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REVIEW ARTICLE
Ahead of print publication  

A critical analysis and recommendation of rating scales to assess the depression and cognitive impairment in the elderly


 Department of Psychiatry, Postgraduate Institute Medical Education and Research, Chandigarh, India

Date of Submission04-Aug-2020
Date of Decision12-Jul-2021
Date of Acceptance16-Aug-2021
Date of Web Publication03-Feb-2022

Correspondence Address:
Aseem Mehra,
Department of Psychiatry, Postgraduate Institute Medical Education and Research, Nehru Hospital, Cobalt Block 3rd Floor, Chandigarh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jgmh.jgmh_34_20

  Abstract 


As the proportion of persons across the world older than 65 years increases, the prevalence of depression and dementia will increase. The older people with depression or dementia are usually underdiagnosed, misunderstood, or did not approach the clinic. This might be because of considering the symptoms of depression and dementia as a part of normal aging. The elderly patients or informants usually hide the problems because of the prevalence of stigma, shame, or fear of discrimination. The people who are in their last innings can have a different meaning for their life which can be misunderstood at the outpatient clinic. Resultantly, the majority of them did not get the treatment or mistreatment. Rating scales are valuable tools to elicit the symptoms in elderly populations. Rating scales have their limitations, which no one looked at or not much highlighted in the existing literature. This review discusses the critical analysis of rating scales and recommendations of scales in old age psychiatry in different settings.

Keywords: Dementia, depression, elderly, rating scales



How to cite this URL:
Mehra A, Grover S, Kumar K, Sahoo S. A critical analysis and recommendation of rating scales to assess the depression and cognitive impairment in the elderly. J Geriatr Ment Health [Epub ahead of print] [cited 2022 Jul 7]. Available from: https://www.jgmh.org/preprintarticle.asp?id=337221




  Introduction Top


The elderly population across the world kept on rising and expected that by 2050, the proportion of the world's elderly population would be doubled (rose from 12% to 22%). Older people face physical and psychiatric challenges more, which needs to be recognized. About one-fifth of the older person suffers from either psychiatric or neurological disorders. 6.6% of all disability attributed to mental and neurological disorders.[1] The most common mental and neurological disorders are depression and dementia, which affects 7% and 5% of the world's population, respectively. In routine clinical settings, the clinician usually missed the diagnosis of depression or dementia in an older person. This might be because of considering these two disorders as a normal part of aging or, at times, patients have their own fear of stigma or shame toward the mental illness.[2] To counter this problem, health experts recommend using the rating scale in the elderly population along with the routine clinical interview. The rating scales used in the elderly population suffering from mental health problems have particular limitation and advantages. These limitations or lack of knowledge about the scale limits the use of rating scales in the elderly population. In this review, we discuss the limitation and advantages of the rating scale used in depression and dementia in elderly populations.


  Rating Scales for Depression in the Elderly Top


Depression is a common mental disorder among the elderly population with more persistent and debilitating consequences.[3],[4] Late-life depression can have different ways of presentation in comparison to the young.[5],[6] Late-life depression is usually undiagnosed or untreated, as it is generally associated with comorbid physical illness and psychiatric problems, which can complicate the identification and management of depression among the elderly. The presence of dementia, medical symptoms, or comorbid physical disease may be misattributed to depression or vice-versa.[3],[4],[7],[8],[9] Hence, depressive disorder in the elderly may be overlooked, misunderstood, or even misattributed with a physical illness easily confused with other illnesses.[5] In the elderly, the symptoms such as pessimism, death wishes, reduced activity or loss of interest, and meaning of life can have a different meaning compared to young adults.[10]

Therefore, considering the complexity in the estimation of depression among the elderly, there is a need for sound, specific, easy-to-administer. The focus should be on the measurement of late-life depression to improve the early recognition and treatment of elderly patient with depression. At present, several instruments are available to measure depression in the elderly.

Broadly, scales are classified into two categories: interviewer-administered scale or observer scale and self-reporting scales

Interviewer-administered scale or observer scale

The advantage of these scales is to ensure the completeness of the reporting of the symptoms, which is essential in the elderly population as well in clinical trials. There is a high probability of interviewer biased; hence, it needs to be administered by a trained professional only.

