psychometric assessment of older adults oct 21 to 26 2013 winter workshop

Psychometric/Psychological Psychometric/Psychological Assessment of Older AdultsAssessment of Older Adults

Bed side cognitive assessment instruments and applicability

Dr. Rakesh Kumar Tripathi, Dr. Rakesh Kumar Tripathi, M Phil, PhDM Phil, PhD Assistant Professor cum Clinical PsychologistAssistant Professor cum Clinical Psychologist

Department of Geriatric Mental Health Department of Geriatric Mental Health King George’s Medical UniversityKing George’s Medical University

Lucknow -226003 (India)Lucknow -226003 (India)

(In house Winter Training Workshop, 21 to 26 October, 2013)

Friends! Please follow the instructions Friends! Please follow the instructions with mistake to learn scoringwith mistake to learn scoring

Draw a clock face (large circle)Draw a clock face (large circle) marking the hours (numbers in the circle)marking the hours (numbers in the circle) draw a time 10 past 11draw a time 10 past 11

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Copy the designs one by one in a page

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Learning Objectives:Learning Objectives: Concept of psychometric/psychological Concept of psychometric/psychological

assessmentassessment Types of Psychometric testsTypes of Psychometric tests Purpose of psychological assessmentPurpose of psychological assessment Steps of psychological assessmentSteps of psychological assessment Areas of assessment for elderlyAreas of assessment for elderly Psychological assessment tools for older adultsPsychological assessment tools for older adults ConclusionConclusion Further ReadingsFurther Readings

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Concept:Concept: Psychometrics is the field of study Psychometrics is the field of study

concerned with the theory and technique concerned with the theory and technique of educational and psychological of educational and psychological measurement.measurement. Knowledge, abilities, attitudes, and Knowledge, abilities, attitudes, and

personality traits etc. traits etc. The field is primarily concerned with the The field is primarily concerned with the

construction and validation of measurement construction and validation of measurement instruments, such as instruments, such as questionnaires, tests, tests, and and scalesscales..

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Concept (contd.)Concept (contd.)Psychological Assessment vs TestPsychological Assessment vs Test

Assessment is more than testing Psychological testing occurs as Psychological testing occurs as partpart of the of the

process of psychological assessment. process of psychological assessment. Psychological assessment includes:Psychological assessment includes: Clinical interview Clinical interview Demographic information Demographic information Medical information Medical information Personal history Personal history Observations by others Observations by others Thus, the results of a psychological test Thus, the results of a psychological test are rarely used on their own. are rarely used on their own.

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Concept (contd.)Concept (contd.)

Psychological AssessmentPsychological Assessment "An extremely complex process of solving "An extremely complex process of solving

problems (answering questions) in which problems (answering questions) in which psychological tests are often used as one psychological tests are often used as one of the methods of collecting relevant data" of the methods of collecting relevant data" (Maloney & Ward, 1976)(Maloney & Ward, 1976)

Psychological TestingPsychological Testing "An objective and standardized measure "An objective and standardized measure

of a sample of behaviour" (Anastasi, 1990)of a sample of behaviour" (Anastasi, 1990)

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Concept (contd.):Concept (contd.): ObjectiveObjective

complete independence from examiners complete independence from examiners effect.effect.

StandardizationStandardization by standardization we mean the by standardization we mean the

establishment of a certain definite method of establishment of a certain definite method of giving a test and the establishment of giving a test and the establishment of adequate norms for the interpretation of the adequate norms for the interpretation of the results. (Pinter, R. 1936)results. (Pinter, R. 1936)

Psychological TestingPsychological Testing

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Properties of Psychological Properties of Psychological Test:Test:Reliability: Reliability: consistency of a measureconsistency of a measureValidity: Validity: ability of the test to measure ability of the test to measure

what it purports to measurewhat it purports to measureNorm: Norm: a range of values within which a range of values within which

members of a given members of a given population are expected to population are expected to perform or functionperform or function

Psychological TestingPsychological Testing

Reliable and ValidReliable but Not ValidNot Reliable and Not Valid

Bull’s-eye

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Types of Psychological TestsTypes of Psychological Tests

Ability Tests:Ability Tests: Intelligence testsIntelligence tests Neuropsychological testsNeuropsychological tests Aptitude testsAptitude tests

Personality tests:Personality tests: Paper pencil tests (Questionnaire/Inventories)Paper pencil tests (Questionnaire/Inventories) Projective testsProjective tests

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Psychological Assessment of Older Psychological Assessment of Older AdultsAdults

Purpose of Assessment:Purpose of Assessment: DiagnosisDiagnosis CertificationCertification Severity of symptomsSeverity of symptoms Management/RehabilitationManagement/Rehabilitation ImprovementImprovement PrognosisPrognosis ResearchResearch

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Areas of assessmentAreas of assessment Cognitive:Cognitive:

Orientation, Calculation, Memory, Language etc.Orientation, Calculation, Memory, Language etc. Behavioral:Behavioral:

Irritation, Suspiciousness, Muttering, Smiling to self Irritation, Suspiciousness, Muttering, Smiling to self Violence, etc.Violence, etc.

