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Instrumental activities of daily living scale for dementia

screening in elderly people

Article  in  International Psychogeriatrics · October 2005

DOI: 10.1017/S1041610205001547 · Source: PubMed

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 International Psychogeriatrics (2005), 17:3, 461–474

C 2005 International Psychogeriatric Association
doi:10.1017/S1041610205001547 Printed in the United Kingdom

Instrumental activities of daily living scale for

dementia screening in elderly people
..............................................................................................................................................................................................................................................................................

P. S. Mathuranath,1 Annamma George,1 P. Joseph Cherian,1

Robert Mathew and P. Sankara Sarma2
1
Cognition and Behavioral Neurology Center (CBNC), Department of Neurology, Sree Chitra Tirunal Institute
for Medical Sciences and Technology (SCTIMST), Trivandrum, India
2
Departments of Medical Statistics and Epidemiology, Achutha Menon Center for Health Sciences Studies,
Trivandrum, Kerala, India

ABSTRACT

Objective: To develop and validate an Instrumental Activities of Daily Living

Scale for elderly people (IADL-E) to use in conjunction with cognitive screening
tests for dementia in an educationally and socioculturally heterogeneous
population.
Method: Eleven IADL items were selected and weighted for major factors
causing heterogeneity in the population – gender, education, social (rural/urban)
setting and age. Each item was rated for its applicability (yes/no), degree of
disability (scored from 0 to 2) and causative impairment (cognitive and/or
physical). From this a composite index of cognitive (CDI) or physical (PDI)
disability was derived. Validation was performed retrospectively on 240 subjects:
135 without and 105 with dementia by DSM-IV.
Results: The IADL-E had a high internal consistency (α = 0.95). The area
under the receiver operating characteristic (ROC) curve was 0.97 (CI = 0.94–
0.99). A cutoff score of 16 on CDI provided a sensitivity of 0.91, specificity
0.99 and positive predictive value 0.76 (at 5% base rate). IADL-E correlated
highly with clinical (DSM-IV, κ = 0.89), functional (CDR, 0.82) and cognitive
(Mini-mental Status Examination, MMSE, 0.74) diagnoses. It showed good
responsiveness, with the change on CDI over a median of 23 months
correlating significantly with that on MMSE (coefficient = –0.382, CI = –0.667
to –0.098; p = 0.009). Individual items had good interrater and test–retest
reliability.

Correspondence should be addressed to: Dr. P. S. Mathuranath, CBNC, Department of Neurology, SCTIMST, Trivandrum
695011, India. Phone +91 (0) 471 2524523/2524584; Fax: +91 (0) 471 2446433. Email: mathu@sctimst.ac.in. Received
23 Apr 2004; returned for revision 28 May 2004; revised version received 16 Jun 2004; accepted 17 Jun 2004.

461
462 P. S. Mathuranath et al.

Conclusions: The IADL-E is a reliable, sensitive and responsive scale of func-

tional abilities useful in dementia screening in a socioculturally heterogeneous
population.

Key words: instrumental activities of daily living, elderly, dementia, developing countries, screening,
impairment, scale

Introduction
The knowledge of an individual’s ability to carry out social and occupational
functions is important for diagnosing dementia. This is commonly assessed
using functional activities tools. The basic Activities of Daily Living (ADL)
Scales assess the basic mobility and self-care while the extended ADL Scales
assess the Instrumental ADL (IADL) activities such household, community,
social and cognitive activities (Lindeboom et al., 2003). The ADL, especially
the IADL tools, are culture-sensitive (Fillenbaum, 1984; Heikkinen et al., 1983;
Punia et al., 1987). Many elderly people in Eastern countries living in extended
families are often not required to take responsibility for medications, or do
the laundry, etc., as they receive assistance from the younger members of the
family in executing these activities. Even within a country, socio-economic status
(Jitapunkul et al., 1994), social setting (rural or urban) (Punia et al., 1987)
or gender roles (Heikkinen et al., 1983; Vijaykumar, 1995) may contribute to
the differences in the ADL. For instance, in many communities, men seldom
participate in housekeeping and women seldom manage finances. In addition,
differences in infrastructure and resource availability in the less industrialized
nations also result in some of the common activities, such as cooking, washing,
etc., being performed in a different way from that in the industrialized world
(Fillenbaum et al., 1999). The IADL tools developed for a population in one
setting may therefore not assess the same parameters for a population in another
setting. An additional factor of concern in the less industrialized world is that of
uncorrected physical impairments, such as cataracts, deafness, etc., which are
common in older individuals, interfere with the IADL, and, if undetected, can
increase the false positive rates of dementia (Chandra et al., 1998b). For this
reason, defining the nature of the underlying impairment causing the disability
(physical/cognitive/both) assumes importance in the assessment of IADL in these
populations.
We intended to assess the occupational and functional abilities of subjects in
an epidemiological study on dementia in a multi-religious population of urban
and rural elderly subjects with diverse literacy and socio-economic levels in
the southern Indian state of Kerala. Although ADL tools have been developed
to characterize the performance of people with dementia (Blessed et al., 1968;
 IADL Scale for dementia screening 463