Self-reporting scales

They are cost-effective, not many efforts required from the clinician or interviewer. However, an older person with a fragile illness needs help from either a caregiver or a third person, a person with poor motivation, and may not be able to comply with the assessment because of the severity of the depression. Besides, fear of discrimination and stigma results in underreporting of the symptoms.


  Geriatric Depression Scale Top


It is one of the most common scales used in the elderly to assess depression. This scale can discriminate the depressive symptoms from the nondepressive symptoms.[11],[12] Originally, it has 100 items, which were condensed to 30 items to detect depression among the elderly.

Geriatric Depression Scale-30 (long form)

The scale was designed as self-administered but can be used in interviewer-administered form too. The items are in “yes/no” format, which may be more acceptable in the elderly population. Initially, it was validated for hospitalized depressed patients or elderly living in a community without depressive symptoms.[13] A cutoff score of 11 has 84% sensitivity and 95% specificity, with a cutoff score of 14 having a specificity of 100% but with a lower sensitivity of 80%. It suggests that a score of more than 11 is a possible indicator of depression. It is easy to administer and not require the skills of a trained interviewer.[14] It is found to be a valid scale to measure depression in the elderly in treatment settings like medical inpatients/outpatient's services and in-day treatment settings with good sensitivity and specificity.[15],[16],[17],[18] The scale is also available in different languages and has been found to be effective when administered by telephone.[19] The scale capacity to differentiate depressed from nondepressed was satisfactory in patients with medical illness or demented elderly. Furthermore, it did not show age or sex effects and proved to be a practical choice as a self-report measure for assessing depression in the elderly.[14]

The major limitation of the scale is that it does not assess the vegetative symptoms in the elderly. The scale also has low test–retest reliability.[20],[21] It does not evaluate for suicidality. In a nursing home or patients with moderate-to-severe cognitive impairment, the scale does not have good sensitivity and specificity.[22],[23] Even the lower accuracy is reported among the healthy, highly educated, community-dwelling older adults.[24] The scale does not maintain its validity in people with dementia because it fails to identify depression among the person with mild–moderate dementia. The scale items are in the present sentence, which implies the recent experience, not about the past 2 weeks or more. From an Indian setting perspective, it is not validated across all the colloquial languages. It is a self-rated scale, but most of the elderly population in India are still not literate. The cultural components are not included, which may miss the symptoms of depression. The meaning of hopelessness and worthlessness varies from culture or religion to religion, which can significantly impact the findings in Indian settings. When asked, “Do you prefer to stay at home, rather than going out and doing new things?” a positive response may not indicate depression in Indian settings. As in India, older people used to stay at home and did not contribute so much in household chores or doing paid employment as older adult do in the developed countries like the United States. The item included for emotions can have a different meaning across the different cultures.

Geriatric Depression Scale short form

The scale has 15 items and takes 5–7 min to administer. It is composed of those 15 items from the Geriatric Depression Scale (GDS) long form that had the highest correlation with the depressive symptoms. GDS short form (GDS-SF) and long form are highly correlated with each other (r = 0.884; P < 0.001). A cutoff score of 5/6 has a sensitivity and specificity of 85% and 74%, respectively. It has been validated in the geriatric outpatient clinic.[25],[26] However, several items (item 2 and 3 in GDS-30/15 and item 10 on GDS-30, item 8 on GDS-15) were found to have low clinical validity, did not contribute to constructing elderly depression, and are more related to the subjective aspect of depression-like satisfaction with life.[27],[28]

Logistic regression analysis has been used to drive brief form of GDS (GDS-10, GDS-6, GDS-5, GDS-4, and GDS-1), raised supplementary problems to compare the scores across the different culture and languages.[29] Besides, the binary response format in GDS (yes/no) does not indicate the relative intensity or frequency of depressive symptoms.[30] The advantage and limitation of the short form of GDS are more or less similar to the long form of GDS-30.

