Introduction
The incidence of mortality and illness-related complications has long been documented in the medical literature. More recently, the measurement of outcomes has gained increasing attention because advanced medical procedures, medications, and therapies have led to better survival rates. One of the main reasons to measure status at the time of injury or illness or soon after is that long-term outcomes can be predicted from these initial assessments. In addition, the efficacy of treatment must be determined through objective measures rather than simply using clinical judgment or behavioral observation. The medical community has recognized the need to measure outcomes in several areas, including medical and physical progress and functional or rehabilitation recovery. However, inadequate or incomplete assessment occurs all too frequently and does not provide enough data to reasonably predict long-term outcome.
The term outcomes no longer refers to simply one or two functional areas. To establish a complete picture of an individual’s status or level of functioning, several outcomes should be considered, and if possible, measured at different time points. In this chapter functional outcomes, including quality of life measures, and neuropsychologic or neurocognitive outcomes, are reviewed and discussed. These measures are of particular importance to the management of patients with acute neurologic abnormalities as patients with no physical deficit can be profoundly disabled because of cognitive or neurobehavioral deficits. It is now well documented that critical illness or a stay in an intensive care unit (ICU) can be associated with long-term neurocognitive function. Additional outcomes, including mood and behavioral functioning, also are important in determining a patient’s complete status, but they are not reviewed in this chapter. This chapter does not present an exhaustive list of measures, but hopefully will provide the reader with a representative sampling of measures that could be useful in critical care and post–critical care settings. The reader is referred to recent reviews on these topics, recommendations from the traumatic brain injury clinical trials network, and the Common Data Elements Workgroups.
Functional Outcome Scales
Functional outcome scales have been used at the time of discharge from critical care units but more often in post–critical care settings to supplement physical and medical measurements of status, progress, and stability. These scales include general measures of disability, more detailed measures of motor skills and other physical abilities, and comprehensive assessments of physical, cognitive, and emotional functioning. Outcome scales are typically used by raters to determine levels of functioning through observation of behavior or alternatively, caregiver report of patterns of behavior. Factors that should be considered in deciding which scales to use are:
- 1.
Level of patient arousal and alertness: Patients who are either in coma, have fluctuating consciousness, or are in a minimally conscious state will not exhibit many behaviors that can be rated on these measures. Instead, a coma-emergent scale should be chosen as a more meaningful alternative to standard outcome measures. A consistent level of arousal and alertness is typically needed for meaningful assessment on the measures that are reviewed in the following text.
- 2.
Environmental factors (e.g., limited available observation time): Observation periods may be limited due to the fragile medical status of the patient. This may dictate the specific scale chosen for outcome ratings, or the frequency with which ratings can be made.
- 3.
Training of raters: Raters who have extensive training in observation of critical care patients are much better suited to using the more in-depth scales with finer gradations of functioning. In contrast, raters with less training may be limited to the more popular, easier-to-administer scales.
Two types of functional outcome scales are reviewed: (1) brief functional outcome measures appropriate for ratings of critical care clients and (2) comprehensive tests of functional outcome.
Brief Tests of Functional Outcome
The measures reviewed here are essentially global ratings completed by observers. Typically observed patients are either critically ill or emerging from critical states. These patients are usually incapable of either completing ratings themselves, or participating in cognitive testing.
Glasgow Outcome Scale and Extended Glasgow Outcome Scale
The Glasgow Outcome Scale (GOS) is one of the earliest outcome measures developed. It has been used frequently in outcome studies after acute neurologic disorders such as traumatic brain injury (TBI) for which it was originally described, as well as stroke and subarachnoid hemorrhage (SAH). It has five levels of outcome, and is the basis for other scales that have followed, including the Extended Glasgow Outcome Scale (E-GOS) and the Disability Rating Scale (DRS). These two scales are now more widely used than the GOS, which is regarded as too broad in its categories and therefore not sensitive to changes in patient status. In addition the GOS is not an adequate assessment measure after mild brain injury such as concussion, for which there are many specific concussion assessment tools: Axon Sports Computerized Cognitive Assessment Tool (CCAT) or CogState-Sport, Standardized Concussion Assessment Tool 2 (SCAT2), and Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), among others. Research in mild TBI and sports-related concussion suggests that no one measure is ideal for obtaining a comprehensive picture of the client’s status. Instead, a combination of measures or specific neurocognitive tests assessing multiple domains is more effective.
