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The Cognitive Abilities Screening Instrument (CASI): A Practical

Test for Cross-Cultural Epidemiological Studies of Dementia

Article  in  International Psychogeriatrics · February 1994

DOI: 10.1017/S1041610294001602 · Source: PubMed

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International Psychogeriatrics, Vol. 6, No. 1, I994
0 1994 Springer Publishing Company

Third Place
1993 ZPA Research Awards in Psychogeriatrics
The Cognitive Abilities
Screening Instrument (CASI):
A Practical Test for Cross-Cultural
Epidemiological Studies of Dementia
Evelyn L. Teng, Kazuo Hasegawa, Akira Homma,
Yukimuchi Imai, Eric Larson, Amy Graves,
Keiko Sugimoto, Takenori Yamaguchi, Hideo Sasaki,
Darryl Chiu, and Lon R. White

ABSTRACT. The Cognitive Abilities Screening Instrument (CASI) has a score

range of 0 to 100and providesquantitativeassessmenton attention,concentration,
orientation, short-term memory, long-term memory, language abilities, visual
construction, list-generating fluency, abstraction, and judgment. Scores of the
Mini-Mental State Examination, the Modified Mini-Mental State Test, and the
Hasegawa Dementia Screening Scale can also be estimated from subsets of the
CASI items. Pilot testing conducted in Japan and in the United States has
demonstrated its cross-cultural applicability and its usefulness in screening for
dementia, in monitoring disease progression, and in providing profiles of cogni-
tive impairment. Typical administration time is 15 to 20 minutes. Record form,
manual, videotape of test administration,and quizzes to qualifypotential users on
the administration and scoring of the CASI are available upon request.

Demographicdata have shown asteady increase in the proportion of older individuals

in the general population and a continuation of this trend well into the next century.
Alzheimer’s disease and vascular dementia are aging-associatedconditions. Substan-
tial efforts have been made to investigate the risk factors, etiology, pathology, and
possible treatments, but the success of all such efforts depends critically on good
neuropsychologicalassessment to aid early detection of cases, accuratediagnosis, and
sensitive monitoring of disease progression and treatment effects.

From the University of Southern California School of Medicine, LQSAngeles, California, U.S.A. (E.
L. Teng, PhD); the St. Marianna University School of Medicine, Kawasaki, Japan (K. Hasegawa, MD;
A. Homma, MD, and Y. Imai, MD); the University of Washington School of Medicine, Seattle,
Washington, U.S.A. (E. Larson, M D and A. Graves, PhD); the NationalCardiovascular Center, Osaka.
Japan (K. Sugimoto, MA; and T. Yamaguchi, MD); the Radiation Effects Research Foundation,
Hiroshima, Japan (H. Sasaki,MD); and the Honolulu-Asia Aging Study, National Institute on Aging,
Honolulu, Hawaii, U.S.A. (D. Chiu, MS; and L. R. White, MD).
45
 46 E. L Teng et al.
Neuropsychological assessment for dementia usually follows a two-step proce-
dure. A short screening test is given first, then a long test battery is administered to
those identifiedby the screening test as suspect cases. The reasons for using along test
battery includethe following:(a) Ingeneral,alongertest is more reliable than ashorter
one; (b) a test with a wider score range can better monitor disease progression and
treatment effects; and (c) abattery of tests with arangeof scores for separatecognitive
domains can provide profiles of performance that may help distin-guish different
forms of dementia. The use of neuropsychologicaltest batteriesis a common practice
at major universities and research centers in a number of countries.
On the other hand, smaller clinics often do not have qualified personnel to
administer the tests and interpret the results. It is difficult for various research
centers to agree on a comprehensive set of common tests to facilitate data
comparison. For cognitively impaired patients or individuals with little or no
schooling, lengthy cognitive testing can be very stressful.
The Cognitive Abilities Screening Instrument (CASI) is a short, practical test
that has been designed to serve multiple functions. It can be used (a) as a screening
instrument for dementia, (b) to monitor disease progression, and (c) to provide a
profile of impairment among various cognitive domains.