Mahurin et al., 1991; Pfeffer et al., 1982), some are not sufficiently structured for
use in epidemiological surveys and others include activities that are inappropriate
outside the type of setting in which they were developed. Published functional
abilities scales developed for Eastern populations are very few. The Chula ADL
index of extended ADL was developed with items applicable to the largely
illiterate elderly population living in a Bangkok slum community (Jitapunkul
et al., 1994). The Everyday Abilities Scale for India is a well-conceived and well-
developed tool that incorporates elements of self-care and extended ADL. This
too was developed for the largely illiterate rural population in north India and
elicits a dichotomous response for all items (Fillenbaum et al., 1999). By contrast,
the Old Age Disability Scale (Jamuna and Ramamurti, 1990) is applicable to
a more diverse population, although it largely focuses on the basic ADL and
self-care. Thus, while some scales were developed for a particular section of
the population, others made only a limited assessment of the extended ADL.
We therefore found these scales to be inadequate for evaluating subjects in our
educationally and culturally diverse population.
Our aim was to develop an IADL scale as a screening tool to be used in
conjunction with global cognitive screening tests to identify persons with
dementia. We intended that the scale should grade the subject’s performance
objectively, have a provision for defining the underlying impairment (cognitive/
physical/both) causing the disability on each task, and be universal in terms of
its application to the different sections of our population.

Methodology
As a preparatory step, we assessed the demographic and cultural characteristics
of the population for whom we intended to develop the new IADL scale. We
then developed the scale and a scoring system and optimized it by pretesting.
Finally, the validation was performed by retrospectively analyzing prospectively
collected data. The various steps involved are explained below.

Preparatory phase
The target population for our epidemiological study consisted of all subjects
≥ 55 years of age, living in a predefined geographical area according to the
1991 Census and the 1999 Electoral List, in the Trivandrum district of Kerala
(n = 2932). Men constituted 41% of the total, Hindus 69.8%, Christians 24.4%,
Muslims 5.8%, < 75 years of age 76.9%, ≥ 75 years of age 23.1%, and illiterate
subjects (≤ 4 years of formal education) 31.4%. We chose 4 years as the
cutoff as our experience in this population suggests that the neuropsychological
performance of subjects with less than 5 years of formal education (i.e. up to
464 P. S. Mathuranath et al.

Table 1. The domains and component items of IADL included for developing the
IADL scale
ADL DOMAINS COMPONENTS
............................................................................................................................................................................................................................................

Cognitive activities Managing finances, telephone use, taking responsibility for

one’s medications, prayer activity
Social/recreational activities Social activity/interaction, entertainment and information,
looking after grandchildren, taking care of farm/pet
animals, pursuing hobbies (e.g. gardening/knitting)
Community activities Shopping, travel
Household activities Housekeeping, laundry, meal preparation
Self-care items Shaving, personal care

primary school level) is comparable to that of those with no formal education.

The reported monthly household incomes varied from ≤ 1000 Indian National
Rupees (Rs.) (ca. 22 US $) in 35%, to ≥ Rs. 10 001 (≥ 223 US $) in 2%. Work
types included unskilled laborers (12.4%), clerks or vocational practitioners
(29.2%), professionals (14.8%) and housewives (43.6%).
In consultation with a senior citizens forum, a dementia self-help group,
medical doctors and rural and urban community leaders, we selected 16 IADL
items that are applicable to most older people from different sociocultural
backgrounds in this population (Table 1). We modeled our scale on the widely
used IADL scale of Lawton and Brody (1969).

