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    RELIABILITY Since the original publication of the DRS in 1973 (Coblentz et al.) and the subsequent publi cation of the DRS Professional Manual (Mattis, 1988), @ tremendous amount of research has been conducted on the DRS itself as well as its use in validating other neuropsychological meas- ures and neuropsychiatric and behavioral corre- lates. Prior to publication of the DRS-2, a thorough literature review was conducted. This literature review searched PsycINFO and MEDLINE from January of 1990 to January of 2001. Search Parameters used were “Mattis” and “dementia,” ‘and “Dementia Rating Scale.” The results from these searches were reviewed, and those articles viewed as most pertinent have been included in this manual where appropriate. However, the References section of this manual does not include all of the articles identified in the literature review. Researchers interested in a specific aspect of the DRS or its use with a particular patient popula- tion are recommended to conduct a similar search adding the appropriate search parameter key- word(s). In addition to the articles identified in this literature search, studies from two other sources have been included in the DRS-2 Professional Manual. First, much of the research cited in the original DRS Professional Manual has been included (ie., these references may have been excluded by the date parameters of the literature search, yet contain seminal data relevant to the reliability and validity of the DRS). Second, arti- cles referenced by Lucas et al. (1998) that ‘were Rot identified by the Ilterature search have also been incorporated when appropriate, AND VALIDITY Reliability Test-Retest Reliability AAs cited in the original DRS Professional Manual (Mattis, 1988), Coblentz et al. (1973) studied the test-retest reliability for the DRS Total Score and subscale scores. The DRS was administered twice with a I-week interval between administrations to @ group of 30 patients diagnosed with dementia of the Alzheimer’s type (DAT). The correlation Coefficient for the DRS Total Score was .97, with subscale correlation coefficients ranging from .61 to 94. The means and standard deviations for the Total Score and subscale scores at test and retest, as well as the test-retest correlations are presented in Table 4. Internal Consistency The splithalf reliability of the DRS was exam- ined using a sample of 25 patients, ages 65 to 94 years, who received diagnoses of either organic brain syndrome or senile dementia (Gardner, Oliver-Munoz, Fisher, & Empting, 1981). The split. half reliability coefficient was .90. A t test yielded no significant difference between the two halves used in the study, thus indicating that the test was split into balanced halves. Vitaliano, Breen, Russo, et al. (1984) examined the intemal consistency of the DRS. The alpha coefficients were calculated for four DRS subscales using a combined demen- tia sample. The alpha coefficients were Attention (95), Initiation/Perseveration (.87), Conceptual ization (.95), and Memory (.75) 19 Table 4 Test-Retest Reliability of the Original DRS Clinical Data Initial test DRS scale/subscale M ~~ sD Total Score 7955 33.98 Attention 2355 9.91 Initiation Perseveration 2136 9.78 Construction 255 1.81 Conceptualization 21.18 10.58 Memory 1091 6.58 Retest ————_Test-retest correlation M ~~ sD r 83.18 30.60 7 24.16 6.80 61 22.00 7.34 29 291 1.70 83 2191 9.28 94 1220 6.00 92 Note. N= 30. From “Presenile Dementia: Clinical Aspects and Evaluation of Cerebrospinal Dynamics," by J. M. Coblentz, S. Matt, LH. Zingesser, S. S. Kasolf, H. M. Wisniewski, and R. Katzman, 1973, Archives of Neurology, 29, 1973, p. 302. Copyright 1973 by the American Medical Association. Adapted with permission, The internal consistency of the DRS is further supported by a study conducted by Smith et al (1994). The alpha coefficients were computed and compared for the DRS Total Score using a mixed population of patients with DAT, vascular demen- tia (VaD), other types of dementia, and patients with only mild cognitive impairments and no dementia diagnosis. Alpha coefficients for the DRS Total Scores were .84 for the entire mixed group and .82 for the dementia group (excluding patients without a dementia diagnosis). Validity Factor Analysis The strongest support for the organizational structure of the DRS subscales is provided by a study by Hofer, Piccinin, and Hershey (1996) which