CONTENTS OF THE CASI

The CASI consistsof itemseither identicalor similar to the ones used in the Hasegawa
Dementia Screening ScaleO S S ) (Hasegawa, 1983),the Mini-MentalStateExami-
nation (MMSE) (Folstein et al., 1975), and the Modified Mini-Mental State (3MS)
Test (Teng & Chui, 1987).A new item onjudgment has been added because impaired
judgment may contribute to a diagnosis of dementia according to the DSM-111-R
criteria (American Psychiatric Association, 1987).
The inclusion of items from established dementia screening instruments not
only helps to ensure the validity of the CASI for dementia assessment, but also
enables the estimation of the HDSS, MMSE, and 3MS scores to provide continu-
ity with existing and future literature that involves the use of these instruments.
However, some of the items in the HDSS, the MMSE, and the 3MS Test have been
modified or replaced in the CASI for one or more of the following reasons: (a) The
difficulty level of the item is likely to change over time, or be different for
individuals in different countries, such as “What year was the great Kanto
earthquake?”; (b) The administration or scoring of the item is not standardized,
such as the alternativeways used to assess concentration in the MMSE, and “How
long has it been since (a certain event)?”; (c) The item is difficult to translate into
other languages, such as asking the subject to repeat “No ifs, ands, or buts.”; (d)
The influence of an item on the total score is too large, such as the scoring of
temporal orientation in the 3MS Test. Whenever an item is modified or replaced,
care has been taken to base the substitution on “universal” experiences in order
to maximize its cross-cultural applicability.
The CASI consists of the following items according to the order of their
administration: place and date of birth, age, number of minutes in an hour,
direction of sunset, repeating three words, repeating digits backward, first recall
of the three words, serial subtractions of 3, temporal orientation, spatial orienta-
tion, generating names of four-legged animals, abstracting similarities between
The Cognitive Abilities Screening Instrument 41

pairs of items, judgment, repeating sentences, executing a simple written com-

mand, writing a dictated simple sentence, copying two intersecting pentagons,
following a three-step oral command, second recall of three words, naming five
body parts and five common objects, and recalling the five objects.
Responses on the individual items are grouped into nine cognitive domains by
consensus among the coauthors according to the items’ face validity. The range of
scoreson the majority of the domainsis from0 to 10. The CASI total score has arange
from 0 to 100. The various domains and their constituentitems are shown in Table 3.
It is recognized that probably no cognitive test or test item can be equally
appropriate for all potential study populations. Local modifications of some of
the CASI items will be needed in some cases in order to better suit the language,
dialect, and cultural, educational, geographic, and other backgrounds of the
intended subject group. The first prototype version in English just described is
intended for literate English-speaking subjects and is identified as CASI E-1.0,
where E represents the English language and 1.0 represents the first unrevised
major version in this language. To distinguish the various future adaptations of
the CASI, all variations of the CASI should be identified by a version code.

PILOT TESTING OF CASI E-1.0 AND CASI J-1.0

Method
The first versions in English (CASI E-1.0) and in Japanese (CASI J-1.0) were
developed in parallel at three workshops attended by the coauthors, and manuals
in the respective languages that include detailed instructions on the administra-
tion and scoring of the individual items were prepared. Pilot testing of CASI E-
1.0 in Los Angeles and Seattle and of CASI J-1.0 in Osaka and Tokyo was
conducted simultaneously with dementia patients and control subjects.
All patients met the DSM-111-R criteria for dementia (American Psychiatric
Association, 1987); the diagnosis was made by physician experts based on
history, functional assessment, clinical examinations, and neuropsychological
testing results excluding the scores on the CASI. All control subjects considered
themselves to be reasonably healthy, and none of them showed or reported current
medical or mental conditions that would have significant adverse effects on their
cognition. The method of subject recruitment was dictated by budget and resource
limitations and varied from site to site. At the Los Angeles site, the dementia
patients were from a regional geriatric neurobehavior and dementia referral
center; the control subjects were either spouses of the patients or unrelated
community residents. At the Osaka site, the dementia patients were from the
neuropsychology clinic of a national medical care and research center; the control
subjects were patients who had had minor strokes but were judged to be well
recovered by their physicians during their follow-up visits. At the Seattle site,
both the patients and the controls were subscribers of a health maintenance
program and had volunteered to participate in a long-term research project with
annual return visits. At the Tokyo site, the dementia patients were from the
outpatient clinic of a geriatric hospital; the control subjects were students at a
community college for the elderly. The demographic characteristics of all the
subjects are presented in Table 1.
 48 E. L Teng et al.