Hamilton Rating Scale for Depression

The scale was developed as a measurement of treatment outcome rather than a screening or diagnostic tool for depression.[31] It is commonly used to screen depression, specifically in the clinical trial, to detect an individual with depressive disorder. It takes 20–30 min to administer. It is simple to use and is readily taught to or rapidly learned by raters. The scale has 21 items, with 10 items rated on a scale of 0–4, 9 items rated from 0 to 2, and the other 2 items rated from 0 to 3. A break score of 18–20 is used to distinguish a person with depression from the nondepressive persons.[32],[33] The scale has a high negative predictive value with an acceptable positive predictive value. The scale has good sensitivity and specificity.[34] It is an interviewer-based scale for assessing depression, but has not been validated to evaluate the elderly population.[35] The problem with the scale is an intermingling of frequency and intensity of symptoms in scoring, emphasizing somatic and behavioral symptoms, resulting in less reporting of feelings of distress among the elderly populations.[36] Administration of scale is time-consuming and not suitable for screening purpose. It requires the training of the interviewer. The scale cannot be used day-to-day to see a patient's progress, as items such as weight gain/loss and loss of libido cannot changes meaningfully on day one or two. Furthermore, the scale has not been validated convincingly to use in the elderly population and cannot differentiate between depression and anxiety among the elderly population. The scale's item emphasizes sleep rather than on feeling of thoughts, self-destructive thoughts, suicidal ideation, or cognition. The antidepressant with side effects of gastrointestinal disturbances or sexual symptoms may underestimate the impact of antidepressant and overrepresentation of depression. The factor structure studies among the Indian population are not uniformly distributed. The scale is conceptually flawed as per the Indian population, and content validity is poor. The cultural content of depression is missing.

Zung Self-Rating Depression Scale

The scale has 20 items and developed as a self-rating scale.[37] It is widely used in epidemiological studies. The scale's item has graded responses such as never and always. A cutoff score of 60 has a range of sensitivity and specificity from 56%–76% to 82%–86%, respectively.[38],[39] The advantage of the scale is that items are based on the diagnostic criteria of depression. To prevent the bias, half of the questionnaire worded positively and half worded as negatively. The scale has a good correlation with the clinical assessment and psychometric assessment of depression. However, it is commonly used in European countries among the elderly population but has certain limitations. First, the graded responses may be confusing for the elderly and may require assistance from the interviewer or caregivers.[40] Second, a cutoff score of 40 used for depression in the elderly populations may assess the healthy elderly population as depressed. The score of 40 has a false positive rate of 44%.[41] Third, it does not measure the somatic symptoms adequately.[42] Because of these problems, it is not suitable to assess depression in research or clinical settings.[43] When using the scale in the very old age group (≥70 years), reliability is not acceptable, and internal consistency is very low.[44] The scale may be more vulnerable to overestimating syndrome in the elderly because of its overemphasis on somatic symptoms. A short form of 12 items has been developed, but proper validation has not been tested in the elderly.[45],[46] The scale is not validated among the elderly population in the Indian setting. The scoring system is very complex, challenging to interpret the results or scores. The responses are based on 4-point Likert scale, which is difficult for the elderly population, specifically for illiterate people.

Beck Depression Inventory

This is a self-rated questionnaire for measuring the severity of depression in diagnosed patients and detecting possible depression in normal populations, including the elderly population. Compared to its predecessors, the Beck Depression Inventory-I (BDI-I)[47] and the BDI-IA,[48] the BDI-II was designed to align more closely with the diagnostic criteria of DSM-IV for major depressive disorder (MDD). BDI-II also includes the agitation, concentration difficulties, and energy loss that were not present in the previous version. The scale has 21 items rated from 0 to 3, with a score ranging from 0 to 63. It usually takes 5–10 min to administer. It is more valuable to detect depressive symptoms in older nonclinical samples[49] or among the cognitively normal elderly population.[50] It is also a useful tool to assess the progress of the treatment. The major limitation of the scale is that assessment can be influenced by the level of educational attainment, social desirability, or the gender effect.[51],[52],[53] The other limitations are that it does not take into account fluctuations of the patient's condition. There are symptoms like motor retardation, agitation, and loss of insight that are not covered and anxiety is represented only by irritability. The rating procedure is also open to observer bias and is not self-rating in the real sense. The scales are not suitable for a person with cognitive impairment or physical illness.[54],[55] The administerer should be very cautious in applying the inventory in the elderly population with acute or chronic medical conditions, as 7 out of 21 items refers to symptoms such as fatigue, sleep difficulty, appetite problems, weight loss, loss of libido, and worrying about health, which can be due to medical conditions.

