Alzheimer’s & Dementia 5 (2009) 375–379

Severe Impairment Battery Language scale: A language-assessment

tool for Alzheimer’s disease patients
Steven Ferrisa,*, Ralf Ihlb, Philippe Robertc, Bengt Winbladd, Gudrun Gatze,
Frank Tennigkeite, Serge Gauthierf
a
Alzheimer’s Disease Center, New York University School of Medicine, New York, NY, and Nathan Kline Institute, Orangeburg, NY, USA
b
Department of Psychiatry, University of Düsseldorf and Department of Geriatric Psychiatry, Alexian Hospital, Krefeld, Germany
c
Memory Center, CHU - University of Nice Sophia Antipolis, Nice, France
d
Alzheimer Center, Karolinska Institutet, Stockholm, Sweden
e
Merz Pharmaceuticals, Frankfurt am Main, Germany
f
McGill Centre for Studies in Aging, McGill University, Montreal, Quebec, Canada

Abstract Background: Communication problems are common in Alzheimer’s disease (AD) patients, but in-
struments to assess these symptoms are limited. Our objective was to create a new scale, based on
the language subscale of the Severe Impairment Battery (SIB), as a sensitive and reliable measurement
of treatment effects on language performance.
Methods: All 24 items of the SIB language subscale were chosen for analysis. Baseline scores of
1320 moderate-to-severe patients (Mini-Mental State Examination [MMSE] score, ,15), from a com-
bined AD database of four Memantine clinical trials (Study Codes: IE-2101, MEM-MD-01, MEM-
MD-02, and MRZ-9605), were used for item reduction according to a standard principal components
factor analysis. All items with loadings .0.5 on the identified factors were selected for inclusion in the
new language scale. Correlations with existing AD scales were examined.
Results: The analysis indicated six factors, with 21 of 24 items showing loadings .0.5. The resulting
21-item SIB Language (SIB-L) scale exhibited high internal consistency (Cronbach’s a 5 0.809). The
maximal SIB-L score was 41 points, with a measurement error of 3.7 points. The stratification of base-
line SIB-L scores (mean, 31.7; SD, 8.4) by MMSE scores (mean, 9.7; SD, 3.3) showed a high variance
in SIB-L scores. This confirms that patients with a low MMSE score can possess preserved language
abilities. The SIB-L scale did not exhibit substantial floor-and-ceiling effects.
Conclusions: The new SIB-L is a fast (,15 minutes) and easily administered scale with favorable
psychometric characteristics for assessing language impairment and treatment effects on the language
performance of patients with moderate to severe AD.
Ó 2009 The Alzheimer’s Association. All rights reserved.
Keywords: Alzheimer’s disease; Clinical trial; Severe Impairment Battery; Language; Scale