Results
CASIadministruiiontime. Based on the pooled data from all four sites,the mean,
SD, and range of the loth to 90th percentile of testing time in minutes were
respectively 18.2,8.6,and 10 to 30 for dementiapatients, and 13.7,6.3,and 8 to 20
for control subjects.
Performance on the CASI by control subjects in relation to age and education.
In general, at each study site, performance increased with education and decreased
with advancing age at each education level, as shown in Table 2. Table 2 also shows
that at comparable education and age ranges, the average level of performance
differed among the four sites. This is at least partly attributableto the differences in
subject recruitment. The group with the highest general level of performance
(Seattle) were volunteers in a long-term research project and had an unusually large
proportion of older subjects with more than high-school education (Kukull et al.,
1992);many of them had been tested at return annual visits and might have benefited
from the practiceeffects from similartests. Participants with the lowest general level
of performance (Osaka) were actually patients who had had minor strokes; they
might have sustained some subtle lasting cognitive impairment even though they
appeared to be well recovered according to clinical interview and observation.
Item andysis. To compare the relative sensitivity of the various CASI items in
distinguishing dementia patients from controls among the four sites, for each site a
“relative prevalence ratio for dementia” (RP) was calculated for each item in the
following manner: First, based on the pooled data from both patients and controls
from all four sites, the median score was used to dichotomize subjects into “pass”
versus “fail” categories. The RP for eachitem was calculated separately for each site,
defined as the rate of dementia among those who failed the item divided by the rate
of dementia among those who passed the item. The higher the RP, the better the item
distinguisheddementia patients from controls. The results are presented in Table 3.
The absolute values of the RPs differed among the sites, and this again is at least
partly accounted for by the differences in subject recruitment. However, when the

Table 1. Demographic Characteristicsof the Subjects

Los Angeles Osaka Seattle Tokyo
Dementia Control Dementia Control Dementia Control Dementia Control
No. of cases 62 50 23 61 71 86 52 38
Sex
Men 20 27 15 46 27 31 10 21
Women 42 23 8 15 44 55 42 17
Age (Y.1
Mean 74.2 70.0 70.7 63.6 78.3 77.5 78.1 73.3
SD 7.8 13.3 8.4 9.7 6 .O 6.4 6.7 4.9
Range 51-91 3 1-95 53-84 33-86 65-93 54-9 1 62-9 1 66-84
Education (yr.)
Mean 12.1 12.7 11.2 11.9 12.5 13.8 8.40 11.1
SD 4.1 3.5 4.0 3.4 3.0 2.9 2.9 4.3
Range 2-20 3-20 6-18 6-18 5-20 7-22 3-19 6-24
The Cognitive Abilities Screening Instrument 49
Table 2. Mean CASI Score by Control Subjects in Relation to Age and Education

Education in years
< 12 = 12 > 12
Site Age (yr.) Mean ( N ) Mean ( N) Mean ( N )

c 70 87.3 ( 2) 87.3 ( 5) 93.8 (13)

Los Angeles 70 - 79 85.5 ( 4) 91.3 (5) 91.0(10)
>= 80 72.3 ( 6) 77.2 ( 3) 79.3 ( 2)

< 70 84.5 (21) 84.0( 7) 88.4(14)

Osaka 70 - 79 82.0(13) - ( 0) 85.3 ( 5)
>= 80 - ( 0) - ( 0) 74.7 ( 1)

c 70 - ( 0) 97.0( 2) 97.1 ( 6)
Seattle 70 - 79 90.9 ( 6) 92.7( 9) 95.5 (27)
>= 80 87.5 ( 2) 88.7 (13) 91.9 (21)
< 70 90.3 ( 4) 93.0( 2) 95.0 ( 2)
Tokyo 70 - 79 85.2 (14) 79.0 ( 1) 94.8 (10)
>= 80 84.0 ( 4) - ( 0) 92.0( 1)

items were evenly divided into three groups of relatively high, medium, and low
discriminative power for each site, a remarkably consistent pattern among all four
sites emerged: In general, items that assess short-term memory, temporal orienta-
tion, and list-generating fluency were most sensitivein distinguishingpatients from
controls, whereas items that assess attention, language abilities, and long-term
memory of vital personal information were least sensitive.
The use of selected CASI &emto screenfor dementia To examine how well a
small subset of judiciously selected CASI items can be used instead of the whole
CASI to screen for dementia, for each subject the scores from the four items of
repeatingthree words, temporal orientation,generating animal names, and (thefirst)
recall of three words were combined and designated as the score of CASI-Short.For
each site, the sensitivity (the proportion of patients performing at or below the cutoff
score) and specificity (the proportion of controls performing above the cutoff score)
at an “optimal” cutoff point were determined for CASI, CASI-Short, HDSS-CE,
MMSE-CE, and the 3MS-CE, where “-CE indicates that the score was estimated
from a subset of the CASI items. The optimal cutoff point was defined as the score
closest to the point where the sensitivity curve crossed the specificity curve. The
results are presented in Table 4 and show that all five measures were fairly
comparable in their sensitivity and specificity for dementia.
The use of CASI total score for monitoring within-individual change. How
useful a test can be for monitoring diseaseprogression depends in part on the range
of its difficulty level and its sensitivityin detecting differences within this range. In
general, the larger the ranges of the obtained as well as the possible scores, and the
larger the SD of the score distribution, the better a test can fulfill this function. In this
regard, the CASI was comparable to the 3MS-CE but clearly better than the CASI-
Short, the HDSS-CE, and the MMSE-CE, as shown in Table 5. Other studies have
shown that the 3MS Test has less floor and ceiling effects than the MMSE (Teng et
 50 E. L Teng et al.
Table 3. The Relative Prevalence Ratio for Dementia of the Various CASI Items
~ ~