Psychological:Psychological: Intelligence, Personality, Conflicts, PsychopathologyIntelligence, Personality, Conflicts, Psychopathology

Functional:Functional: ADLADL

Quality of life:Quality of life: Physical, Psychological, Environmental, Social, Physical, Psychological, Environmental, Social,

spiritualspiritual Carer’s Burden:Carer’s Burden:

Physical, Psychological, Financial, SocialPhysical, Psychological, Financial, Social

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Steps of psychological assessment:Steps of psychological assessment: ScreeningScreening

Screening is defined as a process for Screening is defined as a process for collecting objective evidence to discern collecting objective evidence to discern probable presence or absence of a probable presence or absence of a psychopathology psychopathology

Detailed assessmentDetailed assessment process for collecting objective evidence to process for collecting objective evidence to

confirm the presence or absence of a confirm the presence or absence of a psychopathology psychopathology

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ScreeningScreening Mini Mental State Examination (MMSE) Mini Mental State Examination (MMSE) (Folstein et al. 1975)(Folstein et al. 1975) Hindi Mental State Examination (HMSE) Hindi Mental State Examination (HMSE) (Ganguli et al. 1995)(Ganguli et al. 1995) Hindi Cognitive Screening Test Hindi Cognitive Screening Test (Tiwari and Tripathi, 2011) (Tiwari and Tripathi, 2011) St. Louis University Mental State (SLUMS) Exm. St. Louis University Mental State (SLUMS) Exm. (JE Morley, 2000)(JE Morley, 2000) Clock Drawing Test (CDT) Clock Drawing Test (CDT) (Shulman et al. 1993)(Shulman et al. 1993) Bender Gestalt Test (BGT) Bender Gestalt Test (BGT) (Lauretta Bender, 1938) (Lauretta Bender, 1938) Hachinski Ischemic Scale Hachinski Ischemic Scale (1975)(1975) 7 Minute Neurocognitive Screening Battery 7 Minute Neurocognitive Screening Battery (Solomon et al. 1998)(Solomon et al. 1998) Short Portable Mental State Questionnaire Short Portable Mental State Questionnaire (E. Pfieffer, 1975)(E. Pfieffer, 1975) Community Screening Instrument for Dementia Community Screening Instrument for Dementia (Hall et al. 1993)(Hall et al. 1993) Brief Cognitive Rating Scale (BCRS) Brief Cognitive Rating Scale (BCRS) (Reisberg and Ferris, 1998)(Reisberg and Ferris, 1998) Functional Assessment Staging (FAST) Functional Assessment Staging (FAST) (Reisberg, 1988)(Reisberg, 1988) Global Deterioration Scale (GDS) Global Deterioration Scale (GDS) (Reisberg, 1988)(Reisberg, 1988) Cognistat Cognistat (Northern California Neurobehavioural Group, 1995 )(Northern California Neurobehavioural Group, 1995 ) Indian adaptation of Cognistat Indian adaptation of Cognistat (Gupta and Kumar, 2009)(Gupta and Kumar, 2009) Addenbrooke’s Cognitive ExaminationAddenbrooke’s Cognitive Examination Montreal Cognitive AssessmentMontreal Cognitive Assessment


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Detailed Assessment Survey Psychiatric Assessment Schedule (Bond et al. 1980) CAMDEX-R (Roth et al. 1986, 1998-R) Alzheimer's Disease Assessment Scale (Rosen et al. 1984) Schedule for Clinical Assessment in Neuropsychiatry (SCAN)

(WHO, 1996) Clinical Dementia Rating (Morris, 1993) Blessed Dementia Scale (Blessed, 1968) BEHAVE-AD (Reisberg et al. 1987) Geriatric Mental State Schedule (GMSS) (Copeland et al. 1976) Dementia Rating Scale (DRS) (Mattis, 1988) DRS-2 (Jurica et al. 2001) Neuropsychiatric Inventory (NPI) (Cummings et al. 1994) Everyday Abilities Scale for India (EASI) (Fillenbaum et al. 1999) Thai Activities of Daily Living Scale (Senanarong et al. 2003) Senior Apperception Test (Choudhury Uma, 1978)

Psychological Assessment of Older AdultsPsychological Assessment of Older Adults

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Neuropsychological Test Batteries (NPB): Halstead and Reitan NPB Luria Nebraska NPB Wechsler Adult Intelligence Scale (WAIS) PGI Battery of Brain Dysfunction (PGIBBD) PGI Assessment of Mental Efficiency in Elderly

(PGIAMEE) NIMHANS NPB AIIMS Comprehensive NPB in HindiRorschach Psychodiagnostics

Psychological Assessment of Older Adults Psychological Assessment of Older Adults Detailed Assessment (contd.)Detailed Assessment (contd.)

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Mini Mental State Examination Mini Mental State Examination ((Folstein et al. 1975)Folstein et al. 1975) Brief assessment of an individual’s orientation to time Brief assessment of an individual’s orientation to time

& place, recall ability, arithmetic ability, language, & place, recall ability, arithmetic ability, language, Praxis.Praxis.

Can be administered by a nonprofessional.Can be administered by a nonprofessional. Time- 5 to 10 minutes Time- 5 to 10 minutes Total Score 30 ; Score Categories : 0- 4, 5-14, 15-19 Total Score 30 ; Score Categories : 0- 4, 5-14, 15-19

Severe, Moderate, Mild Dementia; 20-24 Mild Severe, Moderate, Mild Dementia; 20-24 Mild Cognitive Impairment, 25-28 Age related Memory Cognitive Impairment, 25-28 Age related Memory Impairment, 29-30 Normal cognitionImpairment, 29-30 Normal cognition

The test has education bias The test has education bias

In the areas of Cognitive FunctioningIn the areas of Cognitive Functioning

Psychological Assessment of Older AdultsPsychological Assessment of Older AdultsScreening (contd.)Screening (contd.)

