Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-033Rating Scales Designed for Nursesand Other WorkersKenneth C. M. Wilson, Ben Green and P. MottramDepartment of Psychiatry, University of Liverpool, UKThe changing role of nurses and other workers in the context ofclinical audit and community care has provided a fertile backdropfor the development of brief and easy-to-use clinical ratinginstruments. Few of these are of diagnostic validity and theyrequire little or no training. The are usually employed to rateclusters of signs, symptoms, syndromes, behaviours or needs.They have often been developed from other instruments orthrough clinical observation. The majority have been exposed tovalidation and inter-rater reliability and some are furnished with‘‘cut-off’’ scores corresponding to external diagnostic criteria.Nurses and other professionals have been successfully trained inthe delivery of more complex diagnostic and assessment instruments,including CAMDEX and GMS. However, this chapter willfocus on relatively brief clinical instruments requiring little or notraining, primarily designed for nurses and carers. This chapter isby no means exhaustive but is designed to provide an overview ina rapidly developing field.ORGANIC STATES INCLUDING DEMENTIASome of the specialized neuropsychological instruments, includingthe Kendrick Battery, are usually carried out by psychologists andhave been extensively validated 1 . However, there now exists awide range of brief cognitive assessments that have gained bothscientific and clinical credibility, readily available to clinicians ofall professions. The Mini-Mental State Examination 2 is preeminentin this field. It is easily administered and requires notraining. The test consists of verbal and performance components.The verbal subtests evaluate orientation in time, memory andattention. The performance subtests involve the naming ofobjects, execution of written and spoken orders, writing, andcopying a complex polygon. It takes a relatively short time toadminister, and can be carried out by medical and paramedicalstaff. It has been extensively validated and has high inter-rater andtest–retest reliability. Culture and social status significantly affectthe scores 3 but it has been employed in the context of transculturalepidemiological studies in which modifications have been made 4 .The Standardized Mini-Mental State Examination is a derivativedesigned to promote standardization and inter-rater reliability 5 .The Blessed Dementia Rating Scale 6 has been a source scale forthe development of further rating instruments. Cognitive assessmentincludes memory and information items. The second partconsists of items of behaviour. The scale has been validatedthrough correlation with mean brain cortical plaque counts. It‘‘ceilinged’’ with the correlation declining sharply in clinicallysevere dementia sufferers. The 10 most useful questions differentiatingbetween normal and abnormal cognitive functioninghave been extracted 7 and are used as the Abbreviated Mental TestScore, giving comparable results to the full Blessed scale. Thelatter has been used in a simple test of mental impairment infunctionally and mildly organically ill patients attending a dayhospital 8 and has been used in screening for organic disorder andpredicting change over a 2-year period 9 . The study evaluated thedegree of disability and was used in the planning of social support.The Clifton Assessment Procedures for the Elderly (CAPE)consists of two sub-scales, the Cognitive Assessment Scale and theBehaviour Rating Scale, derived from the Stockton GeriatricRating Scale, designed to be used by nurses 10 . It was devised as abrief measure of psychological functioning for chronic psychiatricpatient groups and has been validated against the outcome of dayhospital and day centre care 13 . There is poor inter-rater reliabilityof the Gibson Maze component, which has to be completed by thepatient. Despite these problems, the CAPE provides a wellvalidated,useful instrument that does not take too long tocomplete. Other common instruments include the Mental StatusQuestionnaire 14 (MSQ), requiring some training, as questions areasked in a standardized fashion. The Short Orientation–Memory–Concentration Test was developed from the MSQ and consists ofsix items concerning orientation and memory 15 . One of the morerecent developments has been the Clock Drawing Test, whichassesses frontal and temporoparietal functions, providing a usefulbedside assessment 16 .SCALES FOR RATING BEHAVIOURAND SELF-CAREThe Stockton Rating Scale (from which items of the CAPE werederived) is pre-dated by the Crichton Behavioural Rating Scale(CBRS) 17 . The CBRS rates 10 aspects of behaviour, including thefunctions of orientation, communication and mood. The additionof a memory item allows the generation of a ‘‘confusion’’ scorethat is sensitive to change in mentally ill patients. A modifiedversion has been used in the context of nursing home residents.The Performance Test for Activities of Daily Living (PADL) 18was developed for the US/UK Cross-National Project. It assessesthe degree of autonomy of elderly psychiatric subjects in activitiesof daily living. It is presented as a test of praxis containing 16 subtests.Lawton and Brodie developed the Instrumental Activities ofDaily Living Scale (IADL) and the Physical Self-maintenanceScale 19 . The IADL is widely used to evaluate the degree ofPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd