Psychometric assessment of older adults oct 21 to 26 2013 winter workshop

Psychometric/PsychologicalPsychometric/Psychological
Assessment of Older AdultsAssessment of Older Adults
Bed side cognitive assessment instruments and
applicability
Dr. Rakesh Kumar Tripathi,Dr. Rakesh Kumar Tripathi, M Phil, PhDM Phil, PhD
Assistant Professor cum Clinical PsychologistAssistant Professor cum Clinical Psychologist
Department of Geriatric Mental HealthDepartment of Geriatric Mental Health
King George’s Medical UniversityKing George’s Medical University
Lucknow -226003 (India)Lucknow -226003 (India)
(In house Winter Training Workshop, 21 to 26 October, 2013)

Friends! Please follow the instructionsFriends! Please follow the instructions
with mistake to learn scoringwith mistake to learn scoring
 Draw a clock face (large circle)Draw a clock face (large circle)
 marking the hours (numbers in the circle)marking the hours (numbers in the circle)
 draw a time 10 past 11draw a time 10 past 11
2
Copy the designs one by one in a page

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Learning Objectives:Learning Objectives:
 Concept of psychometric/psychologicalConcept of psychometric/psychological
assessmentassessment
 Types of Psychometric testsTypes of Psychometric tests
 Purpose of psychological assessmentPurpose of psychological assessment
 Steps of psychological assessmentSteps of psychological assessment
 Areas of assessment for elderlyAreas of assessment for elderly
 Psychological assessment tools for older adultsPsychological assessment tools for older adults
 ConclusionConclusion
 Further ReadingsFurther Readings

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Concept:Concept:
 Psychometrics is the field of studyPsychometrics is the field of study
concerned with the theory and techniqueconcerned with the theory and technique
of educational and psychologicalof educational and psychological
measurement.measurement.
 Knowledge, abilities, attitudes, andKnowledge, abilities, attitudes, and
personality traits etc.traits etc.
 The field is primarily concerned with theThe field is primarily concerned with the
construction and validation of measurementconstruction and validation of measurement
instruments, such asinstruments, such as questionnaires, tests,tests,
andand scalesscales..

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Concept (contd.)Concept (contd.)
Psychological Assessment vs TestPsychological Assessment vs Test
Assessment is more than testing
 Psychological testing occurs asPsychological testing occurs as partpart of theof the
process of psychological assessment.process of psychological assessment.
Psychological assessment includes:Psychological assessment includes:
 Clinical interviewClinical interview
 Demographic informationDemographic information
 Medical informationMedical information
 Personal historyPersonal history
 Observations by othersObservations by others
Thus, the results of a psychological testThus, the results of a psychological test
are rarely used on their own.are rarely used on their own.

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Concept (contd.)Concept (contd.)
Psychological AssessmentPsychological Assessment
 "An extremely complex process of solving"An extremely complex process of solving
problems (answering questions) in whichproblems (answering questions) in which
psychological tests are often used as onepsychological tests are often used as one
of the methods of collecting relevant data"of the methods of collecting relevant data"
(Maloney & Ward, 1976)(Maloney & Ward, 1976)
Psychological TestingPsychological Testing
 "An objective and standardized measure"An objective and standardized measure
of a sample of behaviour" (Anastasi, 1990)of a sample of behaviour" (Anastasi, 1990)

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Concept (contd.):Concept (contd.):
 ObjectiveObjective
 complete independence from examinerscomplete independence from examiners
effect.effect.
 StandardizationStandardization
 by standardization we mean theby standardization we mean the
establishment of a certain definite method ofestablishment of a certain definite method of
giving a test and the establishment ofgiving a test and the establishment of
adequate norms for the interpretation of theadequate norms for the interpretation of the
results. (Pinter, R. 1936)results. (Pinter, R. 1936)

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Properties of PsychologicalProperties of Psychological
Test:Test:
Reliability:Reliability:
 consistency of a measureconsistency of a measure
Validity:Validity:
 ability of the test to measureability of the test to measure
what it purports to measurewhat it purports to measure
Norm:Norm:
 a range of values within whicha range of values within which
members of a givenmembers of a given
population are expected topopulation are expected to
perform or functionperform or function
Reliable and Valid
Reliable but Not Valid
Not Reliable and Not Valid
Bull’s-eye

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Types of Psychological TestsTypes of Psychological Tests
 Ability Tests:Ability Tests:
 Intelligence testsIntelligence tests
 Neuropsychological testsNeuropsychological tests
 Aptitude testsAptitude tests
 Personality tests:Personality tests:
 Paper pencil tests (Questionnaire/Inventories)Paper pencil tests (Questionnaire/Inventories)
 Projective testsProjective tests

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Psychological Assessment of OlderPsychological Assessment of Older
AdultsAdults
Purpose of Assessment:Purpose of Assessment:
 DiagnosisDiagnosis
 CertificationCertification
 Severity of symptomsSeverity of symptoms
 Management/RehabilitationManagement/Rehabilitation
 ImprovementImprovement
 PrognosisPrognosis
 ResearchResearch

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AdultsAdults
Areas of assessmentAreas of assessment
 Cognitive:Cognitive:
 Orientation, Calculation, Memory, Language etc.Orientation, Calculation, Memory, Language etc.
 Behavioral:Behavioral:
 Irritation, Suspiciousness, Muttering, Smiling to selfIrritation, Suspiciousness, Muttering, Smiling to self
Violence, etc.Violence, etc.
 Psychological:Psychological:
 Intelligence, Personality, Conflicts, PsychopathologyIntelligence, Personality, Conflicts, Psychopathology
 Functional:Functional:
 ADLADL
 Quality of life:Quality of life:
 Physical, Psychological, Environmental, Social,Physical, Psychological, Environmental, Social,
spiritualspiritual
 Carer’s Burden:Carer’s Burden:
 Physical, Psychological, Financial, SocialPhysical, Psychological, Financial, Social

