The Test for Severe Impairment: an instrument for the assessment of patients with severe cognitive dysfunction

Association of the Resident Assessment Instrument (RAI) with changes in function, cognition, and psychosocial status

OBJECTIVE

To evaluate the impact of the Resident Assessment Instrument (RAI) on changes in nursing home residents' functional status, cognitive status, and psychosocial well-being.

DESIGN

A quasi-experiment involving the collection of longitudinal data on two cohorts of nursing home residents. One cohort was assessed before the implementation of the RAI, and the other was assessed after the implementation of the new assessment process.

SETTING AND PARTICIPANTS

Over 2000 nursing home residents in 267 nursing homes located in 10 geographic areas were assessed during the pre-RAI period. In the post-RAI period, 2000 new residents in 254 of the same facilities were assessed.

INTERVENTION

RAI implementation began in October 1990 and continued until October 1991. The RAI includes a structured, multidimensional resident assessment and problem identification system designed to form the basis for residents' care plans.

MEASUREMENTS

All residents were assessed at baseline and at 6 months using the Minimum Data Set for Nursing Home Resident Assessment and Care Screening (MDS) and its protocols. All data were collected by research nurses employed and trained by the research team.

RESULTS

Implementation of the RAI significantly reduced the rate of decline in seven of the nine outcomes under consideration. Reductions in improvement were also observed in all outcomes. In activities of daily living, social engagement, and cognitive function, the reduced decline far outweighed any reductions in improvement. In mood problems, problem behaviors, and understanding others, however, reductions in improvement were greater than any reductions in decline. Changes in the rates of decline and improvement were not uniform across all residents.

CONCLUSION

The RAI may have improved the quality of care of nursing home residents by reducing overall rates of decline in important areas of resident function. However, this innovation may have generated trade-offs in that it may have reduced improvement rates in some areas of function. The system's implementation also seems to have focused staff's attention on the needs and strengths of specific subpopulations of residents. Revisions of the RAI must assist staff in generalizing their efforts to all residents and to increasing improvement rates, especially in areas related to mood and behavior.

Diagnosis of dementia in individuals with intellectual disability

The foremost impediment to progress in the understanding and treatment of dementia in adults with intellectual disability is the lack of standardized criteria and diagnostic procedures. Standardized criteria for the diagnosis of dementia in individuals with intellectual disability are proposed, and their application is discussed. In addition, procedures for determining whether or not criteria are met in individual cases are outlined. It is the intention of the authors, who were participants of an International Colloquium on Alzheimer Disease and Mental Retardation, that these criteria be appropriate for use by both clinicians and researchers. Their use will improve communication among clinicians and researchers, and will allow researchers to test hypotheses concerning discrepancies in findings among research groups (e.g. dementia prevalence ranges and age of onset).

A Scale to Measure Impairment in Severe Dementia and Similar Conditions

The authors describe an 11-item, 22-point scale that measures cognitive capacity in severely cognitively impaired individuals. The Severe Impairment Rating Scale (SIRS) has acceptable interrater reliability (r = 0.992; P < 0.001), test-retest reliability (r = 0.97; P < 0.0001), and internal consistency (Chronbach's alpha = 0.76). Validity is supported by correlations with the Glasgow Coma Scale (r = 0.866; P < 0.001) and Mini-Mental State Examination (r = 0.770; P < 0.001).

Longitudinal changes in cognitive functioning in adult day care participants

This study examines longitudinal changes in cognitive functioning over the course of 2 years in participants of adult day cae programs. Cognitive measures included the Brief Cognitive Rating Scale (BCRS) and the Mini-Mental State Examination (MMSE). Longitudinal data were available for five measurement points over 2 years for 82 participants (22 males and 60 females). Overall, results from this study suggest that there were significant cognitive declines on BCRS and MMSE, even after only 1 or 2 years in the study. The rates of impairment over the 2 years for BCRS and MMSE were highly correlated. Within each measure, the individual rates of decline were very heterogenous and were influenced by the presence, type, and prognosis of dementia. Participants with multi-infarct dementia had greater cognitive decline than did those with other types of dementias. Initial cognitive functioning and physician's prognosis of dementia trajectory were also significant predictors of change over time. Results suggest a floor effect in the BCRS.