Development of a scoring system

The IADL items may be administered to the carer or the subject. First, each
item is rated for its applicability (yes/no). It is rated as not applicable if the
subject has not done it in the past for either want of opportunity (e.g. banking
is done by the husband) or necessity (e.g. is an atheist and so does not pray).
If a task was performed in the past but not any longer (as help is available),
then it is rated as “applicable.” Next, the degree of “disability” on the item is
rated by choosing one of the three descriptive responses provided for each item
and graded from 0 (able to complete it competently) to 2 (unable to perform).
Efforts were made to develop a linear gradation such that the middle grade
of 1 (e.g. “can soap but needs help with the razor” in the “shaving” item)
represents a quantum of functional disability that is approximately between
grade 0 (e.g. “fully independent”) and grade 2 (e.g. “unable to shave on his
own”). However, the distance between each step on the rating scale is not
equal on every item. Finally, the item is rated for the underlying impairment
(cognitive/physical/both) considered responsible for the disability. If both types
of impairments affect the performance to varying extents on an item, then the
rater gives different “disability” scores for the different impairments on that
 IADL Scale for dementia screening 465

item. A Cognitive Disability Index (IADL-CDI) is derived as the sum of the

disability ratings due to cognitive impairment (i.e. cognitive disability score)
divided by the product of the maximum possible “disability” on an item (i.e. 2)
and the number of items reported applicable (NAI). A similar formula can
be used for the physical disability index (IADL-PDI). For these indices to be
clinically meaningful in individual cases, a minimum number of applicable items
are necessary. For this we used the fifth percentile value of the NAI reported by
the cohort.

Pretesting
Forty community-dwelling healthy older subjects responded on the 16 IADL
items and gave a descriptive comment on the appropriateness of the gradation of
the responses. Five items (laundry, responsibility for one’s medications, looking
after grandchildren, taking care of farm/pet animals and pursuing hobbies such as
gardening/knitting) were reported applicable by < 33% and therefore excluded.
Thus, 11 items are included in the IADL for elderly people (IADL-E) (see
Appendix in Supplementary Data, published online). Changes were also made
to the descriptive responses based on the respondents’ suggestions.

Validation phase
The IADL-E was validated on 240 subjects (105 with dementia and 135
controls). There were 132 males (55%), 172 urban residents (72%), 64 illiterate
subjects (27%) and 187 below 75 years of age (78%). All subjects underwent a
detailed evaluation for dementia on a dementia evaluation protocol (described
below), and neuropsychologists administered the IADL-E to the carers (or family
members) of these subjects.
From among the subjects attending our memory clinic, we selected 105
consecutive patients who, following the dementia evaluation protocol, received
the diagnosis of dementia in a consensus conference of the neurologist,
the psychiatrist and the neuropsychologist. All subjects met the criteria for
dementia according to DSM-IV (American Psychiatric Association, 1994).
The dementia evaluation protocol at our memory clinic consists of a clinical
evaluation (which includes a semistructured interview for cognitive complaints
and a clinical examination by a neurologist, as well as examination by a
psychiatrist), detailed neuropsychological testing [including the Weschler’s
Memory Scale – Revised (Wechsler, 1987), the Trail Making Test (Reitan, 1958),
Addenbrooke’s Cognitive Examination (ACE; Mathuranath et al., 2000), the
Mini-mental Status Examination (MMSE; Folstein et al., 1975), the Hospital
Anxiety and Depression Scale (Zigmond and Snaith, 1983), the Wisconsin
Card Sorting Test (Nelson, 1976), and the modified Barthel Index (Hobart
and Thompson, 2001)], and laboratory investigations [including magnetic
466 P. S. Mathuranath et al.

resonance imaging (MRI) or computed tomography (CT) scan of the brain,

an electroencephalogram (EEG) and a battery of blood tests]. Of the 105
subjects, 42 had probable Alzheimer’s disease (AD by NINCDS-ADRDA
criteria) (McKhann et al., 1984), 26 vascular dementia (VaD by NINDS-AIREN
criteria) (Román et al., 1993), 15 frontotemporal lobar degeneration (FTLD;
Neary et al., 1998), 10 other dementias, and in 12 the dementia remained
unclassified. On the Clinical Dementia Rating (CDR) Scale (Hughes et al.,
1982), 61 scored ≤ 1 and 44 scored > 1.
The controls were from a random sample of 5% (n = 140) of the target
population (described in the preparatory phase). All received the clinical
evaluations and the neuropsychological tests in the dementia evaluation protocol
of our memory clinic. Five subjects were excluded as one refused to participate,
one had dementia, one was unavailable for testing and two failed to complete the
evaluation protocol. Of the 135, 100 were cognitively unimpaired and 35 fulfilled
the criteria for Mild Cognitive Impairment (MCI; Petersen et al., 1999).

