Dementia Rating Scale (DRS)

Notes

Purpose:

Assess Cognitive Decline: The DRS is used to measure the severity of general cognitive decline
associated with dementia.

Track Progression: It can be administered repeatedly to track how an individual’s cognitive

abilities change over time.

Differential Diagnosis: Helps distinguish various forms of dementia by identifying patterns of

strengths and weaknesses in different cognitive domains.

Structure:

The DRS consists of 36 tasks organized into five subscales measuring the following cognitive
domains:

Attention:

- Tasks include attention span, mental control, digit repetition (forwards and backwards), and
responding to complex commands.

Attention (37 points)

o Digit Span (Forward & Backward): Tests immediate attention and working
memory by having the individual repeat increasing strings of digits.
o Mental Control: Assesses sustained focus and ability to manipulate information
mentally (e.g., counting backward from 20).
o Complex Commands: Requires following multi-step instructions and selective
attention.
Initiation/Perseveration (I/P):
 - Assesses an individual’s ability to start tasks, generate sequential actions, and avoid getting
stuck on a single action or idea. Tasks include graphomotor patterns, word list generation, and
alternating patterns.

Initiation/Perseveration (I/P) (37 points)

o Motor Sequencing: Involves tapping a table in alternating patterns to assess

motor planning, sequencing, and the ability to disengage from a previous pattern.
o Verbal Fluency (Word List Generation): Measures ability to initiate and
generate words within a category (e.g., animals), while also assessing inhibition
(not repeating words).
o Graphomotor Patterns: Copying sequences of lines or patterns tests planning
and motor execution, as well as perseveration (getting stuck on a pattern).
Construction:

- Examines visuospatial abilities and ability to carry out tasks with a motor component.
Involves copying designs and arranging shapes.

Construction (6 points)

o Copying Designs: Assesses visuospatial skills, visual perception, and ability to

execute motor actions based on a visual model (drawing shapes/figures).
o Three-Dimensional Construction: Requires arranging blocks to match a model,
tapping into visuospatial and constructional abilities.
Conceptualization:

- Tests abstract thinking and reasoning. Tasks assess concept formation, sorting objects into
categories, and identifying similarities.

Conceptualization (39 points)

o Similarities: Measures abstract reasoning by asking the individual to explain how

things are alike.
o Conceptual Sorting: Evaluates categorization and conceptualization by having
the individual sort objects.
 o Idea Formulation: Tests complex reasoning by asking the individual to provide
solutions to situations or explain the meaning of proverbs.
Memory:

- Focuses on recent memory and orientation. Tasks measure the recall of short stories, recent
events, and temporal orientation (time, date, etc.).

Memory (25 points)

o Orientation: Assesses if the individual is oriented to person, place, and time.

o Recent Memory: Tests recall of a short story presented earlier.
o Remembering a List: Measures immediate and delayed recall of a word list and
tests learning abilities.

Hierarchical Administration

The DRS tasks are presented in a hierarchical format within each subscale. This means:

 Basal Difficulty: Tests start with the most difficult items in each subscale.
 Crediting Successes: If the individual performs the first one or two items correctly, they
automatically get credit for the easier items that follow in that subscale. This streamlines
the administration process.

Rationale for the structure:

1. Targeting Key Cognitive Domains: The five subscales of the DRS were carefully
chosen to target the core cognitive areas most commonly impacted by dementia. These
domains align with the major brain networks affected in neurodegenerative conditions.
o Attention and Initiation/Perseveration: These reflect processes linked to frontal
lobe and subcortical structure function. They help identify impairments common
in subcortical dementias (Parkinson's, Huntington's, etc.)
o Construction: Visuospatial and motor abilities associated with parietal lobe
function are tested here. Deficits can signal Alzheimer's disease or other
dementias with a cortical focus.
 o Conceptualization: Abstract thinking and reasoning, often dependent on frontal
lobe and temporal lobe function, are tapped into. Decline in this area suggests a
range of dementias.
o Memory: Focuses on assessing functions tied to the medial temporal lobes,
crucial for new memory formation. Decline is core to Alzheimer's disease and
other conditions impacting these structures.
2. Differentiating Dementia Types: The pattern of scores across these subscales helps
inform differential diagnosis. While the DRS isn't definitive on its own, it offers clues
about likely underlying pathologies. For example:
o Lower I/P and Attention: Might be more typical of dementias with subcortical
involvement.
o Predominant Memory and Conceptualization deficits: Likely to be seen in
Alzheimer's disease affecting temporal and frontal regions.
3. Hierarchical Structure: This design was meant for efficiency. By crediting success on
harder items within a subscale, it avoids unnecessary testing of easier items, reducing
administration time and potential frustration for the patient.
4. Sensitivity to Progression: The wide range of item difficulties within the DRS makes it
sensitive to both early and late stages of dementia. This allows its use for tracking the
overall progression of the disease.

Limitations to Consider
 Specificity: While the structure helps with general differentiation, it's not always specific
enough to reliably distinguish between subtypes of dementia without additional tests.
 Cultural Bias: Some tasks may have inherent cultural or linguistic biases.

Scoring:
Raw Score: Each task has points assigned based on correct responses. The total raw score can
range from 0 – 144.

Scaled Scores: Raw scores can be converted to scaled scores for each subscale, allowing
comparison of an individual’s performance across different cognitive areas.

Interpretation:

Cutoff: A DRS total score below 123 is generally suggestive of cognitive impairment. However,
interpretation should always be done within a broader clinical context.

Subscale Analysis: While the total score helps determine the overall severity of dementia, the
pattern of scores on individual subscales can be important. For example:

- Lower scores on Attention and I/P may point toward subcortical dementia or Parkinson’s
related cognitive decline.

- Lower scores on Conceptualization and Memory are often seen in Alzheimer’s disease.

Important Considerations:

Complementary Assessments: The DRS provides valuable information, but it’s intended to be
one part of a comprehensive dementia evaluation alongside medical history, neuropsychological
tests, and brain imaging.

Sensitivity: The DRS is quite sensitive in detecting cognitive decline, but it’s not always
specific enough in distinguishing subtypes of dementia on its own.

DRS-2: There’s an updated version, the Dementia Rating Scale–2 that offers better
standardization, additional test items, and improved sensitivity for mild cognitive impairment.

References:

 Jurica, P. J., Leitten, C. L., & Mattis, S. (2001). Dementia Rating Scale-2: Professional
manual. Psychological Assessment Resources.
 Mattis, S. (1988). Dementia Rating Scale (DRS). Psychological Assessment Resources.
 Monsch, A. U., Bondi, M. W., Salmon, D. P., Butters, N., Thal, L. J., Hansen, L. A., ... &
Klauber, M. R. (1995). Clinical validity of the Mattis Dementia Rating Scale in detecting
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Neurology, 52(9), 899-904.
 Okura, T., Plassman, B. L., Steffens, D. C., Llewellyn, D. J., Potter, G. G., & Langa, K.
M. (2010). Prevalence of neuropsychiatric symptoms and their association with
functional limitations in older adults in the United States: the aging, demographics, and
memory study. Journal of the American Geriatrics Society, 58(2), 330-337.
 Pinto, T. C., Machado, L., Bulgacov, S., Rodrigues-Júnior, A. L., & Costa, M. G. F.
(2019). The Dementia Rating Scale (DRS) in the diagnosis of vascular dementia.
Psychology & Neuroscience, 12(3), 307.