1. Introduction tives and caregivers have increasing difficulties understand-

ing patients and their needs, which worsens the situation
The progression of Alzheimer’s disease (AD) is accompa-
and leads to even more patient distress [1]. For example, be-
nied by progressive language impairment, resulting in disor-
cause demented patients are often unable to express painful
dered communication between patients with AD and their
conditions verbally, a high portion of nursing-home patients
caregivers. This causes major distress for patients who are was shown to receive inadequate palliative care [2–4]. Un-
no longer able to express themselves adequately and maintain
treated or undertreated pain can increase the effect of cogni-
their usual social habits and relationships. Conversely, rela-
tive impairment and result in depression, sleep disturbances,
and disruptive behavior [5,6]. Therefore, treatments improv-
*Corresponding author. Tel.: 212-263-5703; Fax: 212-263-6991. ing language abilities might enable a more sensitive pain as-
E-mail address: steven.ferris@nyumc.org sessment and more efficient pain management, leading to
1552-5260/09/$ – see front matter Ó 2009 The Alzheimer’s Association. All rights reserved.
doi:10.1016/j.jalz.2009.04.1236
376 S. Ferris et al. / Alzheimer’s & Dementia 5 (2009) 375–379
substantially enhanced quality of life for both patients and
their relatives/caregivers.
Despite the immense importance of language perfor-
mance, only a few rating scales include evaluations of symp-
toms specifically related to it. This may be because most
scales were designed to focus on cognitive outcomes in
mild to moderate patients [7,8]. Consequently, widely used
scales such as the Mini-Mental State Examination (MMSE)
and Alzheimer’s Disease Assessment Scale-cognitive sub-
scale (ADAS-cog) include only a few items related to lan-
guage and communication, and they are not sensitive
enough for patients in the later stages of AD. Scales designed
to evaluate language and communication, such as the Refer-
ential Communication Task [9] or the Functional Linguistic
Communication Inventory [10], are difficult to administer,
and are suitable only for patients in earlier stages of AD.
An exception is the Severe Impairment Battery (SIB),
which contains a language subscale with items related to
naming, reading, writing, and repetition. The SIB was devel-
oped in 1990 to assess cognition specifically in later AD
stages, and is now frequently administered in several lan-
guages [11–14]. Its sensitivity, reliability, and validity were
established in several studies. The current version consists
of 51 items in nine ‘‘cognitive’’ domains (social interaction,
memory, orientation, language, attention, praxis, visuospatial
abilities, constructional abilities, and orientation to name),
has a maximal score of 100, and requires approximately
30 minutes to administer.
Recently, a short form of the SIB was developed by means
of exploratory factor analyses, based on data from two patient
groups [12]. In this shortened SIB, the original nine-domain
structure was maintained and 25 items were dropped, yield-
ing a 26-item scale with a maximal score of 50 and reduced
administration time.
The goal of the present study was to establish a language
scale specifically for patients with moderate to severe AD. To
identify items for the new instrument, we constructed a com-
bined AD clinical trial database and performed a factor anal-
ysis on the SIB language subscale, using the respective
baseline scores.
2. Methods
2.1. Overall database
A combined database was constructed with data from
1320 patients in four randomized, placebo-controlled,
double-blind Memantine clinical trials with study codes:
IE-2101 [15], MEM-MD-01 [16], MEM-MD-02 [17], and
MRZ-9605 [18]. These studies were performed to assess
the effects of Memantine versus placebo treatment in patients
with moderate to severe AD. In the study MEM-MD-02,
Memantine or placebo was administered to patients on stable
donepezil treatment. In all studies, the following clinical out-
come measures were applied at baseline and during the
course of the study: the Severe Impairment Battery [11],
the Mini-Mental State Examination [19], the Functional As-
sessment Staging (FAST) instrument [20], the Neuropsychi-
atric Inventory (NPI) [21], and the 19-item severe AD version
of the Alzheimer’s Disease Cooperative Study Activities of
Daily Living Inventory (ADCS-ADL19) [22]. Only patients
with an MMSE score of ,15, designated as the group of
moderate-to-severe AD patients, were included in these
four clinical trials and therefore in the overall database, which
was used for statistical analyses in this study.
2.2. Scale construction
A factor analysis, based on the principal-components
method using an orthogonal rotational procedure (Varimax),
was performed on baseline scores of the 24-item SIB lan-
guage subscale. All analyses were performed using SAS soft-
ware, version 9.1.3 (SAS, Inc., Cary, NC). Initial factors were
selected on the basis of Eigen values .1. To decide whether
scale items should be retained or drop out of the new lan-
guage scale, a threshold of 0.5 was chosen for the single-
item loading of each identified factor. Items with a factor
loading of ,0.5 were deleted.
2.3. Statistical analyses
To determine the internal consistency of the resulting
instrument, Cronbach’s a was calculated from baseline SI-
B language subscale data. The measurement error of the
SIB language subscale was calculated using the formula:
Standard deviation  Oð12 Cronbach’s aÞ;
and Pearson correlation coefficients were calculated with
baseline scores of the complete SIB, nonlanguage SIB items,
MMSE, FAST, NPI, and ADCS-ADL19.
3. Results
3.1. Development of the SIB-L scale
A database was constructed with baseline data from 1320
patients from four previously conducted clinical trials. The
characteristics of the safety populations (all patients who
took at least one dose of study medication) of each trial
and the combined total sample are provided in Table 1. At
baseline, the mean age was 75.8 (SD, 8.7) years, the mean
MMSE score was 9.7 (SD, 3.3), and the mean total SIB score
was 73.9 (SD, 18.6).
The SIB language subscale consists of seven categories
(writing, reading, comprehension, verbal fluency, naming,
repetition, and discourse), comprising the 24 items shown
in Table 2. The internal consistency of this subscale was cal-
culated using data from the combined database. The resulting
value for Cronbach’s a was 0.570, indicating only moderate
internal consistency of the SIB language subscale.
A factor analysis was also performed on the SIB language
subscale, using the respective baseline scores of the
 S. Ferris et al. / Alzheimer’s & Dementia 5 (2009) 375–379 377

Table 1
Patient baseline characteristics in database
IE-2101 MEM-MD-01 MEM-MD-02 MRZ-9605 Total
n 315 350 403 252 1320
Age (years) 73.3 (9.4) 78.2 (7.9) 75.5 (8.6) 76.1 (8.1) 75.8 (8.7)
Female (%) 70.8 71.4 65.0 67.5 68.6
Education (years) 10.0 (2.9) 12.5 (3.1) 11.1 (3.2)
BMI (kg/m2) 22.0 (3.1) 25.1 (4.3) 25.5 (4.5) 24.7 (4.4) 24.4 (4.4)
MMSE 10.1 (3.0) 10.1 (3.0) 10.1 (3.1) 7.9 (3.6) 9.7 (3.3)
SIB 71.0 (17.9) 75.8 (18.6) 78.7 (14.9) 67.1 (21.7) 73.9 (18.6)
NOTE. Data represent means, with standard deviations in parentheses.
Abbreviations: n, number of patients; BMI, body mass index; MMSE, Mini-Mental State Examination; SIB, Severe Impairment Battery.

