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Assessment of Behavioral Symptoms in Community-Dwelling Dementia Patients
Assessment of Behavioral Symptoms in CommunityDwelling Dementia Patients Myron F. Weiner, M.D. Brent Williams, M.A. Richard C. Risser, M. S. The autbors compared the CERAD Behavior Rating Scale for Dementia (CBRSD) with the Cohen-Mansfield Agitation Inventory (CMN) for their ability to detect behavioral symptoms in community-dwelling dementia patients with mild-to-moderate global impairment. Both instruments were administered to caregivers of 33 cognitively impaired patients seen in a dementia clinic at initial evaluation or folloui-up visit. Endorsement of a higher percentage of items on the CBRSD than the CMAI suggests greater sensitivity of this instrument to the behavioral symptoms seen in community-dwelling patients. There was good correlation between the number of items endorsed on both scales but not between subscales of the CMAI and factors of the CBRSD that appeared related to agitation. Thus, the CBRSD and CMAI both seem to measure behaviors that occur in dementia patients, but the CBRSD's two agitation-related factors do not appear to measure agitation as defined by the eMAI. (American] OUfnal of Geriatric Psychiatry 1997; 5:26-30)
T
he quantification of behavioral symptoms in dementia patients is important for the assessment of behavioral intervention strategies and for the assess.. ment of psychotropic and cognition-enhancing drug effects on such symptoms. Scales for the evaluation of psychiatric symptoms in cognitively intact persons
are not useful for assessing behavioral symptoms in dementia patients because they are based on self-report or clinical observation. Scales based on direct clinical observation are not useful because the behaviors are often infrequent. Self-report scales are not useful because ofcognitively impaired patients' inability to report on
Received August 2, 1995; revised December 12, 1995; accepted May 9, 1996. From the Departments of Psychiatry and Neurology, University of Texas Southwestern Medical Center, DaIL'1s, TX. Address correspondence to Dr. Weiner, 5323 Harry Hines Blvd., Dallas, TX 75235-9070. Copyright © 1997 American Association for Geriatric Psychiatry
26
VOLUME 5 • NUMBER 1 • WINTER 1997
Weiner et al. their own behavior.' For these reasons, informant-based scales, such as the CERAD Behavior Rating Scale for Dementia (CBRSD) and the Cohen-Mansfield Agitation Inventory (CMAI) have been developed. We compared the CBRSD, a new instrument, with a commonly used instrument, the CMAI, to determine the sensitivity of each instrument to behaviors in community-dwelling Alzheimer's disease (AD) patients with mild-to-moderate dementia. The CMAI 2 measures so-called agitated behaviors in nursing home residents with and without a formal diagnosis of dementia. It was chosen as the instrument for comparison because it was developed without reference to psychopatholop or psychiatric syndrome. The CBRSn3 , was developed by the Consortium to Establish a Registry for Alzheimer's Disease (CERAD)5 as a broad-based scale to quantify behavioral and emotional symptoms in community..d welling AD patients.
METHODS Subjects
Subjects were a convenience sample of 33 consecutive caregivers of community-dwelling individuals seen for initial evaluation or in regular follow-up visits at the Clinic for Alzheimer's and Related Diseases at the University ofTexas Southwestern Medical Center. Our evaluation process is described els ewhe re ," Caregivers included spouses and children of patients. The CMAI7 sB and CBRSD were administered to caregivers during the course of their patient's visit by a clinician (BW)well trained in the administration of the CMAI and CBRSD. For every caregiver, the CMAIwas administered first. The origi4 nal version of the CBRSn was used. Responses were coded to maintain patient confidentiality: Weestimated that a sample of about 30 subjects would provide better THE AMERICAN JOURNAL OF GERIATlUC PSYCHIATRY
than 90% power to detect moderately high correlations (at least r = 0.70) between measures as opposed to low-incidence (1· = 0.30 or less) alternatives. Descriptive statistics concerning age, duration of symptoms, onset age, MiniMental State Exam (MMSE)9 score, and Clinical Dementia Rating (CDR) 10 score for the 33 patients are provided in Table 1. As suggested by MMSE and CDR scores, the patients were mildly to moderately impaired. The 33 patients included 19 women (58%) and 14 men. Using NINCDS criteria for the diagnosis of AD, 24 of the 33 patients (73%) were classified as probable (18) or possible (11) AD. Some patients had various other diagnoses, including prodromal AD (3), unclassifiable dementia (2), progressive dysphasic dementia (1), and cognitive impairment without dementia (2).