Hindi Mental State Examination (HMSE) Hindi Mental State Examination (HMSE) ((Ganguli et Ganguli et al. 1995): al. 1995): Adapted for illiterate Hindi speaking populations. Developed by: Indo-US cross-national dementia epidemiology study.

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International Psychogeriatrics (2009), 21:1, 123–128 C 2008 International Psychogeriatric Association

Applicability of the Mini-mental State Examination (MMSE) and the Hindi Mental State Examination (HMSE) to the urban elderly in India: a pilot study.......................................................................................................S. C. Tiwari, Rakesh Kumar Tripathi and Aditya KumarDepartment of Geriatric Mental Health, C.S.M. Medical University (Uttar Pradesh), Lucknow, India

Results: Either HMSE is screening

more false negatives within the urban literate population or MMSE is screening more false positives within the illiterate population.

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Sensitivity: 0.93

Specificity: 0.96

Reliability (r): -0.87

with Brief Cognitive Rating Scale (Reisberg & Ferris, 1988)

IAGMH/Intas Award 2011 at 3rd place.

Development of an Education and Culture Fair Hindi Cognitive Screening Test (HCST) for the

Elderly Population of India S. C. Tiwari and Rakesh Kumar Tripathi (2011)

Department of Geriatr ic Mental HealthC. S. M. Medical University, U P, Lucknow, India

Indian Journal of Geriatric Mental Health, 7(2), 83-96, 2011.Hindi Cognitive Screening Test (HCST) (Tiwari and Tripathi, 2011)

ON HCST (items may change according to Literacy language and culture) No.

Areas (Score) Total score: 30

Items

1. Orientation to Time (5) Year (of any calendar), weather, month, date, day

Either ‘which Place is this’, or ‘whose house is this’ depending on whether the testing was conducted in a home or healthcare centre or other location in the village/muhalla/town

Police Station or Tehsil or Post office

District State

2. Orientation to Place (5)

Country 3. Registration (3) Mango (or any local fruit), Chair, Rupee 4. Attention and

Calculation (5) Items exchangeable to the literacy level: • For illiterate: days backward Serial subtractions: • Up to 5th : 3 starting at 20. • Up to 10th: 4 starting at 40 . More than 10th : 7 starting at 100

5. Recall (3) Mango, Chair, Rupee

6. Naming (2) Pen, wristwatch/ Mobile phone

7. Repetition (1) ‘Neither this nor that’ 3 stage Follow command (3)

Give the individual a plain piece of paper and say, “Take the paper in your hand, fold it in half, and put it on the floor.”

8.

Read & Follow Command (1)

• Item exchangeable to the literacy level according to MMSE and HMSE ‘Close your eyes’ for Literate; and Examiner says ‘Look at me and do exactly what I do’ and then closes his own eyes for three seconds for illiterate.

9. Sentence (1) Items exchangeable to the literacy level according to MMSE and HMSE. Writing a sentence for literate and ‘Tell me something about your house’ for illiterate

10. Copying (1) Items exchangeable to the literacy level according to MMSE and HMSE

Up to 5th : Diamond More than 5th: Two Pentagons Total Score: 30 Cut off Score: At or below 23: Screen positive (Cognitive Impairment)

Score: 24 and above: No cognitive impairment

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High School Education

Clinical Clinical ConditionCondition

Less ThanHigh SchoolEducation

27-30 Normal 25-30

21-26 MNCD* 20-24

1-20 Dementia 1-19

St. Louis University Mental State Examination (SLUMS St. Louis University Mental State Examination (SLUMS Exam.) Morley JE, 2000Exam.) Morley JE, 2000

• It is a simple 11 items toolIt is a simple 11 items tool

* Mild Neurocognitive Disorder * Mild Neurocognitive Disorder •Takes about 5-10 minutes in Takes about 5-10 minutes in administrationadministration• SLUMS is more sensitive in detecting SLUMS is more sensitive in detecting MCI and dementia than Mini MentalMCI and dementia than Mini Mental State ExaminationState Examination


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Bender Gestalt Test:Bender Gestalt Test: Lauretta Bender,1938; Lauretta Bender,1938;

Brannigan et al.2004 9 figures asked to copy on 9 figures asked to copy on

a blank papera blank paper Pencil with erasurePencil with erasure Admn. Time- 7-10 min.Admn. Time- 7-10 min. Used as screening test for Used as screening test for

brain damagebrain damage Score more than 12 Score more than 12

indicates cognitive indicates cognitive impairmentimpairment


Sign on BGT Score

Perseveration, Rotation/reversal, Concretism

4 each

Added angles, Separation of lines, Overlap, Distortion

3 each

Embolishments, Partial rotation

2 each

Omission, Abbreviation, Separation, Absence of erasure, Closure, Point of contact

1 each

Features Score1. Abrupt 22. Stepwise deterioration 13. Fluctuating course 24. Nocturnal confusion 15. Relative preservation of personality