examined the test’s factor analysis in a group of Alzheimer’s disease patients, mixed dementia patients, and controls. They found five factors which they labeled Longterm Memory (Recall)/Verbal Fluency, Construction, Memory (shortterm), Initiation Perseveration, and Simple Commands. These results closely resemble the earlier work of Vitaliano, Breen, Russo, et al. (1984) who conducted an analysis of the DRS that resulted in four factors with “accept. able” alpha coefficients as previously discussed in this chapter. Hofer et al, (1996) did caution, as is true with all factor analyses of the DRS, that there is a 20 confound of “scoring dependence.” That is, in many of the subscales, ifthe participant completes a complex item he or she automatically receives complete credit for some of the other items in the subtest. This results in an artificial correlation which the authors state "stacks the cards” in favor of the items loading on the same factor. Other researchers have found simplified struc- ture in analyses of the DRS in patients with Alzheimer’s disease. In a study by Colantonto, Becker, and Huff (1993), 219 patients were admin- istered the DRS; analyses resulted in a three- factor model: conceptualization, construction, and memory. These same three factors were confirmed in a subsequent study that included 171 patients with Alzheimer's disease (Woodard, Salthouse, Godsall, & Green, 1996). The validity of a fourth factor, the Attentionnitiation-Perseveration factor, was found to be the least reliable. On the other hand, other researchers, using a population of 185 participants, tested one- to five- factor models (Kessler, Roth, Kaplan, & Goode, 1994). They determined a two-factor model to have the best fit with some items in the Memory and Conceptualization subscales having complete (+1.00) overlap, that is, they were interpreted as an inseparable, single factor. Other individual items, such as name writing and imitating move- ments, did not load on any factor, which was attributed to their low level of variance. The authors concluded that the two-factor model best describes a verbal/nonverbal factor structure to the DRS. Construct Validity The Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975) is a brief screening instrument used to evaluate cognitive status. To examine the relationship between the DRS and the MMSE, Salmon, Thal, Butters, and Heindel (1990) administered the tests to a group of patients diagnosed with probable DAT during a 3year period. The MMSE and DRS displayed a significant correlation (r = .82). The results indi- cated that the DRS displayed greater sensitivity to change than the MMSE jin patients with severe dementia and is the instrument of choice to track progression of dementia at that level of severity. ‘Subsequent studies of the relationship between the DRS and the MMSE are consistent with the correlational findings of Salmon et al. The corre- lation between the DRS Total Score and the MMSE Total score was found to be .78 in a study of 50 patients referred for neuropsychological assessment (Bobholz & Brandt, 1993). Additionally, McFadden, Sampson, and Mohr (1994) found a strong correlation (r = .78) in a study of patients with DAT, Table 5 lists the correlations between the DRS subscales and MMSE tasks found by Bobholz and Brandt. Correlations with the Wechsler Adult Intelligence Scale (WAIS; Wechsler, 1945, 1955) and the Paired Associate Learning (PAL) subtest of the Wechsler Memory Scale (WMS; Wechsler, 1974) were cal- culated for a mixed sample of 31 individuals, ages 58 to 71 years (Coblentz et al., 1973). The group included 11 healthy individuals and 20 patients with organic brain syndromes. All healthy indi viduals with WAIS Full Scale IQs above 85 and normal PAL scores obtained DRS Total Scores above 140. A correlation of .75 was obtained between WAIS Full Scale IQ and DRS Total Score among the patient group. An I-DRS Total Score correlation of .86 was obtained for patients who had PAL scores 1 SD below the mean. In studying the convergent validity of the DRS, Brown et al. (1999) found statistically significant correlations between DRS subscales and the sub- scales of other wellvalidated measures in a sample Of patients with Parkinson’s disease (PD). Among the observed correlations, presented in Table 6, were DRS ATT with Wechsler Adult Intelligence Scales Revised (WAIS-R; Wechsler, 1981), Digits Span Forward (.54); DRS I/P with Wisconsin Card Sorting Test (WCST; Heaton, 1981), Perseverative Responses (-.47); DRS CONCEPT with WAIS-R Table 5 Correlations Among MMSE Items and DRS Subscales DRS subscales ‘Concept- MMSE items ‘tention Initaton Construction alization Memory Date 26 ais 24 35 63"** Place 31 a2e* 20 sae" 7186 Registration 27 52nee 30 aise 4o** Serial Sevens 27 alt Agee 27 13 Recall 3a a5ee* 25 aqeee a5ees Name 12 35" 07 39** 30 Repeat 03 21 Az 2 AT Obey 26 34 Aree Agee 23 Read 13 36** 38** 36** 15 Write 57 ase 67eee 5a 37 Copy agee* agee* 62e** 43ee* 15 MMSE Total 50" 6a*** s7te 66r** 64see ‘Note. Y= 50. From “Assessment of Cognitive Impairment: Relationship of the Dementia Rating Scale to the MintMental State Examination,’ y JH. Bobholz and J. Brandt, 1993, Journal of Geriatric Psychiatry and Neurology, 6, p. 212. Copyright 1993 by B. C. Decker, Inc. Reprinted with permission. MMSE ~ MiniMental State Exemination, Pp <.01. **p < 001 21 Similarities (.85); and DRS MEM with Logical ‘Memory paragraphs from the WMS (.58). Marson, Dymek, Duke, and Harrell (1997) also Investigated the correlations of the DRS ATT, CON- CEPT, MEM, and CONST subscales with corre- sponding scales of the WAIS and WMSR (Wechsler, 1955, 1987). The correlation coefficient observed between the attention scales of the DRS and WMS- R was .70. The DRS CONCEPT and the WAIS Similarities correlation coefficient was .56. The DRS ‘MEM subscale and the WMS Verbal Memory Index score correlated at .69. No significant correlation was observed between the DRS CONST subscale and the WAIS Block Design indicating that they tap different construction abilities. However, a correla- tion of .62 was found between DRS ATT and WAIS Block Design. One hypothesis provided by the authors is that Block Design is a timed, complex format to which attentional measures are strongly correlated. This study also noted that the DRS I/P subscale significantly correlated (r= .63) with the Controlled Oral Word Association Test (COWAT; Benton & Hamsher, 1989). Other Uses of the DRS as a Construct Validity Measure The DRS has also been used as a measure of construct validity in the standardization and validation of the Severe Cognitive Impairment Profile (SCIP; Peavy, 1998), the Short Test of Mental Status (STMS; Kokmen, Naessens, & Offord, 1987), the MacNeillLichtenberg Decision Tree (MLDT; Bank, MacNeill, & Lichtenberg, 2000), and the Frontal Assessment Battery (FAB; Dubois, Slachevsky, Litvan, & Pilon, 2000) Clinical Validity The original intent in designing the DRS was to create a instrument for the purpose of quantita- tively assessing the status of patients with demen- tia and tracking the progression of their disease. The original research results and further studies in this population will be presented here for the convenience of the examiner. Since its publication, the DRS has been used as an experimental measure in several other neuropsychiatric populations, including various dementia populations, Parkinson's disease, Huntington's disease, Mental Retardation, Schizo- phrenia, and patients who are HIV positive or have AIDS. A brief review of some of the more pert nent studies is presented in this section and sum- marized in Table 7. However, the examiner should note that a review of all literature regarding the DRS would be quite extensive and beyond the scope of this manual. For information on the use of the DRS with a specific instrument or popula- tion, it is recommended that any review of the lit erature should use the keywords listed in the beginning of this chapter as well as additional key- words to refine the search parameters and obtain the desired results. Table 6 Correlation of DRS Subscales With Extended Battery Measures Extended neuropsychology battery WMS WAISR west WAISR Immediate WMS Digits Span Perseverative Block WAISR Logical Visual DRS subscales Forward Responses Design _— Similarities Memory ‘Reproduction Attention 54* 06 -.05 17 48" 05 Initition/Perseveration 10 a7 31 04 24 26 Construction 04 4 28 17 “19 42 Conceptualization 12 48" 62t* B5** 19 Ae Memory 09 43 2B 14 58* 26 ‘Note. = 14, From “Valdty ofthe Dementia Rating Scale in Assessing Cognitive Function in Parkinson's Disease” by G. G. Brown, ‘A.A: Rahill J. M. Gorell C. MeDonald, S. J. Brown, M. Silanpaa, and C. Shults, 1999, Journal of Geriatric Psychiatry & Reurology, 12, p. 184. Copytight 1999 by B. C. Decker, Ine. Adapted with permission, DRS = Dementia Rating Scale, WAISR = Wechsler Adult Intelligence Scale-Revised. WCST = Wisconsin Card Sorting Test. 