JAMDA xxx (2017) 1e12

JAMDA
journal homepage: www.jamda.com

Review Article

A Comprehensive Review of the Quality and Feasibility of Dementia

Assessment Measures: The Dementia Outcomes Measurement Suite
Adam Bentvelzen PhD a, Liesbeth Aerts PhD a, Katrin Seeher PhD a,
Jacqueline Wesson MA b, Henry Brodaty MD, DSc a, c, *
a
Dementia Collaborative Research Center (DCRC) Network, University of New South Wales Australia, Sydney, Australia
b
Aging Work and Health Research Unit, Faculty of Health Sciences, University of Sydney, Sydney, Australia
c
Center for Healthy Brain Aging (CHeBA), University of New South Wales Australia, Sydney, Australia

a b s t r a c t

Keywords: The diagnosis of dementia and the management of its associated symptoms are aided by high-quality
Dementia assessment tools. However, there is disagreement on the optimal tools among abundant alternatives
measure and lack of consistent quality standards across the different domains of dementia-related change (ie,
assessment
cognition, severity, function, behavioral and psychological symptoms, delirium, quality of life). Stan-
outcome
dardization is difficult because the relevance of a measurement tool for health professionals may depend
clinical
screen on the clinical setting and on the dementia type and severity. To address this need, we conducted a
comprehensive and clinically relevant evidence-based review of dementia-related tools and present a set
of recommended tools, the Dementia Outcomes Measurement Suite. The review revealed that consid-
erable development has occurred in terms of assessment of persons with mild cognitive impairment,
executive dysfunction, cognitively mediated functional change, and apathy. More research is needed to
develop and validate tools to assess health-related quality of life and specific symptoms of dementia
including anxiety, wandering, and repetitive vocalizations. This extensive overview of the quality of
different measures may serve as a guide for health professionals clinically and for researchers developing
new or improved dementia assessment tools.
Ó 2017 AMDA e The Society for Post-Acute and Long-Term Care Medicine.

High-quality assessment tools are important for the diagnosis symptoms of dementia (BPSD) may help reduce distress and
and management of dementia and its associated symptoms. Early healthcare costs.3,4
diagnosis of dementia by cognitive screens may enable the timely Despite an abundance of tools for many domains of dementia-
provision of care services and family education, and advance legal related change (ie, cognition, function, BPSD), consensus is lacking
directives while the person still has capacity.1 Measuring the on which one should be used.5 This may hinder effective commu-
functional ability of a person with dementia may facilitate the nication between health professionals and could lead to misdiag-
provision of appropriately targeted care services.2 Tracking the ef- nosis or mismanagement.6,7 Some tools, such as the Mini-Mental
fects of interventions to reduce the behavioral and psychological State Examination (MMSE),8 serve as a proxy “gold standard” but
nonetheless have significant limitations (eg, to detect mild cognitive
decline or dementia that present with executive dysfunction).9e11
Several reviews have helped identify the most promising options
Over the last 3 years, Henry Brodaty has been on advisory boards of or a to test cognition,12 staging,13 function,14 BPSD,3 or delirium,15 and
consultant to Eli Lilly, Merck and Nutricia. His department has received payment to
protocols such as the International Consortium for Health Outcomes
participate in drug trials for Alzheimer disease by Merck, Sanofi, Servier, Eli Lilly,
and Tau Therapeutics. He has been recipient of grants for research by the National Management16 offer excellent breadth of coverage by recommend-
Health and Medical Research Council and Australian Department of Health and ing 1 standard tool per domain. However, less attention is paid to
Ageing. The other authors declare no competing interests. important qualitative variations in the clinical scenario including
* Address correspondence to Henry Brodaty, MD, DSc, Dementia Collaborative differences in practice setting, types of dementia, and levels of de-
Research Center (DCRC) Network, University of New South Wales Australia, Sydney
mentia severity.17 Conversely, many reviews focus intensively on
2052, Australia.
E-mail address: h.brodaty@unsw.edu.au (H. Brodaty). tools for specific clinical scenarios, such as dementia screening in

http://dx.doi.org/10.1016/j.jamda.2017.01.006
1525-8610/Ó 2017 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
2 A. Bentvelzen et al. / JAMDA xxx (2017) 1e12

primary care18,19 or functional assessment in persons with fronto- Selection Criteria

temporal dementia (FTD),20 but lack broader integration with other
affected domains. Thus, an acceptable trade-off is needed between A short list of tools was compiled based on the recommendations
standardization, and breadth and depth of coverage. in the initial 2007 DOMS review and on the current literature search,
In 2007, the Australian Center for Health Service Development and if they met all of the following criteria:
conducted an exhaustive review of tools used to measure the multi-
dimensional changes associated with dementia, the Dementia Out-
Content validity: the content of the tool must be appropriate for
comes Measurement Suite (DOMS).21 The underlying rationale was to assessing dementia and the tool must not be designed for
encourage clinicians to use the same tools to enhance interprofes- another specific purpose (eg, psychosis in persons with schizo-
sional communication, while flexibly accommodating for different phrenia, motor impairment in persons with stroke), except if it
clinical scenarios. A secondary goal was to use the review outcomes to has been shown to have clinical validity in dementia (see below).
identify gaps in research and clinical practice. Criteria with clinical To reduce the number of (general) cognitive screening tools and
relevance (eg, psychometric properties, cost, feasibility, user- maximize their clinical relevance with respect to current diag-
friendliness) were used to select and rate a short-list of tools, and nostic guidelines,24,25 only cognitive screens with at least 1 item
the same rating system was used across domains allowing for broader testing recent memory and at least 1 item from another cogni-
standardization. Since the original publication in 2007, however, there tive domain (executive, visuospatial, or language function) were
have been substantial advances in research on dementia assessment included. This rule did not apply to tools specifically designed to
tools, including increased attention for mild cognitive impairment detect types of dementia for which executive dysfunction was
(MCI) and non-Alzheimer types of dementia.22,23 the primary presenting feature.
We present the updated DOMS, a set of recommended
Psychometric validity: evidence of the tool’s inter-rater reli-
dementia-related tools based on a comprehensive evidence-based ability and/or test-retest reliability (preferably in persons with
overview, which has been translated into a user-friendly online dementia) from at least 1 peer-reviewed publication.
database for health care professionals at: http://www.dementia-
Clinical validity: quantitative evidence in support of the tool’s
assessment.com.au. discriminant validity in a clinical context relevant to dementia
(eg, in distinguishing persons with dementia from those
Methods without dementia, or from those with depression) when
assessed concurrently (eg, sensitivity and specificity) and/or
A steering committee of a diverse group of health professionals from longitudinally (responsiveness).
clinical psychology/neuropsychology, general practice, geriatric medicine,
Affordability: free to use or at low cost
mental health, nursing, and occupational therapy met during 2015 and
Feasibility: <45 minutes of administration time, and no highly
2016 to discuss the aim, scope, and primary target audience of the DOMS complicated scoring and/or administration procedures that
update. Although the original DOMS review was an exhaustive summary would contraindicate use in a (typical) clinical context (eg,
of dementia-related tools that led to a database of 844 instruments,21 the requirement for a computer or other special equipment and/or
update focused on integrating new evidence into this database and pri- to perform a complex algorithm to calculate the score).
marily targeted health professionals and secondarily, dementia re-
Redundancy: for tools with multiple versions (eg, revised or
searchers. Therefore, the update was restricted to the domains of abbreviated forms), only the version that best satisfied the
cognition, staging, function, BPSD, delirium, and dementia-specific health- selection criteria was included.
related quality of life (HRQoL). Although social isolation, multi-attribute Tools that were short-listed and considered promising but did not
utility measures and patient/carer treatment satisfaction were consid- meet our selection criteria are listed in Supplementary Table S2 with
ered clinically important and associated with relevant research, they were their respective failed selection criteria.
not considered to be firmly integrated within current routine clinical
practice. We also categorized tools within each domain to maximize the Rating System
coverage of different clinical practice settings, contexts, dementias, de-
mentia severities, and patient types (Supplementary Table S1). Tools were rated based on 18 criteria scored 0e2 and with a
weighting of 1 or 2, making up a maximum weighted total score of 60
Literature Search (Table 1). Psychometrics (criteria 1 to 13) counted for two-thirds of the
total rating, with validity and reliability making up three-quarters and
Peer-reviewed articles, written in English, were identified by one-quarter of the total rating for psychometrics, respectively. The
searching electronic databases (CINAHL, ProQuest, Scopus, Psy- remaining 5 criteria were weighted equally and included the tool’s
chARTICLES, Biomed Central, EMBASE, PubMed, PsychINFO, MEDLINE, international adoption, administration time, ease of administration,
ScienceDirect, Web of Science, Cochrane Reviews) using the key word professional qualifications, and cost of instrument/training. As the
“dementia” combined with “assessment,” “measure,” “screen,” “scale,” administration mode differed across scales, ease of administration
or “rating” and the following MESH terms: “cognition,” “staging,” (criterion 16) was rated differently for clinician-administered and self/
“global,” “severity,” “function*,” “BPSD,” “behaviour/behavior,” “neuro- informant-completed tools. To maximize the clinical usefulness of the
psychiatr*,” “delirium,” and “quality of life,” where “*” indicates a wild rating system across all domains, validity criteria 1 to 6 could apply to
card. These searches were restricted to articles published after 2003, to a range of different clinical situations, ranging from diagnostic (eg,
ensure thorough coverage of articles on tools that were very recently discriminating persons with vs those without dementia) to descriptive
published at the time of the 2007 review. (eg, categorizing the severity of apathy). Partial scores were given
The reference lists of articles were also searched. Tool names when the evidence showed equal support for 2 scoring categories.
relevant to dementia were identified by scanning titles and abstracts The criterion for responsiveness was based on recommendations
and additional searches using the key word “dementia” combined that distinguished “external responsiveness” (the extent to which
with the tool name were conducted. After removing duplicates, the measured change relates to change in a reference measure of clinical
general and tool-specific searches yielded 7764 titles in total (cogni- or health status, such as progressing from MCI to dementia) as more
tion: 2704; staging: 916; function: 1211; BPSD: 2378; delirium: 235; clinically important than “internal responsiveness” (the ability of a
dementia-specific HRQoL: 320). measure to change over a prespecified time frame, often in the context
 A. Bentvelzen et al. / JAMDA xxx (2017) 1e12 3

