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14 Interventions in Alzheimer’s Disease KCE Reports 111
A 4 point improvement has been reported as a clinically relevant improvement in mild
to moderate AD. Other authors considered only a 7 point change as clinically
relevant. 10 Some of the experts consulted find ADAS-cog too rigid, not enough sensitive
to change in the early stages and not appropriate for the differential diagnosis with
other forms of dementia. Recently, an alternative neuropsychological test battery (NTB)
to the cognitive subscale of the ADAS has been proposed for measuring drug efficacy in
AD trials, especially for trials involving mild AD patients. 22
The MMSE (Mini-mental state examination) is frequently used for screening and to help
define study populations. MMSE scores range from 0 (severe impairment) to 30
(normal). Mild to moderate AD is usually defined as a MMSE above 10 or 11. A 2 point
change on the ADAS-cog roughly corresponds to a one point change on the MMSE. The
main interest of the MMSE is that it is an universal tool at hand, feasible by specialists
but also by generalists and even by trained nurses, and it is not too lengthy. It allows the
professionals in the field to “communicate” the patient’s state in a common language.
The SIB (Severe Impairment Battery) evaluates cognitive performance in more
advanced Alzheimer’s Disease and assesses social interaction, memory, language,
visuospatial ability, attention, praxis and construction. The scores range from 0 (greatest
impairment) to 100.
According to the experts involved in this study, in the French speaking part of Belgium
neuropsychologists use currently an ad-hoc battery that can be adapted to the dementia
level. It includes tests of:
• episodic memory (verbal and visual)
• working memory
• language & conceptual and semantics
• visio-spatial abilities & praxis
• attention
• executive functions
Other tests and questionnaires may be required depending on the clinical situation (ex.
driving competency assessment) and the differential diagnosis to be made.
2.4.3 Activities of daily living and function
The ADCS-ADL (Alzheimer’s Disease Cooperative Study-Activities of Daily Living)
was specifically designed to assess functional capacity over a broad range of severity in
patients with Alzheimer’s disease. The 19 item ADCS-ADLsev19 has 54 points and is
used for patients with moderate to severe AD, and assesses mainly basic functions. The
23 item ADCS-ADL23 has 78 points and is used for patients with mild to moderate AD.
Many other scales are being used, including the ADL-scale of Katz (Activities of Daily
Living), the IADL-scale of Lawton and Brody (Instrumental Activities of Daily Living), the
PDS (Progressive Deterioration Scale) and the DAD (Disability Assessment in
Dementia).
In Belgium, frequently used scales are the Katz scale for basic ADL (washing, dressing,
eating) and the Lawton-scale for instrumental ADL (shopping, use of telephone). 10
2.4.4 Behavioural disturbances
The NPI (Neuropsychiatric Inventory) assesses the frequency and the severity of
behavioral and neuropsychiatric symptoms in patients with dementia based on an
interview with the caregiver. There are 12 items with a total score ranging from 0 to
144 (severe). Caregiver quality of life is assessed as part of the NPI, the NPI Caregiver
Distress Scale (NPI-D).
The European Alzheimer’s Disease Consortium Behavioural group, an EU funded
consortium, 23, 24 has argued against the idea of BPSD (Behavioral and Psychological
Symptoms in Dementia) associated with AD as a unitary concept and distinguishes
symptom clusters: apathy, depression, psychotic symptoms, aggressiveness & agitation,
and sleep disorders.