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(qu) osvosip s,uo,Bupuny (s)eouarayoy sunsoy dnosB yeoquyt> dnorp yeaqurD Aq emnqesoqr] SUC peDeIIg jo AreuuNg (penuyjuos) 2 21421, 24 5 861 “Ie 19 “Heqly ‘uaasg ‘ouRyENA 8661 “Ie 32 UyeD 6661 “Ie 12 wnyo0y UeR 0002 “Ie 19 sing, 1 19 altapneag (@eous19ou (8381 x2dui0> aloUL Jo Bi 389} sppfs Buray Atop jo 50} 1 isd UM JOU ING Suynry Ajeg Jo sanmandy [ewauinnsuy yw poreje109 9109g [BIOL SC, “sleasqns g/| 24 uo eyo eaneBaU IseBuONS sy pey UoIssaidaq “se1008 WawW ue d/ panoiduu Apuesytubis pey uojssaidap 105 parean siuaqed, ‘Pouiad swap e sono paysisiod yeu 4/| ue WW UO SUTeB aaqisod amoys (193) Adeuays aaisjnaucsonsol Yum paren siuaned passoudaq sunsoy, dnorp jea1uyD Aq eimjeseqr] Sud PeHDe/9g Jo AreuUNg (penuyuos) 1 a1qe, saqejeuos eiojaeyog uoyssordog, dnos6 yeoquy>, Dementia Because a primary use of the DRS has been the longitudinal study of cognitive status in patients with dementia (dementia of the Alzheimer’s type), a separate sample based on scores for this patient population was collected. It provides the examiner with a basis for tracking disease progression rela- tive to patients with other forms of dementia. The data originally reported in the DRS manual was collected by Coblentz et al. (1973). Table 8 pres- ents the means and standard deviations of the DRS Total Score and subscale scores for the patients from the Coblentz et al. study. Table 8 Performance of DAT (Dementia of the Alzheimer’s Type) Sample DRS scale/subscale M SD Total Score 79.55 33.98 Attention 2355 9.91 Initiation/Perseveration 2137 9.78 Construction 255° 181 Conceptualization 2118 10.58 Memory 10.91 6.58 Note. N= 30. From *Presenile Dementia: Clinical Aspects and Evaluation of Cerebrospinal Fluid Dynamics,” by J. M. Coblentz, S. Mats, L. H. Zingesser, S. S, Kasoff, H. M. Wisniewski, and R. Katzman, 1973, Archives of Neurology, 29, p. 302. Copyright 1973 by the American Medical ‘Association. Adapted with permission, Vitaliano, Breen, Russo, et al. (1984) compared DRS performance between patients with mild to moderately severe DAT and controls. Large and nificant differences were found across mean DRS Total Scores for controls, mild dementia, and moderately severe dementia groups. Significant differences were also found between the mild and moderately severe DAT groups on all subscales and between the control and mild DAT groups for the I/P, CONCEPT, and MEM subscales. Vitaliano, Breen, Albert, et al. (1984) reported that the ATT subscale was able to discriminate severity of func- tional impairment in people with dementia but was not able to distinguish controls from patients with mild dementia, Shay and colleagues (1991) showed that the ATT subscale could distinguish mild from moderate impairment (DAT), whereas 26 the MEM subscale distinguished controls from those with mild impairment, thus supporting the findings of Vitiliano, Breen, Albert, et al. and Vitaliano, Breen, Russo, et al Troster, Moe, Vitiello, and Prinz (1994) com- pared DRS performance among persons atrisk (AR) of developing DAT, persons diagnosed with DAT, and normal controls (NC). Significant ferences between the DAT and NC groups were noted on the MEM subscale. Furthermore, a cut off score set at 20 for the MEM subscale would predict with 93% accuracy which AR individuals would develop DAT within a 4- to 6year period. Monsch et al. (1995) further corroborated the find- ings of Trdster et al. through a study concluding that the MEM and I/P subscales can significantly differentiate between control and DAT groups, Persons diagnosed with DAT also perform signif- ‘antly worse on the MEM subscale as compared to other neuropsychological disordered groups (Brown et al., 1999; Connor et al., 1998; Paolo, Troster, Glatt, Hubble, & Koller, 1995; van der Hurk & Hodges, 1995). In a sample of 66 individuals, Emery, Gillie, and Smith (1996) compared DRS performance of vascular dementia patients (VaD; single infarct, multiinfarct, and noninfarct) to elderly controls. Individuals with VaD had DRS Total Scores indi- cating a greater degree of dementia than elderly individuals. Analysis of subscale performance demonstrated that all three VaD groups had lower scores on the MEM, I/P, and CONCEPT subscales compared to the control group. No significant dif- ferences were noted between the three VaD groups on these subscales. However, significant differences were found between the multiinfarct