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A New Rating Scale for Alzheimer’s Disease

Wilma G. Rosen, Ph.D., Richard C. Mohs, Ph.D., and Kenneth L. Davis, M.D.

items from all three categories, although evaluation of

A new rating instrument, the Alzheimer’s Disease cognition is limited and multiple cognitive functions
Assessment Scale, was designed specifically to are rated on single items. Critical shortcomings of the
evaluate the severity of cognitive and noncognitive Sandoz scale include lack of justification for item
behavioral dysfunctions characteristic of persons selection and poorly established interrater reliability.
with Alzheimer’s disease. Item descriptions, Geriatric psychopharmacologic research has become
administration procedures, and scoring are outlined. directed increasingly toward amelioration of decline in
Twenty-seven subjects with Alzheimer’s disease and memory functions associated with normal aging and
28 normal elderly subjects were rated on 40 items. organic disorders, with Alzheimer’s disease receiving
Twenty-one items with significant intraclass much attention. Psychopharmacologic studies of pa-
correlation coefficients for interrater reliability tients with Alzheimer’s disease have used rating scales
(range, .650-.989) and significant Spearman rank- ( 1 1 ) or structured psychological tests of memory and
order correlation coefficients for test-retest reliability other cognitive abilities (12, 13). The latter approach
(range, .514-1) constitute the final scale. Subjects precludes research with more impaired patients who
with Alzheimer’s disease had significantly more cannot perform the tasks. The former approach is
cognitive and noncognitive dysfunction than the deficient because the scales either fail to rate primary
normal elderly subjects. characteristics of Alzheimer’s disease or include items
(AmJ Psychiatry 141:1356-1364, 1984) irrelevant to the disease.
In contrast to the nonspecificity of available scales,
the rating scale presented here is designed specifically
T he few rating
search with
scales
elderly
designed
demented
specifically
persons have
for re-
two
for the evaluation
cognitive and noncognitive
of severity of major
behaviors
dysfunctions
characteristic
in
of
major flaws (1). First, insensitivity to the range of persons with Alzheimer’s disease. Since the amount of
impairment results in scales appropriate for only very research in Alzheimer’s disease has accelerated in
demented (2-4) or mildly demented (5) persons. Sec- recent years and is likely to increase, the need for a
ond, most scales evaluate problems in only one or two rating instrument specific to Alzheimer’s disease is
categories: behavioral disorders (2, 5-7), mood states apparent. In this report we present a rating scale
(2-5), or cognitive functions (6, 8, 9). One widely used designed for this purpose. We provide information
scale in geriatric psychopharmacologic research, the about interrater reliability, test-retest reliability, and
Sandoz Clinical Assessment-Geriatric (10), includes concurrent validity of the rating scale for persons with
presumed Alzheimer’s disease and for normal elderly
subjects. We show that the scale is a valid indicator of
Presented at the annual meeting of the American College of the increasing severity of dysfunction occurring over
Neuropharmacology, San Juan, P.R., Dec. 14-17, 1982. Received time in Alzheimer’s disease.
Feb. 18, 1983; revisedJuly 21 and Dec. 23, 1983; accepted Feb. 22,
1984. From the Psychiatry Service, VA Medical Center, Bronx, N.Y.;
and the Departments of Psychiatry and Pharmacology, Mount Sinai
School of Medicine, New York, N.Y. Address reprint requests to Dr. METHOD
Mohs, Psychiatry Service (1 16A), VA Medical Center, 130 West
Kingsbridge Rd., Bronx, NY 10468.
The Alzheimer’s Disease Assessment Scale
Supported by grant AG-02219 from the National Institute on
Aging and by the Medical Research Service of the VA.
The authors thank Esterina D’Alessio, John DiMino, Edward The Alzheimer’s Disease Assessment Scale was de-
McCabe, Alison Ross, and James Shanahan for their participation. signed according to the following guidelines (14): 1)