The E-GOS added three additional disability and outcome categories to the original five, resulting in these eight categories: Dead, Vegetative State, Lower Severe Disability, Upper Severe Disability, Lower Moderate Disability, Upper Moderate Disability, Lower Good Recovery, and Upper Good Recovery. Global outcome, rather than specific ability-related outcomes, is the main outcome assessed by the E-GOS. A well-designed study of 399 patients with intracerebral hemorrhage utilized the E-GOS together with the modified Rankin Scale described in this chapter to determine global outcome at 90 days. Although not as extensively cited as the DRS, several studies have used the E-GOS to determine functional outcome, including investigations several years after the neurologic event. One study explored functional outcome 10 years after TBI. Poorer outcome on the E-GOS was associated with significantly longer posttraumatic amnesia; more impairment on cognitive measures of information processing speed, attention, memory, and executive function; and higher anxiety levels. The E-GOS is used also to measure functional outcome after SAH. Rating reliability has been improved from the original GOS with the addition of a structured interview. The E-GOS is popular in neurosurgical-based outcome studies, but in rehabilitation and neuropsychology studies it has not had the popularity afforded the DRS.
Disability Rating Scale
DRS is a widely used measure consisting of eight items that fall within four categories. Scores range from 0 (no disability) to 29 (extreme vegetative state). It is brief but more comprehensive than other short scales because it contains items that measure all three categories listed by the World Health Organization: Impairment, Disability, and Handicap. The first three items were incorporated from the Glasgow Coma Scale (GCS) with slight modifications: Eye Opening, Communication Ability, and Motor Response. These items are measures of impairment, and are very important behaviors to observe and rate in critically ill or emerging patients whose behavioral repertoire is severely restricted. Measures of Feeding, Toileting, and Grooming reflect disability, and the category of Employability is a measure of handicap. An early study indicated that it was more sensitive than the GCS in measuring clinical changes in severe TBI patients. Similarly, it was found to be more sensitive to detect improvement than the GOS for an inpatient rehabilitation sample.
The DRS is used commonly because it has been demonstrated to be reliable and valid, is relatively brief and easy to score, and can either be self-administered (though not a common mode of administration) or scored through interview with the client, family member, or other caretaker. One limitation of this scale is that it does not usually detect subtle changes that may occur in higher functioning individuals, especially mild TBI survivors.
Modified Rankin Scale
The original Rankin Scale was developed in 1957 by J. Rankin. It generally is used to measure the degree of handicap in stroke patients. This six-level version has been supplanted by the modified Rankin Scale (mRS), which was published in 1988. It has an additional grade ranging from 0 (no symptoms) to 6 (dead). The grades in between all provide a degree of detail that sets it apart from other less descriptive measures, and hence increases its utility even though it is unidimensional. For example, level three is: “Moderate disability. Requires some help, but able to walk unassisted.” A study using neurologists, nurses, and physiotherapists as raters found reliability to be satisfactory. To improve interobserver reliability, another study used a multimedia training process, another feature that sets it apart from other equally brief scales. The mRS (or dichotomized mRS) has been used extensively in critical care studies to measure medical status and outcomes at various time points after serious neurologic events including intracerebral hemorrhage and acute ischemic stroke.