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AdultsAdults
Steps of psychological assessment:Steps of psychological assessment:
 ScreeningScreening
 Screening is defined as a process forScreening is defined as a process for
collecting objective evidence to discerncollecting objective evidence to discern
probable presence or absence of aprobable presence or absence of a
psychopathologypsychopathology
 Detailed assessmentDetailed assessment
 process for collecting objective evidence toprocess for collecting objective evidence to
confirm the presence or absence of aconfirm the presence or absence of a
psychopathologypsychopathology

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ScreeningScreening
 Mini Mental State Examination (MMSE)Mini Mental State Examination (MMSE) (Folstein et al. 1975)(Folstein et al. 1975)
 Hindi Mental State Examination (HMSE)Hindi Mental State Examination (HMSE) (Ganguli et al. 1995)(Ganguli et al. 1995)
 Hindi Cognitive Screening TestHindi Cognitive Screening Test (Tiwari and Tripathi, 2011)(Tiwari and Tripathi, 2011)
 St. Louis University Mental State (SLUMS) Exm.St. Louis University Mental State (SLUMS) Exm. (JE Morley, 2000)(JE Morley, 2000)
 Clock Drawing Test (CDT)Clock Drawing Test (CDT) (Shulman et al. 1993)(Shulman et al. 1993)
 Bender Gestalt Test (BGT)Bender Gestalt Test (BGT) (Lauretta Bender, 1938)(Lauretta Bender, 1938)
 Hachinski Ischemic ScaleHachinski Ischemic Scale (1975)(1975)
 7 Minute Neurocognitive Screening Battery7 Minute Neurocognitive Screening Battery (Solomon et al. 1998)(Solomon et al. 1998)
 Short Portable Mental State QuestionnaireShort Portable Mental State Questionnaire (E. Pfieffer, 1975)(E. Pfieffer, 1975)
 Community Screening Instrument for DementiaCommunity Screening Instrument for Dementia (Hall et al. 1993)(Hall et al. 1993)
 Brief Cognitive Rating Scale (BCRS)Brief Cognitive Rating Scale (BCRS) (Reisberg and Ferris, 1998)(Reisberg and Ferris, 1998)
 Functional Assessment Staging (FAST)Functional Assessment Staging (FAST) (Reisberg, 1988)(Reisberg, 1988)
 Global Deterioration Scale (GDS)Global Deterioration Scale (GDS) (Reisberg, 1988)(Reisberg, 1988)
 CognistatCognistat (Northern California Neurobehavioural Group, 1995 )(Northern California Neurobehavioural Group, 1995 )
 Indian adaptation of CognistatIndian adaptation of Cognistat (Gupta and Kumar, 2009)(Gupta and Kumar, 2009)
 Addenbrooke’s Cognitive ExaminationAddenbrooke’s Cognitive Examination
 Montreal Cognitive AssessmentMontreal Cognitive Assessment
AdultsAdults

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Detailed Assessment
 Survey Psychiatric Assessment Schedule (Bond et al. 1980)
 CAMDEX-R (Roth et al. 1986, 1998-R)
 Alzheimer's Disease Assessment Scale (Rosen et al. 1984)
 Schedule for Clinical Assessment in Neuropsychiatry (SCAN)
(WHO, 1996)
 Clinical Dementia Rating (Morris, 1993)
 Blessed Dementia Scale (Blessed, 1968)
 BEHAVE-AD (Reisberg et al. 1987)
 Geriatric Mental State Schedule (GMSS) (Copeland et al. 1976)
 Dementia Rating Scale (DRS) (Mattis, 1988)
 DRS-2 (Jurica et al. 2001)
 Neuropsychiatric Inventory (NPI) (Cummings et al. 1994)
 Everyday Abilities Scale for India (EASI) (Fillenbaum et al. 1999)
 Thai Activities of Daily Living Scale (Senanarong et al. 2003)
 Senior Apperception Test (Choudhury Uma, 1978)
Psychological Assessment of Older AdultsPsychological Assessment of Older Adults

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Neuropsychological Test Batteries (NPB):
 Halstead and Reitan NPB
 Luria Nebraska NPB
 Wechsler Adult Intelligence Scale (WAIS)
 PGI Battery of Brain Dysfunction (PGIBBD)
 PGI Assessment of Mental Efficiency in Elderly
(PGIAMEE)
 NIMHANS NPB
 AIIMS Comprehensive NPB in Hindi
Rorschach Psychodiagnostics
Detailed Assessment (contd.)Detailed Assessment (contd.)