Statistical analysis
Applicability of each item was measured as the percentage of subjects reporting
it as applicable and rank-ordered (with the highest percentage receiving rank
1) for comparison within demographic subgroups of gender, literacy, age and
social setting (urban/rural). The validity measures were sensitivity and specificity
against DSM-IV, and positive (PPV) and negative (NPV) predictive values (at
prevalence rates of 1, 3, 5 and 10%, figures reported from different developing
regions; Chandra et al., 1998a; Hendrie et al., 1995; Rajkumar et al., 1997; Shaji
et al., 1996; Vas et al., 2001; Zhang et al., 1990). Reliability was measured
on internal consistency and interrater and test–retest reliability. Test–retest
reliability was evaluated over 1 to 60 days (median = 1 day) by readministering
the IADL-E to the 22 informants (seven with and 15 without dementia) who
had provided the data during the first administration. Interrater reliability
was obtained by asking a second rater (blinded to the diagnosis) to rate the
IADL-E after listening to the audiotapes of its administration by the first
rater to 30 informants (10 with and 20 without dementia). To determine the
sensitivity of IADL-E to changes in the cognitive state over time, we measured
its responsiveness against the MMSE. This we did by readministering (second
round) the IADL-E and the MMSE to all 68 subjects (25 cognitively unimpaired,
26 with MCI and 17 with dementia) who had provided data during the first
administration (first round). The interval between the two rounds of assessment
varied from 12 to 28 (median = 23) months. The change on the IADL-CDI was
regressed (forward linear regression) on (a) the change in the MMSE score and
(b) the time interval (in days) between the two rounds of assessment.
 IADL Scale for dementia screening 467

Results
The average time to complete the IADL-E was 9 min. Table 2 shows that the
patients were comparable to controls on education but were younger and differed
significantly on the MMSE, the ACE and the IADL-E. Patients with mild
dementia (CDR ≤ 1) were comparable to those with moderate/severe dementia
(CDR > 1) on age, education and IADL-PDI but differed on the MMSE, the
ACE and the IADL-CDI. The fifth percentile on the NAI for the cohort was 6.
The NAI was < 6 in two (0.8%), 6–8 in 83 (35.2%) and > 8 in 155 (64%)
subjects. Thirty patients and 64 controls had physical impairment (IADL-
PDI > 0).

Applicability
All items, except “shaving” (52%) and “meal preparation” (63%), were reported
applicable by more than 78% of the cohort (see Table I in Supplementary
Data). “Shaving” was applicable only to men, but to nearly all of them (> 90%).
Similarly, “meal preparation” was highly applicable to women (> 93%, rank 7),
but less so to men (38%, rank 11). “Telephone use” was rated higher among
the literate (89%; rank 8) than among the illiterate people (49%; rank 10).
All other items showed comparable applicability and rank-order between the
corresponding demographic subgroups.

Criterion validity (Table 3)

On the receiver operating characteristic (ROC) curve, a score of 16 on the IADL-
CDI provided the optimal cutoff for diagnosing dementia. The area under the
ROC curve was 0.97 (CI = 0.94–0.99). The sensitivity was 0.91, specificity 0.99
and the PPV at 5% base rate 0.76. Of the 240 subjects, two (1%) received a
false positive and 10 (4%) a false negative diagnosis of dementia. The detection
rate was 80% (49/61) in mild (CDR ≤ 1), 100% (44/44) in moderate/severe
dementia (CDR > 1), 92% (38/42) in probable AD, 100% (26/26) in VaD, and
93% (14/15) in FTLD. It was 93% (70/75) in subjects without (IADL-PDI = 0)
and 83% (25/30) in those with (IADL-PDI > 0) physical impairment, and 92%
(34/37) in those with NAI of 6–8 and 90% (61/68) in those with NAI > 8.