Instruments The CMAI is a compilation of "agitated" behaviors observed in nursing home residents. In the development of this scale, agitation was defined as "inappropriate verbal, vocal, or motor activities not explained by apparent needs or confusion.,,2 The scale is well anchored, and its reliability and validity are well estab.. lished. 6,7 The informant is the patient's caregiver. Symptoms are assessed for the preceding 2 weeks. There are 37 items and 3 agitationsubscales: physically aggressive (directed against a person or object), physically nonaggressive (not directed against a person or object, such as pacing and wandering), and verbal. Items are scored on a seven-point scale: 1 = never; 2 = < once a week; 3 = 1-2 times/week; 4 = several times/week; 5 = 1-2 times per day; 6 = several times/day; 7 = several times/hour. Severity is not rated on this scale. The CBRSDwas designed to assess AD patients. It samples a wide range ofbehaviors and psychopathology and is intended 27
Behavioral Assessment in Dementia TABLE 1.
Descriptive statistics: dementia clinic outpatients Mean ± SD
Age, years Age at onset of illness Duration of illness, years MMSE score CDR scale Note:
SD
TABLE 2.
73.6 69.5 4.1 16.5 1.3
59 52 1 5 1
90 87 15 25 3
CDR scale
= Clinical Dementia Rating.
CERAD Behavior Rating Scale for Dementia (CBRSD): summary scale scores of items overall and for each factor
Total Depressive Psychotic Defective Self-Regulation Irritation/Agitation Vegetative Apathy Aggression Affective Lability
Maximum Attainable Score
Maximum Score
Minimum Score
Mean ± SD
48 7 6 10
168 28 20 37
22 0 0 0
112 26 23 28
48.8 9.7 6.1 10.5
± ± ± ±
20.3 6.0 4.8 6.6
4 4 4 4 4
16 10 10 16 13
0 0 1 0 0
16 10 10 12 12
7.4 5.6 7.2 2.9 5.5
± ± ± ± ±
4.7 3.0 2.5 3.1 3.5
SD = standard deviation.
TABLE 3.
Cohen-Mansfield Agitation Inventory (CMAI): summary scale scores of items overall and for each subscale No. of Items
Total Physical Aggression Non-physical Aggression Verbal Agitation
37 12
10 8
Maximum Attainable Score 222 72 60 48
for use as a structured caregiver interview: Items were selected from a literature review and consultation with experts in the field. The items are well-anchored, and most are homogeneously scaled. The authors of the scale chose to quantify only frequency of behaviors because severity judgments are more difficult to anchor and thus appear to be less reliable. Based on a pilot study of 303 subjects with NINCDS probable AD,11 the scale is under evaluation in further studies and will then be released for general use. 28
Maximum
6.2 7.2 3.0 5.6 0.7
= standard deviation; MMSE = Mini-Mental State Exam;
No. of Items
Note:
± ± ± ± ±
Minimum
Maximum Score
Minimum Score
58 2 26 24
1 0 0 0
Mean ± SD 25.2 0.1 6.4 9.9
± ± ± ±
13.2 0.4 6.6 5.9
The scale assesses behavior over the preceding month, but also notes behaviors over 1 month ago and since the onset of dementia. It is administered to a caregiver. Of the 48 items, 40 are rated as 0 = has not occurred since illness began; 1 = present 1-2 days in the last month; 2 = 3-8 days; 3 = 9-15 days; and 4 = > 16 days. Factor analysis of the initial study suggested 8 factors: depressive symptoms, psychotic symptoms, defective self-regulation, irritability/agitation, vegetative features, apathy, aggression, and affective lability. VOLUME 5 • NUMBER 1 • WINTER 1997
Weiner et al. There are no firmly established traditions for the scoring of the CMAI, and no recommendations have yet been made for scoring tile CBRSD. For the purpose of analysis, we summarized the responses for both instruments in terms of number of items endorsed instead of using the scale values associated with the items. Standard correlation analysis was used to compare responses for the two instruments.