Table 1 Table 1 (continued )

DOMS Rating System
No. Rating Criteria
No. Rating Criteria
12 Generalizability 3: validity in patients with low education/literacy
1 Reliability 1: inter-rater 2 scale shown to be resistant to low education/literacy, or effects of
4 excellent (ICC/k  .90) education/literacy shown but alternative cut-offs or corrections
2 adequate (ICC/k .70 to .89) published
0 low (ICC/k < .70) or no data 1 effect of low education/literacy on validity, but no alternative
cut-offs or corrections available
2 Reliability 2: test-retest 0 not investigated
4 excellent (ICC/k  .90)
2 adequate (ICC/k .70 to .89) 13 Generalizability 4: validity in multiple countries/languages
0 low (ICC/k < .70) or no data 2 multiple countries or languages
1 different countries but only 1 language
3 Reliability 3: internal consistency 0 1 country and language
2 excellent (Cronbach’s a  .90)
1 adequate to good (Cronbach’s a from .70 to .89) 14 Recommended in published international dementia guidelines
0 low (Cronbach’s a < .70) or no data 4  2 countries
2 1 country
4 Validity 1: Content validityddomain of interest is comprehensively 0 0 countries
sampled by the items
2 domain comprehensively sampled 15 Administration time (minutes)
1 domain reasonably well sampled 45
0 important aspects of domain are not sampled or irrelevant items 2 6-15
included 0 > 15

5 Validity 2: Concurrent validitydexpected correlations with 16A Ease of administration and scoring (for clinician-administered tools)
similar validated measures 4 does not require algorithm to score or special equipment
4 high (jr/kj  .70) 2 requires an algorithm to compute score OR special equipment
2 moderate (jr/kj from .40 to .69) 0 requires an algorithm to compute score AND special equipment
0 low concurrent validity (jr/kj < .30), or no data
16B Burden on respondent (for self-reported or proxy tools)
6 Validity 3: Discriminant validity - cross-sectional (eg, dementia 4 items are worded simply
vs depression; low vs high levels of severity/impairment; AD 2 minor challenges for respondent (eg, minority of items are
vs FTD etc.) worded in a complex manner)
4 can distinguish between >2 clinically important categories 0 reasonable degree of burden on respondent (majority of
of respondents items worded in a complex manner)
2 can distinguish between 2 categories of respondents
0 no evidence 17 Clinical qualifications required to administer tool
4 untrained rater (eg, general nursing staff, patient/informant)
7 Validity 4: Sensitivity to diagnosis/category 2 paraprofessional/staff member (eg, clinical nurse; research assistant)
4 high (.85) 0 professional (eg, doctor, occupational therapist, or neuropsychologist)
2 moderate (.70 to .84)
0 low (<.70) 18 Cost of the tool and training for clinicians
4 no charge for tool or for training
8 Validity 5: Specificity to diagnosis/category 2 small 1-time costs to acquire tool or for training
4 high (.85) 0 costs charged each time tool is used
2 moderate (.70 to .84)
0 low (<.70)
of response to drug treatment).26 External validity (referring to
9 Validity 6: Responsivenessdability to detect clinically important
change over time (eg, because of course of the condition or “generalizability” as opposed to criterion validity) involved 4 criteria
in response to intervention) so that external validity with respect to dementia type, clinical setting,
4 availability of minimum clinically important difference (MCID) education/literacy, and language could be considered separately.
in appropriate metrics (eg, standardized response means) at the The criterion for international acceptance was scored based on
individual patient level on external clinical criteria
2 can detect statistically significant changes over time in hypothesized
whether a tool was recommended by national or international de-
direction on external clinical criteria, but no metrics available to mentia guidelines, such as those released by the National Institute for
quantify MCID at the individual patient level Health in the United Kingdom, Intervention in Dementia (INTERDEM)
0 no evidence for responsiveness in Europe,27 or the International Association of Gerontology and Ge-
riatrics (IAGG).28 Tools recommended in an international guideline
10 Generalizability 1: validity in different dementia populations (eg, AD,
FTD, PD etc.) automatically achieved the maximum score.
2 > 2 types of dementia
1 two different types of dementia Rating Process
0 only 1 type of dementia

11 Generalizability 2: validity in different clinical settings (ie, nursing home, Each tool that passed the selection criteria was rated based on
community, primary care, specialist) systematic evaluation of 878 articles. Two raters each assessed a
2 > 2 types of setting different set of tools and a random selection of 10% of the scored
1 two different types of setting criteria (1e13) per domain for each rater were independently scored
0 only 1 type of setting
by the other rater as a quality control check. A weighted kappa of 0.71
indicates good inter-rater reliability.29,30 Consensus was reached on
(continued on next column)
the final score where discrepancies occurred.
4 A. Bentvelzen et al. / JAMDA xxx (2017) 1e12

Results Comprehensive screens

The Addenbrooke Cognitive Examination, Third Edition (ACE-III)22
Cognition outscored the Alzheimer Disease Assessment ScaleeCognitive Scale44
(ADAS-COG) while being considerably briefer (15 vs 30e40 minutes
Measures of cognition (Table 2) include very brief and brief screens administration time). (The relatively new ACE-III22 was reviewed
for dementia, comprehensive tools designed for differential diagnosis instead of the well-studied ACE-R11 because the former makes the latter
or tracking change (16e45 minutes), tools that are administered to an redundant and has arguably superior content validity, the authors no
informant, tools focused on screening executive function, and tools longer advise use of the ACE-R because of its overlap with the MMSE. As
developed for special populations. the ACE-III and ACE-R correlate highly (.99),22 they can be considered
effectively equivalent. Therefore, findings on the ACE-III and ACE-R
Very brief screening tests (5 minutes administration time) were used interchangeably.) Both tools have excellent diagnostic effi-
The 3 tests with the highest scores were the General Practitioner ciency for dementia that numerically surpasses that of very brief and
Assessment of Cognition (GPCOG),31 the Abbreviated Mental Test brief screens. The ACE-III is sensitive to MCI and dementias that may
Score (AMTS),32 and the Six-Item Cognitive Impairment Test (6CIT),33 present with executive dysfunction (eg, FTD, Parkinson disease de-
with the Mini-Cog34 scoring slightly lower. All except the 6CIT attained mentia, dementia with Lewy bodies).45 The ADAS-COG is responsive to
maximum scores for sensitivity and specificity for dementia (.85) cognitive change because of drug treatments.46
with the GPCOG and Mini-Cog having the highest numerical score.35
The 6CIT showed reduced sensitivity or specificity depending on the Informant ratings of cognition
setting.36,37 An informant can provide valuable complementary information
The GPCOG and the Mini-Cog test executive function. The AMTS that can assist in determining whether a person has dementia. The
and 6CIT are completely verbal (ie, can be administered without tools highest scoring informant rating tools in order were the Informant
such as pencil and paper), but the 6CIT requires an algorithm to Questionnaire for Cognitive Decline in the Elderly (IQCODE, short
calculate its total score which may not be convenient in some settings. version), the Psychogeriatric Assessment ScaledCognitive Decline
Only the 6CIT had evidence for responsiveness.38 All 4 tests have been Scale (PAS-CDS), and the Ascertain Dementia 8 (AD8).47e49 Much
applied in different clinical settings, translated into many different evidence supports the use of the IQCODE across different clinical
languages, and are either minimally affected by education or have contexts, languages and in illiterate populations. The PAS-CDS has an
alternative cut-offs available to correct for educational status MCID value for predicting cognitive deterioration and mortality.50 The
(AMTS).39 AD8 is the briefest informant tool (<5 minutes) and has been very
rapidly adopted, but is less sensitive to MCI than the MoCA.51
Brief screening tests (6e15 minutes)
The Modified Mini-Mental Status Exam (3MS)40 and Montreal Cognitive screens for special populations
Cognitive Assessment (MoCA)41 both scored highly on almost all The Rowland Universal Dementia Assessment Scale (RUDAS) is
criteria. The MoCA has well-established validity in patients with MCI designed for people from non-English speaking backgrounds living in
and dementia, with only relative weaknesses in terms of its specificity English speaking countries.52 Its strengths include excellent general-
in detecting MCI or dementia. There is evidence that both tools show izability (literacy, education, translations) and psychometric proper-
responsiveness though without minimum clinically important dif- ties, including high specificity (.86) for detecting dementia but lower
ference (MCID) values.42,43 Both have been validated in multiple set- sensitivity (.77).53 It has a low one-off cost for administration and
tings, across different types of dementia, and in several languages. training materials.