1

6. Depression 17. Somatic Complaints 18. Emotional incontinence 1

Features Score9. History or presence of hypertension

1

10. History of strokes 211. Evidence of associated atherosclerosis

1

12. Focal neurologic symptoms

2

13. Focal neurologic sign 2Total Score 18


Screening (contd.)Screening (contd.)Hachinski Ischemic Scale (1975)Hachinski Ischemic Scale (1975)

Scoring 0-4: Alzheimer's Dementia; 5-6: diagnosis unclear; 7 or more : Vascular Dementia

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Clock drawing Test Score Error(s)1 No error2 Minor visuospatial

error3 Inaccurate

representation of “10 after 11”

4 Moderate visuospatial disorganization of times

5 Several disorganization

6 No reasonable representation of a clock

Score≥ 3: Cognitive deficit

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Brief Cognitive Rating Scale, Brief Cognitive Rating Scale, Barry Reisberg & Barry Reisberg & Ferris (1988)Ferris (1988) BCRS is part of the triad of assessment with BCRS is part of the triad of assessment with

the Global Deterioration Scale and the Global Deterioration Scale and Functional Assessment Staging instrumentFunctional Assessment Staging instrument

It is divided into 5 axes – concentration, It is divided into 5 axes – concentration, recent memory, past memory, orientation recent memory, past memory, orientation and function/self careand function/self care

It takes about 15 minutes It takes about 15 minutes It is used for the screening of cognitive It is used for the screening of cognitive

functions functions


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Functional Assessment Staging Technique Functional Assessment Staging Technique (FAST), Barry Reisberg (1988)(FAST), Barry Reisberg (1988) A 16 items scale to assess functional staging with A 16 items scale to assess functional staging with

cognitive disturbances cognitive disturbances The scale is more detailed version of 7 point The scale is more detailed version of 7 point

functioning and self care axis of BCRS functioning and self care axis of BCRS It has optimal concordance with Global Deterioration It has optimal concordance with Global Deterioration

Scale (GDS) Scale (GDS) It measures progression of deficits in AD It measures progression of deficits in AD Fast can also be used for staging dementia with Fast can also be used for staging dementia with

behavioural disturbances behavioural disturbances Scored by a trained clinicianScored by a trained clinician Takes 10-15 minutes Takes 10-15 minutes


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Global Deterioration Scale (GDS), Global Deterioration Scale (GDS), Barry Reisberg Barry Reisberg (1988)(1988) A 7 point instrument for the staging of the A 7 point instrument for the staging of the

magnitude of cognitive and functional capacity in magnitude of cognitive and functional capacity in normal aging, age associated memory normal aging, age associated memory impairment (AAMI) and Primary Degenerative impairment (AAMI) and Primary Degenerative Dementia (PDD)Dementia (PDD)

Widely used scale Widely used scale Takes 10-15 minutes Takes 10-15 minutes


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Community Screening Instrument for Dementia. Community Screening Instrument for Dementia. Hall K, et al., 1993 Hall K, et al., 1993 CSI-D is used to find out the caregiver CSI-D is used to find out the caregiver

perception of mental health. perception of mental health. It is vital to know the caregiver burden to It is vital to know the caregiver burden to

ensure the quality of care provided by the ensure the quality of care provided by the relative relative


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Survey Psychiatric Assessment Schedule (SPAS), Bond et al. 1980

3 sections for assessment 1-Cognitive, 2-Affective neurosis, 3- Psychosis Different cut off scores For cognitive-less than 9 For Affective neurosis- more than 11 For Psychosis any one score

Psychological Assessment of Older Psychological Assessment of Older Adults Adults Detailed Assessment (contd.)Detailed Assessment (contd.)

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The Cambridge Mental Disorders of the Elderly The Cambridge Mental Disorders of the Elderly Examination (CAMDEX) ,Examination (CAMDEX) , M. Roth et al.(1986, 1998- M. Roth et al.(1986, 1998-R.)R.) Complete assessment of an older adults in 8 Complete assessment of an older adults in 8

Sections.Sections. Sec A- Clinical Information about current Sec A- Clinical Information about current

condition, past history and family history of the condition, past history and family history of the patient; patient;

Sec B-Sec B-Cognitive function (CAMCOG); Cognitive function (CAMCOG); Sec C- Interviewer’s observation on the Sec C- Interviewer’s observation on the

patients appearance & behaviour;patients appearance & behaviour; Sec D- Physical Exam.; Sec D- Physical Exam.;


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CAMDEX (contd.):CAMDEX (contd.): Sec E- Results of Laboratory tests; Sec E- Results of Laboratory tests; Sec F- Medication received by the patient; Sec F- Medication received by the patient; Sec G- Additional information;Sec G- Additional information; Sec H- Structured interview with the Sec H- Structured interview with the

relative/caregiver.relative/caregiver. Dementias, Delirium, Depression, Anxiety, Dementias, Delirium, Depression, Anxiety,

Paranoid disorder, and other psychiatric Paranoid disorder, and other psychiatric disorders.disorders.