Barthel Index
The Barthel Activities of Daily Living (ADL) Index is one of the earliest measures that focuses specifically on activities of daily living as well as mobility. It was originally introduced in 1965, and although the initial version is still widely used, a modified Barthel Index with a 100-point assessment of independence in 10 activities of daily living is even more comprehensive and allows for finer discriminations between ratings. The variables measured are feeding, bathing, grooming, dressing, bowel, bladder, toilet use, transfers (bed to chair and back), mobility, and stairs. The usefulness of the scale has been demonstrated in several diagnostic groups, including stroke, TBI, and even spinal cord injury. Obviously, a scale such as the Barthel Index gives a more specific and complete picture of the individual than global measures of disability or handicap. Yet ratings of the 10 variables in this index can only be made when the individual progresses to a more advanced stage of recovery.
Ordinal Analysis and Sliding Dichotomy
In most phase III clinical trials ordinal outcome measures are collapsed into a binary scale. For example, in TBI trials the 5-point GOS at 6 months often is used as the primary outcome measure. For analysis it is dichotomized to unfavorable (Dead, Vegetative, or Severe Disability) or favorable outcome (Moderate Disability or Good Recovery). In stroke trials the mRS, an ordinal scale (six categories), or Barthel Index also is collapsed into binary scales. This collapse of an ordinal scale has two potential problems: (1) loss of information and (2) precedence is given to a specific transition in the scale. For example, for the GOS, this is the difference between moderate and severe disability. The failure of many phase III TBI trials over the past several decades has raised questions about conventional statistical approaches. To address this use of ordinal rather than dichotomous outcome, analysis is recommended. Simulation studies suggest that this can increase statistical power because all patients can contribute to the detection of a treatment effect. The analysis is performed through a sliding dichotomy in which the point of dichotomy is customized to each patient’s baseline prognosis. Analysis of the Corticosteroid Randomization After Significant Head Injury (CRASH) trial data demonstrates that ordinal analysis of the GOS can improve statistical power to detect a treatment effect with equal sample size. The Optimising Analysis of Stroke Trials (OAST) collaboration suggests a benefit of ordinal analysis in stroke research.
Comprehensive Tests of Functional Outcome, Quality of Life, or Health Status
Measures designed to assess health status after the acute stages of critical care are typically more comprehensive in evaluating areas of functioning. These measures can be administered as early as several days after discharge from intensive care, and indefinitely afterward. These questionnaires are completed either by the patient or an observer or caretaker familiar with the person’s functional status. These measures are different from the brief tests covered in the previous section in which an observer must rate the patient’s functions rather than the patient participating actively in answering test items.
Short Form-36 and Short Form-12
The Short Form-36 Health Survey (SF-36) consists of 36 items that measure health status, outcomes, and quality of life. It measures 8 health concepts and yields 2 summary measures, making it a relatively comprehensive instrument often selected by clinicians and researchers alike to assess status and change. The 8 health domains cover physical and emotional or psychological status: (1) physical functioning, (2) role limitations due to physical health problems, (3) bodily pain, (4) general health, (5) vitality (energy or fatigue), (6) social functioning, (7) role limitations due to emotional problems and (8) mental health (psychological distress and psychological well-being). Each of these domains is important to assess for patients who have had neurointensive illnesses, injuries, or interventions, because they are all basic areas of functioning that can be negatively affected in seriously ill patients. The SF-36 is widely cited in the health and medical literature for many different diagnostic groups including severe TBI, spinal cord injury, or even elective surgery. It has even been discussed as a quality-of-life measure. The SF-36 has been very useful in determining progress over time with repeat assessments and in assessing functional outcome many years post injury.
The Short Form-12 (SF-12) is a much shorter version of the SF-36 that still measures the eight domains but contains only one or two items from each of these. The SF-12 is gaining increasing popularity and more recently has been used in place of its longer counterpart. Several studies have compared the SF-36 with the SF-12, and although some information inevitably will be missing with any shortened form including the SF-12, there appears to be enough evidence suggesting that this shorter version can be a good substitute, especially when assessment time is limited or a number of other measures are also employed in the study. In comparing the SF-12 with the SF-36 in a trauma population, one conclusion was that the Physical Component Score in both was moderately responsive to change and was equivalent using either the short or longer measure. Other studies comparing these two measures in non-neurologic patients have also shown the usefulness of the SF-12 as an alternative to the longer version.