Montgomery–Asberg Depression Rating Scale

It is an interviewer-based scale in which trained clinician interviews the patients that move from broad questions to more detailed ones. It takes around 10 min. It has 10 questions, and each question has 6 possible ratings. It covers the core symptoms of depression like sadness, sleeps problems, changes in appetite, attention and concentration difficulties, pessimistic views, and suicidal ideation. A cutoff score of more than 6 indicates the presence of depression (0–6 indicates an absence of depression or recovery in the clinical trial setting; 7–19 mild depression; 20–34 moderate depression; and ≥35 severe depression). The scale is very sensitive to measuring the change in symptoms with treatment over a period of time.[56] The fundamental problem with this scale is that it does not measure the somatic symptoms, which can be valuable in assessing the elderly population. It is also not been validated in elderly populations.[57],[58],[59] As it does not assess the physical symptoms, hence more useful in patients with physical illness. The scale requires to be purchase for large-scale research projects.[60] The scale is not much used in Indian settings and even not validated.

Centre for Epidemiological Studies-Depression scale

It is a self-rated scale, usually takes 5 min to complete. Initially, it was developed for the general population,[61] but later on, found to be useful, particularly for the elderly population. The scale consists of 20 items, rated from 0 to 3 with a scoring range from 0 to 60. A cutoff score of 16 has been suggested to differentiate patients with mild depression from nondepressive persons, and a cutoff score of 23 indicated a significant level of depression. The major limitation is that at a cutoff score of 16, it has a high rate of false-positive cases.[62],[63] Thus, the appropriate cutoff score, specifically in the elderly population, has not been validated to date.[61],[64] However, the scale has good sensitivity and specificity but not suitable for a clinical setting.[64] The scale format is slightly difficult, which may not appear reliable in an individual with cognitive impairment.[65] The scale has differential responses depending on the ethnic or cultural variance.[66] Using a diagnosis of major depression as a criterion suggests that it must be used as a screening tool instead of a diagnostic tool. The scale is not validated and studied among the Indian elderly population. However, the scale has been used in the clinical setting but did not match with the diagnosis of DSM or ICD.

Shorten versions are also available like CES-D 11,[65] CES-D10,[67] and CES-D 8.[68] Different cutoff score has been proposed for these scales, but to date, no scale has been found with adequate sensitivity and specificity to use in the elderly population.

Patient Health Questionnaire-9: It is a self-rated questionnaire consisting of 9 items. The scales include all the nine items of the diagnostic criteria of DSM-IV for MDD. Each item is rated on a score of 0–4.[69] The total score ranges from 0 to 27, with a higher score indicating the greater severity of depression.[70] It is widely used across the world, available in several languages. Despite this fact, this scale has not been validated among the elderly population to diagnose depression. The items are in graded response; it is difficult for the elderly. The scale has no role in diagnosing depression among patients with cognitive impairment or comorbid neurological and physical illness. The scale has not been validated across different cultures. The purpose of the scale is to screen the patient for depression and has a limited role in the diagnostic system role. The scale has a very high rate of “false negative” is the most severe limitation. Even the patient found to be positive on the scale needs detailed evaluation for a diagnosis of depression, an exasperated fashion, specifically in countries like India where the resources are minimal. In India, no studies have evaluated the diagnostic accuracy of PHQ-9 with a known gold standard, such as Structured Clinical Interview for DSM-5.

Brief Assessment Schedule Depression Cards: It is an interviewer-based scale and based on the brief assessment schedule with the novel idea and development that, because of the difficulties of questions being overheard on geriatric wards, patients choose answers from a deck of cards.[71] It takes 2–8 min to complete. The pack has 19 cards with enlarged black print on a white background and is presented one at a time. The cutoff score of 6/7 is found to have a sensitivity of 71% and a negative predictive value of 86% against a psychiatric diagnosis. The scale is not validated in the elderly population in India. It is a screening tool and is not intended to be diagnostic. The older people with cognitive impairment or with low education can put all the cards in one pile and will be difficult to clarify whether piled for a true or false response. The scales need cultural validation too.