Administration:- PsychiatristAdministration:- Psychiatrist Time of Administration-60-90 minutes Time of Administration-60-90 minutes


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Alzheimer’s Disease Assessment Scale (ADAS) Alzheimer’s Disease Assessment Scale (ADAS) (Rosen et al.1984)(Rosen et al.1984)Measures cognitive as well as non-cognitive behaviorsMeasures cognitive as well as non-cognitive behaviors

Cognitive: 11Cognitive: 11 Spoken language Spoken language

ability ability Comprehension of Comprehension of

spoken language spoken language Recall of test Recall of test

instructions instructions Word finding difficulty Word finding difficulty Following commandsFollowing commands

Naming objects Naming objects Construction Praxis Construction Praxis Ideational Praxis Ideational Praxis Orientation Orientation Word recall Word recall Word recognitionWord recognition


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ADAS (Contd.)ADAS (Contd.)

Non-cognitiveNon-cognitive:: 10 10 Tearful Tearful Appears/reports – depressed Appears/reports – depressed

mood mood Concentration, distractibility Concentration, distractibility Uncooperativeness to testing Uncooperativeness to testing Delusions Delusions Hallucinations Hallucinations


PacingPacing Increased motor Increased motor activity activity Tremors Tremors Increase / Decrease Increase / Decrease appetite appetite Total Admn. Time: Total Admn. Time: 45 minutes45 minutes

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Clinical Dementia Rating (CDR) (Morris, 1993)Clinical Dementia Rating (CDR) (Morris, 1993)

1.1. Memory Memory 2.2. Orientation Orientation 3.3. Judgment & Problem Judgment & Problem

Solving Solving 4.4. Community AffairsCommunity Affairs5.5. Home & Hobbies Home & Hobbies

6.6. Personal CarePersonal Care


Global measure of dementia by a clinician.Global measure of dementia by a clinician.CDR scale describes five degrees of impairment in six CDR scale describes five degrees of impairment in six different categories of cognitive impairment:different categories of cognitive impairment:

Degrees of Impairment:0 0 -Normal-Normal0.5 -Questionable 0.5 -Questionable

impairmentimpairment11 -Mild impairment-Mild impairment22 -Moderate impairment-Moderate impairment33 -Severe impairment-Severe impairment

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In the areas of Behavioural and Psychological In the areas of Behavioural and Psychological Manifestations Manifestations BEHAVE-AD ,BEHAVE-AD , Barry Reisberg & Associates(1987)Barry Reisberg & Associates(1987)

Useful in assessing behavioural symptoms in patients with Useful in assessing behavioural symptoms in patients with Alzheimer’s disease. Alzheimer’s disease.

It is a 25 – item scale used to evaluate the behavioural It is a 25 – item scale used to evaluate the behavioural symptoms of AD. These 25 items are divided into (7) symptoms of AD. These 25 items are divided into (7) categories like : categories like :

Paranoid and delusional ideation; Paranoid and delusional ideation; HallucinationsHallucinations Affective disturbances; Affective disturbances; Aggressions;Aggressions; Diurnal rhythm disturbances; Diurnal rhythm disturbances; Affective disturbance;Affective disturbance; Anxiety and phobias Anxiety and phobias

Time to complete scale 10-20 minutes Time to complete scale 10-20 minutes


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Geriatric Mental State Schedule (GMSS) Geriatric Mental State Schedule (GMSS) Copeland JR et al.,1976Copeland JR et al.,1976 This is a standardized psychiatric interview This is a standardized psychiatric interview

schedule and very useful in identifying schedule and very useful in identifying Psychopathology: Psychopathology:

organic and early organic illness (mostly various stages of organic and early organic illness (mostly various stages of dementia) and dementia) and

depressive illnessesdepressive illnesses High level of sensitivity and specificity, and positive High level of sensitivity and specificity, and positive

predictive value. predictive value. GMSS is one among the various flexible and GMSS is one among the various flexible and

effective case-finding instruments effective case-finding instruments Admin. Time: 45 minutes by trained interviewerAdmin. Time: 45 minutes by trained interviewer


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Blessed Dementia Scale (BLS-D), Blessed Blessed Dementia Scale (BLS-D), Blessed (1968) (1968)

It has 22 items organized in three major areas : It has 22 items organized in three major areas : 1- 1- Change in performance of everyday activit ies Change in performance of everyday activit ies

(8 i tems)(8 i tems)2- Change in habits (3 items) 2- Change in habits (3 items) 3- change in personality traits and drive (11 3- change in personality traits and drive (11

items). items). - The information is obtained from a care giver - The information is obtained from a care giver

and the ratings are based on a predetermined and the ratings are based on a predetermined criterion criterion

- Administration by trained cl inician - Administration by trained cl inician - Administration time : 15-30 minutes - Administration time : 15-30 minutes


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In the areas of Activities of Daily LivingIn the areas of Activities of Daily Living Instrumental Activities of Daily Living (IADLInstrumental Activities of Daily Living (IADL), ), Lawton & Brody (1969)Lawton & Brody (1969)

IADL focuses on concrete behaviour and IADL focuses on concrete behaviour and includes 8 domains of activities including includes 8 domains of activities including telephoning, shopping, food preparation, telephoning, shopping, food preparation, housekeeping, laundering use of transportation, housekeeping, laundering use of transportation, use of medication, and financial behaviour.use of medication, and financial behaviour.

Administration by Mental Health workers Administration by Mental Health workers Scoring is based upon information from all available Scoring is based upon information from all available

sources (pt. staff, family record services etc.) sources (pt. staff, family record services etc.)