1356 Am J Psychiatry 1 41 : I 1 November

, 1984
 ROSEN, MOHS, AND DAVIS

The scale rates the major characteristics of persons The Alzheimer’s Disease Assessment Scale was ad-
with Alzheimer’s disease, 2) these major characteristics ministered in approximately 45 minutes. Order of
are identified reliably, 3) the scale rates the range of administration was the word recall task, 10-minute
dysfunction from mild to severe dementia, 4) it can be semistructured interview, cognitive tasks, noncognitive
completed in a relatively short period of time, and 5) it behaviors, and word recognition task. A reliable infor-
is appropriate for patients in different environments. mant provided information about most of the subject’s
The major characteristics of Alzheimer’s disease in noncognitive behaviors for the week before the inter-
patients identified in histopathologically verified cases view.
(15-19) or observed in persons with a clinical diagno-
sis of Alzheimer’s disease (20-23) were classified into Subjects
two broad categories: cognitive dysfunctions and non-
cognitive dysfunctions. The primary cognitive func- The subjects with Alzheimer’s disease were 19 men
tions sampled included components of memory, lan- and eight women who ranged in age from 54 to 80
guage, and praxis, while the noncognitive functions years (mean±SD=65.1±7.4 years) and had 12-20
sampled included mood state and behavioral changes. years of education (mean ± SD = 1 4.6 ± 2.6 years). The
Initially the Alzheimer’s Disease Assessment Scale duration of illness was 1-8 years (mean=3.3 years).
was composed of 40 items (see appendix 1). Thirty- Subjects were unmedicated for at least 2 weeks before
three items were rated on a scale of severity of testing. Diagnosis of Alzheimer’s disease was based on
dysfunction ranging from 0 to S (0=no impairment, complete neurological and psychological examinations
1=very mild, 2=mild, 3=moderate, 4=moderately and appropriate laboratory tests to eliminate other
severe, S=severe). The remaining items were rated on causes of dementia (28), alcoholism, confounding neu-
the presence or absence of the characteristic (1 =pres- rological conditions, and major psychiatric disorders.
ent, 0=absent), the severity (0-2), number of errors All subjects had a history of cognitive impairment with
(item 15), and mean number of errors (items 16 and insidious onset and progressive decline. The number of
17). Definitions of all items were provided; specific their correct responses on an adapted 20-point Memo-
descriptions of performance or behavior corresponded ry-Information Test (29) ranged from 0 to 18
to rating scale points, except for items 16 and 17. (mean±SD=6.6±6.0). The subjects’ scores on the
Cognitive functioning was assessed on items 1-17. Dementia Rating Scale (29) ranged from 1 to 15
Memory functions were evaluated with orientation (mean ± SD = S .4 ± 3 .2). These two measures correlated
questions; with a 10-word, three-trial recall task; with significantly with histopathological changes character-
a 12-word, three-trial recognition task, and by ability istic of Alzheimer’s disease (29).
to remember recognition task instructions (items 3 and The normal elderly subjects were 10 men and 18
15-17). Word recognition and recall tasks are sensitive women who ranged in age from 55 to 73 years
to pharmacologic agents affecting the cholinergic sys- (mean±SD=61.7±5.3 years) and had 12-18 years of
tem (24, 25). Language functions were assessed on education (mean ± SD = I 4.8 ±2.5 years). The subjects
items 1, 2, and 4-12. Two items required performance showed no evidence of significant neurological or
on specific tasks: following one- to five-step corn- psychiatric disorder. Their scores on the Memory-
mands (26) (item 11) and naming fingers and 12 real Information Test ranged from 16 to 20 (mean±SD=
objects of variable word-frequency values (27) (item 19±1), and their scores on the Dementia Rating Scale
12). The other nine language items rated expressive ranged from 0 to 2.5 (mean±SD=0.4±0.6).
and receptive language observed during a semistruc- The normal subjects were significantly younger than
tured interview. A five-part ideational praxis task those with Alzheimer’s disease (t=2.72, df=53,
(item 14) required the patient to put a letter in an p<.01, two-tailed), but the groups did not differ
envelope, to seal, stamp, and address it to himself or significantly in education (t<1). Alzheimer patients
herself. Assessment of constructional praxis (item 13) were significantly impaired, compared with the normal
required copying four increasingly complex geometric subjects, on the Memory-Information Test (t=10.S1,
forms. The maxImum score on the composite cognitive df=53, p<.0001, two-tailed) and the Dementia Rating
functions subscale (items 1-15) was 70. The maximum Scale (t=7.99, df=53, p<.0001, two-tailed).
error score for word recall was 10 and for word For comparison of scores on the Alzheimer’s Disease
recognition, 12. Assessment Scale, 15 subjects from each group were
Noncognitive behaviors were rated on 23 items. matched for sex (eight men and seven women), age
Evaluation of mood state included items relevant to within 4 years (normal subjects, 63.3 years; Alzheimer
depression, anxiety, and vegetative symptoms (items subjects, 63.7 years; t<1), and education level within 2
18, 19, 31, 35-37, 39, and 40). Items rating behavioral years (normal subjects, 14.2 years; Alzheimer subjects,
disorders (items 20-30, 32-34, and 38) pertained to 14.5 years; t<1). Alzheimer patients were significantly
socialization skills, cooperation, initiative for activities impaired, compared with the normal subjects, on the
of daily living, psychotic symptoms, motor activity, Memory-Information Test (mean scores of 4.5 and 19,
agitation, concentration, and nocturnal confusion. The respectively; t= 1 0.5, df= 14, p< .0001 , two-tailed)
maximum score on the composite noncognitive behav- and the Dementia Rating Scale (mean scores of 4.9 and
ioral subscale (items 18-40) was 99. 0.7, respectively; t=8, df=14, p<.000l, two-tailed).

