing to this we can expect lower agreement between raters than at joint ratings. The scale is meant to be used by physicians, psychologists and registered nurses. The statistical analysis showed that these categories of staff groups can use the scale in a sufficient way. As mentioned above the scale was constructed so that different dementia syndromes could be measured. The statistical analysis showed that syndromes of motor impairment, intellectual impairment and, to a greater or lesser extent, emotional bluntness can be delimited. In the patient materials from the somatic wards we found a dementia profile dominated by motor impairment, while in the psychogeriatric materials the intellectual impairment dominated (Figs. 1 and 2). However, there was an overlapping between the subscales, the correlation coefficient for motor impairment/intellectual impairment being 0.60 and for motor i m p a i r m e n t / e m o tional bluntness 0.60. The correlation coefficient for intellectual i m p a i r m e n t / e m o tional bluntness was 0.82. The motor impairment can be due to central as well as peripheral disturbances. This may explain the somewhat lower correlation between motor impairment and other dementia variables. The scale does not discriminate motor deficits due to 'somatic' diseases. If the patient material includes patients with somatic diseases such as polyarthritis, this has to be considered. The reliability coefficients for the emotional subscale were somewhat lower than for the other subscales. We therefore made another reliability test after co-training the raters once. The reliability coefficients improved between physician and psychologist but were still low when nurses took part in the rating. Thus, this subscale seems to give the most reliable results when used by physicians and psychologists. When testing the scale patient materials from long-term care medicine and psychogeriatric medicine were used. It could be expected that the patients from the
321 somatic hospital should have m o r e p r o n o u n c e d m o t o r i m p a i r m e n t while .the patients from the psychogeriatric wards should have intellectual i m p a i r m e n t . The result of the ratings c o n f i r m e d this, which suggests a clinical validity of the scale. S u b g r o u p s from the m a t e r i a l were also rated with a n o t h e r rating scale for geriatric patients. The agreement between the scales was acceptable. Thus, also interscale validity seemed acceptable. In the original scale there was an item - speech d i s t u r b a n c e s - which was excluded later on since this item was far too b r o a d as it covered stammering, dysarthria, d y s p h o n i a a n d dysphasia. W h e n rating wakefulness the reliability was low, but this can p a r t l y be explained b y the low occurrence of this s y m p t o m in the samples. Owing to acceptable validity and reliability a n d due to its easiness to handle the G B S scale m a y in our o p i n i o n be useful in clinical work with geriatric patients with d e m e n t i a syndromes.
Acknowledgements This s t u d y was s u p p o r t e d b y grants from The Swedish M e d i c a l Research Council (B82-21X-05002-06A); Stiftelsen H a n d l a n d e n H j a l m a r Svenssons F o r s k n i n g s f o n d ; F o n d e n F r e d r i k och Ingrid Thurings Stiftelse; G u n a n d Bertil Stohnes Stiftelse f6r M e d i c i n s k F o r s k n i n g and K o n u n g G u s t a v V:s och D r o t t n i n g Victorias Stiftelse.
References Adolfsson, R., Gottfries, C.G., Nystr6m, L. and Winblad, B. (1981): Prevalence of dementia disorders in institutionalized Swedish old people. The work imposed by caring for these patients. Acta Psychiatr. Scand., 63, 225-244. ,~sberg, M., Montgomery, S.A., Perris, C., Schalling, D. and Sedvall, G. (1978): A comprehensive psychopathological rating scale. Acta Psychiatr. Scand., 271, 5-27. Berg, S. and Svensson, T. (1980): An orientation scale for geriatric patients. Age Ageing, 9, 215-219. Gottfries, C.G. and Gottfries, 1. (1968): Geriatriskt skattningsschema, Stencil St. Lars Sjukhus, Lund, Sweden. Kahn, R.L., Goldfarb, A.I., Pollak, M. and Peck, A. (1969): Brief objective measure for the determination of mental status in the aged. Am. J. Psychiatry, 117, 326. Plutchik, R., Conte, H., Lieverman, M., Bakur, M., Grossman, J. and Lehrman, N. (1976): Plutchick geriatric rating scale. In: ECDEU Assessment Manual for Psychopharmacology, pp. 275-281. Editor: W. Guy. Rockville, Maryland. Robinson, R.A. (1961): Some problems of clinical trials in elderly people. Gerontol. Clin., 3, 247-251. Shader, R.J., Harmatz, J.S. and Salzman, C. (1974): A new scale for clinical assessment in geriatric populations: Sandoz Clinical Assessment Geriatric (SCAG). J. Am. Geriatr. Soc., 22, 107.