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In the areas of activities of Daily Living In the areas of activities of Daily Living (Contd.):(Contd.):

The Thai ADL Scale , The Thai ADL Scale , Senanarong & associates (2003) Senanarong & associates (2003)

This scale assess 13 activities of daily living-This scale assess 13 activities of daily living-


• BathingBathing• DressingDressing• Using ToiletUsing Toilet• TransferringTransferring• IncontinenceIncontinence• EatingEating• Telephone useTelephone use

• Using public transportation Using public transportation • ShoppingShopping• CookingCooking• Performing household activitiesPerforming household activities• Taking medication Taking medication • Handling moneyHandling money

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Indo-Us project by Fillenbaum et al. 1999

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In the areas of Behavioural and Psychological ManifestationsIn the areas of Behavioural and Psychological Manifestations Neuropsychiatric Inventory (NPI). Neuropsychiatric Inventory (NPI). Cummings, J and Cummings, J and

Collaborators (1994)Collaborators (1994) The scale assess 10 domains of behavioural The scale assess 10 domains of behavioural

disturbances disturbances Delusions, Hallucinations, Dysphoria, Delusions, Hallucinations, Dysphoria,

Anxiety,agitation/aggression euphoria, inhibition, Anxiety,agitation/aggression euphoria, inhibition, irritability/lability apathy, aberrant motor behaviour irritability/lability apathy, aberrant motor behaviour

2 versions of NPI 2 versions of NPI 1- Pt in nursing home (nursing staff)1- Pt in nursing home (nursing staff) 2- Pt. in home (caregiver)2- Pt. in home (caregiver) N PI – produces 4 scores :-N PI – produces 4 scores :-

one for frequency, second for severity, a third called total which is the one for frequency, second for severity, a third called total which is the multiplication of frequency by severity and a 4th for the multiplication of frequency by severity and a 4th for the distress/excess work caused by the symptoms. distress/excess work caused by the symptoms.


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In the areas of Behavioural and Psychological In the areas of Behavioural and Psychological ManifestationsManifestations

Relative’s Assessment of Global Symptomatology Relative’s Assessment of Global Symptomatology (RAGS-E)(RAGS-E),, Ruskin A. (1988)Ruskin A. (1988)

It is a 21 item scale to evaluate psychiatric and It is a 21 item scale to evaluate psychiatric and behavioral problems of elderly in the community, behavioral problems of elderly in the community, particularly senile dementia.particularly senile dementia.

It is designed to be answered by relatives/caregivers of It is designed to be answered by relatives/caregivers of the patient and it is relatively brief and easy to the patient and it is relatively brief and easy to administer.administer.

5 point rating scale.5 point rating scale. Administration- close relative/friend of the person.Administration- close relative/friend of the person. Time/administration:- 15-20 minutes. Time/administration:- 15-20 minutes.


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In the areas of Behavioural and Psychological In the areas of Behavioural and Psychological ManifestationsManifestations

DISRUPTIVE BEHAVIOUR RATING SCALE DISRUPTIVE BEHAVIOUR RATING SCALE (DBRS),(DBRS), Mungas D, et al. (1989) Mungas D, et al. (1989)

Assessment of disruptive behaviour in patients Assessment of disruptive behaviour in patients with dementia with dementia

CERAD - BEHAVIOUR RATING SCALECERAD - BEHAVIOUR RATING SCALE, Tariot PN, , Tariot PN, et al (1995)et al (1995)

Rating of psychopathology in patients with Rating of psychopathology in patients with probable Alzheimer’s Disease probable Alzheimer’s Disease


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AttentionAttention : : Letter cancellation, Letter cancellation, Diller L, et al. (1974)Diller L, et al. (1974)

This is a paper and pencil task requiring visual This is a paper and pencil task requiring visual selectivity at fast speed on a repetitive motor taskselectivity at fast speed on a repetitive motor task

Trails A test, Trails A test, Reitan RM. (1958)Reitan RM. (1958) A test of complex visual scanning with a motor A test of complex visual scanning with a motor

component with motor speed and agility making a component with motor speed and agility making a strong contribution to success. strong contribution to success.

In the areas of Cognit ive Functioning In the areas of Cognit ive Functioning


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Language : Language : Boston Naming Test, Boston Naming Test, Kaplan EF, et al. (1983)Kaplan EF, et al. (1983)

BNT is known test to assess one’s ability to name pictures of objects through spontaneous responses and need for various types of cueing. Inferences can be made with regard to language facility and possible localization of cerebral damage

Boston Diagnostic Aphasia Examination, Boston Diagnostic Aphasia Examination, Goodglass Goodglass H. & Kaplan EF, (1983)H. & Kaplan EF, (1983)

The BDAE is a comprehensive, multifactorial battery to evaluate a broad range of language impairments that often arise as a consequence of organic brain dysfunction in adults. It’s a know tool for the assessment of aphasia both in inpatient and outpatient

In the areas of Cognitive Functioning In the areas of Cognitive Functioning


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Language (Contd.)Language (Contd.) Western Aphasia Battery, Western Aphasia Battery, Kertesz A. (1982)Kertesz A. (1982)

WAB is commonly used to identify and quantity the Broca’s WAB is commonly used to identify and quantity the Broca’s aphasia population. Interpretations of the results are in terms aphasia population. Interpretations of the results are in terms of the language choice, lexical semantic, syntactic, of the language choice, lexical semantic, syntactic, morphological and phonological levels of switching and morphological and phonological levels of switching and spontaneous translationspontaneous translation

Verbal Fluency (Word and Category), Verbal Fluency (Word and Category), Sciarma T, et al. Sciarma T, et al. (1990)(1990)

Many types of verbal fluency tests are being used world Many types of verbal fluency tests are being used world wide. The use of word and category verbal fluency test is wide. The use of word and category verbal fluency test is made to measure the subjects speed and flexibility of verbal made to measure the subjects speed and flexibility of verbal thought processesthought processes. .