RESULTS Descriptive statistics for the endorsement ofCBRSD items and its subscales (factors) and the CMAIand its subscales are shown in Tables 2 and 3, respectively. There was a significant correlation between the number of items endorsed on both scales (r = 0.480; P = 0.005). Total CBRSD en.. dorsements correlated significantly with endorsements on the CMAI Physically Nonaggressive subscale (r = 0.457; P = 0.007) and Verbal Agitation subscale (r = 0.397; P = 0.022). There were too few re .. sponses among the CMAI Physically Aggressive scale items (only two of the 33 subjects endorsed items for this subscale) to produce a meaningful correlation with the CBRSD total and subscales. Correlations between the number of CMAI items endorsed and the endorse.. ments to CBRSDsubscales indicated some TABLE 4.
significant and some nonsignificant relationships.. The CMAI total correlated sig.. nificantly with CBRSD subscales for psychotic features (1· = O.411;P = 0.017) and defective self-regulation (r = 0.387; P = 0.0269). Other subscale correlations were not significant. Notably; the CMAI endorsements displayed a marginal correlation with endorsements on the CBRSD scale for irritability/agitation (r = 0.332; P = 0 . 06). Also, the CMAI subscale endorsements did not correlate with the CBRSD Irritability/Agitation factors (r = 0.101; P = 0.58) or for the CMAI Nonphysical Aggression subscale (r = 0.263; P = 0.139) for the CMAI Verbal Agitation subscale. Finally; we examined the correlations of the endorsement of CBRSD items pertaining to aggression and agitation across items on the CMAI. Table 4 shows the average as well as the highest inter-item correlations for these seven CBRSD items with all CMAI items and the items contained in the CMAI Verbal Agitation and Nonphysical Aggression subscales. For example, the CBRSD item "agitated or upset" had an average correlation of-0.020 across all CMAI items and an average correlation of-O.064 across the eight CMAI Verbal Agitation items. These various inter-item correlations indicate that there are frequently low as well as negative correlations among endorse.. ments to the agitation..s pecific CBRSD items and the CMAI items in general.
Average (and highest) inter-item correlations (r) pertaining to Agitation and Aggression: average (highest) CBRSD correlation with CMAI items All CMAI Items
Endorsed CBRSD Item: Easily irritated AgitatedIUpset Verbally aggressive Physically aggressive Abandonment Uncooperative Sudden changes in emotion
0.105 (0.410) -0.003 (0.467) 0.116 (0.492) 0.066 (0.348) 0.147 (0.609) 0.168 (0.495) 0.047 (0.398)
THE AMERICAN JOURNAL OF GEIUATIUC PSYGI=lIA-TRY..
CMAIVerbal Agitation Items Endorsed 0.104 -0.027 0.138 0.124 0.152 0.216 0.035
(0.320) (0.220) (0.492) (0.348) (0.605) (0.495) (0.276)
CMAI Non-physical Aggression Items Endorsed 0.052 -0.129 0.045 -0.030 0.279 0.092 -0.023
(0.284) (0.250) (0.340) (0.231) (0.609) (0.175) (0.398)
29
Behavioral Assessment in Dementia DISCUSSION The median number of CBRSD items en.. dorsed overall and for its agitation factor were higher relative to the number of items (20 of 48 and 3 of4) than the median number of CMAI items endorsed relative to the total number of items (7 of 37). Thus, the CBRSD appears sensitive to lesser degrees of behavioral disturbance than the CMAI. This sensitivity may be re .. Iated to the I-month time frame of the CBRSD, compared with the 2-week observational window of the CMAI. We fail to find an overwhelming cor.. relation between the endorsements of the CBRSD items pertaining to agitation and the items endorsed on the CMAI and its subscales. Our sample of 33 caregivers did, however, provide adequate power to find moderately high correlations between measures against low-incidence al.. ternatives. We documented significant correlations between the two total scores and between some subscales/factors, Because direct physical aggression against persons or objects was rare in these 33 subjects, we could not identify a relation-
ship between the instruments for physical aggression. Thus, the modest concurrent validity found is partly because of our community-dwelling population of persons with mild-to-moderate deme.ntia and only mild behavioral symptoms. It is possible that administering the CMAI first and the CBRSD second and the use of a single interviewer introduced bias that limits the generalizability of our study:
CONCLUSION The significant correlation of the CBRSD with the CMAI suggests that the CBRSD measures behavioral symptoms that occur in community..dwelling dementia patients with mild..to-moderate global impairment. It remains to be established whether the CBRSD is sensitive to behavioral changes brought about by various treatment strategies.