Construct validity
IADL-E had an excellent correlation with DSM-IV (κ = 0.89) and CDR
(κ = 0.82), and a high correlation with the MMSE and the ACE (κ = 0.74 and
0.60, respectively).
 468
Table 2. Demographic profile and scores on various parameters for the study cohort (control vs. patient) and within the patient

P. S. Mathuranath et al.
group (mild dementia vs. moderate/severe dementia)
PATIENT

∗
ALL CONTROL PATIENT p C D R ≤1 C D R >1 p∗
..............................................................................................................................................................................................................................................................................................................................................................................
n (males) 240 (132) 135 (67) 105 (65) 61 (43) 44 (22)
Age 67.8 ± 10.5 69.6 ± 9.3 65.4 ± 11.6 0.01 66.1 ± 12.7 64.4 ± 10.2 0.51
Education 9.3 ± 5.5 8.9 ± 5.8 9.9 ± 4.9 0.12 9.6 ± 4.8 10.2 ± 5.3 0.31
MMSE 20.7 ± 7.3 24.3 ± 4.4 15.1 ± 7.4 <0.001 18.3 ± 6.3 10.2 ± 5.7 <0.001
ACE 60.0 ± 23.0 69.9 ± 18.1 44.8 ± 21.6 <0.001 53.3 ± 19.6 32.2 ± 16.8 0.001
IADL-E CDI 29.3 ± 38.4 1.8 ± 5.3 64.6 ± 33.2 <0.001 48.8 ± 30.6 85.2 ± 23.5 <0.001
IADL-E PDI 11.5 ± 20.5 12.8 ± 20.2 9.9 ± 20.8 0.014 11.6 ± 20.5 7.2 ± 21.2 0.15
IADL-E NAI 8.8 ± 1.2 8.7 ± 1.2 8.8 ± 1.3 0.46 8.6 ± 1.2 9.2 ± 1.3 0.03
NAI 5th %ile 7 7 6 6 6
∗ Mann–Whitney U-test.
CDR = Clinical Dementia Rating; MMSE = Mini-mental Status Examination; ACE = Addenbrooke’s Cognitive Examination; IADL-E = Instrumental Activities
of Daily Living Scale for Elderly People; CDI = Cognitive Disability Index; PDI = Physical Disability Index; NAI = Number of Applicable Items.

Table 3. Sensitivity, specificity and positive and negative predictive values for IADL-E at various cutoff scores on the Cognitive
Disability Index (CDI)
POSITIVE PREDICTIVE VALUE NEGATIVE PREDICTIVE VALUE

CUTOFF SENSITIVITY SPECIFICITY 1% 3% 5% 10% 1% 3% 5% 10%

.............................................................................................................................................................................................................................................................................................................................................................................

>2 0.95 0.85 0.06 0.17 0.25 0.42 1.0 1.0 1.0 0.99
>6 0.93 0.90 0.08 0.22 0.32 0.50 1.0 1.0 1.0 0.99
>8 0.92 0.91 0.09 0.24 0.35 0.54 1.0 1.0 1.0 0.99
>10 0.92 0.92 0.10 0.26 0.38 0.56 1.0 1.0 1.0 0.99
>13 0.91 0.95 0.15 0.35 0.48 0.66 1.0 1.0 0.99 0.99
>16 0.91 0.99 0.38 0.65 0.76 0.87 1.0 1.0 0.99 0.99
>19 0.90 0.99 0.38 0.65 0.76 0.87 1.00 1.00 0.99 0.99
 IADL Scale for dementia screening 469

Figure 1. Responsiveness of the IADL-E CDI. Scatter plot, showing change in the CDI (between
the two rounds of assessment of 68 subjects) against that in the MMSE, with a linear
regression line fitted.

Reliability
Internal consistency was high (Cronbach’s α = 0.95). The test–retest reliability
for cognitive disability was high (κ ≥ 0.60) for most items, and moderate for
“manage finance” (κ = 0.54) and “social activity/interaction” (κ = 0.50). For
physical disability it was moderate and Kendall’s τ-b ranged from 0.36 to 0.57.
Interrater reliability for cognitive disability was high (κ ≥ 0.60) for all items and
moderate for “housekeeping” (κ = 0.57) and “meal preparation” (Kendall’s τ-
b = 0.49). It was moderate to high (Kendall’s τ-b 0.46 to 0.98) for physical
disability.