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 Mini Mental State ExaminationMini Mental State Examination ((Folstein et al. 1975)Folstein et al. 1975)
 Brief assessment of an individual’s orientation to timeBrief assessment of an individual’s orientation to time
& place, recall ability, arithmetic ability, language,& place, recall ability, arithmetic ability, language,
Praxis.Praxis.
 Can be administered by a nonprofessional.Can be administered by a nonprofessional.
 Time- 5 to 10 minutesTime- 5 to 10 minutes
 Total Score 30 ; Score Categories : 0- 4, 5-14, 15-19Total Score 30 ; Score Categories : 0- 4, 5-14, 15-19
Severe, Moderate, Mild Dementia; 20-24 MildSevere, Moderate, Mild Dementia; 20-24 Mild
Cognitive Impairment, 25-28 Age related MemoryCognitive Impairment, 25-28 Age related Memory
Impairment, 29-30 Normal cognitionImpairment, 29-30 Normal cognition
 The test has education biasThe test has education bias
In the areas of Cognitive FunctioningIn the areas of Cognitive Functioning
Screening (contd.)Screening (contd.)
 Hindi Mental State Examination (HMSE)Hindi Mental State Examination (HMSE) ((Ganguli etGanguli et
al. 1995):al. 1995): Adapted for illiterate Hindi speaking populations. Developed
by: Indo-US cross-national dementia epidemiology study.

17
International Psychogeriatrics (2009),
21:1, 123–128 C 2008 International
Psychogeriatric Association
Applicability of the Mini-mental
State Examination (MMSE) and the
Hindi Mental State Examination
(HMSE) to the urban elderly in
India: a pilot study
...................................................................
....................................
S. C. Tiwari, Rakesh Kumar Tripathi
and Aditya Kumar
Department of Geriatric Mental Health, C.S.M.
Medical University (Uttar Pradesh), Lucknow,
India
Results:
Either HMSE is screening
more false negatives within the urban
literate population or MMSE is
screening more false positives within
the illiterate population.

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Sensitivity: 0.93
Specificity: 0.96
Reliability (r): -0.87
with Brief Cognitive Rating Scale (Reisberg &
Ferris, 1988)
IAGMH/Intas Award 2011 at 3rd place.
Development of an Education and Culture Fair
Hindi Cognitive Screening Test (HCST) for the
Elderly Population of India
S. C. Tiwari and Rakesh Kumar Tripathi (2011)
Department of Geriatric Mental Health
C. S. M. Medical University, U P, Lucknow, India
Indian Journal of Geriatric Mental Health, 7(2), 83-96, 2011.
Hindi Cognitive Screening Test (HCST) (Tiwari and Tripathi, 2011)
ON HCST (items may change according to Literacy language and culture)No.
Areas (Score)
Total score: 30
Items
1. Orientation to Time (5) Year (of any calendar), weather, month, date, day
Either ‘which Place is this’, or ‘whose house is this’ depending on whether
the testing was conducted in a home or healthcare centre or other location in
the village/muhalla/town
Police Station or Tehsil or Post office
District
State
2. Orientation to Place (5)
Country
3. Registration (3) Mango (or any local fruit), Chair, Rupee
4. Attention and
Calculation (5)
Items exchangeable to the literacy level:
• For illiterate: days backward
Serial subtractions:
• Up to 5th
: 3 starting at 20.
• Up to 10th
: 4 starting at 40 .
More than 10th
: 7 starting at 100
5. Recall (3) Mango, Chair, Rupee
6. Naming (2) Pen, wristwatch/ Mobile phone
7. Repetition (1) ‘Neither this nor that’
3 stage Follow
command (3)
Give the individual a plain piece of paper and say, “Take the paper in your
hand, fold it in half, and put it on the floor.”
8.
Read & Follow
Command (1)
• Item exchangeable to the literacy level according to MMSE and HMSE
‘Close your eyes’ for Literate; and Examiner says ‘Look at me and do
exactly what I do’ and then closes his own eyes for three seconds for
illiterate.
9. Sentence (1) Items exchangeable to the literacy level according to MMSE and HMSE.
Writing a sentence for literate and ‘Tell me something about your house’ for
illiterate
10. Copying (1) Items exchangeable to the literacy level according to MMSE and HMSE
Up to 5th
: Diamond More than 5th
: Two Pentagons
Total Score: 30 Cut off Score: At or below 23: Screen positive (Cognitive Impairment)
Score: 24 and above: No cognitive impairment

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High School
Education
ClinicalClinical
ConditionCondition
Less Than
High School
Education
27-30 Normal 25-30
21-26 MNCD* 20-24
1-20 Dementia 1-19
St. Louis University Mental State Examination (SLUMSSt. Louis University Mental State Examination (SLUMS
Exam.) Morley JE, 2000Exam.) Morley JE, 2000
• It is a simple 11 items toolIt is a simple 11 items tool
* Mild Neurocognitive Disorder* Mild Neurocognitive Disorder
•Takes about 5-10 minutes inTakes about 5-10 minutes in
administrationadministration
• SLUMS is more sensitive in detectingSLUMS is more sensitive in detecting
MCI and dementia than Mini MentalMCI and dementia than Mini Mental
State ExaminationState Examination

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Bender Gestalt Test:Bender Gestalt Test:
 Lauretta Bender,1938;Lauretta Bender,1938;
Brannigan et al.2004
 9 figures asked to copy on9 figures asked to copy on
a blank papera blank paper
 Pencil with erasurePencil with erasure
 Admn. Time- 7-10 min.Admn. Time- 7-10 min.
 Used as screening test forUsed as screening test for
brain damagebrain damage
 Score more than 12Score more than 12
indicates cognitiveindicates cognitive
impairmentimpairment
Sign on BGT Scor
e
Perseveration,
Rotation/reversal,
Concretism
4
each
Added angles,
Separation of lines,
Overlap, Distortion
3
each
Embolishments, Partial
rotation
2
each
Omission, Abbreviation,
Separation, Absence of
erasure, Closure, Point
of contact
1
each