Cornell Scale for Depression in Dementia: The scale was specifically developed for the assessment of depression in dementia.[72] The trained clinician administers it and usually takes 10 min with patients and 20 min with the carers. It has 19 items, each item is rated on a 3-point score of “absent,” “mild or intermittent,” and “severe” symptoms, and when the score is not available, it should be not available. A cutoff score of ≥8 suggests the presence of depression. It is one of the best scales available to assess depression in the presence of cognitive impairment. The method of administration is different from other scales of depression; the analysis of symptom profile is almost similar, as seen in depression with dementia compared to depression alone.[73] For the recommendation of scale used in a clinical setting, [Flowchart 1] should be followed. The cultural adaption method has not been adopted in Indian settings. The trained psychogeriatric can use this scale.



General critical review of the rating scale, as mentioned above:

  • Most of the scales are developed and validated in the younger population, and the applicability of these scales has been doubtful or not sufficiently demonstrated in the elderly population
  • Currently, no self-rated scale can discriminate among the subtype of depression
  • Most of the scales are not suitable for patients with cognitive impairment or people with sensory impairment
  • Majority of the self-reported scales used for the elderly population are tapping the somatic symptoms. In patients with physical illness, there will be underestimation or failure to take up the physical illness. Resulting in overestimation of depression can have adverse consequences
  • Among the patients at the end of their lifespan or suffering from a terminal illness, scales cannot pick differentiable features from an expectable, nonpathological reaction to terminal illness
  • The scale's like suicidal ideation, whether life is worthful or not can have a different meaning at the end of life. These problems may lead to different kinds of interpretations.



  Rating Scales for Dementia Top


Dementia is characterized by progressive deterioration of global impairments of cognitive functions and the ability to perform daily activities.[74] The estimated proportion of dementia at a given time is 5%–8%.[75] It is estimated that people with dementia will be around 152 million.[75] It is seen that people with dementia are usually seen by a general physician, psychiatrist, medical specialist, or neurologist. There is a need to identify cognitive impairment early or differentiate it from other neurological or psychiatric disorders. For this rating, scales are advocated for screening and diagnosing cognitive impairment or dementia. The purpose of an instrument is to increase the precision of a decision by increasing objectivity or reducing subjectivity. For example, using a cognitive screening test score to screen for underlying dementia, distinguish impairment due to dementia from normal age-related cognitive change, or monitor the effects of treatment of dementia in a clinic or controlled trial. Psychometric properties for each scale are summarized in [Table 1].
Table 1: Comparison of psychometric properties of rating scales for cognitive function

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Mini-mental state examination

Mini-mental state examination (MMSE) is the most common and widely used measure of cognitive function in clinical practice across the world.[76] The scale is a screening instrument. A minimally trained person or clinician can use this scale. It takes around 8–10 min to administer. It measures the cognitive function in the domains of orientation, memory, attention and concentration, language, and visual construction. The score ranges from 0 to 30. A cutoff score below 24 indicated cognitive impairment. It is widely translated into various languages. The scale is available in the Hindi language, and another modified version as per the Indian culture is also available as a Hindi cognitive screening test.[77],[78] The scale has good sensitivity and specificity with a high positive predictive value with relatively low negative predictive value. The limitation of the scale is that it has the floor and ceiling effect and limited sensitivity to change. The scoring can be affected by the level of education, language, and cultural barriers;[79],[80] thus, patients with lower levels of education may be wrongly classified as demented, and those with higher levels may be missed. The scale does not have the capacity to examine the frontal/executive or visuospatial functions. The scale is not able to detect features of vascular dementia-like poststroke, frontotemporal or subcortical dementia in early-stage.[81],[82] The scale has limited use in detecting a change in clinical work and research studies. The administerer needs some formal training and familiarization with the instrument. There is some interuser difference in scoring tests and some variation in the questions; for example, the calculation task can use either serial 7s (subtracting 7s from 100) or spelling of the word “WORLD” backward – in some cases, both are performed, and the highest result is used. In addition, orientation to place is dependent on the location in which the test is performed: a familiar (home) vs. unfamiliar (hospital) environment. As these items are not identical, they may result in score variance. As MMSE scores generally decline with advancing age, other authors have recommended lower cutoffs for the elderly, perhaps as low as 20 or less, to indicate impairment.[76],[79],[99] However, average lower scores in the elderly may reflect the higher prevalence of dementia in this age group. The pentagon task of the MMSE simply requires the patient to copy the image and does not assess planning skills. Consequently, it may have a limited ability to detect non-Alzheimer's dementias, such as poststroke cognitive impairment and frontotemporal or subcortical dementia in their early phases.[81],[82]