L. A. Osaka Seattle Tokyo

Attention
Repeating 3 words (1.77) (4.39) (2.13) (1.71)
Repeating 2 sentences (1.55) (3.33) (1.85) (1.82)
ConentrationMentaIManipulation
Digits backward 1.89 6.82 3.20 ( 1.90)
Serial subtractions of 3s 2.38 7.16 * 2.99 2.26
Orientation
Time 4.80 * 8.13 * 3.70 * 5.74 *
Place 2.90 5.86 2.71 3.73 *
Age 2.85 4.44 3.40 2.55
Short-termmemory
First recall of 3 words 6.72 * 12.65 * 8.23 * 10.96 *
Second recall of 3 words 9.58 * 6.10 7.24 * 9.47 *
Recall of 5 objects 3.49 * 12.00 * 6.06 * 6.56 *
Long-term memory
Date and place of birth 1.95 (2.56) (2.38) (1.91)
Sunset, hour 2.12 4.89 2.74 1.96
Language
Read and write (1.86) 4.49 (2.38) 2.08
Naming (1.81) (3.53) 2.40 ( 1.90)
Following 3-step command (1.79) (3.54) (2.22) (1 3 6 )
Visual construction
Copying pentagons 3.43 * (3.90) 4.81 * 2.64
List-generating fluency
Four-legged animals 3.01 * 12.71 * 6.06 * 2.79
Abstraction and judgment
Abstraction 2.06 8.80 * 3.52 2.27
Judgment (0.86) 4.4s (1.73) 4.88 *
Note. For each site, the six highest ratios are followed by an asterisk, and the six lowest ratios are
enclosed in parentheses. See text for details.

. al., 1990), and it is also more sensitive than the MMSE in detecting deteriorationin
dementia patients (Teng & Chui, 1987). Table 5 also shows that although CASI-
Short consists of only four items, its scorerange and SD compared favorablyto those
of the HDSS-CE and the MMSE-CE. Data reported elsewherebased on 57 dementia
patients and 88 normal controls show that the CASI-estimated MMSE score is very
close to the conventionally obtained MMSE score: The two types of scores had a
mean differenceof 0.1 point and acorrelationcoefficientof .92 (Graves et al., 1993).
The use of CASldomain scores to provide profiles of cognitive impairment.
The utility of CASI domain scores is illustrated with the findingson two patients
from the Seattle site. Both patients had the identical CASI total score of 58.
Their domain scores, expressed in units of SD from the mean of the scores of the
control group from the same site, provide the additional information of the
relative impairments among the various cognitive domains, and highlight the
differences as well as the similarities between the two patients, as shown in
Tlte Cognitive Abilities Screening Instrument 51

Table 4. Cut-Off Score (C.S.), Sensitivity, and Specificity of the CASI, CASI-Short,
HDSS-CE, MMSE-CE, and 3MS-CE
Los Angeles Osaka Seattle Tokyo
Test C.S. Sens. Spec. C.S. Sens. Spec. C.S. Sens. Spec. C.S. Sens. Spec.