Am J Psychiatry 141:1 1, November 1984 1357

A NEW RATING SCALE FOR ALZHEIMER’S DISEASE

Procedure TABLE 1 Baseline Scores on the Alzheimer’s Disease Assessment

.

Scale of 27 Subjects With Alzheimer’s Disease and 28 Normal

Elderly Subjects, Interrater Reliability, and Test-Retest Reliability
Two raters, blind to each other’s scores but not to
the subject’s diagnosis, evaluated every subject to Interrater
obtain interrater reliability. One rater conducted the Reliability
interview and task administration. A second evalua- (intraclass Test-Retest
Score . . .
correlation Reliability
tion occurred 1-2 months later (with 18 Alzheimer
Group Mean SD coefficient) (r,)
subjects and 26 normal subjects) to determine test-
Subjects with
retest reliability. A third interview was conducted 12
Alzheimer’s disease
months after the initial session (with 10 Alzheimer Cognitive subscale 23.2 13.3 .989a .915a
subjects and 10 normal subjects) to determine the Noncognitive subscale 11.5 6.7 947a .S88a
validity of the scale as a measure of increased dysfunc- Total scoreb 34.7 18.4 .986a .838a
tion in Alzheimer’s disease. Measures of concurrent Normal elderly subjects
Cognitive subscale 2.0 1.9 .968a .646a
validity with Alzheimer subjects were the Sandoz 5#{216}9c
Noncognitive subscale 6.3 3.8 .826a
Clinical Assessment-Geriatric (N= 17), the Memory- Total scoreb 8.3 4.8 .894a 574c
Information Test (N=27), and the Dementia Rating
ap<.001.
Scale (N=27). bD not include items 16 and 17.
Cp<.Oi.

RESULTS
tion of poor interrater reliability at retest, since intra-
Interrater Reliability class coefficients of these retest scores were significant
(p<.Ol). For the normal elderly group, significantly
Interrater reliability for each item was determined reliable cognitive behavior items were 3, 5, 6, 8, 12-
for each group separately with the intraclass correla- 14, 16, and 17. Inspection of means and standard
tion coefficient (30), except for items 16 and 17, which deviations of nonsignificant cognitive items 1, 2, 11,
were not subject to rater judgment. In this statistic, and 15 revealed extremely small changes. For the
correlations between raters are determined from van- normal elderly group there were 15 reliable noncogni-
ances obtained in a two-factor (raters and subjects) tive items (items 18, 22, 24, 27-30, 32, and 34-40).
analysis of variance. For the patients with Alzheimen’s For both groups subscale and total scores had signifi-
disease, 37 items had highly significant interrater cant test-retest reliability (table 1), with r5 values
reliability, with correlations ranging from .650 to .989 ranging from .509 to .915. On each measure the r5 for
(p<.Ol). For the normal elderly subjects, 38 items had the Alzheimer group was greater than the r5 for the
significant correlations ranging from .658 to 1 normal group, thus indicating less variability in Alz-
(p<.Ol). The nonsignificant items were items 10, 25, heimer’s disease.
and 33 for Alzheimer patients and items 2 and 30 for Practice effects were examined with the Wilcoxon
the normal subjects. The mean, standard deviation, matched-pairs signed ranks test. Alzheimer patients
and intraclass coefficients for the cognitive subscale, showed no significant change on individual items,
noncognitive subscale, and total score for both groups subscales, and total. Normal subjects had significantly
are presented in table 1. lower scores at retest on item 12 (N 12, T=0,
p<.Ol), item 23 (N=17, T=33, p<.OS), the cognitive
Test-Retest Reliability subscale (N= 18, T24, p<.Ol), the noncognitive
subscale (N=26, z=1.83, p=.O34), and total (N=2S,
The means of two raters’ scores on each item for T=61, p<.Ol).
each subject at initial testing and 1- to 2-month
retesting were used to determine test-retest reliability Final Form of the Scale
with the Spearman rank-order correlation (r). In the
Alzheimer group cognitive behaviors measured on Since this scale was designed primarily for Alz-
items 1-4 and 10-17 were highly stable, with r, values heimer’s disease, interrater reliability and test-retest
ranging from .579 (p<.OS) to .919 (p<.OO1). Scores reliability of Alzheimer patients’ scores were more
on items 5-9, which rated specific characteristics of crucial for determination of the final form of the
speech, were variable (p>.lO). Patients showed more Alzheimer’s Disease Assessment Scale than was per-
fluctuation on noncognitive behaviors. Ten items with formance of the normal subjects. Thus, only those
significant retest reliability pertained to mood state, items with significant interrater reliability and test-
concentration, lack of cooperation with testing, psy- retest reliability for Alzheimer patients constitute the
chotic symptoms, and motor activity (items 18-21, final form. The 21 items of the final scale are items 1-
27-29, 32, 34, and 40). Thirteen unreliable items 4, 11-21, 27-29, 32, 34, and 40, which appear on the
included uncooperativeness, initiative for activities, score sheet (see appendix 2). The cognitive subscale
socialization, fidgeting, psychic anxiety, and sleep dis- has nine items and a maximum score of 48 points; the
turbance. Nonsignificant correlations were not a func- maximum score on the two memory tasks is 22 points;