combined database. Of 24 items on the SIB language sub- Two items from the category ‘‘naming’’ (‘‘forced choice
scale, six factors were identified, for a total of 21 items naming—cup’’ and ‘‘shape identification—square’’) and
with factor loadings R0.5 (Table 2). The resulting factor 1 the sole item of ‘‘discourse’’ (‘‘free discourse’’) were not
comprises the categories ‘‘writing,’’ ‘‘reading,’’ and ‘‘com- included, because their factor loading was ,0.5.
prehension,’’ and includes five items, whereas factor 6 con- Compared with the SIB language subscale, the resulting
sists of two items from the category ‘‘repetition.’’ The new SIB-Language (SIB-L) scale exhibited a much-im-
remaining four factors comprise three or four items from proved Cronbach’s a (0.809), indicating its high internal con-
the category ‘‘naming.’’ One of these, factor 2, also includes sistency. The maximal score of the SIB-L is 41 points, with
the ‘‘verbal fluency’’ item. a measurement error of 3.7 points, calculated on the basis
of the standard deviation and Cronbach’s a as an indicator
of the scale’s reliability [23].
Table 2
Items of SIB language subscale used for SIB-L construction*
3.2. Relationship of SIB-L to MMSE and other instruments
SIB language subscale Factor analysis
Item Category Factor Loading The SIB-L baseline scores were stratified into three de-
mentia severity groups, based on MMSE score: %5, 6–9,
4a: Write name Writing Factor 1 0.767
4b: Copy name 0.771
and 10–14 (Fig. 1). According to the data, patients from all
9a: Reading comprehension Reading 0.651 MMSE groups showed a wide range of SIB-L scores. Inter-
9c: Reading 0.569 estingly, patients with very low MMSE scores (%5) also ex-
9b: Verbal comprehension Comprehension 0.622 hibitws a broad range of SIB-L scores, including scores .30
13: Fluency Verbal fluency Factor 2 0.649 points. Therefore, even patients who are severely demented,
6: Months of year Naming 0.516
8a: Responsive naming—cup 0.674
as based on MMSE score, can exhibit fairly well-preserved
8b: Responsive naming—spoon 0.719 language abilities.
30a: Color naming—red Factor 3 0.645 Moreover, the high variation in SIB-L scores indicates an
30b: Color naming—green 0.640 absence of substantial floor-and-ceiling effects, particularly
34a: Shape identification—circle 0.648 for patients with an MMSE score of ,10. For patients with
34b: Shape identification—triangle 0.560
20: Confrontation naming—spoon Factor 4 0.747
an MMSE score R10, a small ceiling effect might occur:
22: Object naming—spoon 0.793 in this study, only 48 (6.8%) patients of the group with
24: Forced 0.720
choice naming—spoon
15: Confrontation naming—cup Factor 5 0.685
17: Object naming—cup 0.691
26: Color naming—blue 0.592
y
19: Forced (0.482)
choice naming—cup
y
30c: Shape identification—square (0.466)
11a: People Repetition Factor 6 0.580
spend money
11b: Baby 0.805
y
40: Free discourse Discourse (0.410)
Cronbach’s a 0.570 0.809
*The SIB-L scale can be obtained upon request from the corresponding
author.
y
Items with a factor loading of ,0.5 were omitted. Fig. 1. Boxplot of SIB-L scores, stratified by MMSE groups.
378 S. Ferris et al. / Alzheimer’s & Dementia 5 (2009) 375–379
MMSE scores of 10–14 achieved the maximum SIB-L value
of 41 points.
Consistent with the observed high variance of SIB-L
scores within the three MMSE severity groups, the Pearson
correlation coefficients between SIB-L and MMSE scores
were low for the group with MMSE scores %5 (r 5
0.203), and moderate for the other two groups (MMSE
6–9, r 5 0.299; MMSE 10–14, r 5 0.392).
Moreover, the Pearson correlation of SIB-L with SIB was
high (r 5 0.943), indicating that the SIB-L scale maintains
the sensitivity of the complete SIB scale. As expected, the
correlation was lower between the nonlanguage SIB items
and SIB-L items (r 5 0.826). A Pearson correlation coeffi-
cient close to zero was found between the total scores of
SIB-L and NPI (r 5 20.096), confirming that these two
scales measure different symptom domains. In contrast, there
were moderate correlations between SIB-L and level of func-
tioning, as measured by the FAST (r 5 20.379) and ADCS-
ADL19 (r 5 0.513), respectively.
4. Discussion
Although AD includes symptoms of impaired communi-
cation [6], limited information exists about language perfor-
mance in the later stages of AD, partly because of the lack of
appropriate assessment tools. We aimed to fill this gap by
choosing the language subscale of the SIB as the basis for de-
veloping a specific AD language tool. The SIB can be admin-
istered by using simple commands and gestures, which
makes it suitable even for patients in very late stages of
AD. The language domain of SIB comprises tasks mainly re-
lated to naming various items in everyday life, reading and
writing, verbal comprehension, and repetition.
A recently developed short version of the SIB maintains