In the areas of Cognit ive Functioning In the areas of Cognit ive Functioning


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MemoryMemory Wechsler Memory Scale, Wechsler Memory Scale, Wechsler D. (1987)Wechsler D. (1987)

Wechsler memory scale is used to assess the four Wechsler memory scale is used to assess the four types of memory. It will assess verbal memory, types of memory. It will assess verbal memory, visual memory and attention and general memory visual memory and attention and general memory of the subject. This is the only test available to of the subject. This is the only test available to measure the subject’s memory quotient (MQ)measure the subject’s memory quotient (MQ)

Rey Auditory Verbal Learning Test, Rey Auditory Verbal Learning Test, Rey A. (1964)Rey A. (1964) This test is used to assess the subjects verbal This test is used to assess the subjects verbal

learning skills, providing option for immediate and learning skills, providing option for immediate and delayed recall and recognition. delayed recall and recognition.



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Executive functionExecutive function Wisconsin Card Sort Test, Wisconsin Card Sort Test, Nelson HE. Nelson HE.

(1976)(1976) This test is a well-known paradigm of This test is a well-known paradigm of

abstraction and cognitive flexibility. abstraction and cognitive flexibility. Studies report that apart from Studies report that apart from executive functions it also elicits a executive functions it also elicits a distinct pattern of cerebral blood flow distinct pattern of cerebral blood flow velocityvelocity

Stroop Test, Stroop Test, Stroop JR. (1935)Stroop JR. (1935) Tests the ability to selectively Tests the ability to selectively

process only one visual feature while process only one visual feature while continuously suppressing the others. continuously suppressing the others. http://cognitivefun.net/test/2 http://cognitivefun.net/test/2



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Neuropsychological TestsPsychological approaches for the assessment of brain pathology

Multifactorial Unitory

assumption of functional unity of the brain as a whole (mass action and equipotentiality)

Assessed by psychological tests of Unitory functions such as

test for Intelligence, Memory,Perceptuomotor Functions,

Nahar- Benson test, WCST etc.

Assessed by Comprehensive Batteries of tests such as Halstead and Reitan,

Luria Nebraska, NIMHANS-BBD, PGI-BBD, AIIMS comprehensive

Neuropsychological Battery inHindi, PGI battery for assessment of mental efficiency in the elderly

Based on the functional autonomy of the structure (Localization)


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Intelligence Intelligence Wechsler Adult Intelligence Scale (WAIS), Wechsler Adult Intelligence Scale (WAIS), Wechsler Wechsler

D. (1981) D. (1981) Widely applicable test for IQ measurement over 16 years .Widely applicable test for IQ measurement over 16 years . Can also be used for diagnosing organic brain syndromesCan also be used for diagnosing organic brain syndromes It has It has 6 verbal:6 verbal: information, comprehension, arithmetic, information, comprehension, arithmetic,

similarities, digit span and vocabulary and similarities, digit span and vocabulary and 5 performance:5 performance: picture completion, Block design, picture arrangement, object picture completion, Block design, picture arrangement, object assembly and digit symbol tests. The test generates a verbal assembly and digit symbol tests. The test generates a verbal IQ, a performance IQ and a full scale or combined IQ. IQ, a performance IQ and a full scale or combined IQ.

A difference between the verbal and performance IQ scores A difference between the verbal and performance IQ scores of greater than 10 points is suggestive of organic brain of greater than 10 points is suggestive of organic brain syndrome. syndrome.

Neuropsychological Test


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Neuropsychological Tests (contd.)PGI Battery of Brain Dysfunction(PGIBBD),

Dwarka Pershad and S.K. Vrma, 1990: PGI Memory Scale Revised Bhatia’s Short Battery of

Performance Test of Intelligence Verbal Adult Intelligence Scale (VAIS) Nahar-Benson Test Bender Visual Motor Gestalt Test (BGT)

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PGI Memory Scale: Remote and recent memory Mental balance Attention and concentration Delayed and immediate Recall Verbal retention (similar and dissimilar pairs) Visual retention and Recognition

Separate norms for: 0-5 yrs. of schooling 6-9 yrs. of schooling 10 and above yrs. of schooling

Neuropsychological Tests (contd.) PGIBBD (contd.)

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Revised Bhatia,s Short Battery of Performance tests of Intelligence:

Koh’s Block Design Test 10 designs

Pass-along Test 8 problems


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Verbal Adult Intelligence Scale (VAIS):It does not take into account the speed or, quickness, rather it emphasizes the power or the capacity of the subjects.