Sickness Impact Profile
This health outcome measure is considerably longer than the more widely used SF-36 but is more comprehensive and detailed in assessing many important components of everyday functioning. The 12 categories of the Sickness Impact Profile (SIP) are (1) Sleep and Rest, (2) Emotional Behavior, (3) Body Care and Movement, (4) Home Management, (5) Mobility, (6) Social Interaction, (7) Ambulation, (8) Alertness Behavior, (9) Communication, (10) Work, (11) Recreation and Pastimes, and (12) Eating. It is relatively lengthy, and may actually be the longest well-known outcomes measure at 136 items that can be self- or interviewer administered. Scoring is done by categories, broader dimensions, or the total SIP score.
In deciding whether to use the shorter SF-36 or the longer SIP, the clinician or researcher must weigh the importance of assessment time limitation versus the need for a very thorough assessment of everyday functioning. For example, in a study of the cognitive, mood, and quality-of-life impairments in acute respiratory distress syndrome (ARDS) survivors, the authors concluded that because ARDS patients had not been well characterized in terms of the broad range of deficits that persist, the most comprehensive quality-of-life measure should be selected. Similarly, Frontera et al. who studied the effect of delayed cerebral ischemia on quality of life 3 months after SAH, used the entire SIP rather than a shorter measure. Others have used both the SIP, which some describe as a measure of functional status, and the SF-36, considered to be a quality of life measure, even though the SIP has been described as a quality-of-life measure also. In another study of long-term health status, the specific categories of Work, Ambulation, Home Management, Recreation and Pastimes, and Alertness Behavior were most problematic at 12- to 18-month follow-up in survivors of major trauma. It is possible, however, to extract only those subscales of the SIP that are needed for a particular clinical or research purpose. For example, in a study of stroke survivors assessed at 6 months post stroke, only 6 of the 12 categories were utilized. The original SIP has sometimes been excluded from outcomes research because of its length; hence, a shorter alternative was developed. The SIP 68 was found to correlate well with the SIP.
Mayo Portland Adaptability Inventory-4
The Mayo Portland Adaptability Inventory-4 (MPAI-4) is the newest version of the original Portland Adaptability Inventory first published in 1987. This fifth version of the scale rates the most common sequelae of acquired brain injury (ABI), including physical, cognitive, emotional, behavioral, and social problems. The areas of communication and employment were further refined for this version. The MPAI-4 is a carefully constructed inventory that provides clinical evaluations of ABI survivors during the postacute stage following injury. Patients who are suitable for evaluation on this scale range from mild to severe brain injury. The MPAI-4 may be completed by persons with ABI, their significant others, and/or medical or rehabilitation professionals. In one study, 134 individuals with ABI were rated by the persons with ABI, family and significant others, and rehabilitation staff. Satisfactory internal consistency for the MPAI-4 was found, regardless of the source of ratings.
The MPAI-4 has three subscales: (1) Ability Index, (2) Adjustment Index, and (3) Participation Index. It has 29 clinical items, as well as six additional items covering preinjury and postinjury information about alcohol use, drug use, psychotic symptoms, law violations, other conditions causing physical impairment, and other conditions causing cognitive impairment. Scoring consists of a total score and each of the three index scores. Outcomes are described by five functional levels: Good Outcome, Mild Limitations, Mild to Moderate Limitations, Moderate to Severe Limitations, and Severe Limitations. The manual, forms, and other language versions (including French and German translations) can be easily downloaded from the Center for Outcome Measurement in Brain Injury (COMBI) website ( http://www.tbims.org/combi ), making it an attractive and comprehensive functional battery.