Canadian guidelines for the development of antidementia therapies: a conceptual summary

The magnitude of the problems faced by Canadian society as a result of an aging population has been identified. Perhaps the most important concern related to this greying of Canada is the increasing incidence of dementia and Alzheimer's disease. Therapeutic options for these disorders have been limited to date. Advances in biotechnology and molecular biology will offer novel approaches to treatment. These and the expansion of more traditional therapeutic avenues require guidelines with the aim of optimizing their development.

The MDS Cognition Scale: a valid instrument for identifying and staging nursing home residents with dementia using the minimum data set

OBJECTIVE

We report the development and validation of an MDS-based cognitive index, the MDS Cognition Scale (MDS-COGS), by evaluating it against two popular dementia rating scales, the Global Deterioration Scale (GDS) and the Mini-Mental State Examination (MMSE).

DESIGN

A Cross-sectional study.

PARTICIPANTS

Two hundred nursing home residents.

MEASUREMENTS

Each study participant was assessed on the GDS and the MMSE by trained medical students. At the same time, but independent of the medical students, a geriatric nurse completed the Minimum Data Set (MDS) instrument on each participant.

MAIN RESULTS

The Cognitive Performance Scale (CPS), a categorical measure of cognition that uses MDS items, was compared with the GDS in 133 subjects, using a split-sample technique. The GDS was found to be more appropriate as a 4-stage than a 7-stage scale, with GDS stages 1-4 acting as a single stage. The CPS showed very poor percent agreement with GDS stages 5 and 7 (50% or less) and, therefore, was revised by adding other MDS predictors. The new instrument, designated MDS-COGS, is a 0-10 point scale generated from eight MDS cognitive items. The MDS-COGS was then validated against the 4-stage GDS and MMSE in the remaining 67 nursing home residents. Chance-corrected agreement (kappa) between the MDS-COGS and GDS in the 67 subjects was 0.80 (95% CI = 0.70, 0.88), and percent agreement with GDS stages 5 and 7 was 60% and 85%, respectively. The MDS-COGS was also demonstrated to be a valid measure of cognitive impairment as defined by the MMSE, with sensitivity, specificity, chance-corrected agreement (kappa), and area under the ROC curve, all above 0.80.

CONCLUSIONS

The MDS Cognition Scale, the MDS-COGS, provides a valid measure of the presence and severity of cognitive impairment in nursing home residents using items from the Minimum Data Set.

Effects of cognitive impairment on the reliability of geriatric assessments in nursing homes

OBJECTIVE

To explore the relationship between an elderly subject's cognitive status and the reliability of multidimensional assessment data.

DESIGN

Survey, with cognitive status as the independent variable and interrater reliability as dependent variable.

SETTING

Medicare/Medicaid-certified nursing homes.

PARTICIPANTS

147 residents age 65 or older.

MEASUREMENTS

Dual assessments of elderly nursing home residents were performed by nurse assessors using the Health Care Financing Administration's new Minimum Data Set for Nursing Home Resident Assessment and Care Screening (MDS). Assessments were classified on the basis of residents' cognitive status, and levels of disagreement between assessors were analyzed.

MAIN RESULTS

Overall assessment reliability, agreement concerning a resident's activities of daily living status, and the reliability of estimates of his or her communication skills and sensory abilities were significantly affected by a resident's cognitive status. The presence of cognitive impairment made these measurements less reliable--especially those related to communication skills, vision, and hearing.

CONCLUSIONS

Assessments of residents suffering from cognitive impairment were significantly less reliable than assessments of cognitively intact residents. However, these differences in reliability were not uniform across all assessment domains. When treating the cognitively impaired elderly, clinicians must exercise caution in their reliance on standardized measurements that may be less reliable for this population.