This work was supported in part by National Institute on Aging Grant I-P30AG12300-01.
References 1. Weiner MF, Koss E, Wild KY, et at: Measures of psychiatric symptoms in Alzheimer's disease pa-
tients: a review. Alzheimer Dis Assoc Disord 1996; 10:20-30 2. Cohen-Mansfield 1: Agitated behaviors in the elderly, II: preliminary results in the cognitively deteriorated. J Am Geriatr Soc 1986; 34: 722-727
3. Tariot PN, Mack 1L, Patterson MB, et al: The CERAD Behavior Rating Scale for Dementia
(BRSD) (abstract). Gerontologist 1992; 32:160 4. Tariot PN, Mack JL, Patterson MB, et al: The Behavior Rating Scale of the Consortium to Establish a Registry for Alzheimer's Disease. Am J Psychiatry 1995; 152:1349-1357 5. Morris JC, Heyman A, Mohs Re, et a1: The consortium to establish a registry for Alzheimer's disease (CERAD), part I: clinical and neuropsychological assessment of Alzheimer's disease. Neurology 1989; 39:1159-1165 6. Weiner MF, Bruhn M, Svetlik OS, et a1: Experiences with depression in a dementia clinic. J
30
Clin Psychiatry 1991; 52:234-238 7. Finkel S, Lyons IS, Anderson RL: Reliability and validity of the Cohen-Mansfield Agitation Inventory in institu tionalized elderly. International Journal of Geriatric Psychiatry 1992; 7:487-490 8. Miller RJ, Snowdon J, Vaughan R: The use of the Cohen-Mansfield agitation inventory in the assessment of behavioral disorders in nursing homes. J Am Geriatr Soc 1995; 43:546-549 9. Folsteln MF, Foistcin SE, McHugh PR: Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12:189-198 10. Hughes CP, Berg L, Danziger WL:A new clinical scale for the staging of dementia. Br J Psychiatry 1982; 140:566-572 11.McKhann G, Drachman D, Folstein M, et al: Clinical diagnosis ofAlzheimer's disease: Report of the NINCDS-ADRDA Work Group under the auspices of the Department of Health and Human Services Task Force on Alzheimer's Disease. Neurology 1984; 34:939-944 VOLUME 5 • NUMBER 1 • WINTER 1997
T
he quantification of behavioral symptoms in dementia patients is important for the assessment of behavioral intervention strategies and for the assess.. ment of psychotropic and cognition-enhancing drug effects on such symptoms. Scales for the evaluation of psychiatric symptoms in cognitively intact persons
are not useful for assessing behavioral symptoms in dementia patients because they are based on self-report or clinical observation. Scales based on direct clinical observation are not useful because the behaviors are often infrequent. Self-report scales are not useful because ofcognitively impaired patients' inability to report on
Received August 2, 1995; revised December 12, 1995; accepted May 9, 1996. From the Departments of Psychiatry and Neurology, University of Texas Southwestern Medical Center, DaIL'1s, TX. Address correspondence to Dr. Weiner, 5323 Harry Hines Blvd., Dallas, TX 75235-9070. Copyright © 1997 American Association for Geriatric Psychiatry
26
VOLUME 5 • NUMBER 1 • WINTER 1997
Weiner et al. their own behavior.' For these reasons, informant-based scales, such as the CERAD Behavior Rating Scale for Dementia (CBRSD) and the Cohen-Mansfield Agitation Inventory (CMAI) have been developed. We compared the CBRSD, a new instrument, with a commonly used instrument, the CMAI, to determine the sensitivity of each instrument to behaviors in community-dwelling Alzheimer's disease (AD) patients with mild-to-moderate dementia. The CMAI 2 measures so-called agitated behaviors in nursing home residents with and without a formal diagnosis of dementia. It was chosen as the instrument for comparison because it was developed without reference to psychopatholop or psychiatric syndrome. The CBRSn3 , was developed by the Consortium to Establish a Registry for Alzheimer's Disease (CERAD)5 as a broad-based scale to quantify behavioral and emotional symptoms in community..d welling AD patients.