CASI 78 .91 .91 71 .95 .94 86 .94 .94 76 .93 .93

CASI-Short 23 .95 .94 21 .89 .88 25 .94 .94 21 .89 .92
HDSS-CE 26 .84 .85 24 .93 .93 28 .86 .88 25 .92 .92
MMSE-CE 22 .86 .86 23 .92 .92 24 .91 .93 21 .94 .94
3MS-CE 76 .92 .92 68 .93 .94 83 .94 .94 74 .93 .93

Table 5. Score Distributions on the CASI, CASI-Short,

HDSS-CE, MMSE-CE, and 3MS-CE
Los Angeles Osaka Seattle Tokyo
Dementia Control Dementia Control Dementia Control Dementia Control
N=62 N=50 N=23 N=61 N=71 N=86 N = 5 2 N=38
CASI
Mean 54.3 88.9 49.4 84.6 57.8 93.0 49.3 89.1
SD 19.5 7.9 16.4 7.3 23.0 5.0 19.0 8.0
Min. - Max. 11-89 69-100 21-83 70-97 0-88 67-100 9-87 60-99
Range 79 32 63 28 89 34 79 40
CASI-Short
Mean 13.5 29.6 12.9 27.8 14.8 30.5 10.9 28.9
SD 7.1 3.2 6.5 4.4 7.8 3.3 6.6 3.9
Min. - Max. 1-29 20-33 4-27 17-33 0-31 9-33 2-26 20-33
Range 29 14 24 17 32 25 25 14
HDSS-CE
Mean 17.9 30.1 16.9 29.2 19.1 30.5 17.1 30.0
SD 8.0 2.4 6.2 2.5 8.1 1.9 7.2 2.7
Min. - Max. 2-30 23.5-32.5 3.5-26.5 21-32 0-30.5 24-32.5 2-30.5 20.5-32.5
Range 29 10 24 12 31.5 9.5 29.5 13
MMSE-CE
Mean 15.8 26.9 15.3 26.6 17.4 27.5 14.4 26.9
SD 5.7 2.6 5.4 2.3 6.4 2.1 5.0 2.7
Min. - Max. 3-26 19-30 7-28 21-30 0-27 17-30 6-27 19-30
Range 24 12 22 10 28 14 22 12
3MS-CE
Mean 52.8 90.1 48.9 84.4 55.5 92.6 46.1 88.9
SD 18.3 8.0 16.8 8.6 22.1 5.7 18.3 8.7
Min. - Max. 11-86 65-100 18-88 63-97 0-88 63-99 9-84 59-100
Range 76 36 61 35 89 37 76 42

Figure 1. To reduce crowding in the graph, the domain scores for language, in
which neither patient showed any impairment, were omitted.
Discussion
The pilot testing of the CASI E-1.0 and CASI J-1.0 was conducted mainly with
convenience samples of subjects without population-based sampling. No strict
 52 E. L Teng et al.
matching on age and education was attempted either among the four sites or
between dementia patients and control subjects. In addition, examiners used only
instructions in the manual as aguide in administration and scoring, and no attempt
was made to check how well the instructions were understood and followed.
Nevertheless, the results show that CASI characteristics did not vary significantly
among the four sites despite differences in language, subject characteristics, and
testing personnel and settings. At all four sites, performance on the CASI by the
control subjects increased with education and decreased with aging within each
education range. The most sensitive and the least sensitive items for distinguish-
ing dementiapatients from the controls were quite consistent across the sites; the
CASI-Short score, based on the summed score from four selected items of the
CASI, showed comparable sensitivity and specificity as the CASI total score and
the estimated HDSS, MMSE, and 3MS scores. The CASI total score yielded a
larger score range than the estimated HDSS and MMSE. The CASI domain scores
could be used to provide profiles of cognitive impairment.
The influence of aging and education on test performance has been a robust finding
in practically all studies that sample subjects with sufficient variation in these
variables. The effects of education include not only the learning of specific knowledge
and skill, but also improved general efficiency in information processing and manage-
ment. It is unrealistic to expect that the influenceof education can be fully eliminated
in dementia screening tests. On the other hand, cognitive skills are not equally
important for individuals of different occupations, cultures, and life roles. Many
individuals may never have had the opportunity or the need to develop their cognitive
skills in some of the areas deemed elemental and important by academicians who
design dementia screening tests. In assessing dementia, care should be taken to
consider the “ecological validity”of the test for the studypopulation; test items, cutoff
points, and even cognitive domains may need to be adjusted accordingly. The
grouping of items into various cognitive domains and the inclusion of a version code
to distinguish different versions of the CASI adapted for different study populations

ATTENTION

CONCENTRAT.