VaD group and the noninfarct VaD group on the CONCEPT subscale. Kertesz and Clydesdale (1994) compared per- formance on the DRS between patients with VaD and DAT. The VaD group had significantly lower scores on the CONST (motor performance) sub- scale. Lukatela and colleagues (2000) also com- pared DRS performance of VaD individuals to individuals with DAT. Groups did not differ on DRS. Total Scores; however, the VaD group had lower CONST scores than the DAT group. Other Neuropsychiatric Populations The DRS has been proven to be an effective measure for differentiating between various types yarkinson’s Disease (PD). DRS performance persons diagnosed with PD fell between a thy individual and a person diagnosed with «T (Paolo et al., 1995a). PD patients typically ad lower DRS Total Scores than controls (Brown bral, 1999; Tréster, Stalp, Paolo, Fields, & Koller, 995). Compared to controls, PD patients had sig- nificantly lower scores on the CONST subscale, a trend toward lower scores on the I/P sub- Je (Paolo et al., 1995b). The DRS CONCEPT, CONST, and |/P subscales also contributed dis- finctive information in the differentiation of PD patients from controls (Brown et al., 1999). The ability of the DRS to differentiate between PD patients with and without depression was inves- figated by Brown and colleagues (1999). The PD ith depression had significantly lower IDRS Total Scores than PD patients without depres- Sion. The performance of PD patients on the DRS lative to other neuropsychological measures as sassessed by Brown et al. is presented in Table 6. Huntington’s Disease (HD). Paulsen et al. (1995) administered the DRS to 60 people with DAT and 60 people with HD. The dementia sever- ity of all persons was classified into three groups— mild, moderate, or severe. The mean DRS Total j Score for each severity group was 129, 117, and 102, respectively. Across all dementia severity groups, individuals with HD had lower I/P subscale scores, with specific performance impairment in double alternating movements, than the DAT | group. Additionally, at moderate and severe levels of dementia, the HD group had lower CONST sub- F scale scores than the DAT group; the HD group showed greater impairment on the copying of sim- ple geometric line drawings, Mental Retardation (MR) and Down’s ‘Syndrome (DS). The DRS has been proven to be an appropriate screening instrument to test for age-related competency loss in individuals diagnosed with Mental Retardation (McDaniel & McLaughlin, 2000) and Down’s Syndrome (Das, Divis, Alexander, Parrila, & Naglieri, 1995; Das, Mishra, Davison, & Naglieti, 1995), with DS par- ticipants over 50 years of age showing a signifi- cant decline in performance. Das, Mishra, et al. (1995) examined the DRS performance in 100 persons with Mental Retard- ation, 46 of whom were also diagnosed with Down's Syndrome. The mean DRS Total Score for participants with DS but without MR sample and the MR only ("NonDS") sample fell between the normal elderly group's performance and the DAT group's performance. When comparing the DS sample to the NonDS sample, there was a pro- nounced drop in DRS Total Scores in the DS sam- ple at age 50 years and above. This result was confirmed in a second study in which MR partic- ipants with and without DS were compared; par- ticipants over 50 years of age with MR and DS had significantly lower DRS scores than the other three groups (Das, Divis, et al., 1995). In a study conducted by McDaniel and McLaughlin (2000), 84 individuals diagnosed with varying degrees of MR were administered the DRS, The results determined that persons with mild MR had significantly less impairment on the DRS. Total Score and all subscales except the CONST subscale, as compared to the moderate MR sam- ple. Persons with severe MR had significantly lower scores on all subscales and the DRS Total Score as compared to the moderate MR sampie. Schizophrenia. Evans et al. (1999) compared the neurocognitive functioning of 25 institutional ized Schizophrenia patients, 25 Schizophrenia out- patients, and 25 healthy elderly adults. The performance on the DRS by the institutionalized patients was more indicative of cognitive impair- ment as compared to the outpatient and healthy control samples. The inpatient and outpatient Schizophrenia groups displayed similar patterns of cognitive deficits, with the most predominant impairment on the I/P subscale. Eyler Zorrilla and colleagues (2000) examined the