METHODS Subjects
Subjects were a convenience sample of 33 consecutive caregivers of community-dwelling individuals seen for initial evaluation or in regular follow-up visits at the Clinic for Alzheimer's and Related Diseases at the University ofTexas Southwestern Medical Center. Our evaluation process is described els ewhe re ," Caregivers included spouses and children of patients. The CMAI7 sB and CBRSD were administered to caregivers during the course of their patient's visit by a clinician (BW)well trained in the administration of the CMAI and CBRSD. For every caregiver, the CMAIwas administered first. The origi4 nal version of the CBRSn was used. Responses were coded to maintain patient confidentiality: Weestimated that a sample of about 30 subjects would provide better THE AMERICAN JOURNAL OF GERIATlUC PSYCHIATRY
than 90% power to detect moderately high correlations (at least r = 0.70) between measures as opposed to low-incidence (1· = 0.30 or less) alternatives. Descriptive statistics concerning age, duration of symptoms, onset age, MiniMental State Exam (MMSE)9 score, and Clinical Dementia Rating (CDR) 10 score for the 33 patients are provided in Table 1. As suggested by MMSE and CDR scores, the patients were mildly to moderately impaired. The 33 patients included 19 women (58%) and 14 men. Using NINCDS criteria for the diagnosis of AD, 24 of the 33 patients (73%) were classified as probable (18) or possible (11) AD. Some patients had various other diagnoses, including prodromal AD (3), unclassifiable dementia (2), progressive dysphasic dementia (1), and cognitive impairment without dementia (2).
Instruments The CMAI is a compilation of "agitated" behaviors observed in nursing home residents. In the development of this scale, agitation was defined as "inappropriate verbal, vocal, or motor activities not explained by apparent needs or confusion.,,2 The scale is well anchored, and its reliability and validity are well estab.. lished. 6,7 The informant is the patient's caregiver. Symptoms are assessed for the preceding 2 weeks. There are 37 items and 3 agitationsubscales: physically aggressive (directed against a person or object), physically nonaggressive (not directed against a person or object, such as pacing and wandering), and verbal. Items are scored on a seven-point scale: 1 = never; 2 = < once a week; 3 = 1-2 times/week; 4 = several times/week; 5 = 1-2 times per day; 6 = several times/day; 7 = several times/hour. Severity is not rated on this scale. The CBRSDwas designed to assess AD patients. It samples a wide range ofbehaviors and psychopathology and is intended 27
Behavioral Assessment in Dementia TABLE 1.
Descriptive statistics: dementia clinic outpatients Mean ± SD
Age, years Age at onset of illness Duration of illness, years MMSE score CDR scale Note:
SD
TABLE 2.
73.6 69.5 4.1 16.5 1.3
59 52 1 5 1
90 87 15 25 3
CDR scale
= Clinical Dementia Rating.
CERAD Behavior Rating Scale for Dementia (CBRSD): summary scale scores of items overall and for each factor
Total Depressive Psychotic Defective Self-Regulation Irritation/Agitation Vegetative Apathy Aggression Affective Lability
Maximum Attainable Score
Maximum Score
Minimum Score
Mean ± SD
48 7 6 10
168 28 20 37
22 0 0 0
112 26 23 28
48.8 9.7 6.1 10.5
± ± ± ±
20.3 6.0 4.8 6.6
4 4 4 4 4
16 10 10 16 13
0 0 1 0 0
16 10 10 12 12
7.4 5.6 7.2 2.9 5.5
± ± ± ± ±
4.7 3.0 2.5 3.1 3.5
SD = standard deviation.
TABLE 3.