0RIENTATION

MEMORY

DRAWING

ANIMALS

ABS.-JUDG.
I I 1
-8 -6 -4 -2 0
2 = (X - M) I SD
Figure 1. Profiles of cognitive impairment of two patients with the identical
CASI total score of 58.
The CognitiveAbilities Screening Instrument 53

have been designed in part to facilitateand encourage local modifications of the CASI
items to suit the particular backgrounds of the subjects.
Item analysis of the CASI showed that practically all items distinguished
dementia patients from the controls, but some items performed much better than
others (Table 3). Items with low RPs should not be considered useless. These are
typically items performed relatively well by patients with mild-to-moderate
dementia. Some of these items assess attention and serve to help distinguish
dementia from delirium. Other items serve to monitor the progression of dementia
into its more severe stages.
Data shown in Table 4, including the cutoff points, sensitivities, and specifici-
ties, are presented mainly to provide comparisons among the five measures of
CASI, CASI-Short, HDSS-CE, MMSE-CE, and 3MS-CE. These values are
influenced by the composition of the particular groups of patients and controls.
It should be emphasized that no effort was made to closely match the patients and
the controls on age and education except that age was closely matched at the
Seattle site (Kukull et al., 1992); although most of the dementia patients were
estimated to be in the mild-to-moderatedementiarange, no standardized indepen-
dent measure of severity was obtained for all patients.
The most interesting finding from Table 4 is that the four-item CASI-Short was
comparable to the other measures in its sensitivity and specificity for detecting
dementia. Since the four items of repeating three words, temporal orientation,
generating animal names, and recalling three words do not involve reading,
writing, drawing, or arithmetic, the CASI-Short should be particularly suitable
for individuals with little or no formal education.

CURRENT STUDIES WITH THE CASI AND TRAINING

AIDS FOR USERS
Several coordinated epidemiological studies of dementia that involve thousands of
subjects and follow the same methodology, including the use of the CASI (White,
1992), are being conducted in the United States, Japan, and Taiwan. Thus,normative
data based on large population-based samples will soon be available. We plan to put
these normative data on computer diskette for distribution. Simple, user-friendly
programs will be included so that any user of the CASI can easily assess the norms of
any specified version of the CASI and compare the performanceof a particular subject
with a group of any specified age and educational range (Pauker, 1988).
For the first version of CASI inEnglish, the following materials are available upon
request: (a) Therecord form and scoring sheet.(See also Appendix.) (b) A manual that
includesdetailed instructionson the administrationandscctringof the individualCASI
items. To guide possible modifications for other populations, comments on what an
item is intended to measure are stated wherever it is not apparent. Formulas for
deriving scores for the various cognitive domains and the HDSS-CE, MMSE-CE, and
3MS-CE are also included. (c) Two alternate forms of a 30-item multiple-choicequiz
designed to test potential users on their knowledge regarding the administration and
scoring of the CASI. (d) A 1-hourvideotapeon the administration of the CASI to three
individuals of different ability levels (normal, mild-to-moderatedementia, moderate-
to-severe dementia).
 54 E. L Teng et al.
It is recommended that potential users of the CASI first study the manual and
the videotape, then take the quiz when they believe they are prepared. Individuals
who have failed the quiz should be required to study the manual and the videotape
more carefully and to take the alternate form of the quiz. This process should be
repeated until the quiz is passed. Our experience shows that the quiz is very
helpful in identifying overlooked or misunderstood aspects in administration and
scoring, and is an invaluable aid in quality control.

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White, L. R. (1992). The Ni-Won-Sea dementia project: Description and progress report. In
H. Orimo, Y. Fukuchi, K. Kuramoto, & M. Zriki (Eds.),New horizons in aging science
(pp. 324-325). Tokyo: University of Tokyo Press.

Acknowledgment. This paper was presented at the Sixth Congress of the Interna-
tional Psychogeriatric Association, Berlin, Germany, September 5-10,1993.

Offprints and other requesfi. Requests for offprints should be directed to Evelyn L.
Teng, PhD, Department of Neurology (GNH 5641), University of Southern Califor-
nia School of Medicine, 2025 Zonal Avenue, Los Angeles, CA 90033, U S A .
To request a copy of the manual and other related material for CASI E- 1 .O, write to:
CASI Materials,d o L. White, EDB Program,National Institute on Aging, Gateway
Building, Room 3C309, National Institute of Health, Bethesda, MD 20892, U.S.A.
The Cognitive Abilities Screening Instrument 55

APPENDIX: Record form and scoring sheet for the CASI E-1.1.
The Difference Between CASI E-1.0 and CASI E-1.1
CASI E-1.1 is identical to CASI E-1.0 except that the raw scores for all items (except
3-step Command) that enter into the domains of Short-term Memory and Language
have been modified in version E-1.1 such that these two domain scores can be obtained
in the same manner as is the case for all the other domains, i.e., by the direct summing
of the raw scores of the constituent items. (In CASI E-1.0, the raw scores are always
integers, but some raw scores are first divided by 2 or 3 before being summed for the
domain scores for Language and Short-termMemory.) Although versions E- 1.O and E-
l. l have different raw scoreson some items, the two versions will always yield identical
domain and total scores. Version E-1.0 is more suitable for large research programs
where item scores are entered into a computerand the domain scoresare calculated with
computer programs. Version E-1.1 is more suitable for the hand calculation of the
domain scores without the use of a computer.