Montreal Cognitive Assessment

The scale was developed by Nasreddine et al.[83] to screen for mild cognitive impairment. Minimal training is required to administer the test and takes about 10–15 min. It assesses attention/concentration, executive functions, memory, language, calculation, orientation, and conceptual thinking. A score of 25 or less indicates cognitive impairment. This scale is also widely used and translated into other languages. The scale has good sensitivity and specificity with a high negative predictive value with relatively low positive predictive value. The advantage of this scale is to screen the patient with vascular dementia. However, the scale is influenced by the level of education, cultural variance, and required trained professional. The scale has limited use in general practice settings. The scale cannot be used in people with other neurological disorder like movement disorder or sensory impairment.[84]

Clock drawing test

The clock drawing test (CDT) is a screen for visuospatial, constructional praxis, and frontal/executive impairment. It takes just 1–2 min. The advantage of this scale is that it is relatively free from bias due to education, language, or cultural factors.[85] It is used as a screening test.[84],[85],[86],[87],[88] The other advantage is that it is fast, requires no training, and most scoring methods are fairly simple. The scale has high sensitivity and specificity with a high negative predictive value. It is simple to administer and also reflects frontal and temporoparietal functions. Furthermore, scores are not significantly affected in the presence of depression alone. The major limitation of the scale is that it assesses a very narrow part of cognition, and other neurological disorders like stroke directly affect it.[74] It is deplorable in differentiating various subtypes of dementia.[89],[90],[91],[92] The scale has no role in monitoring or measurement of severity of dementia, not suitable for illiterate peoples. Opinion is also divided over the merits of the CDT to detect early, mild changes in cognition, and, therefore, its usefulness alone as a screening test. For those who are not customed with paper and pen, performance will be poor. The scoring system is not uniformly accepted; at least 15 different scoring systems have been tested, with some allocating over 30 marks. Opinion is divided as to which method is the best.[86],[87],[88],[89] The scale has a very low positive predictive value. In Indian settings, many older people are not able to read time; many are not familiar with the clocks and use different numerical symbols or pronunciation different in their colloquial language, which can influence the results. The psychometric properties have not been assessed in different treatment, research, or community settings in the Indian population.

Mini-Cog

The scale is a combination of CDT and the three-word recall test. A score of 3–5 is a low likelihood of cognitive impairment, whereas a score of 0–2 is a high likelihood of dementia. The psychometric properties, uses, advantages, or disadvantages are almost similar to the CDT. It showed comparable sensitivity and specificity to the MMSE in classifying community-based cases of cognitive impairment or dementia. The only difference is that it improves memory testing.[93] It is very useful in a primary care setting or community treatment setting to screen for dementia.[94] The test has no value in either monitoring disease progression or rating severity.