Responsiveness
Between the two rounds of testing the MMSE score and the IADL-CDI changed
by 0.7 ± 3.6 and 1.4 ± 3.9, respectively. The IADL-CDI did not correlate with
the time interval between testing but correlated with the MMSE, increasing
where the MMSE score decreased and vice versa (coefficient = –0.31, CI = –1.92
to –4.34; p ≤ 0.001) (Figure 1). However, five out of 68 were outliers in whom a
small (0–3 points) increase (n = 3) or lack of change on the MMSE (n = 2) was
470 P. S. Mathuranath et al.

accompanied by an increase of ≥ 20% (rather than a decrease or lack of change)

in the IADL-CDI. Three of the five outliers had dementia with predominant
frontal lobe involvement (two FTLD and one progressive supranuclear palsy).
The remaining two patients had considerable physical problems and it was
difficult to rate the underlying impairment (cognitive or physical) responsible
for their disability on the IADL-E and this resulted in variations between the
two rounds of assessments.

Effects of demographic variables and measures of diagnosis

on the IADL-E
Forward linear regression of demographic variables (age, education, gender,
social setting) and measures of diagnosis (DSM-IV, CDR and MMSE) on
the IADL-CDI showed a significant (p < 0.001) effect only for DSM-IV
(coefficient = 30.7, 95% CI = 38.2–23.1), CDR (coefficient = 15.5, 95% CI =
9.9–21.1) and MMSE (coefficient = –1.1, 95% CI = –1.5 to –0.6).

Discussion
The IADL-E was developed to characterize and grade the performance of
older subjects on standard domains of extended ADL and should be used in
conjunction with the cognitive tests when screening for dementia. It is well
documented that on ADL scales there can be incongruity between the disability
reported by patients themselves (who tend to underestimate) and that reported
by their carers (who tend to overestimate) (Karagiozis et al., 1998; Mangone
et al., 1993). Although the IADL-E can be administered to the carers or the
patients, it is advisable to maintain consistency by using the subject or the carer
but not one or the other as the informant. In individual cases such as in a clinic
practice, however, it may help to get the perspective of both the patient and the
carer, to plan a better management strategy.
It was practically impossible to have all items equally applicable to all the
sections of our demographically diverse population. We aimed, therefore, at
having items that are applicable to comparable proportions of subjects in
the corresponding demographic subgroups. Although “meal preparation” and
“shaving” had unequal weighting with respect to gender, excluding both would
unduly hamper the assessment of highly applicable and important instrumental
activities of women and men, respectively. On the contrary, retaining both would
allow them to balance each other with respect to gender. Although “telephone
use” was weighted more for the literate than the illiterate subjects, it reflected a
difference in “access” rather than a real difference in the “ability to use.” Hence
 IADL Scale for dementia screening 471

these three items were retained. All other items were applicable to nearly a similar
proportion of men as women, urban as rural residents, literates as illiterates and
those < 75 years as those ≥ 75 years. This finding is also supported by the results
of regression, which show that the IADL-CDI is unaffected by the demographic
variables.
When coexisting, physical and cognitive impairments can affect the same
IADL to varying extents, especially in elderly individuals with dementia. The
IADL-E has the advantage of grading the disability due to cognitive and physical
impairments separately. It should be pointed out that this differentiation may not
be straightforward in every patient and that the rating may incorporate some bias
as it is based on the rater’s judgment. The IADL-E also provides an index that
is preferable to a score for comparing disabilities. It shows good psychometric
properties on a cohort with varied functional abilities resulting from a wide
range of cognitive states (unimpaired, with MCI and with dementia), and a good
correlation with clinical (DSM-IV), functional (CDR) and cognitive (the MMSE
and the ACE) measures of dementia diagnosis. It is also generally responsive to
changes in the cognitive tests (MMSE) over time, although there are limitations
in cases where the underlying impairment responsible for the disability is difficult
to characterize. The lack of correlation of changes on the IADL-CDI to that on
the MMSE in patients with predominant frontal involvement is possibly a result
of the poor sensitivity of the latter tool to frontal functions, a limitation well
documented by earlier investigators (Gregory et al., 1997; Hodges et al., 1999;
Naugle and Kawczak, 1989).
With coexisting physical impairments in patients with dementia, it may
sometimes be difficult to characterize the underlying impairment causing the
disability. This limitation is likely to occur with any instrument relying on
informants. Nevertheless, any level of success in defining the underlying impair-
ment is of value in dementia screening, especially in elderly populations having
a high prevalence of uncorrected physical impairments. It is our experience
that interviewing caregivers who have been caring for more than 6 months
and verifying their information by cross-questioning and eliciting specific
examples on the reported impairments is sometimes helpful in such
situations.
One of the limitations of this study is that the validation cohort is not entirely
community based. This was because of the practical difficulty in obtaining a
large number of well-evaluated patients from the community without a prior
systematic survey. An additional limitation of the study is the test–retest reliability
was affected by a large variation in the time interval between the two rounds
of testing, mainly as a result of delays in the availability of a few subjects for
retesting. We therefore recommend further validation of this tool in community-
based prospective studies.
472 P. S. Mathuranath et al.