1358 Am J Psychiatry 1 41 : 1 1 November

, 1984
 ROSEN, MOHS, AND DAVIS

TABLE 2. Correlation Between Scores of 15 Subjects With Alz- indicate significant group differences. Patients with
heimer’s Disease and 15 Matched Normal Elderly Subjects on 21 Alzheimer’s disease were significantly more impaired
Items of the Alzheimer’s Disease Assessment Scale
than the normal subjects on every cognitive item
Itema rb Significance (p<.000l), the cognitive subscale score (r.754,
1. Spoken language ability .692 p<.000I
df= 14, p<.0001), both memory tasks (p<.0001),
2. Comprehension of spoken language .643 p<.000l three noncognitive items (items 18, 20, and 40), and
3. Recall of test instructions .615 p<.0001 the noncognitive subscale score (r= .487, df 14,
4. Word-finding difficulty .714 p<.0001
p<.003).
1 1. Following commands .715 p<.0001 The subscale scores and total score obtained at
12. Naming: objects, fingers .673 p<.0001
13. Constructions: drawing .668 p<.0001
baseline and 12-month retest were compared with the
14. Ideational praxis .581 p<.000l Wilcoxon matched-pairs signed ranks test for 10 Alz-
is. Orientation .835 p<.0001 heimer and 10 normal elderly subjects (table 3). On all
16. Word recall .834 p<.0001
measures only the group with Alzheimer’s disease
17. Word recognition .818 p<.0001
18. Tearful
showed a significant increase in severity of dysfunction
.316 p.04S
19. Depressed mood .168 n.s. from baseline to retest. On each measure eight Alzhei-
20. Concentration/distractibility .530 p<.OO1 mer subjects had greater scores at the 12-month retest
21. Uncooperative to testing .242 n.s. than at baseline.
27. Delusions -.064 n.s.
The Sandoz Clinical Assessment-Geriatric score cor-
28. Hallucinations 0 n.s.
29. Pacing .116 n.s.
related significantly with the nine-item cognitive sub-
32. Motor activity increase 0 n.s. scale (r=.668, df=16, p<.Ol) and 21-item total score
34. Tremors .247 n.s. (r=.519, df=16, p<.O2) but nonsignificantly with the
40. Appetite change .369 p=022
10-item noncognitive subscale (r=.252, df16,
altem numbers are from scale in appendix 1.
p>.lO). The score on the Memory-Information Test
bJ5jj biserial correlation.
correlated significantly with the cognitive subscale
score, noncognitive subscale score, and the total score
TABLE 3. Baseline and 12-Month Retest Scores on the Alzheimer’s (r-.77S, df=26, p<.OOl; r-.419, df26, p<.02;
Disease Assessment Scale of 10 Subjects With Alzheimer’s Disease r= - .667, df=26, p<.OO1, respectively). The score on
and 10 Normal Elderly Subjects
the Dementia Rating Scale correlated with the cogni-
Baselin e Score I 2-Mont h Score tive score, noncognitive score, and total score (r=.484,
df=26, p<.Ol; r.455, df26, p<.Ol; r.642,
Group Mean SD Mean SD
df=26, p<.OOl, respectively).
Subjects with Alzheimer’s
disease
Cognitive subscale 14.8 15.7 20.02 17.7
Noncognitive subscale 2.6 1.1 4#{149}#{216}b2.8 DISCUSSION
Total score 29.0 13.6 36.8c 19.4
Normal elderly subjects
The Alzheimer’s Disease Assessment Scale was de-
Cognitive subscale 1.0 1.1 0.8 0.9
Noncognitive subscale 1.3 0.9 1.2 1.1
signed as a rating scale for the severity of dysfunction
Total score 5.7 2.2 4.3 1.6 in cognitive and noncognitive behaviors characteristic
ap= .01 ; one-tailed Wilcoxon matched-pairs signed ranks test for all compari-
of persons with Alzheimer’s disease. On the initial 40-
Sons. item scale 37 items had high interrater reliability for
bp=.03.
Cp.02_
ratings of Alzheimer subjects, thus yielding very high
interrater reliability on subscales and total scores. Test-
retest reliability of 40 items indicated that Alzheimer
the noncognitive subscale has 10 items and a maxi- subjects showed a moderate to high degree of stability
mum score of SO points. The mean (±SD) cognitive on nine cognitive subscale items, two memory tasks,
subscale score (original items 1-4 and 1 1-1 7) for and 10 noncognitive subscale items. The final scale is
Alzheimer patients (N=27) was 19.3±12.1. The mean composed of items with significant interrater and test-
noncognitive subscale score (original items 1 8-2 1 , 27- retest reliability for Alzheimer patients. On this 21-
29, 32, 34, and 40) was 4.4±3.5. The mean total item form, cognitive items and memory tasks account
score, including items 16 and 17, was 37.0± 17.5). The for approximately 60% of possible total points. These
cognitive and noncognitive subscale scores correlated stringent inclusion criteria for final scale items were
significantly (r=.S88, df=26, p<.OOl). The total score adopted because the scale’s potential usefulness as an
correlated significantly with the cognitive subscale outcome measure in various types of investigations
score (r=.824, df=26, p<.OOl) and the noncognitive requires items that can be rated reliably by indepen-
subscale score (r=.666, df=26, p<.OOl). dent judges and that reflect relatively stable character-
A point-biserial correlation was used to compare istics of patients.
scores on the 21 items, subscales, and total for 15 Five cognitive subscale items and 1 1 noncognitive
matched Alzheimer patients and normal subjects (table subscale items showed nonsignificant test-i-month
2). In this statistic, groups are dichotomized into retest reliability for Alzheimer’s disease. Sources of
demented versus normal, and significant correlations variance in the test-retest method that may lead to