Features Score
1. Abrupt 2
2. Stepwise deterioration 1
3. Fluctuating course 2
4. Nocturnal confusion 1
5. Relative preservation of
personality
1
6. Depression 1
7. Somatic Complaints 1
8. Emotional incontinence 1
Features Score
9. History or presence of
hypertension
1
10. History of strokes 2
11. Evidence of associated
atherosclerosis
1
12. Focal neurologic
symptoms
2
13. Focal neurologic sign 2
Total Score 18
AdultsAdults
Hachinski Ischemic Scale (1975)Hachinski Ischemic Scale (1975)
Scoring
0-4: Alzheimer's Dementia;
5-6: diagnosis unclear;
7 or more : Vascular Dementia

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Clock drawing Test Score Error(s)
1 No error
2 Minor visuospatial
error
3 Inaccurate
representation of “10
after 11”
4 Moderate visuospatial
disorganization of
times
5 Several
disorganization
6 No reasonable
representation of a
clock
Score≥ 3: Cognitive deficit

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Brief Cognitive Rating Scale,Brief Cognitive Rating Scale, Barry Reisberg &Barry Reisberg &
Ferris (1988)Ferris (1988)
 BCRS is part of the triad of assessment withBCRS is part of the triad of assessment with
the Global Deterioration Scale andthe Global Deterioration Scale and
Functional Assessment Staging instrumentFunctional Assessment Staging instrument
 It is divided into 5 axes – concentration,It is divided into 5 axes – concentration,
recent memory, past memory, orientationrecent memory, past memory, orientation
and function/self careand function/self care
 It takes about 15 minutesIt takes about 15 minutes
 It is used for the screening of cognitiveIt is used for the screening of cognitive
functionsfunctions

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Functional Assessment Staging TechniqueFunctional Assessment Staging Technique
(FAST), Barry Reisberg (1988)(FAST), Barry Reisberg (1988)
 A 16 items scale to assess functional staging withA 16 items scale to assess functional staging with
cognitive disturbancescognitive disturbances
 The scale is more detailed version of 7 pointThe scale is more detailed version of 7 point
functioning and self care axis of BCRSfunctioning and self care axis of BCRS
 It has optimal concordance with Global DeteriorationIt has optimal concordance with Global Deterioration
Scale (GDS)Scale (GDS)
 It measures progression of deficits in ADIt measures progression of deficits in AD
 Fast can also be used for staging dementia withFast can also be used for staging dementia with
behavioural disturbancesbehavioural disturbances
 Scored by a trained clinicianScored by a trained clinician
 Takes 10-15 minutesTakes 10-15 minutes

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Global Deterioration Scale (GDS),Global Deterioration Scale (GDS), Barry ReisbergBarry Reisberg
(1988)(1988)
 A 7 point instrument for the staging of theA 7 point instrument for the staging of the
magnitude of cognitive and functional capacity inmagnitude of cognitive and functional capacity in
normal aging, age associated memorynormal aging, age associated memory
impairment (AAMI) and Primary Degenerativeimpairment (AAMI) and Primary Degenerative
Dementia (PDD)Dementia (PDD)
 Widely used scaleWidely used scale
 Takes 10-15 minutesTakes 10-15 minutes

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Community Screening Instrument for Dementia.Community Screening Instrument for Dementia.
Hall K, et al., 1993Hall K, et al., 1993
 CSI-D is used to find out the caregiverCSI-D is used to find out the caregiver
perception of mental health.perception of mental health.
 It is vital to know the caregiver burden toIt is vital to know the caregiver burden to
ensure the quality of care provided by theensure the quality of care provided by the
relativerelative

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Survey Psychiatric Assessment Schedule (SPAS),
Bond et al. 1980
 3 sections for assessment
 1-Cognitive, 2-Affective neurosis, 3- Psychosis
 Different cut off scores
 For cognitive-less than 9
 For Affective neurosis- more than 11
 For Psychosis any one score
AdultsAdults Detailed Assessment (contd.)Detailed Assessment (contd.)

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The Cambridge Mental Disorders of the ElderlyThe Cambridge Mental Disorders of the Elderly
Examination (CAMDEX) ,Examination (CAMDEX) , M. Roth et al.(1986, 1998-M. Roth et al.(1986, 1998-
R.)R.)
 Complete assessment of an older adults in 8Complete assessment of an older adults in 8
Sections.Sections.
 Sec A- Clinical Information about currentSec A- Clinical Information about current
condition, past history and family history of thecondition, past history and family history of the
patient;patient;
 Sec B-Sec B-Cognitive function (CAMCOG);Cognitive function (CAMCOG);
 Sec C- Interviewer’s observation on theSec C- Interviewer’s observation on the
patients appearance & behaviour;patients appearance & behaviour;
 Sec D- Physical Exam.;

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CAMDEX (contd.):CAMDEX (contd.):
 Sec E- Results of Laboratory tests;Sec E- Results of Laboratory tests;
 Sec F- Medication received by the patient;Sec F- Medication received by the patient;
 Sec G- Additional information;Sec G- Additional information;
 Sec H- Structured interview with theSec H- Structured interview with the
relative/caregiver.relative/caregiver.
 Dementias, Delirium, Depression, Anxiety,Dementias, Delirium, Depression, Anxiety,
Paranoid disorder, and other psychiatricParanoid disorder, and other psychiatric
disorders.disorders.
 Administration:- PsychiatristAdministration:- Psychiatrist
 Time of Administration-60-90 minutesTime of Administration-60-90 minutes