Table 2
Ratings for Cognition Tools

No Rating Criteria Very Brief Screens Brief Screens Comp. Informant Special Executive
Function

6CIT AMTS GPCOG Mini-Cog 3MS MoCA PAS-CIS ACE-III ADAS-COG IQCODE PAS-CDS AD8 RUDAS KICA-Cog FAB EXIT-25

1 Inter-rater reliability (/4) 0 0 2 4 4 4 0 4 4 0 0 2 3 2 4 4

2 Test-retest reliability (/4) 2 4 2 0 4 4 2 4 4 4 4 2 4 0 2 2
3 Internal consistency (/2) 0 1 1 0 1 1 0 1 1 2 1 1 1 1 1 1
4 Content validity (/2) 1 1 2 2 2 2 1.5 2 1.5 1 1 1 2 2 1 2
5 Concurrent validity (/4) 4 4 2 2 4 4 4 4 4 2 4 2 2 2 3 3
6 Discriminant validity (/4) 2 1 2 1 4 4 2 4 4 4 2 2 0 0 4 4
7 Sensitivity (/4) 4 4 4 4 4 4 2 4 4 4 2 2 2 4 4 4
8 Specificity (/4) 2 4 4 4 4 2 0 4 4 2 2 2 4 4 4 4
9 Responsiveness (/4) 4 0 0 0 2 2 2 0 2 2 3 0 0 0 4 0
10 Dementia types (/2) 1 0 0 0 1 2 1 2 2 1 1 1 0.5 0 2 1
11 Clinical settings (/2) 2 2 2 2 2 2 0.5 1 1 2 0.5 1 2 0 1 1
12 Education/literacy (/2) 2 2 2 2 2 2 2 2 2 2 2 1 2 2 1.5 0
13 Translations (/2) 2 2 2 2 2 2 1 2 2 2 1 2 2 2 2 1
14 International acceptance (/4) 4 2 4 4 4 4 2 4 2 4 2 4 2 2 4 2
15 Administration time (/4) 4 4 4 4 2 2 2 0 0 2 2 4 2 0 4 2
16 A: Ease of use (/4) 2 4 4 4 4 4 4 4 0 - - - 4 4 4 2
B: Respondent burden (/4) - - - - - - - - - 4 4 4 - - - -
17 Qualifications required (/4) 4 4 2 2 2 2 2 2 0 4 4 4 2 2 0 0
18 Cost of tool/training (/4) 4 4 4 4 4 4 4 4 4 4 4 4 2 4 4 4
Weighted score (/60) 44 43 43 41 52 51 32 48 41.5 46 39.5 39 36.5 31 49.5 37

PAS-CIS, Psychogeriatric Assessment ScaleeCognitive Impairment Scale; Special, special populations; Administration times: very brief screens, <5 minutes; brief screens,
6e15 minutes; comp, comprehensive screens (16e45 minutes).
Other abbreviated test names are spelled out in full in the text.
 A. Bentvelzen et al. / JAMDA xxx (2017) 1e12 5

The KICA-Cog was designed for indigenous Australians living in rural specific tools are designed to be sensitive to functional impairments
and remote communities and has excellent diagnostic efficiency for in persons with cognitive impairment and contain items on both basic
detecting dementia.54 The KICA-Cog may have value in other indige- activities of daily living (ADLs, eg, eating, self-care, mobility) and
nous populations, as suggested by its successful application in Persian instrumental ADLs (IADLs, eg, taking medications, preparing meals,
populations and adaptation for First Nation persons in Canada.55,56 managing money). As a person with cognitive impairment may be
unreliable in rating their own function, dementia-specific tools usu-
Screens of executive function ally require input from a knowledgeable informant but can also be
Some tools are focused on detecting impairments in executive performance- or observation-based. Generic tools are not specifically
function that are important for diagnosing a range of dementia types designed for persons with dementia and involve a combination of self-
such as FTD. The Frontal Assessment Battery (FAB),57 outscored the reports, reports by an informant, and the clinical observations of a
Executive Interview (EXIT-25)58 as it is briefer and requires less healthcare professional.
training but has similar diagnostic efficiency for distinguishing FTD
from Alzheimer disease.59 Dementia-specific functional measures
The Bayer ADL,67 Bristol ADL,68 Disability Assessment for Dementia
Staging (DAD)69 and Alzheimer Disease Cooperative Study ADL inventory
adapted for MCI patients (ADCS/MCI/ADL)70 are completed by inter-
Staging tools (Table 3) assess whether a person has dementia and viewing an informant. The Cleveland Scale for ADL (CS-ADL)71 is
enable tracking of its severity over time. Consistent with its perception completed by the clinician’s observation of the person in question,
as a “gold standard,” the Clinical Dementia Rating scale (CDR) scored while the Direct Assessment of Functional Status-Revised (DAFS-R)
maximally for validity criteria, with excellent responsiveness and involves a performance assessment.72 The highest rated scales
correlation to practical outcomes such as nursing home placement, is (in order) were the Bayer ADL, DAD, DAFS-R, Bristol ADL, and CS-ADL.
widely translated and is recognized internationally.60,61 Limitations All 6 tools have been validated in both persons with dementia and
include its long administration time and the need for a high level of those with MCI, and have good discriminant validity and respon-
expertise in dementia assessment. siveness for predicting care needs. The Bayer ADL has excellent
Among brief staging instruments, the Blessed Dementia Scale diagnostic efficiency for detecting dementia and MCI.73 Both the DAD
(BDS)62 and Global Deterioration Scale (GDS)63 scored the highest. and DAFS-R distinguish between persons with FTD and AD, although
Both scales have good evidence for responsiveness. They offer trade- with lower efficiency compared with cognitive tools such as the ACE-
offs in terms of higher sensitivity (BDS) or specificity (GDS).64,65 The III or FAB.23 The Bristol has MCID values and good longitudinal diag-
BDS, which has been available longer, has been validated in a greater nostic efficiency and the DAD has strong evidence showing its
variety of populations and the effects of education more thoroughly responsiveness to drug treatments.74 However, many of these tools
investigated. The Dementia Severity Rating Scale’s (DSRS) lower score lack evidence for some form of reliability. The Bayer ADL and DAD
resulted from lower generalizability (ie, dementia types, translations) have many validated translations. None of the tools is brief, although
but can be informant-completed unlike the other tools and has su- the DAD-6, an abbreviated form of the DAD, is available.75
perior diagnostic efficiency for dementia and MCI.66
Generic functional measures
Function Among generic IADL tools, the Barthel Index76 was the ADL tool
with the highest score, followed by the Katz ADL77 and the Functional
Functional assessment (Table 4) of persons with dementia relates Independence Measure (FIM),78 a later adaptation of the Barthel In-
very strongly to practical outcomes including care needs. Dementia- dex. The Lawton and Brody IADL79 scored higher than its later adap-
tation, the OARS-IADL.80 All 5 tools have good longitudinal
Table 3 discriminant validity (eg, predicting dependency), and the OARS-IADL,
Ratings for Staging Tools Barthel Index, and Katz ADL have MCID values.81,82
No Rating Criteria Comp Brief
BPSD
CDR GDS BDS DSRS FAST SCAG

1 Inter-rater reliability (/4) 4 4 2 3 3 2 BPSD tools (Table 5) are important to detect and track changes in
2 Test-retest reliability (/4) 4 4 3 4 0 0
3 Internal consistency (/2) 2 2 2 2 0 1
behavior associated with dementia, and may be valuable in deter-
4 Content validity (/2) 2 2 1 2 0.5 2 mining care needs and in establishing dementia severity. They may
5 Concurrent validity (/4) 4 4 2 2 4 3 also be valuable in differential diagnosis, for example, between
6 Discriminant validity (/4) 4 4 4 4 4 4 depression and dementia, or between different dementias types.
7 Sensitivity (/4) 4 0 4 4 0 0
8 Specificity (/4) 4 4 2 4 0 0
9 Responsiveness (/4) 4 4 4 2 2 2 Global BPSD measures
10 Dementia types (/2) 2 2 0 0 2 2 Global measures of BPSD provide a snapshot of a variety of
11 Clinical settings (/2) 2 2 2 2 2 1 symptoms in persons with dementia. They can be administered in full
12 Education/literacy (/2) 0.5 0.5 2 0 0 0 or separated into subscales that focus on specific symptoms. The
13 Translations (/2) 2 0.5 2 0 0 2
14 International acceptance (/4) 4 4 4 0 4 0
Neuropsychiatric Inventory (NPI)83 scored highest followed by the
15 Administration time (/4) 0 4 4 4 4 4 Behavioral Pathology in Alzheimer Disease (BEHAVE-AD).84 Compared
16 A: Ease of use (/4) 2 4 4 2 4 4 with the BEHAVE-AD, the NPI had much better evidence for reliability,
B: Respondent burden (/4) - - - - - - higher sensitivity to dementia85 and validity in more types of de-
17 Qualifications required (/4) 0 2 4 2 2 2
mentia. Both tools, however, had evidence for good content validity,
18 Cost of tool/training (/4) 4 4 4 4 4 2
Weighted score (/60) 48.5 51 50 41 35.5 31 discriminant validity, and responsiveness including MCID values.
Several adaptations exist for the original NPI, including the NPI-
Brief, brief staging tools (15 minutes administration time); Comp, Comprehensive
staging tools (16e45 minutes administration time); FAST, Functional Assessment
Questionnaire (NPI-Q, a shorter version), the NPI with Caregiver
Staging; SCAG, Sandoz Clinical Assessment-Geriatric scale. Distress Scale (NPI-D, which has an additional question for each
Other abbreviated test names are spelled out in full in the text. domain about the level of carer distress), the NPI-Nursing Home
6 A. Bentvelzen et al. / JAMDA xxx (2017) 1e12