AmJ Psychiatry 141:11, November 1984 1359

 A NEW RATING SCALE FOR ALZHEIMER’S DISEASE

underestimation of reliability are variations in patients Alzheimer’s Disease Assessment Scale is not intended
at each test session, a long time interval between test for use as a diagnostic instrument.
sessions, and changes in raters’ conceptions of items. Test-retest performance by normal elderly subjects
Since the slow, progressive course of Alzheimer’s dis- reflected problems inherent in repeated administration
ease yields increasing dysfunction over years rather of the same test. These subjects showed overall im-
than months, no decline in a 1- to 2-month interval is provement in both subscale and total scores, thus
expected, and our patients did remain stable. While a suggesting a positive adjustment to the test situation.
change in raters’ conceptualization of items cannot be In contrast, Alzheimer patients showed no significant
shown, factors which mitigate this possibility are that improvement on repeated testing.
specific criteria for each item guided ratings and that The Alzheimer’s Disease Assessment Scale appears
six raters participated in various paired combinations to be a potentially useful instrument for assessment of
during the study. The intraclass coefficient statistic severity of dysfunction and for research in patients
assumes that judges are interchangeable, and these with Alzheimer’s disease, including psychopharma-
cOefficients at retesting revealed significant interrater cologic studies, evaluation of care-giving environ-
reliability on all items with nonsignificant test-retest ments, and longitudinal studies. Since the symptoms of
reliability. Most likely, items with nonsignificant test- Alzheimer’s disease and other dementias, e.g., multi-
1-month retest reliabilities reflect behavioral fluctua- infarct, overlap to some extent, the Alzheimer’s Dis-
tions in Alzheimer patients from session to session. ease Assessment Scale may be applicable to other
The Alzheimer’s Disease Assessment Scale appears dementias.
sensitive to increasing dysfunction as the disorder
progresses, since eight of 10 Alzheimer patients
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 ROSEN, MOHS, AND DAVIS

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27. Thorndike EL, Lorge I: The Teacher’s Word Book of 30,000 Subject Rater ____________
Words. New York, Teachers College, Columbia University,
1944 Protocol __________________ Date ____________
28. Wells CE: Diagnostic evaluation and treatment in dementia, in
Dementia. Edited by Wells CE. Philadelphia, FA Davis, 1977 Rating Scale
29. Blessed G, Tomlinson BE, Roth M: The association between * Not assessed
quantitative measures and degenerative changes in the cerebral
gray matter of elderly patients. Br J Psychiatry I 14:797-811, 0=Not present
1968 lVery mild
30. Guilford JP, Fruchter B: Fundamental Statistics in Psychology 2=Mild
and Education. New York, McGraw-Hill, 1978 3 = Moderate
31. Davis KL, Hsieh JY, Levy MI, et al: Cerebrospinal fluid 4 = Moderately severe
acetylcholine, choline, and senile dementia of the Alzheimer’s SSevere
type. Psychopharmacol Bull 18:193-195, 1982
32. Levy MI, Mohs RC, Rosen WG, et al: Research subject
Cognitive Behavior
recruitment for gerontological studies of pharmacological
agents. Neurobiol Aging 3:77-79, 1982
1. Spoken language
ability
2. Comprehension of spoken language
APPENDIX 1. Original 40 Items on the Alzheimer’s Disease Assess- 3. Recall of test instructions _________
ment Scale 4. Word-finding difficulty
S. Following commands _______
Item 6. Naming: objects, fingers
1. Spoken language ability (scale range, 0-5) High: 1 2 3 4 Fingers: Thumb
2. Comprehension of spoken language (0-5) Medium: 1 2 3 4 Pinky Index
3. Recall of test instructions (0-5) Low: 1 2 3 4 Middle Ring
4. Word-finding difficulty (0-5) 7. Constructions: drawing
S. Excessive talking (0-5) Figures correct: 1 2 3 4
6. Poverty of speech (0-5) Closing in: Yes No _____ _____
7. Paraphasia: semantic (0-5) 8. Ideational praxis
8. Paraphasia: phonemic (0-5) Step correct: 1 2 3 4 5
9. Palilalia (0-1) 9. Orientation _________
10. Echolalia (0-1)
11. Following commands (0-5) Day Year _____ Person _____ Time of day
12. Naming: objects, fingers (0-5)
13. Constructions: drawing (0-5) Date _____Month ______ Season _______ Place ______
14. Ideational praxis (0-5)
Is. Orientation (0-8) 10. Word recall: mean error score _________
16. Word recall (0-10) 11 . Word recognition: mean error score _________
17. Word recognition (0-12) Cognition total ________