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Alzheimer’s Disease Assessment Scale (ADAS)Alzheimer’s Disease Assessment Scale (ADAS)
(Rosen et al.1984)(Rosen et al.1984)
Measures cognitive as well as non-cognitive behaviorsMeasures cognitive as well as non-cognitive behaviors
Cognitive: 11Cognitive: 11

Spoken languageSpoken language
abilityability
 Comprehension ofComprehension of
spoken languagespoken language
 Recall of testRecall of test
instructionsinstructions
 Word finding difficultyWord finding difficulty
 Following commandsFollowing commands
 Naming objectsNaming objects
 Construction PraxisConstruction Praxis
 Ideational PraxisIdeational Praxis
 OrientationOrientation
 Word recallWord recall
 Word recognitionWord recognition

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ADAS (Contd.)ADAS (Contd.)
Non-cognitiveNon-cognitive:: 1010
 TearfulTearful
 Appears/reports – depressedAppears/reports – depressed
moodmood
 Concentration, distractibilityConcentration, distractibility
 Uncooperativeness to testingUncooperativeness to testing
 DelusionsDelusions
 HallucinationsHallucinations
 PacingPacing
 Increased motorIncreased motor
activityactivity
 TremorsTremors
 Increase / DecreaseIncrease / Decrease
appetiteappetite
 Total Admn. Time:Total Admn. Time:
45 minutes45 minutes

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Clinical Dementia Rating (CDR) (Morris, 1993)Clinical Dementia Rating (CDR) (Morris, 1993)
1.1. MemoryMemory
2.2. OrientationOrientation
3.3. Judgment & ProblemJudgment & Problem
SolvingSolving
4.4. Community AffairsCommunity Affairs
5.5. Home & HobbiesHome & Hobbies
6.6. Personal CarePersonal Care
Global measure of dementia by a clinician.Global measure of dementia by a clinician.
CDR scale describes five degrees of impairment in sixCDR scale describes five degrees of impairment in six
different categories of cognitive impairment:different categories of cognitive impairment:
Degrees of Impairment:
00 -Normal-Normal
0.5 -Questionable0.5 -Questionable
impairmentimpairment
11 -Mild impairment-Mild impairment
22 -Moderate impairment-Moderate impairment
33 -Severe impairment-Severe impairment

33
 In the areas of Behavioural and PsychologicalIn the areas of Behavioural and Psychological
ManifestationsManifestations
 BEHAVE-AD ,BEHAVE-AD , Barry Reisberg & Associates(1987)Barry Reisberg & Associates(1987)
 Useful in assessing behavioural symptoms in patients withUseful in assessing behavioural symptoms in patients with
Alzheimer’s disease.Alzheimer’s disease.
 It is a 25 – item scale used to evaluate the behaviouralIt is a 25 – item scale used to evaluate the behavioural
symptoms of AD. These 25 items are divided into (7)symptoms of AD. These 25 items are divided into (7)
categories like :categories like :
 Paranoid and delusional ideation;Paranoid and delusional ideation;
 HallucinationsHallucinations
 Affective disturbances;Affective disturbances;
 Aggressions;Aggressions;
 Diurnal rhythm disturbances;Diurnal rhythm disturbances;
 Affective disturbance;Affective disturbance;
 Anxiety and phobiasAnxiety and phobias
 Time to complete scale 10-20 minutesTime to complete scale 10-20 minutes

34
Geriatric Mental State Schedule (GMSS)Geriatric Mental State Schedule (GMSS)
Copeland JR et al.,1976Copeland JR et al.,1976
 This is a standardized psychiatric interviewThis is a standardized psychiatric interview
schedule and very useful in identifyingschedule and very useful in identifying
Psychopathology:Psychopathology:
 organic and early organic illness (mostly various stages oforganic and early organic illness (mostly various stages of
dementia) anddementia) and
 depressive illnessesdepressive illnesses
 High level of sensitivity and specificity, and positiveHigh level of sensitivity and specificity, and positive
predictive value.predictive value.
 GMSS is one among the various flexible andGMSS is one among the various flexible and
effective case-finding instrumentseffective case-finding instruments
 Admin. Time: 45 minutes by trained interviewerAdmin. Time: 45 minutes by trained interviewer

35
Blessed Dementia Scale (BLS-D), BlessedBlessed Dementia Scale (BLS-D), Blessed
(1968)(1968)
 It has 22 items organized in three major areas :It has 22 items organized in three major areas :
1-1- Change in performance of everyday activitiesChange in performance of everyday activities
(8 items)(8 items)
2- Change in habits (3 items)2- Change in habits (3 items)
3- change in personality traits and drive (113- change in personality traits and drive (11
items).items).
- The information is obtained from a care giver- The information is obtained from a care giver
and the ratings are based on a predeterminedand the ratings are based on a predetermined
criterioncriterion
- Administration by trained clinician- Administration by trained clinician
- Administration time : 15-30 minutes- Administration time : 15-30 minutes

36
 In the areas of Activities of Daily LivingIn the areas of Activities of Daily Living
Instrumental Activities of Daily Living (IADLInstrumental Activities of Daily Living (IADL),),
Lawton & Brody (1969)Lawton & Brody (1969)
 IADL focuses on concrete behaviour andIADL focuses on concrete behaviour and
includes 8 domains of activities includingincludes 8 domains of activities including
telephoning, shopping, food preparation,telephoning, shopping, food preparation,
housekeeping, laundering use of transportation,housekeeping, laundering use of transportation,
use of medication, and financial behaviour.use of medication, and financial behaviour.
 Administration by Mental Health workersAdministration by Mental Health workers
 Scoring is based upon information from all availableScoring is based upon information from all available
sources (pt. staff, family record services etc.)sources (pt. staff, family record services etc.)

