Received April 7, 2003; accepted July 28, 2003. From the Department
of Psychiatry, Dartmouth Hitchcock Medical Center, Lebanon, N.H.
(Dr. Oxman); and McLean Hospital, Belmont, Mass. (Dr. Forester).
The authors report no financial affiliation or other relationship
relevant to the subject matter of this article.
Corresponding author and reprints: Thomas E. Oxman, M.D.,
Department of Psychiatry, Dartmouth Hitchcock Medical Center,
One Medical Center Drive, Lebanon, NH 03756
(e-mail: thomas.oxman@dartmouth.edu).
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158
160
159
Direct observation
16
20
Yes
Yes
No
Yes
Interrater reliability
Inpatient
100
of behavior
Abbreviations: ADAS = Alzheimers Disease Assessment Scale, BEHAVE-AD = Behavioral Pathology in Alzheimers Disease Rating Scale, C-BRSD = CERAD (Consortium to Establish a Registry
for Alzheimers Disease) Behavior Rating Scale for Dementia, CMAI = Cohen-Mansfield Agitation Inventory, NPI = Neuropsychiatric Inventory, NPI-Q = Neuropsychiatric Inventory-Questionnaire,
PAS = Pittsburgh Agitation Scale, PGDRS = Psychogeriatric Dependency Rating Scale.
3
Outpatient
Inpatient
Interrater reliability
256
Outpatient
No
No
Yes
Yes
1
Caregiver
Nurse
Nursing staff
NPI-Q17
PAS19
PGDRS20
Direct observation
of behavior
Yes
Caregiver
NPI16
Self-administered
12
Yes
Yes
Yes
Apathy, disinhibition,
irritability, psychomotor,
eating
Apathy, disinhibition,
irritability, psychomotor,
eating
Aberrant vocalizations,
psychomotor, resistance
to care
Orientation, physical
Yes
Yes
Yes
Nursing staff/
caregiver
CMAI14
Clinician interview
12
10
Yes
No
No
Yes
29
15
Yes
Yes
Yes
Yes
Caregiver
C-BRSD12
Structured interview/
technician
Technician
46
2030
Yes
Cross-validated with
NPI
323
101
Outpatient
Nursing
home
Interrater reliability,
construct, content,
convergent validity
Content, concurrent
validity
109
Outpatient
Psychomotor, diurnal
rhythms, anxiety/phobias
Self-regulation, apathy,
irritability
None
Yes
Yes
Yes
Yes
20
26
Caregiver
BEHAVE-AD10
Clinician interview
Informant
Patient/
caregiver
Scale
ADAS9
Method
Technician
Interrater reliability
No. of
Citations
626
Setting
Outpatient
Psychometrics
Interrater & test-retest
reliability, concurrent
validity
Interrater reliability
Agitation
Yes
Behaviors Assessed
Aggression Affect
No
Yes
Average
Completion
No. of
Time
Items
(minutes)
21
45
Psychosis
Yes
Validation
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sections. The cognitive section has 11 parts that test components of memory, praxis, and language. The noncognitive section includes 10 parts and assesses depression,
agitation, psychosis, and vegetative symptoms but omits
anxiety, aggression, and apathy. All forms of hallucinations are combined into one category. The noncognitive
section rates behaviors on a 05 scale of severity and
an if not assessed. The cognitive section is commonly
used to assess change in cognitive function in pharmaceutical trials. A technician, using a patient and caregiver as
informant, administers this scale, which takes approximately 45 minutes to complete. This measure was designed specifically to assess changes in cognitive function and behavioral symptoms in pharmacologic clinical
trials.
The Behavioral Pathology in Alzheimers Disease Rating Scale (BEHAVE-AD) is one of the earliest behavior
rating scales to be used in Alzheimers dementia.10,11 The
items were taken from a chart review of 57 outpatients
with Alzheimers disease. It was designed to prospectively follow behavioral symptoms and to measure behavioral symptoms in pharmacologic trials of patients with
Alzheimers disease. The BEHAVE-AD includes the assessment of symptoms and a global rating of caregiver
distress. A total of 25 symptoms in 7 clusters are rated:
paranoid and delusional ideation, hallucinations, aggressiveness, activity disturbances, diurnal rhythm disturbances, affective disturbances and anxieties, and phobias.