Functional Independence Measure
The Functional Independence Measure (FIM) is used in inpatient rehabilitation settings and even in residential brain injury programs to assess disability rather than impairment. It is a comprehensive measure of essential daily functions, and is widely used across rehabilitation programs. The FIM is reviewed in this chapter because it is frequently used with post–critical care patients who have progressed from the ICU to an acute rehabilitation setting and whose recovery is advanced enough to warrant this level of detailed assessment. This instrument measures the person’s performance along several behavioral dimensions, from total dependence to independence. The scale provides classification of individuals by their ability to carry out an activity either with some level of assistance or supervision, or independently. Each dimension is rated on a 7-point scale: 7 is complete independence, 6 is modified independence, 5 equals supervision or setup, 4 equals minimal contact assistance (client expends 75% or more of the effort), 3 is moderate assistance (client expends between 50% and 75% of the effort), 2 is maximal assistance (client expends between 25% and 50% of the effort), and 1 equals total assistance (client expends <25% of the effort). The FIM is typically completed by a group of rehabilitation specialists with expertise in particular functional areas, often in weekly patient care conferences. Eighteen areas are assessed: Eating; Grooming; Bathing; Dressing—Upper Body; Dressing—Lower Body; Toileting; Bladder Management—Level of Assistance; Bowel Management—Level of Assistance; Transfers: Bed, Chair, Wheelchair; Transfers: Toilet; Transfers: Tub or Shower; Locomotion: Walk/Wheelchair; Locomotion: Stairs; Comprehension; Expression; Social Interaction; Problem Solving; and Memory.
Neuropsychological Measures
Neuropsychological functioning typically refers to a broad range of cognitive abilities. However, a comprehensive definition entails not only cognitive, but also motor, perceptual, and emotional or psychological functions. After a neurologic event, some or all of these domains may be negatively affected. Patients who have been in ICUs are typically assessed after hospital discharge, rather than in the ICU, because their medical status is usually too compromised to proceed with cognitive testing until after discharge. Tests that measure these functions (abilities) vary in length and scope. They can be classified as:
- 1.
Neuropsychological screens
- 2.
Neuropsychological batteries
- 3.
Individual tests measuring specific cognitive domains
In selecting tests and deciding on how extensive testing should be, the evaluator needs to be aware of guidelines in the field and cognitive issues specific to the diagnostic group of the individual being tested. This chapter reviews only neuropsychological screens because they are more appropriate for use in acute care patient assessment. Moreover, an entire chapter on neuropsychological assessment alone would be needed to do full justice to comprehensive batteries and to specific domain-specific measures. Recent reviews, however, are available that discuss this.
Neuropsychological Screens
Neuropsychological screens are objective measures administered directly to testees to determine cognitive status, and to assess whether changes in functioning have occurred after neurologic injury or illness. Unlike functional outcome scales in which observers typically rate patient levels, neuropsychological tests are administered in face-to-face sessions to testees who actively participate in answering specific test questions. Several well-known screens are reviewed here, with limitations listed for each measure.
Mini-Mental Status Examination
The Mini-Mental Status Examination (MMSE) is one of the earliest screens used to measure cognitive functioning. It is a brief but relatively comprehensive test of cognitive abilities, and is directly administered to the patient. As such, the patient must have a reasonable degree of orientation and language ability to participate. Otherwise, a rating scale such as one of those reviewed earlier in this chapter, must be used to determine functional level. It is widely used to detect dementia and even delirium, although there is caution in the literature about using the MMSE alone to yield a diagnosis for either of these conditions.