the nine-domain structure of the complete SIB, but consists
of only 26 out of 51 SIB items [12]. In a convincing argument
for the short SIB, the authors cited the reduced administration
time, which accommodates the restricted attention span of
patients with more severe AD. The SIB-L scale presented
here shares this advantage of relatively short administration
time: the scale consists of 21 out of 51 SIB items, correspond-
ing to a reduction in administration time from approximately
30 minutes to a maximum of 15 minutes. Given its applica-
bility in more severe stages of AD and its derivation from
the SIB, which is a widely used tool in the AD research com-
munity, the SIB-L scale is likely to be acceptable as an instru-
ment to focus on the language abilities of patients with
moderate to severe AD.
We performed a principal-components factor analysis on
the SIB language subscale, leading to the deletion of three
items. The resulting 21-item SIB-L scale consists of 21 items
distributed over six factors, with a maximum score of 41
points. The only SIB item assessing the interactive compo-
nent of language (‘‘discourse’’) was not retained after our
analysis, because its factor loading was ,0.5. Because this
decision was based on a mathematical algorithm and did
not necessarily reflect the clinical relevance of this subdo-
main, the inclusion and testing of further items related to lan-
guage and communication may be appropriate, especially for
a more comprehensive assessment of the communicative and
social-interactive behavior of AD patients.
The value of Cronbach’s a demonstrated that the SIB-L
has high internal consistency. Although the SIB-L is not ex-
pected to exhibit substantially lower reliability than the SIB,
this needs to be confirmed in a study designed to assess psy-
chometric variables, such as interrater and test-retest reliabil-
ity, and specifically to assess floor-and-ceiling effects.
One notable finding of this study was the broad range of
baseline SIB-L scores throughout the assessed population,
especially for patients with very low MMSE scores (%5).
This clearly supports the idea of Livingston et al. [8] that pa-
tients with severe AD comprise a heterogeneous population
with a varying spectrum of abilities and disabilities. As
shown here, patients with MMSE scores of 5 or even lower
may still retain considerable language abilities.
Moreover, only a few patients with MMSE scores of ,10
exhibited very low or very high SIB-L scores. This indicates
the absence of substantial floor-and-ceiling effects for this
population. A small ceiling effect was observed for patients
with MMSE scores of 10 to 14. More than 90% of these pa-
tients showed lower-than-maximum SIB-L scores, and thus
language impairment was detectable in these patients. Also,
clinically relevant changes in SIB-L score, defined as
a change of 3.7 points, was measurable in half of the patients
with an MMSE score R10. Hence, we conclude that SIB-L
can be applied to all patients with MMSE scores of ,15.
However, for moderate AD patients (MMSE 10–14 group)
whose SIB-L scores were .37.3, i.e., for whom clinically rel-
evant changes in language impairment cannot be measured,
a more demanding language scale should be administered.
For AD, as for many other diseases, no ‘‘gold standard’’
exists for determining clinically relevant differences. There-
fore, a change of at least the magnitude of the measurement
error (i.e., 3.7 SIB-L points) might be used to indicate clinical
relevance [23]. If language performance over time is to be
evaluated, no improvement can be measured for patients
with maximum or near-maximum SIB-L scores (and a poten-
tial ceiling effect may mask worsening). Therefore, only pa-
tients with a measurable language deficit should be included
in studies to evaluate treatment effects on language. Because
the measurement error of SIB-L was calculated to be 3.7
points, evaluation over time is desirable only for patients
with a baseline SIB-L score %37.3 (maximal score, 41
points; measurement error, 3.7 points).
In conclusion, the removal of three items from the SIB lan-
guage subscale yielded the SIB-L scale, an efficient and reli-
able tool for language assessment in moderate-to-severe AD
patients. This patient population displays high variance in
language performance. The SIB-L scale seems ideal for the
assessment of basic language abilities and the evaluation of
treatment effects on language abilities in patients with mod-
erate to severe AD.
 S. Ferris et al. / Alzheimer’s & Dementia 5 (2009) 375–379
Acknowledgments
This study was supported by an educational grant from
Merz Pharmaceuticals (Frankfurt am Main, Germany).
The contributions of Dr. Christian Seitz as medical writer,
and of Melanie Needham as biostatistician, are greatly
appreciated.
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