Cohen-Mansfield Agitation Inventory (CMAI): summary scale scores of items overall and for each subscale No. of Items
Total Physical Aggression Non-physical Aggression Verbal Agitation
37 12
10 8
Maximum Attainable Score 222 72 60 48
for use as a structured caregiver interview: Items were selected from a literature review and consultation with experts in the field. The items are well-anchored, and most are homogeneously scaled. The authors of the scale chose to quantify only frequency of behaviors because severity judgments are more difficult to anchor and thus appear to be less reliable. Based on a pilot study of 303 subjects with NINCDS probable AD,11 the scale is under evaluation in further studies and will then be released for general use. 28
Maximum
6.2 7.2 3.0 5.6 0.7
= standard deviation; MMSE = Mini-Mental State Exam;
No. of Items
Note:
± ± ± ± ±
Minimum
Maximum Score
Minimum Score
58 2 26 24
1 0 0 0
Mean ± SD 25.2 0.1 6.4 9.9
± ± ± ±
13.2 0.4 6.6 5.9
The scale assesses behavior over the preceding month, but also notes behaviors over 1 month ago and since the onset of dementia. It is administered to a caregiver. Of the 48 items, 40 are rated as 0 = has not occurred since illness began; 1 = present 1-2 days in the last month; 2 = 3-8 days; 3 = 9-15 days; and 4 = > 16 days. Factor analysis of the initial study suggested 8 factors: depressive symptoms, psychotic symptoms, defective self-regulation, irritability/agitation, vegetative features, apathy, aggression, and affective lability. VOLUME 5 • NUMBER 1 • WINTER 1997
Weiner et al. There are no firmly established traditions for the scoring of the CMAI, and no recommendations have yet been made for scoring tile CBRSD. For the purpose of analysis, we summarized the responses for both instruments in terms of number of items endorsed instead of using the scale values associated with the items. Standard correlation analysis was used to compare responses for the two instruments.
RESULTS Descriptive statistics for the endorsement ofCBRSD items and its subscales (factors) and the CMAIand its subscales are shown in Tables 2 and 3, respectively. There was a significant correlation between the number of items endorsed on both scales (r = 0.480; P = 0.005). Total CBRSD en.. dorsements correlated significantly with endorsements on the CMAI Physically Nonaggressive subscale (r = 0.457; P = 0.007) and Verbal Agitation subscale (r = 0.397; P = 0.022). There were too few re .. sponses among the CMAI Physically Aggressive scale items (only two of the 33 subjects endorsed items for this subscale) to produce a meaningful correlation with the CBRSD total and subscales. Correlations between the number of CMAI items endorsed and the endorse.. ments to CBRSDsubscales indicated some TABLE 4.
significant and some nonsignificant relationships.. The CMAI total correlated sig.. nificantly with CBRSD subscales for psychotic features (1· = O.411;P = 0.017) and defective self-regulation (r = 0.387; P = 0.0269). Other subscale correlations were not significant. Notably; the CMAI endorsements displayed a marginal correlation with endorsements on the CBRSD scale for irritability/agitation (r = 0.332; P = 0 . 06). Also, the CMAI subscale endorsements did not correlate with the CBRSD Irritability/Agitation factors (r = 0.101; P = 0.58) or for the CMAI Nonphysical Aggression subscale (r = 0.263; P = 0.139) for the CMAI Verbal Agitation subscale. Finally; we examined the correlations of the endorsement of CBRSD items pertaining to aggression and agitation across items on the CMAI. Table 4 shows the average as well as the highest inter-item correlations for these seven CBRSD items with all CMAI items and the items contained in the CMAI Verbal Agitation and Nonphysical Aggression subscales. For example, the CBRSD item "agitated or upset" had an average correlation of-0.020 across all CMAI items and an average correlation of-O.064 across the eight CMAI Verbal Agitation items. These various inter-item correlations indicate that there are frequently low as well as negative correlations among endorse.. ments to the agitation..s pecific CBRSD items and the CMAI items in general.
Average (and highest) inter-item correlations (r) pertaining to Agitation and Aggression: average (highest) CBRSD correlation with CMAI items All CMAI Items
Endorsed CBRSD Item: Easily irritated AgitatedIUpset Verbally aggressive Physically aggressive Abandonment Uncooperative Sudden changes in emotion
0.105 (0.410) -0.003 (0.467) 0.116 (0.492) 0.066 (0.348) 0.147 (0.609) 0.168 (0.495) 0.047 (0.398)
THE AMERICAN JOURNAL OF GEIUATIUC PSYGI=lIA-TRY..