How to Use the CASI E-1.1 Scoring Sheet

The subject’s name (or initials), age, education, sex, and ID number are entered in the
first row at the top of the scoring sheet. The date of testing, the examiner’s initials, the
duration of testing, and the judged validity of the obtained scores are entered in the
second row; entries for the last two variables can be found in the lower right corner on
page 3 of the CASI E-1.1 Record Form. Scores from the CASI E-1.1 Record Form are
entered in the SCORE column next to the code names on the left side of the scoring sheet.
(There are three variables on the record form - VRS#, RGS2, and RPNM -that do not
contribute to CASI scores;these three variablesare enclosed with parentheseson the scoring
sheet.)
To obtain the CASZ domain scores: For each score in the SCORE column, copy it in
the same row under one of the domains as indicated on the scoring sheet. The nine
domains (and their abbreviations used on the scoring sheet) are as follows: Attention
(ATT), Concentration (CCT), Orientation (ORT), Long-term Memory (LTM), Short-
term Memory (STM), Language (LAN), Visual Construction (VC), List-generating
fluency (FLU), Abstraction and Judgment (A&J). Add up the scores in each column and
enter the sum above the domain code at the bottom of the scoring sheet. For Language
and Short-termMemory, the sum may have decimalpoints; always round the sum to the
nearest integer, then enter the integer as the domain score. The maximum score for each
domain is shown under the domain code.
To obtain the CASZ total score: Add up the nine domain scores and enter the sum above
CASI** in the lower left comer of the scoring sheet.For subjectswith nearly perfect scores,
an easier way to obtain the CASI total score is to note the differencebetween the maximum
score and the obtained score for each domain, add up the differencesfrom all nine domains,
then subtract the sum from 100.
To obtain the CASI-estimatedMMSE score (MMSE-CE):For each entry under MMSE-
CE, copy the CASI scorein the samemw exceptwhere there is a question mark and a number
before the entry blank. In such cases,enter 1if the CASI score equals the number, otherwise
enter 0. For example: if RClA = 1, the entry for MMSE-CE will be 0;if DRAW = 8,9, or
10, the entry for MMSE-CE will be 1. The MMSE-CE entry for OBJA (naming) will be 2,
1, or 0, which is obtained by dividing the CASI OBJA score (0.6, or 0.3, or 0) by 0.3. The
CASI-estimatedMMSE score is the sum of the entries in the MMSE-CE column.
 VRSX
1
2
3
i a. I AM GOING TO SAY 3 WORDS FOR YOU -
TO REMEMBER. REPEA1 THEM AFTER RGSl SIM
T..llng d.,I 1,m. h, mlnl I HAVE SAID A U THREE.
3 6
- 3 I. SHIRT
-BROWN -HONESTY - 2
5
t WHERE WERE YOU BORN7 0 2 SHOES - B U C K -MODESTY - 1
0 4
3 SOCKS -BLUE -CHARITY -
- 3
[O 11
RGS2
C l w RomNIIIag.)
2
3
2 1

BFI 1 0
2 0 __
16 a. WHAT ACTIONS WOULD YOU TAKE I F YOU SAW
1 YOUR NEIGHBOR'S HOME CATCHING FlRE7
'. I SHALL SAY SOME NUMBERS. AND YOU REPEAT
0 WHAT I SAY BACKWARDS. FOR EXAMPLE, Iprompl 'WHAT ELSE MIGHT 100 DO?. once mniv.
-
IF I SAY 1-2 Y W SAY 2-1. OK? ,In.c..,.,y I
2 WHEN WERE YOU BORN?
REMEMBER. Y W REPEAT WHAT I SAY BACKWARDS No 01 .piropri.h actlon. 0 1 2
BYR
IR.1.: 1 dlglVn.cond I
2 b. WHAT ACTIONS WOULD YOU TAKE
1-2-3 1 I1 unsbla. w.Eh lor 3-2-1. but *Cora 0 I IF YOU LOST A BORROWED
1 UMBRELLA?
0 I gom1 to, ..Sh r.1.qory o( .CI/O".' ,GUT

f Inlwrn1Agol"Olz~ e
RePI.cdComp.n.l.
Month [O 11 5
c. WHAT WOULD YOU DO I F YOU
( 0 I1 FOUND AN ENVELOPE THAT &
D1
.. 3DAY WAS SEILED. ADDRESSED AND
2 HAD A NEW STAMP? 3
1 Mall 2
2
Try 10 105.1. In. om., 1
0
- I".pPropri.l. .cllon 0 1