Table 4
Ratings for Functional Tools

No Rating Criteria Dementia-specific Generic*

Informant Pfmc Obsvn IADL ADL

BAYER-ADL DAD Bristol ADL ADCS/MCI/ADL DAFS-R CS-ADL L&B IADL OARS-IADL BARTHEL KATZ FIM

1 Inter-rater reliability (/4) 0 4 0 0 4 4 4 4 4 0 4

2 Test-retest reliability (/4) 4 4 2 4 4 0 4 4 2 0 4
3 Internal consistency (/2) 2 2 0 0 1 2 1 1 1.5 1 2
4 Content validity (/2) 2 2 2 2 2 2 0 2 0.5 1 0.5
5 Concurrent validity (/4) 4 2 2 2 3 3 2 2 3 4 3
6 Discriminant validity (/4) 4 4 2 2 4 4 4 4 4 4 4
7 Sensitivity (/4) 4 2 4 4 4 4 4 0 0 4 0
8 Specificity (/4) 4 2 2 4 2 4 4 0 0 0 0
9 Responsiveness (/4) 2 2 4 2 2 2 2 4 4 4 2
10 Dementia types (/2) 0 2 1 1 1 0 1 0 2 1 0
11 Clinical settings (/2) 1 1 2 1 2 0 0 2 2 2 2
12 Education/literacy (/2) 2 0 1 2 2 1.5 2 0 0 0 0
13 Translations (/2) 2 2 2 1.5 2 0 2 2 2 2 2
14 International acceptance (/4) 0 2 4 2 0 2 2 0 4 2 4
15 Administration time (/4) 0 1 2 0 0 0 4 4 2 2 0
16 A: Ease of use (/4) - - - - 2 2 4 4 4 4 4
B: Respondent burden (/4) 4 4 4 2 - - - - - - -
17 Qualifications required (/4) 4 2 4 2 2 2 0 0 0 0 0
18 Cost of tool/training (/4) 4 4 4 4 4 4 4 4 4 4 2
Weighted score (/60) 43 42 42 35.5 41 36.5 44 37 39 35 34

Obsvn, clinical observation; Pfmc, performance measure.

Abbreviated test names are spelled out in full in the text.
*Generic tools can be completed using a variety of sources including self-report, informant/proxy report, clinical observation of the healthcare professional, or a combi-
nation of these approaches.

(NPI-NH, for care staff in residential care settings), and the NPI- Symptom-specific BPSD measures
Clinician (NPI-C, with an expanded set of items and domains). Symptom-specific BPSD scales offer more focused and compre-
hensive assessment. Tools for agitation, apathy, aggression, depres-
Frontal/disinhibited behavior sion, and sleep disturbance passed our selection criteria while tools for
The Frontal Behavioral Inventory (FBI) has excellent psychometric other symptoms (eg, wandering, vocal disturbance, psychosis) did not.
validity, excellent diagnostic efficiency for FTD vs non-FTD types of
dementia (eg, sensitivity .90, specificity .94) and adds valuable Agitation. The Cohen-Mansfield Agitation Inventory (CMAI)88,89
discriminative power when combined with cognitive testing.86,87 It is and the Pittsburgh Agitation Scale90 rated well. The CMAI had
lengthy and best suited for specialist settings rather than for more evidence for test-retest reliability and generalizability (across
screening. types of dementia, settings, translations, and international

Table 5
Ratings for BPSD Tools

No Rating Criteria Global Front Agitation Apathy Depression Aggr Anxiety Sleep

NPI BEHAVE-AD DBDS FBI CMAI PAS AES IA LARS GDS CORNELL HDRS RAGE RAID HARS PSQI

1 Inter-rater reliability (/4) 4 4 4 4 3 3 4 4 4 0 2 2 3 2 2 0

2 Test-retest reliability (/4) 2 0 2 3 3 0 4 4 4 2 2 2 4 4 0 2
3 Internal consistency (/2) 1 0 1 2 1 1 2 1.5 1 1 2 1 1 1 1 1
4 Content validity (/2) 2 2 1 2 2 2 2 1 2 2 2 1 2 2 1 1
5 Concurrent validity (/4) 2 2 4 3 2 2 2 4 4 4 4 2 2 2 2 4
6 Discriminant validity (/4) 4 4 2 4 2 2 4 0 0 4 2 4 4 2 2 4
7 Sensitivity (/4) 4 2 0 4 2 2 4 4 2 2 2 2 4 4 0 4
8 Specificity (/4) 2 2 0 4 4 4 0 4 4 2 2 4 4 2 2 4
9 Responsiveness (/4) 4 4 0 0 2 2 2 0 0 2 2 2 4 2 2 2
10 Dementia types (/2) 2 1 0 2 1 0 2 1 2 2 1 2 0 0 1 2
11 Clinical settings (/2) 2 2 2 0 2 1 2 0 0 2 1 0 2 1 2 2
12 Education/literacy (/2)* 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
13 Translations (/2) 2 2 2 2 2 1 2 2 2 2 2 2 2 1 2 2
14 International acceptance (/4) 4 4 0 0 4 2 2 0 0 4 4 0 2 2 0 0
15 Administration time (/4) 2 0 2 0 2 4 2 4 2 2 0 0 4 1 2 2
16 A: Ease of use (/4) 4 4 4 2 2 4 - 4 4 - 2 4 4 4 4 -
B: Respondent burden (/4) - - - - - - 4 - - 4 - - - - - 4
17 Qualifications required (/4) 2 2 4 0 2 2 0 4 2 4 2 0 2 0 2 4
18 Cost of tool/training (/4) 4 4 4 4 4 4 4 2 4 4 4 4 4 4 4 4
Weighted score (/60) 49 41 34 38 42 38 44 42 39 45 38 34 50 36 31 44

Aggr, aggression; front, frontal.

Abbreviated test names are spelled out in full in the text.
*All BPSD scales are scored 2 for education/literacy as these tools depend on clinician observation of behavior rather than patient testing and so should have minimal
dependency on cognitive status.
 A. Bentvelzen et al. / JAMDA xxx (2017) 1e12 7

acceptance), while the Pittsburgh Agitation Scale is briefer to with an item on concentration omitted because of its confounding
administer than the CMAI (<5 vs 10e15 minutes). by dementia symptoms, unlike the HARS, which includes such
items. The RAID has high sensitivity but lower specificity to detect
Apathy. Three scales scored reasonably well, in order: the Apathy generalized anxiety in those with dementia.103 More work is
Evaluation Scale (AES),91 the Apathy Inventory (IA),92 and the Lille needed to establish its responsiveness to treatment and
Apathy Rating Scale (LARS).93 The AES had excellent psychometric generalizability.
validity and can distinguish between apathy and depression.91,94 It
is also responsive to drug or rehabilitation treatment and has good Sleep disturbance. The Pittsburgh Sleep Quality Index (PSQI)105 is
generalizability (across types of dementia, settings, and languages). quick to administer (5e10 minutes), with good concurrent validity
The AES has excellent sensitivity but lower specificity for detecting with other sleep tools. It has evidence for responsiveness to in-
apathy as judged against psychiatrist observation. The IA, devel- terventions aimed at improving sleep quality and has been trans-
oped to assess apathy in persons with MCI, has excellent reliability lated into 56 languages.106,107
and diagnostic efficiency to detect apathy, and is very brief
(<5 minutes).92,95 It requires more evidence for responsiveness and
Delirium
generalizability to surpass the AES. The LARS was designed to
assess apathy in persons with Parkinson disease and has excellent
The accurate detection and discrimination of delirium from de-
psychometric properties for this purpose, though it requires more
mentia (Table 6) is an important task, particularly in acute hospital
evidence for discriminant validity, responsiveness, and generaliz-
settings. The Confusion Assessment Method (CAM)108 and the
ability across settings.93,96,97
Delirium Rating ScaleeRevised 98 (DRS-R-98),109 outscored the
Delirium Index (DI).110 The CAM and DRS-R-98 can distinguish
Aggression. The Rating Scale for Aggressive Behavior in the
delirium from dementia efficiently. The CAM has been used in the
Elderly (RAGE) was designed to assess aggression in persons with
greatest variety of settings (ie, acute and post-acute care including
dementia. It is brief (<5 minutes) and has evidence for respon-
emergency departments, and nursing homes) and is better suited for
siveness, diagnostic efficiency, and generalizability across
brief screening, while the greater comprehensiveness of the DRS-R-98
settings.21,98
(including severity scale and responsiveness) makes it the preferred
tool for more in-depth assessment. In addition, the CAM is designed to
Depression. The Geriatric Depression Scale (GDS)99 outscored the
be administered with a cognitive test, while the DRS-R-98 can be used
Cornell Scale for Depression in Dementia (CSDD)100 and the
stand-alone.111
Hamilton Depression Rating Scale (HDRS).101 The GDS has more
evidence for generalizability (different types of dementia and
settings) and has a shorter administration time (5e10 vs 20 mi- Dementia-specific HRQoL
nutes). The GDS was designed for older persons in general, while
the CSDD was specifically designed for persons with dementia. As Dementia-specific HRQoL tools (Table 6) aim to determine the
the GDS relies on self-report, it may not be valid for persons with general well-being of persons in the context of the medical and psy-
moderate to severe dementia.102 Both the CSDD and GDS have chosocial challenges posed by dementia. The Quality of Life in Alz-
shown responsiveness to treatment effects but neither has MCID heimer disease scale (QOL-AD)112 can distinguish between persons
values. with severe vs mild/moderate stage dementia.113,114 It is also very
simple to administer and score. The DEMQOL115 had the best evidence
Anxiety. The Rating Anxiety in Dementia scale (RAID)103 outscored for responsiveness including MCIDs.116 Both tools are designed for
the Hamilton Anxiety Rating Scale (HARS).104 The RAID contains 5 persons with mild to moderate dementia and can be administered to
out of 6 of the DSM-IV criteria for generalized anxiety disorder, the person assessed or to an informant.