The physical disability index has not been fully validated in this study. The
results of this study are from a particular region of south India that has a relatively
better literacy and living standards profile than many other developing regions.
Caution must be exercised in extrapolating these results to communities with
demographic and cultural profiles different from that in this study.

Conflict of interest declaration

This study was supported in part by a grant-in-aid from the Sir Ratan Tata
Trust, Mumbai, India. The sponsor had no role in the research formulation,
study design, data collection and analysis or in the decision to publish these
results. There is no financial relationship between any of the authors and the
sponsor.

Description of authors’ roles

The first author, PSM, has contributed to all aspects of this research. AG, PJC
and RM have contributed to the study design, carrying out the study and writing
the paper. PSS has contributed to analysis of the results and writing the paper.

Acknowledgments
We thank Professor Immanuel Thomas, Department of Psychology, University
of Kerala, for his valuable suggestions on the scoring system. We gratefully
acknowledge the help extended by Mrs. Meera Pattabi of the Alzheimer’s
and Related Disorders Society of India, Trivandrum chapter (ARDSI-Tvm),
Mr. Radhamonie of the ARDSI-Tvm and the Senior Citizen’s Forum and the
office bearers of various Residents’ Associations in Trivandrum.

References
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV) (4th ed.). Washington, DC: American Psychiatric Association.
Blessed, G., Tomlinson, B. E. and Roth, M. (1968). The association between quantitative
measures of dementia and of senile change in the cerebral grey matter of elderly subjects.
British Journal of Psychiatry, 114, 797–811.
Chandra, V., Ganguli, M., Pandav, R., Johnston, J., Belle, S. and DeKosky, S. T. (1998a).
Prevalence of Alzheimer’s disease and other dementias in rural India: the Indo-US study.
Neurology, 51, 1000–1008.
 IADL Scale for dementia screening 473

Chandra, V. et al. (1998b). Practical issues in cognitive screening of elderly illiterate populations
in developing countries. The Indo-US Cross-National Dementia Epidemiology Study. Aging
(Milan, Italy), 10, 349–357.
Fillenbaum, G. G. (1984). The Wellbeing of the Elderly: Approaches to Multidimensional Assessment.
Geneva: World Health Organization.
Fillenbaum, G. G. et al. (1999). Development of an activities of daily living scale to screen for
dementia in an illiterate rural older population in India. Age and Ageing, 28, 161–168.
Folstein, M. F., Folstein, S. E. and McHugh, P. R. (1975). “Mini-mental State”. A practical
method for grading the cognitive state of patients for the clinician. Journal of Psychiatric
Research, 12, 189–198.
Gregory, C. A., Orrell, M., Sahakian, B. and Hodges, J. R. (1997). Can frontotemporal
dementia and Alzheimer’s disease be differentiated using a brief battery of tests? International
Journal of Geriatric Psychiatry, 12, 375–383.
Heikkinen, E., Waters, W. E. and Brzezinski, J. (1983). The Elderly in Eleven Countries.
Public Health in Europe. Geneva: World Health Organization Regional Office for Europe.
Hendrie, H. C. et al. (1995). Prevalence of AD and dementia in two communities: Nigerian
Africans and African Americans. American Psychiatry, 152, 1485–1492.
Hobart, J. C. and Thompson, A. J. (2001). The five item Barthel index. Journal of Neurology,
Neurosurgery and Psychiatry, 71, 225–230.
Hodges, J. R. et al. (1999). The differentiation of semantic dementia and frontal lobe dementia
(temporal and frontal variants of frontotemporal dementia) from early Alzheimer’s disease: a
comparative neuropsychological study. Neuropsychology, 13, 31–40.
Hughes, C. P., Berg, L., Danziger, W. L., Coben, L. A. and Martin, R. L. (1982). A new
clinical scale for the staging of dementia. British Journal of Psychiatry, 140, 566–572.
Jamuna, D. and Ramamurti, P. V. (1990). Old age disability scale. Journal of Psychometry, 3,
21–27.
Jitapunkul, S., Kamolratanakul, P. and Ebrahim, S. (1994). The meaning of activities of
daily living in a Thai elderly population: development of a new index. Age and Ageing, 23,
97–101.
Karagiozis, H., Gray, S., Sacco, J., Shapiro, M. and Kawas, C. (1998). The Direct
Assessment of Functional Abilities (DAFA): a comparison to an indirect measure of
instrumental activities of daily living. Gerontologist, 38, 113–121.
Lawton, M. P. and Brody, E. M. (1969). Assessment of older people: self-maintaining and
instrumental activities of daily living. Gerontologist, 9, 179–186.
Lindeboom, R., Vermeulen, M., Holman, R. and De Haan, R. J. (2003). Activities of daily
living instruments: optimizing scales for neurologic assessments. Neurology, 60,
738–742.
Mahurin, R. K., DeBettignies, B. H. and Pirozzolo, F. J. (1991). Structured assessment of
independent living skills: preliminary report of a performance measure of functional abilities in
dementia. Journal of Gerontology, 46, 58–63.
Mangone, C. A. et al. (1993). Influence of feelings of burden on the caregiver’s perception of
the patient’s functional status. Dementia, 4, 287–293.
Mathuranath, P. S., Nestor, P. J., Berrios, G. E., Rakowicz, W. and Hodges, J. R. (2000).
A brief cognitive test battery to differentiate Alzheimer’s disease and frontotemporal dementia.
Neurology, 55, 1613–1620.
McKhann, G., Drachman, D., Folstein, M., Katzman, R., Price, D. and Stadlan, E. M.
(1984). Clinical diagnosis of Alzheimer’s disease: report of the NINCDS-ADRDA Work
Group under the auspices of Department of Health and Human Services Task Force on
Alzheimer’s Disease. Neurology, 34, 939–944.
Naugle, R. I. and Kawczak, K. (1989). Limitations of the Mini-mental State Examination.
Cleveland Clinical Journal of Medicine, 56, 277–281.
474 P. S. Mathuranath et al.