The cognitive skills measured are (1) time and place orientation, (2) registration (i.e., immediate auditory recall), (3) attention and calculation, (4) recall, and (5) language (receptive and expressive). A total of 30 points is the maximum score, and cutoff levels of 23 and higher have been proposed to differentiate dementia or cognitive impairment from normal functioning. It has been the screen of choice among health care professionals in medical settings, especially in assessing hospitalized patients with known or suspected neurologic disorders. It is among the most widely used tests of adult mental status. A comprehensive review regarding the psychometric properties of the MMSE was done. Subjects ranging from cognitively intact community dwellers to individuals with dementia were included in the studies reviewed. Satisfactory reliability and construct validity were found, and the test was shown to be sensitive for moderate to severe cognitive impairment but had lower sensitivity for mild degrees of impairment. Content analyses revealed the test to be highly verbal, and not all items were equally sensitive to cognitive impairment. MMSE scores were affected by age, education, and one’s cultural background, but not gender. Age and educational norms were included in one study, with suggestions for using different cutoff levels.
Limitations: (1) The MMSE covers several but not all neuropsychological domains. Some areas that are missing include visual perception, visual attention, and several subcomponents of executive functioning, including verbal fluency and mental flexibility. (2) The MMSE can easily miss neurologically based impairments in higher-functioning individuals. Therefore false-negatives may result. (3) Only one test of executive functioning or motor ability is included, namely, the design construction. Verbal and other nonverbal executive abilities are often disrupted with neurologic damage, and assessment of these areas is advisable, even with a relatively brief screen. (4) There is an overemphasis on language: Other areas are disrupted as much as or even more than language after a neurologic event, and a battery that measures other areas more extensively would have had more utility. (5) Poor sensitivity has been found for the detection of mild cognitive impairment (MCI), which is a transition stage between normal aging and the associated cognitive decreases that may occur, and the more serious cognitive difficulties as a result of Alzheimer’s disease.
Montreal Cognitive Assessment
An alternative to the MMSE is a more recently developed cognitive test called the Montreal Cognitive Assessment (MOCA), which takes about 10 minutes to administer and has a total of 30 points. The cutoff for the MOCA is typically 26 out of 30 points, i.e., scores below 26 are considered impaired. It is gaining popularity, and has been used as a screen for more extensive neuropsychological testing. The MOCA has more emphasis on attention and executive functions than the MMSE, and contains a more difficult memory task, requiring the recitation and recall of five instead of three words. In comparing this measure to the MMSE, the MOCA has been found to be significantly more sensitive. In the original study highlighting the development of the MOCA as an alternative to the MMSE, the MOCA had a sensitivity of 100% in detecting mild Alzheimer’s disease, whereas the MMSE had a 78% sensitivity. The difference in detecting Mild Cognitive Impairment was more dramatic, with a sensitivity of 90% for the MOCA but 18% for the MMSE. This is expected, because one of the main reasons for the development of the MOCA was to create a measure that could detect MCI much more effectively than the MMSE.
Limitations: (1) The MOCA measures a fairly comprehensive set of cognitive domains, especially for a brief screen, but does not sample visual perception, an important function that can be disrupted with TBI, brain tumor, stroke, or other neurologic illness or injury. (2) Although both auditory and visual attention skills are evaluated, only auditory memory is assessed. It would be a more complete test if visual memory also were measured, especially because other visual functions have been included (visual attention, visual executive function, and visual motor construction).
Cognistat
The Cognistat is the short term for the Neurobehavioral Cognitive Status Examination, a screening test that is more extensive in scope than the MMSE or MOCA, and is used by neuropsychologists as preliminary assessment of known or suspected neurologic disorders. In fact, it is the number one choice for cognitive screening among U.S. and Canadian neuropsychologists. It is often used as a starting point, so that additional neuropsychological measures can be selected to further assess specific cognitive functions. It assesses a representative sampling but not complete array of cognitive functions, including level of consciousness, orientation, language, memory, constructional ability, calculations, and reasoning. Language is tested through four subtests: Speech Sample, in which the test taker verbally describes a detailed picture with people and actions; Comprehension; Repetition; and Naming. Reasoning has two subtests: Similarities and Judgment. The Cognistat takes longer than the MMSE and MOCA screens, typically 10 to 20 minutes to administer. It has a unique feature that actually helps to quickly determine normal functioning; Each test has a screen item that is more difficult than the test items that follow, which are called the metric section. If an individual successfully answers the difficult screen item, the metric items under that domain are skipped. If only screen items are administered, the test actually is fast and efficient, and may take only 5 minutes to complete. Another useful feature is that the scores are plotted on the profile sheet, so that average and impaired scores are clearly illustrated. It has been translated and is available in nine languages, including Spanish, Japanese, and Hebrew.