Table 6
Ratings for Delirium and HRQoL Tools

No Rating Criteria Delirium HRQoL

CAM DRS-R/-98 DI QOL-AD DEMQOL QUALID QUALIDEM

1 Inter-rater reliability (/4) 3 4 4 2 0 2 2

2 Test-retest reliability (/4) 0 0 0 2 2 2 2
3 Internal consistency (/2) 0 1 1 1 1 1 1
4 Content validity (/2) 2 1 2 2 2 2 2
5 Concurrent validity (/4) 2 2 4 2 2 2 2
6 Discriminant validity (/4) 2 4 0 4 4 2 2
7 Sensitivity (/4) 4 4 0 0 0 0 0
8 Specificity (/4) 4 4 0 0 0 0 0
9 Responsiveness (/4) 0 2 4 2 4 2 2
10 Dementia types (/2) 0 0 0 1 2 0 2
11 Clinical settings (/2) 2 0.5 2 2 1 1 2
12 Education/literacy (/2) 2 2 2 1.5 1 1 0
13 Translations (/2) 2 2 1 2 2 2 2
14 International acceptance (/4) 2 2 0 0 0 0 0
15 Administration time (/4) 4 2 2 1 1 4 2
16 A: Ease of use (/4) 4 2 4 - 4 4 3
B: Respondent burden (/4) - - - 4 - - -
17 Qualifications required (/4) 2 2 2 3 2 2 2
18 Cost of tool/training (/4) 4 4 4 4 4 4 4
Weighted score (/60) 39 38.5 32 34 32 31 30

Abbreviated test names are spelled out in full in the text.

8 A. Bentvelzen et al. / JAMDA xxx (2017) 1e12

Table 7
DOMS set of Recommended Tools

Tool Score (/60) Purpose Strengths Weaknesses

COGNITION 6CIT 44 Very brief screening Can be used without Content validity (executive/visuospatial);
materials; responsiveness requires algorithm for scoring
AMTS 43 Very brief screening Can be used without materials Content validity (executive/visuospatial)
GPCOG 43 Very brief screening Convenient informant report Unknown generalizability to different types
of dementia
Mini-Cog 41 Very brief screening Best for educational Unknown generalizability to different types
level and language of dementia
3MS 52 Brief screening Excellent all round Responsiveness
MoCA 51 Brief screening Tests executive functions Specificity for dementia/MCI
ACE-III 48 Comprehensive screening Differential diagnosis; MCI Responsiveness unknown; requires some
skill to administer/score
ADAS-COG 41.5 Comprehensive screening Responsiveness, especially to Content validity (executive testing); long
drug treatment administration time
IQCODE-Short 46 Brief informant report Corroborate or replace screen Specificity for dementia/MCI
AD8 39 Very brief informant report Corroborate or replace screen; Diagnostic efficiency
fast and easy
FAB 49.5 Executive function Niche in detecting FTD Not comprehensive
RUDAS 36.5 Non-English speakers International generalizability Sensitivity
KICA-Cog 31 Indigenous populations Diagnostic efficiency Unknown validation in other languages/cultures
STAGING CDR 48.5 Comprehensive staging Excellent validity Long administration time; needs dementia
expertise
Global 51 Brief staging Brief; specificity Sensitivity
Deterioration
Scale (GDS)
BDS 50 Brief staging Brief; user-friendly Specificity; content validity (personality items)
FUNCTION Bayer-ADL 43 Dementia-specific function Differential diagnosis; MCI Responsiveness
DAD 42 Dementia-specific function MCI; validity in drug trials Responsiveness
Bristol ADL 42 Dementia-specific function Responsiveness Reliability
DAFS-R 41 Dementia-specific function Assesses performance; differential Long administration time
diagnosis
Lawton and Brody 44 Generic IADL Very brief; diagnostic efficiency; Content validity (gender bias on some items)
IADL generalizability
OARS-IADL 37 Generic IADL Very brief; responsiveness Generalizability
Barthel Index 39 Generic ADL Responsiveness; generalizability Content validity for dementia
BPSD NPI 49 Global BPSD Comprehensive; responsiveness; Long administration time
differential diagnosis
FBI 38 Global Frontal symptoms FTD; reliability Long administration time
CMAI 42 Agitation Generalizability Long administration time
Pittsburgh 38 Agitation Brief alternative to CMAI Generalizability
Agitation Scale
AES 44 Apathy Responsiveness; generalizability Specificity
IA 42 Brief apathy screen Reliability; diagnostic efficiency Responsiveness; generalizability
LARS 39 Apathy in Parkinson disease Validity in Parkinson disease Discriminant validity; responsiveness;
dementia generalizability
RAGE 50 Aggression Brief; responsiveness; diagnostic Unknown generalizability to different
efficiency types of dementia
Geriatric 45 Depression Brief; user-friendly Self-report less valid in dementia
Depression
Scale
CSDD 38 Depression Comprehensive; dementia-specific Long administration time
RAID 36 Anxiety Content validity vs DSM-IV Long administration time
PSQI 44 Sleep disturbance Brief; responsiveness; discriminant Reliability
validity
DELIRIUM CAM 39 Brief screening Brief; diagnostic efficiency Requires concurrent cognition testing
DRS-R-98 38.5 Comprehensive screening Diagnostic efficiency; does not require Long administration time
concurrent cognition testing
HRQoL QOL-AD 34 Mild/moderate dementia User-friendly; flexible; sensitive Diagnostic efficiency
to dementia stage
DEMQOL 32 Mild/moderate dementia Responsiveness; validated for Diagnostic efficiency; reliability
different dementia types
QUALID 31 Moderate/severe Brief; later stages of dementia Discriminant validity
dementia

Abbreviated test names are spelled out in full in the text or earlier tables.

The Quality of Life in Late-Stage Dementia (QUALID)117 and Quality Discussion

of Life for People with Dementia (QUALIDEM),118 scored modestly. They
are informant tools designed for persons with moderate to severe de- We present a comprehensive review and quantitative evaluation of
mentia, with little to separate them except the shorter administration assessment tools for dementia. Our rationale was to reconcile stan-
time of the QUALID (approximately 5 vs 10 minutes). No HRQoL tool dardization with clinical flexibility by covering a broad range of
showed evidence for sensitivity or specificity to dementia or other dementia-related tools, while covering each domain of change with
clinically relevant categories (eg, depression, care needs). sufficient depth. Table 7 presents a set of recommended measures
 A. Bentvelzen et al. / JAMDA xxx (2017) 1e12 9

based on a combination of the tools’ ratings and whether the tool preference to tools that were more widely used, already had some
occupied an important clinical niche. level of international acceptance both in terms of having adaptations
Several tools that are highly regarded in the clinical context available and having a long history of use and hence validation.
scored well, including the CDR, NPI, and DAD. The rating system Although cognitive tools were restricted to those with memory plus 1
also captured tools that have recently become popular including other domain, a healthcare professional could conceivably combine a
cognitive screens (MoCA, Mini-Cog, GPCOG), informant cognitive few short tools each omitted by our selection (eg, category fluency, a
tools (AD8), and functional tools (Bayer ADL), while also reflecting clock drawing test, and the Memory Impairment Screen, MIS122) to
the advances in tool development for specific symptoms such as achieve a valid dementia screening method. The scoring system we
apathy (eg, IA and LARS). We included tools designed to detect adopted was broadly based on quality guidelines123 but was focused
subtle changes associated with the very early stages of dementia, on the clinical validity of a tool (often corresponding to criterion or
such as the MoCA for cognitive change and the Bayer ADL for predictive validity) over other considerations such as the tool’s in-
cognitively mediated aspects of early functional decline. Assess- ternal or factor structure, which may also have clinical importance in
ment tools for executive/frontal changes were also valuable (eg, the some circumstances (eg, using subscales within a tool to distinguish
ACE-III and FAB for cognition, the DAFS-R for function, and the NPI clinically important syndromes).
for BPSD).
Although psychometric features such as reliability and validity are Future Directions
relevant at any stage of assessment, instruments that are used for
outcome evaluation and monitoring must be sufficiently sensitive Recent developments have mainly focused on cognitive and
and responsive to detect changes over time. Therefore, responsive- functional tools, with significant gaps remaining for other domains.
ness was included in our rating system. We found stronger evidence, The paucity of options to measure anxiety in persons with dementia
relative to similar tools, for the 6CIT for very brief cognitive indicates this area requires more research.124,125 Tools to assess
screening, the Bristol ADL, OARS-IADL, and Barthel Index among particular symptoms of dementia such as wandering (eg, Algase
functional assessment tools, and the DEMQOL for assessing HRQoL. Wandering Scale126), and repetitive vocalizations (eg, Typology of
Generalizability was also emphasized, as it is important to under- Vocalizations scale127) require further validation. The subscales of the
stand when a tool may be applicable (or not) in different populations, NPI may provide a broad screen for these symptoms, but it is not a
settings, and languages. substitute for more substantive evaluation. More validation of
The set of recommended measures usually specified the “full” dementia-specific HRQoL measures is also required as these tools
version of the tool (except for the IQCODE-short) but the use of scored well below the top instruments in other domains. Further
abbreviated versions of these tools is encouraged (eg, AMT4, DAD-6, development of brief tools to assess social cognition, complex atten-
NPI-Q), along with computerized versions (eg, the 6CIT, GPCOG, tion, and perceptual-motor function must occur, particularly as they
MoCA) where feasible. Conversely, extended versions may be justified are part of the diagnostic criteria for mild and major neurocognitive
in some circumstances where diagnosis or management presents disorder in the DSM-V.128
more challenges (eg, NPI-C).119 Future reviews could include expansion to different assessment
The recommendations could be used to combine tools across needs, such as tools to assess cognitive decline in those with intel-
domains to maximize the value of an assessment. For example, lectual disabilities (eg, the Neuropsychological Assessment of De-
combining cognitive with functional assessment tools could help mentia in Intellectual Disabilities129) or visual impairments (eg,
diagnosis of early dementia, cognition plus BPSD tools could help MoCA-Blind). Further work is required on formally validating the
with differential diagnosis, and functional with BPSD tools could discriminative power of battery methods and “adaptive screening”
help determine care needs. The value of combining measures has techniques that use multiple measures in a step-wise manner, such as
been recognized in the differential diagnosis of dementia and using multiple cognitive screens in sequence to efficiently distinguish
delirium in the acute care setting, which requires concurrent MCI from dementia,12 or using item-level discriminant analysis within
cognitive and delirium screening.15 Similarly, the use of multiple a particular tool to extract the maximum useful information from an
types of tools within the same domain (eg, self-report, informant, assessment (eg, Mini-Cog34). Computerized tools could be a promising
clinician observation) could be used to boost the reliability of the means to test such adaptive approaches.130 The rating system used in
assessment.120,121 this study was itself reliable, which suggests it could be replicated
longitudinally or applied to different types of tools using different
Limitations selection criteria.