37
 In the areas of activities of Daily LivingIn the areas of activities of Daily Living (Contd.):(Contd.):
The Thai ADL Scale ,The Thai ADL Scale , Senanarong & associates (2003)Senanarong & associates (2003)
This scale assess 13 activities of daily living-This scale assess 13 activities of daily living-
• BathingBathing
• DressingDressing
• Using ToiletUsing Toilet
• TransferringTransferring
• IncontinenceIncontinence
• EatingEating
• Telephone useTelephone use
• Using public transportationUsing public transportation
• ShoppingShopping
• CookingCooking
• Performing household activitiesPerforming household activities
• Taking medicationTaking medication
• Handling moneyHandling money

38
Indo-Us project
by Fillenbaum et al. 1999

39
In the areas of Behavioural and Psychological ManifestationsIn the areas of Behavioural and Psychological Manifestations

Neuropsychiatric Inventory (NPI).Neuropsychiatric Inventory (NPI). Cummings, J andCummings, J and
Collaborators (1994)Collaborators (1994)
 The scale assess 10 domains of behaviouralThe scale assess 10 domains of behavioural
disturbancesdisturbances
 Delusions, Hallucinations, Dysphoria,Delusions, Hallucinations, Dysphoria,
Anxiety,agitation/aggression euphoria, inhibition,Anxiety,agitation/aggression euphoria, inhibition,
irritability/lability apathy, aberrant motor behaviourirritability/lability apathy, aberrant motor behaviour
 2 versions of NPI2 versions of NPI
 1- Pt in nursing home (nursing staff)1- Pt in nursing home (nursing staff)
 2- Pt. in home (caregiver)2- Pt. in home (caregiver)
 N PI – produces 4 scores :-N PI – produces 4 scores :-
 one for frequency, second for severity, a third called total which is theone for frequency, second for severity, a third called total which is the
multiplication of frequency by severity and a 4th for themultiplication of frequency by severity and a 4th for the
distress/excess work caused by the symptoms.distress/excess work caused by the symptoms.

40
 In the areas of Behavioural and PsychologicalIn the areas of Behavioural and Psychological
 Relative’s Assessment of Global SymptomatologyRelative’s Assessment of Global Symptomatology
(RAGS-E)(RAGS-E),, Ruskin A. (1988)Ruskin A. (1988)
It is a 21 item scale to evaluate psychiatric andIt is a 21 item scale to evaluate psychiatric and
behavioral problems of elderly in the community,behavioral problems of elderly in the community,
particularly senile dementia.particularly senile dementia.
 It is designed to be answered by relatives/caregivers ofIt is designed to be answered by relatives/caregivers of
the patient and it is relatively brief and easy tothe patient and it is relatively brief and easy to
administer.administer.
 5 point rating scale.5 point rating scale.
 Administration- close relative/friend of the person.Administration- close relative/friend of the person.
 Time/administration:- 15-20 minutes.Time/administration:- 15-20 minutes.

41
In the areas of Behavioural and PsychologicalIn the areas of Behavioural and Psychological
 DISRUPTIVE BEHAVIOUR RATING SCALEDISRUPTIVE BEHAVIOUR RATING SCALE
(DBRS),(DBRS), Mungas D, et al. (1989)Mungas D, et al. (1989)
 Assessment of disruptive behaviour in patientsAssessment of disruptive behaviour in patients
with dementiawith dementia
 CERAD - BEHAVIOUR RATING SCALECERAD - BEHAVIOUR RATING SCALE, Tariot PN,, Tariot PN,
et al (1995)et al (1995)
 Rating of psychopathology in patients withRating of psychopathology in patients with
probable Alzheimer’s Diseaseprobable Alzheimer’s Disease

42
 AttentionAttention ::
 Letter cancellation,Letter cancellation, Diller L, et al. (1974)Diller L, et al. (1974)
 This is a paper and pencil task requiring visualThis is a paper and pencil task requiring visual
selectivity at fast speed on a repetitive motor taskselectivity at fast speed on a repetitive motor task
 Trails A test,Trails A test, Reitan RM. (1958)Reitan RM. (1958)
 A test of complex visual scanning with a motorA test of complex visual scanning with a motor
component with motor speed and agility making acomponent with motor speed and agility making a
strong contribution to success.strong contribution to success.

43
 Language :Language :
 Boston Naming Test,Boston Naming Test, Kaplan EF, et al. (1983)Kaplan EF, et al. (1983)
 BNT is known test to assess one’s ability to name pictures of
objects through spontaneous responses and need for
various types of cueing. Inferences can be made with regard
to language facility and possible localization of cerebral
damage
 Boston Diagnostic Aphasia Examination,Boston Diagnostic Aphasia Examination, GoodglassGoodglass
H. & Kaplan EF, (1983)H. & Kaplan EF, (1983)
 The BDAE is a comprehensive, multifactorial battery to
evaluate a broad range of language impairments that often
arise as a consequence of organic brain dysfunction in
adults. It’s a know tool for the assessment of aphasia both in
inpatient and outpatient

44
 Language (Contd.)Language (Contd.)
 Western Aphasia Battery,Western Aphasia Battery, Kertesz A. (1982)Kertesz A. (1982)
 WAB is commonly used to identify and quantity the Broca’sWAB is commonly used to identify and quantity the Broca’s
aphasia population. Interpretations of the results are in termsaphasia population. Interpretations of the results are in terms
of the language choice, lexical semantic, syntactic,of the language choice, lexical semantic, syntactic,
morphological and phonological levels of switching andmorphological and phonological levels of switching and
spontaneous translationspontaneous translation
 Verbal Fluency (Word and Category),Verbal Fluency (Word and Category), Sciarma T, et al.Sciarma T, et al.
(1990)(1990)
 Many types of verbal fluency tests are being used worldMany types of verbal fluency tests are being used world
wide. The use of word and category verbal fluency test iswide. The use of word and category verbal fluency test is
made to measure the subjects speed and flexibility of verbalmade to measure the subjects speed and flexibility of verbal
thought processesthought processes..