3 HOW OCD ARE YOU? AGE

AFFYI.~~ 2
I 7 a REPEAT B Y WHAT I SAY
Missed by t - 3 Y.U. 1 RPTA
'HE WOULD U K E TO GO HOME'
YIs*.4 by >3 yew. 0 con.s, 2
- 1 or 2 mi.& or WOng word. 1
4 HOW MANY H l N U l E S ARE THERE IN AN H W R 7 >= 3 m h m d or wrong word. 0
OI HOW MANY DAYS ARE THERE I N A YEAR7
MHT I ,vr a).ch pert d f7b. ,con I m / y If repenlad
b I S THIS P U C E A HOSPITAL I CLINIC 1. ".CI," P
".
" I
I a6W. 2 If LlMr WY.SllW #mww.d swmsllv I ~

2 A STORE I 1. OR HOME7 b NOW REPEAT

..
RPTB
0
4 WHAT ANIMALS HAVE 4 LEGS? l E L L ME -THIS YELLOW CIRCLE 10 1 I 3
__ AS MANY AS YOU CAN 130 .rJ
ISHEAVIER THAN [ 0 I I I 2
SUN ""rnk,01 ANMl
5. I N WHAT DIRECTION DOES THE SUN SET? COIRSI
BLUE SOUARE' I0 11 1
2 ,n.w,,, 0 t 2 3 4 5 6 7 8 9 I0
I I f Ss"f"..d. m y prorld. 4 cnwc., I
0 .dd'.Mr. 3 IhlvJI M n S I I C b I. an9W.r -+
-
The Cognitive Abilities Screening Instrument 57

13
7
a
r
U
..
3 F
P
P
0 B.
>- *'
$
2
W
0
H
a
K

? a ?
0 0 0

L L
3 5
% B
 58 E. L Teng et al.
SCORING SHEET for CASI E - 1 . 1 Domain Scores, T o t a l Score, and MMSE-CE

S’s i n i t i a l s Age __ Edu _ _ M F ID#

Date _ _ 1-1- E’s i n i t i a l s T Duration VLDY -

CODE SCORE ATT CCT ORT LTM STM LAN VC FLU A&J MMSE-CE

BPL 0 0
BYR 0 0 MMSE-CE = C A S I e x c e p t :
BDAY ( j 0
AGE ( 1 0 ? N: I f CASI = N
MNT ( 1 0 MMSE-CE = 1
SUN ( I 0 E l s e MMSE-CE = 0
(VRS#)
RGSl ( ) ( ) ................................................... (
(RGS2)
DBA ( 1 0 (
DBB ( 0 (
DBC ( 1 0 (
RClA ( ) ........................ ( ) .................... ? 1.5 (
RClB ( 0 ? 1.5 (
RClC ( ) 0 ? 1.5 (

SUB3A( ) 0
SUB3B( ) 0
SUB3C( ) 0
YR ( ) ............( ) ................................ ? 4 0
MO ( 1 0 ? Z 0
DATE ( ) 0 ? 3 0
DAY ( ( ) ....................................... 0
SSN ( 1 0 0
SPA ( 1 0 0
SPB ( ) 0 0
ANML ( .......................................... 0
SIM ( 1 0
JDMT ( ) 0
RPTA ( ( 1
RPTB ( ) ( ) .............................................. ? 3 0

READ 0 ? 1.5 ( )
WRITE 0 ? 2.5 ( )
DRAW ) ( ) ? 8, 9, or 10 ( )
CMD 0 0
RCZA ) . . ...................... 0
RCZB 1 0
RCZC ( 1 0
BODY ( ) .............................. 0
OBJA ( ) ( ) ....... OBJA 1 0.3 = ( )
OBJB ( ) 0
(RPNM)
RCOBJ( ) 0

-=-+__
t __ t t -t ___ t --.-+-
t
MMSE-CE
~

CASI** ATT CCT ORT LTM STM* LAN* VC FLU A&J

Max. 100 8 10 18 10 12 10 10 10 12 30

( * To round t h e domain score t o t h e nearest i n t e g e r .

** To o b t a i n t h e C A S I T o t a l Score by summing t h e n i n e domain scores.)

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