Am J Psychiatry 1 41 : 1 1 November, 1984 1361

 A NEW RATING SCALE FOR ALZHEIMER’S DISEASE

Noncognitive Behavior
1=very mild; one instance of misunderstanding
2=mild
12. Tearful ________ 3=moderate
13. Appears/reports depressed mood ________ 4=moderately severe; requires several repetitions and
14. Concentration, distractibility
rephrasing
15. Uncooperative to testing
S = severe; patient rarely responds to questions appropri-
16. Delusions ________ ately, not due to poverty of speech
17. Hallucinations ________
18. Pacing 3. Recall of test instructions. The patient’s ability to re-
19. Increased motor activity member the requirements of the recognition task is
20. Tremors ________ evaluated. On each recognition trial, the patient is asked
21. Increase/decrease appetite prior to presentation of the first two words, “Did you
Noncognition total ________ see this word before or is this a new word?” For the
third word, the patient is asked, “How about this one?”
Total Scores If the patient responds appropriately, i.e., “yes” or
“no,” then recall of instructions is accurate. If the
Cognitive behavior ________ patient fails to respond, this signifies that the insttuc-
Noncognitive behavior ________ tions have been forgotten. Then instruction is repeated.
Word recall _________ The procedure used for the third word is repeated for
Word recognition words 4-24. Each instance of recall failure is noted.
Total ________ 1 very mild; forgets once
2=mild; must be reminded two times
3=moderate; must be reminded three or four times
ADMINISTRATION AND SCORING PROCEDURES
4=moderately severe; must be reminded five or six
times
The word recall task is administered first. The next 10
Ssevere; must be reminded seven or more times
minutes are spent in open-ended conversation in order to
assess various aspects of expressive and receptive speech. 4. Word-finding difficulty in spontaneous speech. The pa-
Then the remaining cognitive tasks are administered. Non- tient has difficulty in finding the desired word in sponta-
cognitive behaviors are evaluated from report of the patient neous speech. The problem may be overcome by circum-
or reliable informant or observed during the interview. If the locution, i.e, giving explanatory phrases or nearly satis-
patient has more than a mild memory impairment, ratings on factory synonyms. Do not include finger and object
behavioral items are based on the informant’s report. naming in this rating.
The rating scale of 0-S reflects the degree of severity of
1 =very mild; one or two instances, not clinically signifi-
dysfunction. A rating of 0 signifies no impairment on a task
cant
or absence of a particular behavior. A rating of 5 is reserved
2=mild; noticeable circumlocution or synonym substi-
for the most severe degree of impairment or very high
tution
frequency of occurrence of a behavior. A rating of 1 signifies
3=moderate; loss of words without compensation on
a very mild presence of a behavior or corresponds to a
occasion
particular performance on a task. Ratings of 2, 3, or 4
4=moderately severe; frequent loss of words without
correspond to mild, moderate, and moderately severe, re-
compensation
spectively. Ratings on many cognitive behaviors correspond
S=severe; nearly total loss of content words; speech
to levels of performance on task.
sounds empty,; one-two-word utterances.