Mental Test Score and Abbreviated Mental Test Score

Mental Test Score (MTS) and its abbreviated version are brief instruments to assess the degree of cognitive function, particularly memory and orientation. MTS takes 8–10 min to administer and the abbreviated form 3–5 min.[95] MTS has 34 items, and a score of ≥25 (out of 34) was within a normal range. AMTS was shortened to 9 or 10 items (an item is optional). A cutoff score 7/8 out of 10 or 6/7 out of 9 is suggested to differentiation between cognitive impairment and the normal person.[96] It includes components requiring intact short- and long-term memory, attention, and orientation. AMTS can be easily used in emergency settings and primary and secondary care nonspecialist settings. It is easy to administer without any bias of education, culture, or language. It has good sensitivity and specificity. The major limitation is that it assesses only a narrow part of cognitive function, has a low positive predictive value, and does not examine the frontal/executive or visuospatial functions. It does not seem to differentiate subtype of dementia.[97],[98] A second-stage comprehensive evaluation of the patient for cognitive impairment is always required. Familiarity has led to numerous adaptations of the questions, leading to questionable validity. The culture-specific questions are not included. From India, there are very limited validity data. The validity and significance of scale from the Indian perspective is questionable as questions such as the date of the First World War and the name of the monarch carry no relevance. The scale needs to be modified according to Indian culture and validation of tool in a different setting.

There is also a four-question version of the AMT (the AMT4), using the questions age, date of birth, place, and year only. AMT 4 also has a good correlation property with other scales. It is easy, quicker to perform, and easier for an investigator to remember, which may increase the chances of using it in busy hospital settings such as emergency among the elderly.[99]

Test your memory

It is a recently developed test with 10-item self-rated cognitive examination under medical supervision.[100] The total score ranges from 10 to 50, with a score ≤30, has good sensitivity and specificity (comparable to MMSE and Addenbrookes Cognitive Assessment–Revised) in distinguishing dementia from nondementia.[101] The test is very useful in primary care settings or gathering the information in a community in a short span of time. The scale is not tested in Indian settings; hence, usefulness is questionable.

The General Practitioner Assessment of Cognition

The scale has similarities with the Mini-Cog. There are also brief components testing recent memory and orientation.[102] A short informant questionnaire is performed in those patients with an intermediate score for the first part of the questionnaire. It usually takes 5–6 min to administer.[103] It has 15 questions, out of which 9 are for patients and 6 for informants. The scale has good sensitivity and specificity comparable with MMSE in detecting cognitive impairment in primary care settings.[104] The scale is suited to the multicultural population. Although it has been translated into several languages, research is lacking on how different cultures and languages impact the test's results. In addition, this test requires the physical ability to write/draw. The scale validation has been done in an urban setting, but most older adults live in a rural area in India. Hence, it is crucial to assess the validity of the instruments for detecting risk for cognitive impairment in rural elderly populations, which are also characterized by limited formal education. In India, most elderly people have not capacity to cope with complex instructions and unfamiliar tasks and which may lead to an overestimation of cognitive impairment risk

Addenbrooke's Cognitive Examination

The Addenbrooke's Cognitive Examination (ACE)[105] and its commonly used revision of the ACE-R[106] was initially developed as a screening for dementia. It takes 15–20 min to administer and includes items from MMSE and CTD. The scale has very high reliability and excellent diagnostic accuracy. A score of <87 indicates a significant cognitive impairment. Those people who do not have clinical dementia have a low score predictive of future development of dementia.[105],[107] The ACE is reported to have a better ability than the MMSE to detect subcortical dementia syndromes. Initially, it was also supposed to distinguish Alzheimer dementia from frontotemporal dementia, but not evident in subsequent research.[108] The years of education can impact the screening of older persons like the use of irregular words, phonemic verbal fluency, naming task, and constructional abilities. Age is another limiting factor that is found to be associated with poor performance on ACE. Although the ACE has been translated into different languages, translation and cultural adaption have not been validated.

Memory impairment screen

The Memory Impairment Screen is a very brief four-item scale. It is easy to administer and takes 4–6 min to administer. The scale has good sensitivity and specificity in classifying dementia.[109] The scale ranges from 0 to 8. A score of ≤4 is considered a possible cognitive impairment. It can be used in primary care settings as an alternative of CDT, Mini-Cog, or General Practitioner Assessment of Cognition. The scale has the various limitations that it does not assess the executive function or visuospatial component and it is not suitable for illiterate peoples. The major limitation of the scale is that it cannot be used with persons who cannot read due to illiteracy or have a visual impairment. This test cannot distinguish a noncognitively impaired person from a person with cognitive impairment or depressive disorder.