20-69 yrs. of age Information Digit span Arithmetic Comprehension


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Nahar-Benson Test (Nahar and Benson,1070): Total 8 items 5 drawing to copy 3 instructions to draw figuresBender Visual Motor Gestalt Test (BGT),

(Bender,1938): 9 drawings to be copied


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PGI Battery for assessment of Mental Efficiency in the Elderly (PGI-AMEE), Kohli et al. 1996:

For 55yrs. and above. 5 subtests: The Set Test (Isaacs & Akhtar,1972)

Recall items on 4 categories: 1-colours, 2-animals, 3-fruits and 4-cities

Mental Status Questionnaire (Kahn et al. 1960) Recent and remote events General Informations

Nahar and Benson Scale (Nahar et al. 1970) 8 drawings to make

Geriatric Depression Scale (Brink et al. 1982) 30 items in english version 20 items adopted in Hindi version

Neuropsychological Tests (contd.)

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AIIMS Comprehensive Neuropsychological Battery in Hindi (Adult form) (AIIMS-CNBH), Surya Gupta et al. 2000:

Based on Luria,s functional approach in the detection, lateralization, localization of discrete brain lesions

Useful for both in diagnosis and rehabilitation 160 items and 13 subscales Total raw score converted into t scores High t score than expected – organic brain syndrome t score R. hem. - t score L. hem. Found positive then right

hemisphere dysfunction and if, negative then left hemisphere dysfunction.

Neuropsychological Tests (contd.)

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13 Subscales: Motor Scale Tactile Scale Visual scale Receptive speech Expressive Speech Reading Scale Writing scale

Neuropsychological Tests (contd.)AIIMS-CNBH (Contd.)

Arithmetic Scale Memory scale Intellectual processes

scale Pathognomonic Scale Left hemisphere scale Right Hemispheric Scale

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Rorschach Psychodiagnostics Herman Rorschach, 1921 There are ten official inkblots, Each printed on a separate white card,

approximately 18x24 cm in size. Each of the blots has near perfect bilateral

symmetry. Five inkblots are of black ink, two are of black

and red ink and three are multicolored, on a white background

Response Inquiry: Determinants- shape, structure, colour, shading,

M Location- W, D, Dd, Ds etc. Content- H, A, An, Ms, Na

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Rorschach Psychodiagnostics (contd.)

1 2

5 6 7

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9 10

8

Ink blots

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Piotrowoski’s signs for organic brain disorders:10 Response less than 15 IRT > 60 seconds Less than 2 human movement response F+% < 70% Popular response <4 One or more colour naming (overlap with sch.) Perseveration of response Impotence Perplexity Automatic phrasesMinimum any 5 signs are required for diagnosis.

Rorschach Psychodiagnostics (contd.)

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ConclusionsConclusions A number of tools are available for A number of tools are available for

screening/assessing various problems of older adults. screening/assessing various problems of older adults. The commonly used tests are MMSE,BGT, CAMDEX, The commonly used tests are MMSE,BGT, CAMDEX,

GMS,BEHAVE-AD, ADL, FAST, GDS, CDT, PGIBBD, GMS,BEHAVE-AD, ADL, FAST, GDS, CDT, PGIBBD, Rorschach inkblot test etc. Rorschach inkblot test etc.

Some vital areas are still untouched such as a Some vital areas are still untouched such as a Screening tools for dietary habits, elderly expectations Screening tools for dietary habits, elderly expectations with regard to mental health care, elderly specific with regard to mental health care, elderly specific quality of life scale etc. quality of life scale etc.

Most of the scales are in foreign languages and of Most of the scales are in foreign languages and of foreign origin and often require appropriate foreign origin and often require appropriate modifications. The normative data in Indian matrix is modifications. The normative data in Indian matrix is not available. not available.

Need to develop indigenous tools. Need to develop indigenous tools.

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Further readings:Further readings: Burns et al. (2004). Assessment scales in old age Burns et al. (2004). Assessment scales in old age

psychiatry (2psychiatry (2ndnd ed.). Informa healthcre, replika Press Pvt. ed.). Informa healthcre, replika Press Pvt. Ltd.Ltd.

Bhargav M. (1999). Modern psychological testing and Bhargav M. (1999). Modern psychological testing and measurement. Print Palace, Agra.measurement. Print Palace, Agra.

Burns A., Lawlor B., Craig s.(2002). Rating Scales in Old Burns A., Lawlor B., Craig s.(2002). Rating Scales in Old Age Psychiatry. British Journal of Psychiatry, 180,161-Age Psychiatry. British Journal of Psychiatry, 180,161-167. 167.

Gupta, A. & Kumar, NK. (2009). Indian adaptation of the Gupta, A. & Kumar, NK. (2009). Indian adaptation of the Cognistat : Psychometric properties of a cognitive Cognistat : Psychometric properties of a cognitive screening tool for patients of traumatic brain injury. screening tool for patients of traumatic brain injury. Indian Journal of Neurotrauma, 6 (2), 123-132.Indian Journal of Neurotrauma, 6 (2), 123-132.

Solomon et al. (1998) A 7 Minute Neurocognitive Solomon et al. (1998) A 7 Minute Neurocognitive Screening Battery: Highly Sensitive to Alzheimer’s Screening Battery: Highly Sensitive to Alzheimer’s Disease. Arch Neurol. 55, 349-355.Disease. Arch Neurol. 55, 349-355.

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King George’s Medical University,King George’s Medical University, Lucknow, U.P., INDIA Lucknow, U.P., INDIA

Contact: R K Tripathi [email protected]

91+9454202905

psychometric assessment of older adults oct 21 to 26 2013 winter workshop

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