Cognitive Behavior S. Following commands. Receptive speech is assessed also

on the patient’s ability to carry out one- to five-step
Language. Language abilities are evaluated throughout the commands (26).
interview and on specific tests. Questions eliciting “yes” and
1. Make a fist.
“no” answers assess comprehension on a very basic level.
2. Point to the ceiling, then to the floor.
Other questions should require specific information and
well-developed communication skills. Line up a pencil, watch, and card, in that order, on a
table in front of the patient.
1 . Spoken language ability. This item is a global rating of
the quality of speech, i.e., clarity, difficulty in making 3. Put the pencil on top of the card, then put it back.
oneself understood. Quantity is not rated on this item. 4. Put the watch on the other side ofthe pencil and turn
over the card.
lvery mild; one instance of lack of understandability
S. Tap each shoulder twice with two fingers, keeping
2 = mild
. your eyes shut.
3=moderate; subject has difficulty 2S%-S0% of the
time Each underlined element represents a single step. The
4=moderately severe; subject has difficulty 50% of the command may be repeated once in its entirety. Each
time command scored is as a whole. Ratings correspond to
5=severe; one or two word utterances; fluent but empty the highest level of command correctly performed.
speech; mute
0=five steps correct
2. Comprehension ofspoken language. This item evaluates 1 = four steps correct
the patient’s ability to understand speech. Do not in- 2three steps correct
dude responses to commands. 3 = two steps correct

1362 Am J Psychiatry 1 41 : 1 1 November, 1984

 ROSEN, MOHS, AND DAVIS

4=one step correct . ac/a’c or a’c/ac ranges from .75 to 1.00. The ratio of
S=cannot do one step correctly bc/b’c or b’c/bc ranges from .60 to 1.00. The ratio
bb’/aa’ ranges from 3 to .75. Figure is incorrect if any
6. Naming objects and fingers. The patient names the
ratio is outside these ranges.
fingers of his/her dominant hand. The patient names 12
4. Cube. The form is three-dimensional, with front face
randomly presented real objects, whose frequency val-
in the correct orientation, internal lines drawn cor-
ues (27) are high, medium, or low. Objects and their
rectly between corners. If opposite sides of faces are
frequency are:
not parallel by more than 20#{176}
it is incorrect.
Frequency *2 Correct Incorrect 3. Model 4. Incorrect
High Medium Low
Flower (plastic) Rattle Wallet EJLT1
Bed (doll-house
furniture)
Mask Harmonica
__ n bb’

Whistle Scissors Stethoscope Ll\/

‘UI
Pencil Comb Tongs

0=all correct; one finger incorrect and/or one object

8. Ideational praxis. The patient is given an 8#{189}”
X I 1”
sheet of paper and a long envelope. The patient is
incorrect
1 two-three fingers and/or two objects incorrect instructed to pretend to send the letter to himself or
2two or more fingers and three-five objects incorrect herself. The patient is told to put the paper into the
envelope, seal it, address it to himself or herself, and
3=three or more fingers and six-seven objects incorrect
4=three or more fingers and eight-nine objects incorrect stamp If the patient
it. forgets part of the task, reinstruc-
tion is given. Impairment on this item should reflect
7. Constructional praxis. The ability to copy four geomet- dysfunction in executing an overlearned task only and
tic forms is assessed. These forms, in the order of pre- not recall difficulty. The five components to this task are
sentation, are 1) fold letter, 2) put letter in envelope, 3) seal envelope,
1. Circle, approximately 20 cm in diameter. 4) address envelope, 5) put stamp on envelope.

1=difficulty or failure to perform one component

2. Two overlapping rectangles 1 The vertical 2=difficulty and/or failure to perform two components
rectangle is 20 cm x 25 cm. The horizontal rectangle 3=difficulty and/or failure to perform three components
is 10 cm X 35 cm. 4=difficulty and/or failure to perform four components
5=difficulty and/or failure to perform five components
9. Orientation. The components of orientation are date,
3. Rhombus . Each side is 20 cm. AcuteSO#{176}, month, year, day of the week, season, time of day, place,
obtuse= 130#{176}. and person. One point is given for each incorrect
response (maximum = 8). Acceptable answers include
± 1 for the date, within I hour for the hour, partial name
for place, naming of upcoming season within 1 week
4. Cube . Each side is 20 cm. Internal lines are before its onset, and name of previous season for 2
present. weeks after its termination.

Each form is located in the upper middle of a S #{189}”

x 10. Word-recall task. The patient reads 10 high-imagery
8 #{189}”
sheet of white paper. The patient is instructed, “Do words exposed for 2 seconds each. The patient then
you see this figure? Make one that looks like this one recalls the words aloud. Three trials of reading and
anywhere on the paper.” Two attempts are permitted. recall are given. The score equals the mean number of
words not recalled on three trials (maximum= 10).
0=all four drawings correct
I =one form incorrect I 1. Word-recognition task. The patient reads aloud 12 high-
2two forms incorrect imagery words. These words are then randomly mixed
3=three forms incorrect with 12 words the patient has not seen. The patient
4=closing in (draws over or around model or uses parts indicates whether or not the word was shown previous-
of model); four forms incorrect ly. Then two more trials of reading the original words
S=no figures drawn; scribbles; parts of forms; word and recognition are given. The score equals the mean
instead of form number of incorrect responses for three trials (maxi-
mum= 12).
Scoring criteria for each form (examples shown be-
low*):
Noncognitive Behavior
1. Circle. A closed curved figure.
2. Two overlapping rectangles. Forms must be four-
The time period for evaluation includes the entire week
sided and overlap must be similar to presented form.
before the interview for the following items:
Changes in size are not scored.
3. Rhombus (diamond). Figure must be four-sided, 1. Appears or reports feeling sad, down, hopeless,
obliquely oriented, and the sides approximately discouraged
equal length. Four measurements are taken (see 2. Tearful
figure below*). These are ac, a’c, bc, b’c. The ratio of 3. Delusions