Neary, D. et al. (1998). Frontotemporal lobar degeneration: a consensus on clinical diagnostic

criteria. Neurology, 51, 1546–1554.
Nelson, H. E. (1976). A modified card sorting test sensitive to frontal lobe damage. Cortex, 12,
313–324.
Petersen, R. C., Smith, G. E., Waring, S. C., Ivnik, R. J., Tangalos, E. G. and Kokmen,
E. (1999). Mild cognitive impairment: clinical characterization and outcome. Archives of
Neurology, 56, 303–308.
Pfeffer, R. I., Kurosaki, T. T., Harrah, C. H. Jr., Chance, J. M. and Filos, S. (1982).
Measurement of functional activities in older adults in the community. Journal of Gerontology,
37, 323–329.
Punia, P. K., Malik, R. S. and Punia, D. (1987). Aging problems: a study of rural–urban
differentials. In M. L. Sharma and T. M. Dak (Eds.) Aging in India (pp. 57–66). New Delhi:
Ajanta Publications.
Rajkumar, S., Kumar, S. and Thara, R. (1997). Prevalence of dementia in a rural setting: a
report from India. International Journal of Geriatric Psychiatry, 12, 702–707.
Reitan, R. M. (1958). Validity of the trail making test as an indicator of organic brain damage.
Perceptual and Motor Skills, 8, 271–276.
Roman, G. C. et al. (1993). Vascular dementia: diagnostic criteria for research studies. Report
of the NINDS-AIREN International Workshop. Neurology, 43, 250–260.
Shaji, S., Promodu, K., Abraham, T., Roy, K. J. and Verghese, A. (1996). An
epidemiological study of dementia in a rural community in Kerala, India. British Journal of
Psychiatry, 168, 745–749.
Vas, C. J. et al. (2001). Prevalence of dementia in an urban Indian population. International
Psychogeriatrics, 13, 439–450.
Vijaykumar, S. (1995). Challenges Before the Elderly: an Indian Scenario. New Delhi: MD
Publications.
Wechsler, D. (1987). Wechsler Memory Scale – Revised Manual. San Antonio, TX: Psychological
Corporation.
Zhang, M. Y. et al. (1990). The prevalence of dementia and Alzheimer’s disease in Shanghai,
China: impact of age, gender, and education. Annals of Neurology, 27,
428–437.
Zigmond, A. S. and Snaith, R. P. (1983). Hospital anxiety and depression (HAD) scale. Acta
Psychiatrica Scandinavica, 67, 361–370.

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