45
 MemoryMemory
 Wechsler Memory Scale,Wechsler Memory Scale, Wechsler D. (1987)Wechsler D. (1987)
 Wechsler memory scale is used to assess the fourWechsler memory scale is used to assess the four
types of memory. It will assess verbal memory,types of memory. It will assess verbal memory,
visual memory and attention and general memoryvisual memory and attention and general memory
of the subject. This is the only test available toof the subject. This is the only test available to
measure the subject’s memory quotient (MQ)measure the subject’s memory quotient (MQ)
 Rey Auditory Verbal Learning Test,Rey Auditory Verbal Learning Test, Rey A. (1964)Rey A. (1964)
 This test is used to assess the subjects verbalThis test is used to assess the subjects verbal
learning skills, providing option for immediate andlearning skills, providing option for immediate and
delayed recall and recognition.delayed recall and recognition.

46
 Executive functionExecutive function
 Wisconsin Card Sort Test,Wisconsin Card Sort Test, Nelson HE.Nelson HE.
(1976)(1976)
 This test is a well-known paradigm ofThis test is a well-known paradigm of
abstraction and cognitive flexibility.abstraction and cognitive flexibility.
Studies report that apart fromStudies report that apart from
executive functions it also elicits aexecutive functions it also elicits a
distinct pattern of cerebral blood flowdistinct pattern of cerebral blood flow
velocityvelocity
 Stroop Test,Stroop Test, Stroop JR. (1935)Stroop JR. (1935)
 Tests the ability to selectivelyTests the ability to selectively
process only one visual feature whileprocess only one visual feature while
continuously suppressing the others.continuously suppressing the others.
http://cognitivefun.net/test/2http://cognitivefun.net/test/2

47
Neuropsychological Tests
Psychological approaches for the assessment of brain pathology
Multifactorial Unitory
assumption of functional unity of the brain
as a whole (mass action and equipotentiality)
Assessed by psychological tests of
Unitory functions such as
test for Intelligence, Memory,
Perceptuomotor Functions,
Nahar- Benson test, WCST etc.
Assessed by Comprehensive Batteries
of tests such as Halstead and Reitan,
Luria Nebraska, NIMHANS-BBD,
PGI-BBD, AIIMS comprehensive
Neuropsychological Battery in
Hindi, PGI battery for assessment
of mental efficiency in the elderly
Based on the functional autonomy
of the structure (Localization)

48
 IntelligenceIntelligence
 Wechsler Adult Intelligence Scale (WAIS),Wechsler Adult Intelligence Scale (WAIS), WechslerWechsler
D. (1981)D. (1981)
 Widely applicable test for IQ measurement over 16 years .Widely applicable test for IQ measurement over 16 years .
 Can also be used for diagnosing organic brain syndromesCan also be used for diagnosing organic brain syndromes
 It hasIt has 6 verbal:6 verbal: information, comprehension, arithmetic,information, comprehension, arithmetic,
similarities, digit span and vocabulary andsimilarities, digit span and vocabulary and 5 performance:5 performance:
picture completion, Block design, picture arrangement, objectpicture completion, Block design, picture arrangement, object
assembly and digit symbol tests. The test generates a verbalassembly and digit symbol tests. The test generates a verbal
IQ, a performance IQ and a full scale or combined IQ.IQ, a performance IQ and a full scale or combined IQ.
 A difference between the verbal and performance IQ scoresA difference between the verbal and performance IQ scores
of greater than 10 points is suggestive of organic brainof greater than 10 points is suggestive of organic brain
syndrome.syndrome.
Neuropsychological Test

49
Neuropsychological Tests (contd.)
PGI Battery of Brain Dysfunction(PGIBBD),
Dwarka Pershad and S.K. Vrma, 1990:
 PGI Memory Scale
 Revised Bhatia’s Short Battery of
Performance Test of Intelligence
 Verbal Adult Intelligence Scale (VAIS)
 Nahar-Benson Test
 Bender Visual Motor Gestalt Test (BGT)

50
PGI Memory Scale:
 Remote and recent memory
 Mental balance
 Attention and concentration
 Delayed and immediate Recall
 Verbal retention (similar and dissimilar pairs)
 Visual retention and Recognition
Separate norms for:
 0-5 yrs. of schooling
 6-9 yrs. of schooling
 10 and above yrs. of schooling
PGIBBD (contd.)

51
Revised Bhatia,s Short Battery of Performance
tests of Intelligence:
 Koh’s Block Design Test
 10 designs
 Pass-along Test
 8 problems
PGIBBD (contd.)

52
Verbal Adult Intelligence Scale (VAIS):
It does not take into account the speed or,
quickness, rather it emphasizes the power or the
capacity of the subjects.
 20-69 yrs. of age
 Information
 Digit span
 Arithmetic
 Comprehension
PGIBBD (contd.)