relationship of age and DRS performance in 116 Schizophrenia patients and 122 nonclinical comparison adults. Ages ranged from 40 to 85 years. The Schizophrenia group exhibited lower DRS Total Scores as compared to the control group. However, when examining the age-related rate of cognitive decline, no appreciable differ- ences were found between the two groups. HIV and AIDS. Kovner et al. (1992) found in a study of 43 IV drug users that the DRS can dis- criminate between those IV drug users who are HIV-positive and those who are HIV-negative. All individuals with abnormal DRS Total Scores were 20 HIV-positive (57%). Of the HIV-positive individuals only 43% had DRS Total Scores within the nor mal range. All HIV-negative individuals had DRS Total Scores within the normal range. Furthermore, Kovner et al. found the DRS to be a functional screening instrument for discerning neuropsychological impairment in mildly or severely symptomatic HIV-positive persons with an IV drug use history. Suarez et al. (2000) used the DRS and the MMSE to assess four groups of AIDS patients: (a) AIDS patients who were asymptomatic; (b) AIDS patients without cognitive impairment; (c) AIDS patients with mild cognitive impairment; and (a) AIDS patients with dementia. The DRS MEM subscale was able to differentiate between AIDS patients with dementia versus AIDS patients with mild cognitive impairment but no dementia. The authors concluded that, in contrast to the MMSE, the DRS could make this distinction and assess the level of impairment in this population. ‘Neuroanatomical and Physiological Correlates. Stout, Jemigan, Archibald, and Salmon (1996) investigated cortical gray matter (CGM) and abnor- mal white matter (AWM) volumes and dementia severity as measured by the DRS in DAT patients. AWM volume was positively related to low scores for all DRS subscales, whereas CGM volume was negatively related to low scores for all DRS sub- scales with the exception of the I/P subscale. Therefore, lower scores on the ATT, CONCEPT, CONST, and MEM subscales were significantly related to both CGM and AWM volumes; however, a lower score on the I/P subscale was related only to AWM volume. Both lower CGM volumes and higher AWM volumes were found to independently relate to DRS performance and dementia severity. Fama et al. (1997) compared brain volume with DRS performance among 50 DAT patients, ages 51 to 87 years with an average education level of 14.7 years and a control group of 136 healthy adults ages 20 to 84 years. DRS Total Score per- formance correlated significantly with left hip- pocampal and right posterosuperior temporal gray matter in DAT patients, Additionally, in patients with DAT, ATT subscale scores were significantly correlated with bilateral volumes of the lateral ven- tricles and performance on MEM was predicted independently by hippocampal volume. CONST scores were positively correlated with anterosupe- Hior and posterosuperior gray matter with a trend 28 toward greater lateral ventricle volume. Lack of association between prefrontal gray matter vol ume and the I/P subscale was also noted, further supporting the findings of Stout et al. (1996). Chase et al. (1984) examined the relationship between local cerebral glucose metabolism, as measured by positron emission tomography, and performance on the WAIS, WMS, and DRS among @ group of patients with DAT and healthy age- matched controls. Mean cortical glucose metabo- lism was reduced by 30% in the patient group in comparison to controls. DRS Total Score, the WMS memory quotient, and WAIS Full Scale IQ scores were 30% to 45% lower in the patient group than the controls. The correlation between the DRS Total Score and cortical metabolism was .59. Individuals with cerebellar degeneration pro- duced DRS scores indicative of greater dementia as compared to controls, with specific impairment on the 1/P subscale and to a lesser degree on the CONST subscale (Appolionio, Grafman, Schwartz, Massaquoi, & Hallett, 1993) Depression. Latedlife onset of depression fre- quently is associated with cognitive impairment. A greater percentage of the late-onset depression (LOD) group (47.5%) showed impaired DRS per- formance relative to the early onset group of whom only 31% showed impaired DRS scores (van Reekum, Simard, Clarke, Binns, & Conn, 1999). In another study, van Reekum et al. (2000) found that for patients with central nervous sys- tem disease, depression may have the strongest effect on