Limitations: (1) Standardization data in the manual are limited, because only 60 subjects are used, divided into two age groups of 30 each (ages 20 to 30 and 40 to 66). For a screen so extensively used and translated, a larger normative group would have been expected. (2) As with other screens, a select but not comprehensive battery of cognitive domains is provided. (3) There is a somewhat uneven emphasis on certain but not other cognitive areas, particularly too many tests of language and no tests of executive functions, an area often affected by neurologic insult. (4) The utility of a sentence repetition test in a general neuropsychological screen is questionable; for example, aphasic patients would be better tested using a language battery, such as the Boston Diagnostic Aphasia Examination.
Dementia Rating Scale-2
The original Dementia Rating Scale was developed in 1988, and further refined into a second edition in 2001. The same 36 tasks and 32 stimulus cards have been retained for the Dementia Rating Scale-2, together with the 5 subscales that measure specific cognitive abilities vulnerable to deterioration in aging dementia patients: Attention (8 items), Initiation/Perseveration (11), Construction (6), Conceptualization (6), and Memory (5). A total score and the 5 subscale scores are generated, which assists the test evaluator to decide whether additional testing is necessary. For example, a university professor who scores considerably above the cutoff for his age group but who has significant problems with Memory and Conceptualization probably should be referred for more comprehensive testing. The upgraded aspects of the Dementia Rating Scale-2 are expanded normative data, greater ease of administration and scoring based on user-friendly test forms, and additional validity information in the manual’s literature review. The norms for the Dementia Rating Scale-2 are based on a sample of healthy, nondementing adults, ages 56 to 105 from the Mayo Clinic’s impressive and comprehensive Mayo’s Older Americans Normative Studies (MOANS) database, which also has been used for other testing instruments specific to elderly populations. The authors of the Dementia Rating Scale-2 caution the user to rely more on the subscale scores than the total score to determine meaningful cognitive decline, because an individual may score above the total score cutoff for his or her age range but demonstrate significant cognitive impairments in two or more subscale areas, for example. With the original Dementia Rating Scale, there was a single cut-off score of 123 out of a total of 144, and the common practice was to rate an individual as having a probable dementia disorder if he/she scored below this total. However, researchers in geriatric assessment have questioned this practice. One study argued that different cutoff scores should be used for different age groups. The Mayo Clinic research group found that 16% of adults older than 85 years of age in the MOANS normative data scored below the cutoff of 123 even though they were not considered a dementia sample.
The Dementia Rating Scale-2 also can be used with geriatric patients who have suspected neuropsychological impairments that are not necessarily dementia, including head injury, or are community dwellers with cognitive problems who have not yet been diagnosed with dementia. Like the Cognistat, test items can be eliminated based on successful performance of previous items, making it a time-efficient test to administer, especially for the geriatric population who may have limited tolerance for testing. For example, a client may have no difficulty in Initiation/Perseveration, but problems with Attention and Memory, requiring all of these latter two subscale items to be administered but only a limited number of items for the former.
The MOANS database has one limitation: The database consists of predominantly Caucasian adults with an education level higher than the average (M = 13.1 years). This implies that scores for non-Caucasians and for persons with less than 8 years of education must be interpreted with caution, especially if they fall in the dementia range.
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