Mohammed T. Abou-Saleh

190 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYAgreement was higher for ‘‘yes–no’’ DSM-III-R diagnosesthan for the multilevel Clinical Dementia Rating (CDR) scale,in which six domains (memory, orientation, judgement, communityaffairs, home and hobbies, and personal care) are eachrated on a five-point scale 5 . Kappa levels ranged from 0.61 to0.76 within teams and from 0.50 to 0.69 between teams.Personal care was rated most consistently (85% mean agreement)and community affairs least so (74%). As with DSM-III-R, concordance was higher for cognitively intact (95%) andseverely impaired (84%) persons than for those with minimal(78%) and mild (68%) dementias.Univariate analyses of CDR ratings pointed to loweragreement levels for persons described as physically ill, deaf,partially sighted, anxious or depressed. However, multivariateanalysis detected only two main effects: dementia severity andphysical illness. Other variables made no significant independentcontribution.These findings suggest that dementia can be diagnosed withacceptable reliability in community surveys. Agreement is likely tobe higher, though, when teams train intensively and useinstruments that require simple ‘‘yes–no’’ choices. The reductionin agreement associated with physical illness is important giventhe high co-morbidity of physical and mental illness in representativeelderly populations.REFERENCES1. American Psychiatric Association. Diagnostic and Statistical Manual ofMental Disorders, 4th edn. Washington, DC: American PsychiatricAssociation, 1994.2. World Health Organization. The ICD-10 Classification of Mental andBehavioural Disorders. Clinical Descriptions and Diagnostic Guidelines.Geneva: World Health Organization, 1992.3. American Psychiatric Association. Diagnostic and Statistical Manual ofMental Disorders. 3rd edn, revised. Washington, DC: AmericanPsychiatric Association, 1987; 470.4. O’Connor DW, Blessed G, Cooper B et al. Cross-national interraterreliability of dementia diagnosis in the elderly and factors associatedwith disagreement. Neurology 1996; 47: 1194–9.5. Hughes CP, Berg L, Danziger WL, Coben LA et al. A newclinical scale for the staging of dementia. Br J Psychiat 1982;140: 566–72.