Caregivers rate behavioral symptoms over the preceding
2 weeks on a 03 scale. The maximum score is 75. The
caregiver also determines a global assessment of caregiver distress on a scale of 03. The BEHAVE-AD has
been found to be sensitive to changes in behavior and
suitable for measuring effects of medications.
The CERAD (Consortium to Establish a Registry for
Alzheimers Disease) Behavior Rating Scale for Dementia (C-BRSD) was developed out of the large CERAD
initiative.12 This instrument is composed of 46 questions
rated on a 5-point severity scale. The items were taken
from existing scales and designed to be administered to
an informant who knows the patient well. The ratings
measure behavioral symptoms over the past month. The
original sample consisted of 303 patients attending 16
Alzheimers centers within the United States.13
The Cohen-Mansfield Agitation Inventory (CMAI)
was designed primarily for nursing home use.14,15 A
7-point rating scale is used to assess the frequency of 29
individual behaviors. The behaviors are broken down into
2 primary dimensions: aggression and agitation. Aggressive behaviors are categorized as verbal, physical, or
sexual. Agitated behaviors are categorized as physical or
verbal. The measure requires approximately 10 to 15 minutes to complete. Caregivers, usually nurses or certified
nursing assistants in the nursing home setting, rate the
behaviors but need training first. The maximum score is
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tates communication of treatment response among the patient, caregiver, primary care physician, and, when necessary, a consulting specialist. The key for communication
in these systems of care is a practical, reliable, and valid
assessment tool. This is the imperative for further evaluation of tools such as the NPI-Q.
REFERENCES
1. Cummings JL, Masterman DL. Assessment of treatment-associated
changes in behavior and cholinergic therapy of neuropsychiatric symptoms in Alzheimers disease. J Clin Psychiatry 1998;59(suppl 13):2330
2. Lyketsos C, Steinberg M, Tschanz JT, et al. Mental and behavioral disturbances in dementia: findings from the Cache County Study on Memory
in Aging. Am J Psychiatry 2000;157:708714
3. Deimling GT, Bass DM. Symptoms of mental impairment among elderly
adults and their effects on caregivers. J Gerontol 1986;41:778784
4. Rabins PV, Mace NL, Lucas MJ. The impact of dementia on the family.
JAMA 1982;248:333335
5. Steele C, Rovner B, Chase GA, et al. Psychiatric symptoms and nursing
home placement of patients with Alzheimers disease. Am J Psychiatry
1990;147:10491051
6. Cohen-Mansfield J. Assessment of disruptive behavior/agitation in the
elderly: function, methods and difficulties. J Geriatr Psychiatry Neurol
1995;8(suppl 1):5260
7. Robinson BE, Barry PP, Renick N, et al. Physician confidence and interest in learning more about common geriatric topics. J Am Geriatr Soc
2001;49:963967
8. Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: a practical
method for grading the cognitive state of patients for the clinician.
J Psychiatr Res 1975;12:189198
9. Rosen WG, Mohs RC, Davis KL. A new rating scale for Alzheimers
disease. Am J Psychiatry 1984;141:13561364
10. Reisberg B, Franssen E. Stage specific incidence of potentially remediable behavioral symptoms in aging and AD: a study of 120 patients using
the BEHAVE-AD. Bull of Clinical Neuroscience 1989;54:95112
11. Reisberg B, Borenstein J, Salob SP, et al. Behavioral symptoms in
Alzheimers disease: phenomenology and treatment. J Clin Psychiatry
1987;48(suppl 5):915
12. Tariot PN, Mack JL, Patterson MB, et al. The behavioral rating scale
for dementia of the consortium to establish a registry for Alzheimers
disease. Am J Psychiatry 1995;152:13491357
13. Burns A, Lawlor B, Craig S. Assessment Scales in Old Age Psychiatry.
London, England: Martin Dunitz Ltd.; 1999
14. Cohen-Mansfield. Agitated behaviors in the elderly. 2: preliminary results in the cognitively deteriorated. J Am Geriatr Soc 1986;34:722727
15. Cohen-Mansfield J, Marx MS, Rosenthal AS. A description of agitation
in a nursing home. J Gerontol 1989;44:M77M84
16. Cummings JL, Mega M, Gray K, et al. The Neuropsychiatric Inventory:
comprehensive assessment of psychopathology in dementia. Neurology
1994;44:23082314
17. Kaufer D, Cummings JL, Ketchel P, et al. Validation of NPI-Q: a brief
clinical form of the NPI. J Neuropsychiatry Clin Neurosci 2000;12:
233239
18. Mega MS, Cummings JL, Fiorello T, et al. The spectrum of behavior
changes in Alzheimers disease. Neurology 1996;46:130135
19. Rosen J, Burgio L, Kollar M, et al. The Pittsburgh Agitation Scale:
a user-friendly instrument for rating agitation in dementia patients.
Am J Geriatr Psychiatry 1994;2:6074
20. Wilkinson IM, Graham-White J. Psychogeriatric Dependency
Rating Scale (PGDRS): a method of assessment for use by nurses.
Br J Psychiatry 1980;137:558565
21. Riegel B, Carlson B, Kopp Z, et al. Effect of standardized nurse casemanagement telephone interventions on resource use in patients with
chronic heart failure. Arch Intern Med 2002;162:707712
22. Unutzer J, Katon W, Williams JW Jr, et al. Improving primary care
for depression in late life: the design of a multicenter randomized trial.
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Informant:
Spouse
Child
Other
Date: ____________________________
Please answer the following questions based on changes that have occurred since the patient first began to experience memory problems.
Circle Yes only if the symptom(s) has been present in the last month.
Otherwise, circle No. For each item marked Yes:
a) Rate the SEVERITY of the symptom (how it affects the patient):
1 = Mild (noticeable, but not a significant change)
2 = Moderate (significant, but not a dramatic change)
3 = Severe (very marked or prominent, a dramatic change)
b) Rate the DISTRESS you experience due to that symptom (how it affects you):
0 = Not distressing at all
1 = Minimal (slightly distressing, not a problem to cope with)
2 = Mild (not very distressing, generally easy to cope with)
3 = Moderate (fairly distressing, not always easy to cope with)
4 = Severe (very distressing, difficult to cope with)
5 = Extreme or Very Severe (extremely distressing, unable to cope with)
Please answer each question carefully. Ask for assistance if you have any questions.
Delusions
Yes
Does the patient have false beliefs, such as thinking that others are stealing from him/her or planning to harm him/her in
some way?
No
Hallucinations
Yes
No
Agitation/Aggression
Yes
No
Depression/Dysphoria
Yes
No
Anxiety
Yes
No
No
Apathy/Indifference
Yes
No
Disinhibition
Yes
No
No
Motor disturbance
Yes
No
Nighttime behaviors
Yes
No
Appetite/Eating
Yes
a
DISTRESS: 0
Does the patient have hallucinations such as false visions or voices? Does he or she seem to hear or see things
that are not present?
SEVERITY:
DISTRESS: 0
DISTRESS: 0
DISTRESS: 0
SEVERITY:
DISTRESS: 0
Does the patient appear to feel too good or act excessively happy?
SEVERITY:
DISTRESS: 0
Does the patient seem less interested in his/her usual activities or in the activities and plans of others?
SEVERITY:
DISTRESS: 0
Does the patient seem to act impulsively, for example, talking to strangers as if he/she knows them,
or saying things that may hurt peoples feelings?
Irritability/Lability
Yes
Does the patient become upset when separated from you? Does he/she have any other signs of nervousness
such as shortness of breath, sighing, being unable to relax, or feeling excessively tense?
Elation/Euphoria
Yes
SEVERITY:
No
SEVERITY:
DISTRESS: 0
Is the patient impatient and cranky? Does he/she have difficulty coping with delays or waiting for planned activities?
SEVERITY:
DISTRESS: 0
Does the patient engage in repetitive activities such as pacing around the house, handling buttons, wrapping string,
or doing other things repeatedly?
SEVERITY:
DISTRESS: 0
Does the patient awaken you during the night, rise too early in the morning, or take excessive naps during the day?
SEVERITY:
DISTRESS: 0
Has the patient lost or gained weight, or had a change in the type of food he/she likes?
SEVERITY:
DISTRESS: 0
Reprinted with permission from Cummings et al.16 This questionnaire may be photocopied for clinical use in the physicians office. Developed by
D. Kaufer, M.D. Final version 6/99. All rights reserved, Jeffrey L. Cummings, M.D.
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