Alzheimer's Disease Assessment Scale-Cognitive Section

It is a detailed cognitive assessment scale for dementia and takes about 45 min to administer.[110] To conduct the test requires a trained observer. It is a gold standard to measure a change in cognitive function in drug trials. It has a good sensitivity to change. It has 11 domains of cognitive function, including memory, language, and praxis. The length of the questionnaire makes it unsuitable for clinical settings.[111] The training of the interviewer is required before the administration of the scale. The limitation of the scale is that it involves paper and pencil to administer; those who are not customed may underperform on this test. The scale has not been translated and validated in Indian settings. Among the Indian population, cultural adaption requires. The level of education, presence of physical morbidities like Parkinson disorder, and hearing or visual impairment may affect the performance on the task. The scale is generally not used for people with higher severity of cognitive impairment.

Cambridge Assessment of Memory and Cognition

The Cambridge Mental Disorders of the Elderly Examination (CAMDEX) is a structured schedule for the assessment of cognition in the elderly, including structured history-taking from the patient and an informant, a structured examination, and a mental state assessment.[112] The Cambridge Assessment of Memory and Cognition (CAMCOG)[113] is the cognitive section of this comprehensive CAMDEX assessment. CAMCOG shares the domains of MMSE and covers abstract thinking, perception, and praxis. The total score is up to 107, and a score of <80 indicates the diagnosis of cognitive impairment.[113] It usually takes 25–45 min to complete the evaluation of the cognitive section and requires a modest degree of training.[114] The major limitation is that it is not suitable for clinical settings. In a selected sample of patients with suspected cognitive impairment, the CAMCOG had moderately better sensitivity and specificity to detect dementia than standardized criteria than either the AMT or MMSE.[108] In addition, it had a sensitivity of 92% and specificity of 96% to detect 'organic' mental impairment in a cohort of elderly people, compared to a sensitivity of 94% and specificity of 85% for the MMSE (cutoff of <24) in the same sample.[114] However, the combination of the CDT with the MMSE offered equivalent sensitivity and specificity in detecting dementia to the longer CAMCOG in a psychogeriatric outpatient setting.[112] The scale should not be used with clients with severe cognitive impairment. The scale's items related to aphasia and upper extremity paresis might not be tested on all clients, and appropriate use depends on stroke severity. A ceiling effect was found in 2 out of 10 orientation items, 8 out 17 language items, 2 out of 13 memory items, 1 out of 8 praxis items, and 1 out of 3 perception items in various studies. The psychometric properties have not been studied in Indian population.

Psychometric properties of different scales used to assess the cognitive function are given in [Table 2].
Table 2: Comparison of psychometric properties of rating scales for cognitive function

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A key consideration in deciding what dementia assessment scales to choose is to clarify the question being asked. Consensus guidelines have been attempted.[115],[116] Most of the brief screening instruments like clock drawing and AMTS are probably psychometrically as good as a common instrument like MMSE in screening for significant cognitive impairment and are a little shorter. The scale-like MMSE and Montreal Cognitive Assessment are comparatively longer with certain limitations; use is limited to certain situations. For research purposes, the properties of an instrument should be entirely different and cover each cognitive function domain with a trained professional. The following are the recommendations from certain guidelines or health experts to evaluate a person present with dementia or cognitive impairment [Flowchart 2].




  Conclusion Top


It can be concluded that rating scales can be helpful in the screening of depression and dementia or comorbid depression and dementia, but no scale is perfect. The clinician should decide the use of the scale keeping in mind certain facts: the purpose of scale whether for research or clinical, self-rated, or interviewer based with good psychometric properties, intend to measure the symptoms, and for screening, diagnostic or response to therapy. The scales should be used as a helping diagnostic tool, not as a replacement for detailed clinical interview. The detailed history from the informant and reliable informant is the gold standard to diagnose or label a disease. It is evident and recommended that comprehensive geropsychiatric assessment is more effective rather than using a single modality. There is a need of scales specific to Indian culture. Examination of the patient, observation, information from the reliable informant, and instrument must be the standard gold practice to examine the patient for any psychiatric disorders.

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Conflicts of interest

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