While the total score was an important indication of the quality Conclusions
of a tool, we acknowledge that it does not capture all the impor-
tant information about a tool. For example, the high-scoring MoCA This review provides comprehensive and clinically valuable rec-
has relatively low specificity for dementia or MCI vs healthy per- ommendations on the use of assessment tools for persons with de-
sons.35 Similarly, the weighting scheme used may not reflect a mentia and an overview of areas that require further investigation.
tool’s value in all situations, and lower-scoring measures may have Use of a common language by clinicians and researchers facilitates
features such as excellent responsiveness that are rightly judged more efficient communication and comparability of findings
to overrule their weakness in other areas. Beyond the choice of internationally.
tools within each domain per se, the set of recommended tools in
Table 7 is intended to be a useful reference summarizing the Acknowledgments
strengths and weaknesses of each selected tool. In some instances,
the weaknesses highlight important clinical gaps requiring further We thank the Dementia Outcomes Measurement Suite expert
research. steering committee: Belinda Goodenough, Lyndal Newton, Daniella
This review was not an exhaustive account of every single tool Kanareck, Simone Reppermund, Kim Burns, Anne-Nicole Casey, Julie
available nor of their effectiveness in all possible populations (eg, with Strukovski, and Sharon Levy.
different literacy levels). The selection criteria were relatively strict A.B., L.A., K.S. and H.B. are supported by the Australian National
and this may have filtered out potentially useful tools. We gave Health and Medical Research Council-funded Dementia Collaborative
10 A. Bentvelzen et al. / JAMDA xxx (2017) 1e12

Research Center Assessment and Better Care at UNSW Australia. J.W. Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alz-
heimer’s disease. Alzheimer’s Dement 2011;7:280e292.
was supported by a Dementia Collaborative Research Center (Assess-
26. Husted JA, Cook RJ, Farewell VT, Gladman DD. Methods for assessing
ment and Better Care) PhD scholarship (UNSW); Center of Excellence in responsiveness: A critical review and recommendations. J Clin Epidemiol
Population Ageing Research (CEPAR) Supplementary Scholarship; and 2000;53:459e468.
Mary Frances Stephens Scholarship (University of Sydney). The funding 27. Moniz-Cook E, Vernooij-Dassen M, Woods R, et al. A European consensus on
outcome measures for psychosocial intervention research in dementia care.
sources had no involvement in the study design; in the collection, Aging Ment Health 2008;12:14e29.
analysis and interpretation of data; in the writing of the report; or in the 28. Morley JE, Morris JC, Berg-Weger M, et al. Brain health: The importance of
decision to submit the article for publication. recognizing cognitive impairment: An IAGG consensus conference. J Am Med
Dir Assoc 2015;16:731e739.
29. Cicchetti DV. Guidelines, criteria, and rules of thumb for evaluating normed
and standardized assessment instruments in psychology. Psychol Assess
References 1994;6:284.
30. Landis JR, Koch GG. The measurement of observer agreement for categorical
1. Boise L, Neal M, Kaye J. Dementia assessment in primary care: Results from a data. Biometrics 1977;33:159e174.
study in three managed care systems. J Gerontol A Biol Sci Med Sci 2004;59: 31. Brodaty H, Pond D, Kemp NM, et al. The GPCOG: A new screening test for
M621eM626. dementia designed for general practice. J Am Geriatr Soc 2002;50:530e534.
2. Feldman H, Van Baelen B, Kavanagh SM, Torfs K. Cognition, function, and 32. Hodkinson HM. Evaluation of a mental test score for assessment of mental
caregiving time patterns in patients with mild-to-moderate Alzheimer dis- impairment in the elderly. Age Ageing 1972;1:233e238.
easeda 12-month analysis. Alzheimer Dis Assoc Dis 2005;19:29e36. 33. Katzman R, Brown T, Fuld P, et al. Validation of a short orientation-memory-
3. Gitlin LN, Marx KA, Stanley IH, et al. Assessing neuropsychiatric symptoms in concentration test of cognitive impairment. Am J Psychiatry 1983;140:
people with dementia: A systematic review of measures. Int Psychogeriatrics 734e739.
2014;2:1805e1848. 34. Borson S, Scanlan J, Brush M, et al. The mini-cog: A cognitive “vital signs”
4. Murman DL, Chen Q, Colucci PM, et al. Comparison of healthcare utilization measure for dementia screening in multi-lingual elderly. Int J Geriatr Psy-
and direct costs in three degenerative dementias. Am J Geriatr Psychiatry chiatry 2000;15:1021e1027.
2002;10:328e336. 35. Tsoi KK, Chan JY, Hirai HW, et al. Cognitive tests to detect dementia a sys-
5. Harrison JK, Noel-Storr AH, Demeyere N, et al. Outcomes measures in a decade tematic review and meta-analysis. JAMA Intern Med 2015;175:1450e1458.
of dementia and mild cognitive impairment trials. Alzheimers Res Ther 2016; 36. Abdel-Aziz K, Larner AJ. Six-item cognitive impairment test (6CIT): Pragmatic
8:48. diagnostic accuracy study for dementia and MCI. Int Psychogeriatrics 2015;
6. Bruce DG, Paley GA, Underwood PJ, et al. Communication problems between 27:991e997.
dementia carers and general practitioners: Effect on access to community 37. Brooke P, Bullock R. Validation of a 6 item cognitive impairment test with a
support services. Med J Aust 2002;177:186e188. view to primary care usage. Int J Geriatr Psychiatry 1999;14:936e940.
7. Brodaty H, Griffin D, Hadzi-Pavlovic D. A survey of dementia carers: Doctors’ 38. Morris JC, Edland S, Clark C, et al. The Consortium to Establish a Registry for
communications, problem behaviours and institutional care. Aust N Z J Psy- Alzheimer’s Disease (CERAD) Part IV. Rates of cognitive change in the longi-
chiatry 1990;24:362e370. tudinal assessment of probable Alzheimer’s disease. Neurology 1993;43:2457.
8. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: A practical method 39. Sahadevan S, Lim PP, Tan NJ, Chan SP. Diagnostic performance of two mental
for grading the cognitive state of patients for the clinician. J Psychiatr Res status tests in the older Chinese: Influence of education and age on cut-off
1975;12:189e198. values. Int J Geriatr Psychiatry 2000;15:234e241.
9. Ihl R, Frölich L, Dierks T, et al. Differential validity of psychometric tests in 40. Teng EL, Chui HC. The Modified mini-mental state (3MS) examination. J Clin
dementia of the Alzheimer type. Psychiatry Res 1992;44:93e106. Psychiatry 1987;48:314e318.
10. Mitchell AJ. A meta-analysis of the accuracy of the mini-mental state exam- 41. Nasreddine ZS, Phillips NA, Bedirian V, et al. The Montreal cognitive assess-
ination in the detection of dementia and mild cognitive impairment. ment, MoCA: A brief screening. J Am Geriatr Soc 2005;53:695e699.
J Psychiatr Res 2009;43:411e431. 42. Krishnan K, Rossetti H, Hynan LS, et al. Changes in Montreal cognitive
11. Hansen RA, Gartlehner G, Webb AP, et al. Efficacy and safety of donepezil, assessment scores over time. Assessment; June 18, 2016.
galantamine, and rivastigmine for the treatment of Alzheimer’s disease: A 43. Zahodne LB, Devanand DP, Stern Y. Coupled cognitive and functional change
systematic review and meta-analysis. Clin Interv Aging 2008;3:211e225. in Alzheimer’s disease and the influence of depressive symptoms.
12. Mitchell AJ, Malladi S. Screening and case finding tools for the detection of J Alzheimers Dis 2013;34:851e860.
dementia. Part I: Evidence-based meta-analysis of multidomain tests. Am J 44. Rosen WG, Mohs RC, Davis KL. A new rating scale for Alzheimer’s disease. Am
Geriatr Psychiatry 2010;18:759e782. J Psychiatry 1984;141:1356e1364.
13. Reisberg B. Global measures: Utility in defining and measuring treatment 45. Mioshi E, Dawson K, Mitchell J, et al. The Addenbrooke’s cognitive examina-
response in dementia. Int Psychogeriatr 2007;19:421e456. tion revised (ACE-R): A brief cognitive test battery for dementia screening. Int
14. Sikkes SA, De Lange-De Klerk SM, Pijnenburg YA, et al. A systematic review of J Geriatr Psychiatry 2006;21:1078e1085.
instrumental activities of daily living scales in dementia: Room for 46. Doraiswamy PM, Kaiser L, Bieber F, Garman RL. The Alzheimer’s Disease
improvement. J Neurol Neurosurg Psychiatry 2009;80:7e12. Assessment Scale: Evaluation of psychometric properties and patterns of
15. Morandi A. Tools to detect delirium superimposed on dementia: A systematic cognitive decline in multicenter clinical trials of mild to moderate Alzheimer’s
review. J Am Geriatr Soc 2012;60:2005e2013. disease. Alzheimer Dis Assoc Disord 2001;15:174e183.
16. Porter ME, Larsson S, Lee TH. Standardizing patient outcomes measurement. 47. Jorm AF, Korten AE. Assessment of cognitive decline in the elderly by infor-
N Engl J Med 2016;374:10e12. mant interview. Br J Psychiatry 1988;152:209e213.
17. Saver BG, Martin SA, Adler RN, et al. Care that matters: Quality measurement 48. Jorm A, Mackinnon AJ, Henderson AS, et al. The Psychogeriatric assessment
and health care. PLoS Med 2015;12:1e10. scales: A multidimensional alternative to categorical diagnoses of dementia
18. Brodaty H, Low LF, Gibson L, Burns K. What is the best dementia screening and depression in the elderly. Psychol Med 1995;25:447e460.
instrument for general practitioners to use? Am J Geriatr Psychiatry 2006;14: 49. Galvin JE, Roe CM, Powlishta KK, et al. The AD8: A brief informant interview to
391e400. detect dementia. Neurology 2005;65:559e564.
19. Milne A, Culverwell A, Guss R, et al. Screening for dementia in primary care: A 50. Jorm AF, Christensen H, Jacomb PA, et al. The cognitive decline scale of the
review of the use, efficacy and quality of measures. Int Psychogeriatrics 2008; Psychogeriatric assessment scales (PAS): Longitudinal data on its validity. Int J
20:911. Geriatr Psychiatry 2001;16:261e265.
20. Lima-Silva TB, Bahia VS, Nitrini R, Yassuda MS. Functional status in behavioral 51. Brown DS, Bernstein IH, McClintock SM, et al. Use of the Montreal cognitive
variant frontotemporal dementia: A systematic review. Biomed Res Int 2013; assessment and Alzheimer’s Disease-8 as cognitive screening measures in
2013:837120. Parkinson’s disease. Int J Geriatr Psychiatry 2016;31:264e272.
21. Sansoni J, Marosszeky N, Jeon YH, et al. Final report: Dementia outcomes 52. Storey JE, Rowland JTJ, Basic D, et al. The Rowland Universal dementia
measurement suite project. Wollongong, Australia: University of assessment scale (RUDAS): A multicultural cognitive assessment scale. Int
Wollongong-Centre for Health Service Development; 2008. Psychogeriatr 2004;16:13e31.
22. Hsieh S, Schubert S, Hoon C, et al. Validation of the Addenbrooke’s Cognitive 53. Naqvi RM, Haider S, Tomlinson G, Alibhai S. Cognitive assessments in multi-
Examination III in frontotemporal dementia and Alzheimer’s disease. Dement cultural populations using the Rowland Universal dementia assessment scale: A
Geriatr Cogn Disord 2013;36:242e250. systematic review and meta-analysis. Can Med Assoc J 2015;187:E169eE176.
23. Lima-Silva T, Bahia V, Carvalho VA, et al. Direct and indirect assessments of 54. LoGiudice D, Smith K, Thomas J, et al. Kimberley Indigenous Cognitive
activities of daily living in behavioral variant frontotemporal dementia and Assessment tool (KICA): Development of a cognitive assessment tool for older
Alzheimer disease. J Geriatr Psychiatry Neurol 2015;28:19e26. indigenous Australians. Int Psychogeriatr 2006;18:269e280.
24. McKhann GM, Knopman DS, Chertkow H, et al. The diagnosis of dementia due 55. Ebrahimi A, Poorbafrani M, Omranifard V, et al. Preparing a persian version of
to Alzheimer’s disease: Recommendations from the National Institute on kimberley indigenous cognitive assessment for assessing the cognitive
Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alz- problems of illiterate geriatric patients. Adv Biomed Res 2015;4:7.
heimer’s disease. Alzheimer’s Dement 2011;7:263e269. 56. Pitawanakwat K, Jacklin K, Blind M, et al. Adapting the Kimberly indigenous
25. Sperling RA, Aisen PS, Beckett LA, et al. Toward defining the preclinical stages cognitive assessment for use with indigenous older adults in Canada. Alz-
of Alzheimer’s disease: Recommendations from the National Institute on heimer’s Dement J Alzheimer’s Assoc 2016;12:P311.
 A. Bentvelzen et al. / JAMDA xxx (2017) 1e12 11