Am J Psychiatry I 4 1 : I 1 , November 1984 1363

A NEW RATING SCALE FOR ALZHEIMER’S DISEASE

4. Hallucinations 1 very mild; one transient delusional belief

S. Pacing 2=mild; delusion definitely present but subject ques-
6. Increased motor activity tions his or her belief
7. Increase/decrease in appetite 3=rnoderate; patient convinced of delusion but it does
not affect behavior
12. Tearful. Patient/informant is asked about the frequency 4=moderately severe; delusion has effect on behavior
of occurrence of tearfulness. S=severe; significant actions based on delusions
1 very mild; occurs one time during week or during test 17. Hallucinations. Inquiry about visual, auditory, and tac-
session only tile hallucinations is made. The frequency and degree of
2=mild; occurs two-three times during the week disruptiveness of hallucinations are rated.
3 = moderate
1 very mild; hears voice saying one word; visual hallu-
4=moderately severe; frequent crying spells nearly every
cination once
day
2=mild
S=severe; frequent and prolonged crying spells every
3=moderate; hallucinates numerous times during day,
day
which interferes with normal functioning
13. Depression. The patient or informant is asked if the 4 = moderately severe
patient has been sad, discouraged, down. If a positive S =severe; nearly constantly hallucinating, which totally
response is given, further inquiry into the severity and disrupts normal functioning
pervasiveness of the mood, loss of interest or pleasure in
18. Pacing. Rating on this item must distinguish between
activities, and reactivity to environmental events is
normal physical activity and excessive walking back and
made. The interviewer also assesses the patient for
forth. -
depressed facies and the ability to respond to encourage-
ment and jokes. 1 very mild; very rare occurrence
2=mild
1 #{176}#{176}feels
slightly dysphoric; clinically significant
3 = moderate; paces frequently each day
2=mild; appears and reports mild dysphoric mood,
4 = moderately severe
reactivity present, some loss of interest
S=severe; cannot sit still and must pace excessively
3 = moderate; feels moderately dysphoric often
4moderately severe; feels dysphoric almost all the time 19. Increased motor activity. This item is rated relative to
with considerable loss of reactivity and interest the person’s normal activity level or previously obtained
S=severe; pervasive and severe degree of dysphoric baseline.
mood; total lack of reactivity; pervasive loss of interest
1 very mild; very slight increase
or pleasure
2=mild

14. Concentration/distractibility. This item rates the fre- 3moderate; significant increase in amount of move-
ment
quency with which the patient is distracted by irrelevant
stimuli and/or must be reoriented to the ongoing task 4 = moderately severe
because of loss of train of thought or the frequency with Ssevere; person must be moving constantly; rarely sits
still
which the patient appears to be caught up in his or her
own thoughts. 20. Tremors. Patient extends both hands in front of body
and spreads the fingers, holding this position for ap-
1 very mild; one instance of poor concentration
2=mild; two-three instances of poor concentration or proximately 10 seconds.
distractibility 1 very mild; very slight tremor; barely noticeable
3 moderate
= 2=mild; noticeable tremor
4moderately severe; poor concentration throughout 3moderate
much of interview and/or frequent instances of distracti- 4 = moderately severe
bility S=severe; very rapid movements with sizable displace-
Ssevere; extreme difficulty in concentration and nu- ments
merous instances of distractibility
21 . Increased/decreased appetite. This item is included be-
IS. Uncooperative to testing. This item rates the degree to cause appetite change may be associated with depression
which the patient objects to some aspects of the inter- and because clinical observations of some Alzheimer
view. patients reveal both increases and decreases in appetite.
This item is rated relative to the person’s normal appe-
1 very mild; one instance of lack of cooperation tite or previously obtained baseline.
2=mild
3 = moderate lvery mild; slight change, probably clinically signifi-
4moderately severe; needs frequent cajoling to corn- cant
plete interview 2mild; noticeable change, patient still eats without
S severe; refuses to continue interview encouragement
3=moderate; marked change; patient needs encourage-
16. Delusions. This item rates
the extent and conviction of ment to eat; patient asks for more food
the patient’s belief in ideas that are almost certainly not 4 = moderately severe
true. In rating severity, consider conviction in delusions, Ssevere; patient will not eat and needs to be force-fed;
preoccupation, and effect they have on the patient’s patient complains of constant hunger despite consump-
actions. tion of sufficient quantities

1364 Am J Psychiatry 141:11, November 1984