53
Nahar-Benson Test (Nahar and Benson,1070):
 Total 8 items
 5 drawing to copy
 3 instructions to draw figures
Bender Visual Motor Gestalt Test (BGT),
(Bender,1938):
 9 drawings to be copied
PGIBBD (contd.)

54
PGI Battery for assessment of Mental Efficiency in
the Elderly (PGI-AMEE), Kohli et al. 1996:
For 55yrs. and above. 5 subtests:
 The Set Test (Isaacs & Akhtar,1972)
Recall items on 4 categories:
 1-colours, 2-animals, 3-fruits and 4-cities
 Mental Status Questionnaire (Kahn et al. 1960)
 Recent and remote events
 General Informations
 Nahar and Benson Scale (Nahar et al. 1970)
 8 drawings to make
 Geriatric Depression Scale (Brink et al. 1982)
 30 items in english version
 20 items adopted in Hindi version

55
AIIMS Comprehensive Neuropsychological Battery
in Hindi (Adult form) (AIIMS-CNBH), Surya Gupta
et al. 2000:
 Based on Luria,s functional approach in the detection,
lateralization, localization of discrete brain lesions
 Useful for both in diagnosis and rehabilitation
 160 items and 13 subscales
 Total raw score converted into t scores
 High t score than expected – organic brain syndrome
 t score R. hem. - t score L. hem. Found positive then right
hemisphere dysfunction and if, negative then left
hemisphere dysfunction.

56
13 Subscales:
 Motor Scale
 Tactile Scale
 Visual scale
 Receptive speech
 Expressive Speech
 Reading Scale
 Writing scale
AIIMS-CNBH (Contd.)
 Arithmetic Scale
 Memory scale
 Intellectual processes
scale
 Pathognomonic Scale
 Left hemisphere scale
 Right Hemispheric Scale

57
Rorschach Psychodiagnostics
 Herman Rorschach, 1921
 There are ten official inkblots,
 Each printed on a separate white card,
approximately 18x24 cm in size.
 Each of the blots has near perfect bilateral
symmetry.
 Five inkblots are of black ink, two are of black
and red ink and three are multicolored, on a
white background
Response Inquiry:
 Determinants- shape, structure, colour, shading,
M
 Location- W, D, Dd, Ds etc.
 Content- H, A, An, Ms, Na

58
Rorschach Psychodiagnostics (contd.)
1 2
5 6 7
43
9 10
8
Ink blots

59
Piotrowoski’s signs for organic brain disorders:10
 Response less than 15
 IRT > 60 seconds
 Less than 2 human movement response
 F+% < 70%
 Popular response <4
 One or more colour naming (overlap with sch.)
 Perseveration of response
 Impotence
 Perplexity
 Automatic phrases
Minimum any 5 signs are required for diagnosis.
Rorschach Psychodiagnostics (contd.)

60
ConclusionsConclusions
 A number of tools are available forA number of tools are available for
screening/assessing various problems of older adults.screening/assessing various problems of older adults.
 The commonly used tests are MMSE,BGT, CAMDEX,The commonly used tests are MMSE,BGT, CAMDEX,
GMS,BEHAVE-AD, ADL, FAST, GDS, CDT, PGIBBD,GMS,BEHAVE-AD, ADL, FAST, GDS, CDT, PGIBBD,
Rorschach inkblot test etc.Rorschach inkblot test etc.
 Some vital areas are still untouched such as aSome vital areas are still untouched such as a
Screening tools for dietary habits, elderly expectationsScreening tools for dietary habits, elderly expectations
with regard to mental health care, elderly specificwith regard to mental health care, elderly specific
quality of life scale etc.quality of life scale etc.
 Most of the scales are in foreign languages and ofMost of the scales are in foreign languages and of
foreign origin and often require appropriateforeign origin and often require appropriate
modifications. The normative data in Indian matrix ismodifications. The normative data in Indian matrix is
not available.not available.
 Need to develop indigenous tools.Need to develop indigenous tools.

61
AdultsAdults
 Further readings:Further readings:
 Burns et al. (2004). Assessment scales in old ageBurns et al. (2004). Assessment scales in old age
psychiatry (2psychiatry (2ndnd
ed.). Informa healthcre, replika Press Pvt.ed.). Informa healthcre, replika Press Pvt.
Ltd.Ltd.
 Bhargav M. (1999). Modern psychological testing andBhargav M. (1999). Modern psychological testing and
measurement. Print Palace, Agra.measurement. Print Palace, Agra.
 Burns A., Lawlor B., Craig s.(2002). Rating Scales in OldBurns A., Lawlor B., Craig s.(2002). Rating Scales in Old
Age Psychiatry. British Journal of Psychiatry, 180,161-Age Psychiatry. British Journal of Psychiatry, 180,161-
167.167.
 Gupta, A. & Kumar, NK. (2009). Indian adaptation of theGupta, A. & Kumar, NK. (2009). Indian adaptation of the
Cognistat : Psychometric properties of a cognitiveCognistat : Psychometric properties of a cognitive
screening tool for patients of traumatic brain injury.screening tool for patients of traumatic brain injury.

62
King George’s Medical University,King George’s Medical University,
Lucknow, U.P., INDIALucknow, U.P., INDIA
Contact: R K Tripathi
rastripathi@gmail.com
91+9454202905

Psychometric assessment of older adults oct 21 to 26 2013 winter workshop

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