57. Dubois B, Slachevsky A, Litvan I, et al. A frontal assessment battery at bedside. 87. Kertesz A, Nadkarni N, Davidson W, Thomas AW. The frontal behavioral in-
Neurology 2000;55:1621e1626. ventory in the differential diagnosis of frontotemporal dementia. J Int Neu-
58. Royall DR, Mahurin RK, Gray KF. Bedside assessment of executive cognitive ropsychol Soc 2000;6:460e468.
Impairmentdthe executive interview. J Am Geriatr Soc 1992;40:1221e1226. 88. Cohen-Mansfield J, Billig N. Agitated behaviors in the elderly. I. A conceptual
59. Moorhouse P, Gorman M, Rockwood K. Comparison of EXIT-25 and the review. J Am Geriatr Soc 1986;34:711e721.
frontal assessment battery for evaluation of executive dysfunction in pa- 89. Cohen-Mansfield J. Agitated behaviors in the elderly. II. Preliminary results in
tients attending a memory Clinic. Dement Geriatr Cogn Disord 2009;27: the cognitively deteriorated. J Am Geriatr Soc 1986;34:722e727.
424e428. 90. Rosen J, Burgio L, Kollar M, et al. The Pittsburgh agitation scale: A user-
60. Hughes CP, Berg L, Danziger WL, et al. A new clinical scale for the staging of friendly instrument for rating agitation in dementia patients. Am Assoc Ger-
dementia. Br J Psychiatry 1982;140:566e572. iatr Psychiatry 1994;2:52e59.
61. Heyman A, Wilkinson WE, Hurwitz BJ, et al. Early-onset Alzheimer’s disease: 91. Marin RS, Firinciogullari S, Biedrzycki RC. The sources of convergence be-
Clinical predictors of institutionalization and death. Neurology 1987;37:980. tween measures of apathy and depression. J Affect Disord 1993;28:7e14.
62. Blessed G, Tomlinson BE, Roth M. The association between quantitative 92. Robert PH, Clairet S, Benoit M, et al. The apathy inventory: Assessment of
measures of dementia and of senile change in the cerebral grey matter of apathy and awareness in Alzheimer’s disease, Parkinson’s disease and mild
elderly subjects. Br J Psychiatry 1968;114:797e811. cognitive impairment. Int J Geriatr Psychiatry 2002;17:1099e1105.
63. Reisberg B, Ferris SH, de Leon MJ, Crook T. The Global Deterioration Scale for 93. Sockeel P, Dujardin K, Devos D, et al. The Lille apathy rating scale (LARS), a
assessment of primary degenerative dementia. Am J Psychiatry 1982;139: new instrument for detecting and quantifying apathy: Validation in Parkin-
1136e1139. son’s disease. J Neurol Neurosurg Psychiatry 2006;77:579e584.
64. Erkinjuntti T, Hokkanen L, Sulkava R, Palo J. The Blessed dementia scale as a 94. Malloy P, Grace J. A review of rating scales for measuring behavior change due
screening test for dementia. Int J Geriatr Psychiatry 1988;3:267e273. to frontal systems damage. Cogn Behav Neurol 2005;18:18e27.
65. Heun R, Papassotiropoulos A, Jennssen F. The validity of psychometric in- 95. Robert PH, Berr C, Volteau M, et al. Apathy in patients with mild cognitive
struments for detection of dementia in the elderly general population. Int J impairment and the risk of developing dementia of Alzheimer’s disease A
Geriatr Psychiatry 1998;13:368e380. one-year follow-up study. Clin Neurol Neurosurg 2006;108:733e736.
66. Roalf DR, Moberg PJ, Xie SX, et al. Comparative accuracies of two common 96. Dujardin K, Sockeel P, Carette AS, et al. Assessing apathy in everyday clinical
screening instruments for classification of Alzheimer’s disease, mild cognitive practice with the short-form Lille Apathy rating scale. Mov Disord 2013;28:
impairment, and healthy aging. Alzheimer’s Dement 2013;9:529e537. 2014e2019.
67. Hindmarch I, Lehfeld H, de Jongh P, Erzigkeit H. The Bayer activities of daily 97. Fernandez-Matarrubia M, Matias-Guiu JA, Moreno-Ramos T, et al. Validation
living scale (B-ADL). Dement Geriatr Cogn Disord 1998;9:20e26. of the Lille’s apathy rating scale in very mild to moderate dementia. Am J
68. Bucks RS, Ashworth DL, Wilcock GK, Siegfried K. Assessment of activities of Geriatr Psychiatry 2015;24:517e527.
daily living in dementia: Development of the Bristol activities of daily living 98. Patel V, Hope RA. A rating scale for aggressive behaviour in the elderlyethe
scale. Age Ageing 1996;25:113e120. RAGE. Psychol Med 1992;22:211e221.
69. Gélinas I, Gauthier L, McIntyre M, Gauthier S. Development of a functional 99. Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric
measure for persons with Alzheimer’s disease: The disability assessment for depression screening scale: A preliminary report. J Psychiatr Res 1983;17:
dementia. Am J Occup Ther 1999;53:471e481. 37e49.
70. Pedrosa H, De Sa A, Guerreiro M, et al. Functional evaluation distinguishes 100. Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornell scale for
MCI patients from healthy elderly peopledthe ADCS/MCI/ADL scale. J Nutr depression in dementia. Biol Psychiatry 1988;23:271e284.
Heal Aging 2010;14:703e709. 101. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry
71. Patterson MB, Mack JL, Neundorfer MM, et al. Assessment of functional ability 1960;23:56e62.
in Alzheimer disease: A review and a preliminary report on the Cleveland 102. Burke WJ, Houston MJ, Boust SJ, Roccaforte WH. Use of the geriatric depres-
scale for activities of daily living. Alzheimer Dis Ass 1992;6:145e163. sion scale in dementia of the Alzheimer type. J Am Geriatr Soc 1989;37:
72. McDougall GJ, Becker H, Vaughan PW, et al. The revised direct assessment of 856e860.
functional status for independent older adults. Gerontologist 2010;50: 103. Shankar K, Walker M, Frost D, Orrell M. The development of a valid and
363e370. reliable scale for rating anxiety in dementia (RAID). Aging Ment Health 1999;
73. Reppermund S, Brodaty H, Crawford JD, et al. Impairment in instrumental 3:39e49.
activities of daily living with high cognitive demand is an early marker of mild 104. Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol
cognitive impairment: The Sydney Memory and Ageing Study. Psychol Med 1959;32:50e55.
2013;43:2437e2445. 105. Buysse DJ, Reynolds CF, Monk TH, et al. The Pittsburgh sleep quality index: A
74. Loy C, Schneider L. Galantamine for Alzheimer’s disease and mild cognitive new instrument for psychiatric practice and research. Psychiatry Res 1989;28:
impairment. Cochrane Databse Syst Rev; 2009:1e115. 193e213.
75. de Rotrou J, Wu YH, Hugonot-Diener L, et al. DAD-6: A 6-ltem version of the 106. Mollayeva T, Thurairajah P, Burton K, et al. The Pittsburgh sleep quality
disability assessment for dementia scale which may differentiate Alzheimer’s index as a screening tool for sleep dysfunction in clinical and nonclinical
disease and mild cognitive impairment from controls. Dement Geriatr Cogn samples: A systematic review and meta-analysis. Sleep Med Rev 2016;25:
Disord 2012;33:210. 52e73.
76. Mahoney FI, Barthel DW. Functional Evaluation: The Barthel Index. Md State 107. Hancock P, Larner AJ. Diagnostic utility of the Pittsburgh sleep quality index in
Med J 1965;14:61e65. memory clinics. Int J Geriatr Psychiatry 2009;24:1237e1241.
77. Katz S, Ford AB, Moskowitz RW, et al. Studies of illness in the aged. The index 108. Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: The Confusion
of ADL: A standardized measure of biological and psychosocial function. J Am Assessment Method. Ann Intern Med 1990;113:941e948.
Med Assoc 1963;185:914e919. 109. Trzepacz PT, Baker RW, Greenhouse J. A symptom rating scale for delirium.
78. Keith RA, Granger CV, Hamilton BB, Sherwin FS. The functional independence Psychiatry Res 1988;23:89e97.
measure: A new tool for rehabilitation. Adv Clin Rehabil 1987;1:6e18. 110. McCusker J, Cole M, Bellavance F, Primeau F. Reliability and validity of a new
79. Lawton MP, Brody EM. Assessment of older people: Self-maintaining and measure of severity of delirium. Int Psychogetiatr 1998;10:421e433.
instrumental activities of daily living. Gerontologist 1969;9:179e186. 111. Adamis D, Sharma N, Whelan PJP, Macdonald AJD. Delirium scales: A review
80. Fillenbaum GG. Multidimensional Functional Assessment of Older Adults: The of current evidence. Aging Ment Health 2010;14:543e555.
Duke Older Americans Resources and Services Procedures. Hillsdale, NJ: 112. Logsdon RG, Gibbons LE, McCurry SM, Teri L. Quality of life in Alz-
Lawrence Erlbaum Associates, Inc.; 1988. heimer’s disease: Patient and caregiver reports. J Ment Health Aging
81. Stolee P, Stadnyk K, Myers AM, Rockwood K. An individualized approach to 1999;5:21e32.
outcome measurement in geriatric rehabilitation. J Gerontol A Biol Sci Med Sci 113. Gräske J, Verbeek H, Gellert P, et al. How to measure quality of life in shared-
1999;54:M641eM647. housing arrangements? A comparison of dementia-specific instruments. Qual
82. Stone SP, Ali B, Auberleek I, et al. The Barthel index in clinical practice: Use on Life Res 2014;23:549e559.
a rehabilitation ward for elderly people. J R Coll Physicians Lond 1993;28: 114. Smith SC, Murray J, Banerjee S, et al. What constitutes health-related
419e423. quality of life in dementia? Development of a conceptual framework for
83. Cummings JL, Mega M, Gray K, et al. The Neuropsychiatric Inventory: people with dementia and their carers. Int J Geriatr Psychiatry 2005;20:
Comprehensive assessment of psychopathology in dementia. Neurology 889e895.
1994;44:2308e2314. 115. Banerjee S, Smith S, Murray J, et al. Demqol: A new measure of health related
84. Reisberg B, Borenstein J, Franssen E, et al. BEHAVE-ad: A clinical rating scale quality of life in dementia. Neurobiol Aging 2002;23:S154.
for the assessment of Pharmacologically Remediable behavioral Symptom- 116. Mulhern B, Rowen D, Brazier J, et al. Development of DEMQOL-U and
atology in Alzheimer’s disease. In: Alzheimer’s Disease. Boston, MA: Springer DEMQOL-PROXY-U: Generation of preference-based indices from DEMQOL
US; 1987. p. 1e16. and DEMQOL-PROXY for use in economic evaluation. Health Technol Assess
85. Ismail Z, Emeremni CA, Houck PR, et al. A Comparison of the E-BEHAVE-AD, (Rockv) 2013;17:1e160.
NBRS, and NPI in quantifying clinical improvement in the treatment of 117. Weiner MF, Martin-Cook K, Svetlik DA, et al. The quality of life in late-stage
agitation and psychosis associated with dementia. Am J Geriatr Psychiatry dementia (QUALID) scale. J Am Med Dir Assoc 2000;1:114e116.
2013;21:78e87. 118. Ettema TP, Droes RM, de Lange J, et al. QUALIDEM: Development and eval-
86. Kertesz A, Davidson W, Fox H. Frontal behavioral inventory: Diagnostic uation of a dementia specific quality of life instrumentdValidation. Int J
criteria for frontal lobe dementia. Can J Neurol Sci 1997;24:29e36. Geriatr Psychiatry 2007;22:424e430.
12 A. Bentvelzen et al. / JAMDA xxx (2017) 1e12