CMAIVerbal Agitation Items Endorsed 0.104 -0.027 0.138 0.124 0.152 0.216 0.035
(0.320) (0.220) (0.492) (0.348) (0.605) (0.495) (0.276)
CMAI Non-physical Aggression Items Endorsed 0.052 -0.129 0.045 -0.030 0.279 0.092 -0.023
(0.284) (0.250) (0.340) (0.231) (0.609) (0.175) (0.398)
29
Behavioral Assessment in Dementia DISCUSSION The median number of CBRSD items en.. dorsed overall and for its agitation factor were higher relative to the number of items (20 of 48 and 3 of4) than the median number of CMAI items endorsed relative to the total number of items (7 of 37). Thus, the CBRSD appears sensitive to lesser degrees of behavioral disturbance than the CMAI. This sensitivity may be re .. Iated to the I-month time frame of the CBRSD, compared with the 2-week observational window of the CMAI. We fail to find an overwhelming cor.. relation between the endorsements of the CBRSD items pertaining to agitation and the items endorsed on the CMAI and its subscales. Our sample of 33 caregivers did, however, provide adequate power to find moderately high correlations between measures against low-incidence al.. ternatives. We documented significant correlations between the two total scores and between some subscales/factors, Because direct physical aggression against persons or objects was rare in these 33 subjects, we could not identify a relation-
ship between the instruments for physical aggression. Thus, the modest concurrent validity found is partly because of our community-dwelling population of persons with mild-to-moderate deme.ntia and only mild behavioral symptoms. It is possible that administering the CMAI first and the CBRSD second and the use of a single interviewer introduced bias that limits the generalizability of our study:
CONCLUSION The significant correlation of the CBRSD with the CMAI suggests that the CBRSD measures behavioral symptoms that occur in community..dwelling dementia patients with mild..to-moderate global impairment. It remains to be established whether the CBRSD is sensitive to behavioral changes brought about by various treatment strategies.
This work was supported in part by National Institute on Aging Grant I-P30AG12300-01.
References 1. Weiner MF, Koss E, Wild KY, et at: Measures of psychiatric symptoms in Alzheimer's disease pa-
tients: a review. Alzheimer Dis Assoc Disord 1996; 10:20-30 2. Cohen-Mansfield 1: Agitated behaviors in the elderly, II: preliminary results in the cognitively deteriorated. J Am Geriatr Soc 1986; 34: 722-727
3. Tariot PN, Mack 1L, Patterson MB, et al: The CERAD Behavior Rating Scale for Dementia
(BRSD) (abstract). Gerontologist 1992; 32:160 4. Tariot PN, Mack JL, Patterson MB, et al: The Behavior Rating Scale of the Consortium to Establish a Registry for Alzheimer's Disease. Am J Psychiatry 1995; 152:1349-1357 5. Morris JC, Heyman A, Mohs Re, et a1: The consortium to establish a registry for Alzheimer's disease (CERAD), part I: clinical and neuropsychological assessment of Alzheimer's disease. Neurology 1989; 39:1159-1165 6. Weiner MF, Bruhn M, Svetlik OS, et a1: Experiences with depression in a dementia clinic. J
30
Clin Psychiatry 1991; 52:234-238 7. Finkel S, Lyons IS, Anderson RL: Reliability and validity of the Cohen-Mansfield Agitation Inventory in institu tionalized elderly. International Journal of Geriatric Psychiatry 1992; 7:487-490 8. Miller RJ, Snowdon J, Vaughan R: The use of the Cohen-Mansfield agitation inventory in the assessment of behavioral disorders in nursing homes. J Am Geriatr Soc 1995; 43:546-549 9. Folsteln MF, Foistcin SE, McHugh PR: Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12:189-198 10. Hughes CP, Berg L, Danziger WL:A new clinical scale for the staging of dementia. Br J Psychiatry 1982; 140:566-572 11.McKhann G, Drachman D, Folstein M, et al: Clinical diagnosis ofAlzheimer's disease: Report of the NINCDS-ADRDA Work Group under the auspices of the Department of Health and Human Services Task Force on Alzheimer's Disease. Neurology 1984; 34:939-944 VOLUME 5 • NUMBER 1 • WINTER 1997