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Assessments Validate Treatments, Enhance Care

Tools establish a baseline to monitor progress and can offset need for medications.
      Alicia Ault is a senior writer with Elsevier Global Medical News.
      NEW ORLEANS – The dizzying array of scales available for measuring dementia and mental illness in the elderly can be whittled down to create an essential picture of an individual patient. Most importantly, these scales can be used to establish a baseline to monitor progression or worsening and to meet federal documentation requirements in nursing homes, speakers said at the annual meeting of the American Association for Geriatric Psychiatry.
      “You should choose scales that are brief, easy to score and have proven validity and reliability,” said Dr. Allan Anderson, director of geriatric psychiatry at Shore Behavioral Health Services, Cambridge, Md.
      Scales can enhance clinical practice and measure the effectiveness of psychiatric treatments, Dr. Anderson said.
      Deborah Weber helps administer scales to patients at Shore Behavioral Health. Usually, she said, she spends an hour or more with patients and their caregivers. The tests are not used to make a diagnosis, she said, rather they are used to establish a baseline for each patient and to track patients' function over time.
      The Mini-Mental Status Exam is one of the most frequently administered scales at Shore Behavioral Health, said Ms. Weber, a licensed clinical professional counselor.
      Although this is a common exam measuring cognitive ability, it has some limitations. Patients have to be fluent in English, or they may not do well, she said. Patients also have to be literate. If they can't spell “world” forward, then they won't be able to spell it backward, she notes. The MMSE usually only takes 10 minutes to administer, but, some patients may take longer.
      Ms. Weber also uses several executive function tests, which occasionally require family or caregiver input. Examples include the Tinker Toy Test, Tower of Hanoi, and Proteus Mazes. Failure doesn't automatically mean dementia, she said, noting that medical illness or other mental disorders can interfere with executive function. Fluency tests–such as asking patients to categorize items–also are good ways to measure executive function, she said.
      The clinician-administered CLOX test, developed by Dr. Donald Royall, has rapidly gained followers, Ms. Weber said. It is a good test, but “it's important that you understand the nuances of this scoring,” she said.
      To measure depression, she uses the Geriatric Depression and the Cornell Scale for Depression in Dementia. Independence can be assessed with the Physical Self-Maintenance Scale or the Functional Activities Questionnaire, which takes 5-10 minutes to complete, rating the patient's abilities in 10 areas.
      Another test she likes is the Dementia Rating Scale II, which is clinician administered and computer scored, measuring competency in attention, initiation/preservation, construction, conceptualization, and memory. However, this test is not sensitive enough to detect mild forms of dementia in people who are intelligent or well educated, Ms. Weber said.
      The choice of scales should be based on each patient's needs, she said. However, each battery should measure memory, executive function, and activities of daily living. For nursing home patients, there are several scales to help establish a baseline of behavior and help meet federal documentation requirements under the Omnibus Reconciliation Act (OBRA '87), said Dr. Alan Siegal of the department of psychiatry at Yale University, New Haven, Conn.
      The Behave-AD can be done in 10 minutes once the test-giver is familiar with the format. This exam should be given by certified nurses' aides, as nurses are generally too overwhelmed, Dr. Siegal said.
      The patient is asked questions covering behaviors over the most recent 2 weeks in seven domains: paranoid and delusional ideation, hallucinations, activity disturbances, aggressiveness, diurnal rhythm disturbances, affective disturbances, and anxieties and phobias. There are 25 questions with answers rated from 0 to 3. The staff is then asked to assign a global rating from 0 (not at all troubling to the caregiver or dangerous to the patient) to 3 (severely troubling or dangerous). The scale establishes a baseline documenting the behaviors that led to a medication, or some other intervention, he said.
      Another useful scale is the Cohen-Mansfield Agitation Inventory. It provides “a wonderful thesaurus for ‘agitation,’” Dr. Siegal said. It also allows the caregiver to give the physician a descriptive picture of what's happening with the patient. It only takes about 10-15 minutes to complete. The short form rates 14 areas of distressed behavior, including hitting, verbal aggression, grabbing, constant requests for attention, repetitive sentences, weird laughter, and hiding or hoarding things. The frequency of these behaviors is tabulated on a 5-point scale, from never to a few times an hour. Documenting the initial frequency allows the institution and the clinician to show what progress has occurred after a few weeks of intervention, he said.
      Another scale that rates frequency and severity of behaviors is the Neuropsychiatric Inventory for Nursing Homes. It is more difficult to complete but becomes easier with experience, Dr. Siegal said. It has good concurrent reliability with the Hamilton Depression Scale and the Behave-AD, measuring behaviors in 12 domains. If the symptom has been present in the past month, the rater answers yes and rates the frequency and severity on a 4-point scale and caregiver distress on a 0-5 scale.
      These scales are often used to establish baselines for medication-based intervention, but pharmaceuticals are not always necessary, Dr. Siegal said. Sometimes, it's as simple as giving the patient a little attention and acquiescing to some requests. This can head off escalation and the need for pharmacologic intervention.

      For More Information

      The following resources offer additional information about the scales and how to order them:
      ▸ Rush, AJ, Pincus, HA, First MB et al, Handbook of Psychiatric Measures, the American Psychiatric Association, 2000.
      ▸ For the Mini-Mental Status Exam, go to www.minimental.com.