119. de Medeiros K, Robert P, Gauthier S, et al. The Neuropsychiatric Inventory- 125. Therrien Z, Hunsley J. Assessment of anxiety in older adults: A systematic
Clinician rating scale (NPI-C): Reliability and validity of a revised assessment of review of commonly used measures. Aging Ment Health 2012;16:1e16.
neuropsychiatric symptoms in dementia. Int Psychogeriatr 2010;22:984e994. 126. Algase DL, Beattie ER, Song J, et al. Validation of the Algase wandering
120. McCusker J, Kakuma R, Abrahamowicz M. Predictors of functional decline in scale (version 2) in a cross-cultural sample. Aging Ment Health 2004;8:
hospitalized elderly patients: A systematic review. J Gerontol Med Sci 2002; 133e142.
57:569e577. 127. Cohen-Mansfield J, Werner P. Management of verbally disruptive behaviors in
121. Moore DJ, Palmer BW, Patterson TL, Jeste DV. A review of performance-based nursing home residents. J Gerontol Med Sci 1997;52A:M369eM377.
measures of functional living skills. J Psychiatr Res 2007;41:97e118. 128. Sachdev PS, Blacker D, Blazer DG, et al. Classifying neurocognitive disorders:
122. Buschke H, Kuslansky G, Katz M, et al. Screening for dementia with the The DSM-5 approach. Nat Rev Neurol 2014;10:634e642.
memory impairment screen. Neurology 1999;52:231e238. 129. Crayton L, Oliver C, Holland A, et al. The neuropsychological assessment of age
123. Mokkink LB, Terwee CB, Knol DL, et al. The COSMIN checklist for evaluating related cognitive deficits in adults with Down’s syndrome. J Appl Res Intellect
the methodological quality of studies on measurement properties: A clarifi- Disabil 1998;11:255e272.
cation of its content. BMC Med Res Methodol 2010;10:22. 130. Butcher JN, Perry J, Hahn J. Computers in clinical assessment: Historical de-
124. Sami MB. The natural course of anxiety disorders in the elderly: A systematic velopments, present status, and future challenges. J Clin Psychol 2004;60:
review of longitudinal trials. Int Psychogeriatrics 2015;27:1061. 331e345.