the I/P subscale of the DRS. However, the effects of depression have also been found on DRS MEM subscale performance (Stoudemire, Hill, Morris, & Dalton, 1995). Butters and colleagues (2000) compared 45 elderly depressed patients without dementia and 20 elderly controls. They found that after treat- ment for depression, the DRS performance of eld- erly depressed patients improved significantly on the the I/P and MEM subscales relative to the scores of the control group. They concluded that treatment for depression may improve cognitive status but may not be sufficient to increase per- formance to baseline levels. Behavioral Correlates. The DRS has been shown to have a significant predictive relationship in determining everyday functioning in various populations (Cahn et al., 1998; Nadler, Richardson, Malloy, Marran, & Brinson, 1993; Vitaliano, Breen, Albert et al. 1984). In a study of 39 PD patients, Cahn et al. found a significant correlation (r= .48) between the DRS Total Score and instrumental activities of daily living (IADL; e.g., shopping, preparing meals) but not between the DRS Total Score and physical activities of daily living (PADL; e4g., gait, balance). This indicates that integrity of executive functioning is essential in successfully completing IADLs but not PADLs. On the other hand, Vitaliano, Breen, Albert, et al. noted that the DRS Total Score was correlated with two meas- ures of functional competence. The coefficients with an activity of daily living scale (measuring basic function, such as eating and washing) and an independence scale (measuring more complex functions, such as recreation and reading) were 76 and .56, respectively The DRS has been shown to be predictive of daily living skills using other instruments as well The I/P subscale showed a significant relationship living that were meas- ured, with the exception of cooking. MEM was also significantly correlated with each of the six functional domains with the exception of cooking and money management (Nadler et al., 1993). Summary Mattis’ original intent was the development of an instrument that assessed multiple skills in patients with dementia and to track patients’ pro- gression over time. With the growth of the elderiy population as well as advances in treatment of dementia, it is likely that the DRS-2 will continue to provide clinical utility in the assessment and tracking of dementia. The instrument Mattis designed has proven to be a valuable tool in per- forming similar clinical functions, but with a wider range of populations than was ever imagined. APPENDIX A I DRS-2 Raw Score To MOANS Scaep ScoRE AND it PERCENTILE RANGE CONVERSIONS BY AGE GROUP Table A1 DRS-2 MOANS Scaled Scores and Percentile Ranges for Persons 56 to 68 Years of Age DRS raw scores Scaled ile Initiation/ Conceptual score range Attention Perseveration Construction ization Memory Total Score 10 4159 - 36 6 37 24 137-139 2 <24 02 <7 <5 ‘Note, Age range = 5672 years, = 116, MOANS= Mayo Older American Normative Studies, From "Normative Date forthe Matis Dementia Reting Scale,” by J. A. Lucas, R. J. vnik,G.E. Smith, D. L. Bohac, E.G. Tangelos, E. Kekmen, N.R. Graff Radford, and RC. Petersen, 1998, Journal of Clinical and Experimental Neuropsychology, 20, p. 540. Copyright 1998 by Swets & Zeitinger. ‘Adapted with permission. | Table A2 L DRS-2 MOANS Scaled Scores and Percentile Ranges for Persons 69 to 71 Years of Age DRS raw scores Scaled ile Initiation/ Conceptual score range Attention Perseveration Construction ization ‘Memory Total Score 18 399 - - - - - - 7 99 zi = = s - = 16 98 - - - - - - is 95.97 = = z = 2 144 4 90-94 - - - _ - 143 B 8289 7 = = 39 2 142 12 7281 - - - — - 141 if 6071 36 7 = 38 = 140 10 41.59 35 36 6 3637 2% 137139 9 2940 = = = 35 23 1354136 8 19-28 34 35 - 34 — 133134 z 148 33 3334 a 3233 22 130-132 6 610 32 3132 - 3031 21 127-129 5 33 31 29:30 a 2829 20) 122126 4 2 29.30 27-28 _ 2 18191204121 zg 1 27.28 24-26 3 2526 im 049 2 <1 <7 <24 02 <5 <17 <110 Note, Age range = 65-75 years, n = 166. MOANS = Mayo Older American Normative Studies. From “Normative Data for the Mattis Dementia Rating Seale,” by J. A. Lucas, RJ. Ivnik, G. E. Smith, D. L Bohac, E. G. Tangalos, E. Kokmen, N. R. Graf-Radford, and R.C, Petersen, 1998, Journal of Clinical and Experimental Neuropsychology, 20, p. 540. Copyright 1998 by Swets & Zettinger. ‘Adapted with permission, 37 Table A3 DRS-2 MOANS Scaled Scores and Percentile Ranges for Persons 72 to 74 Years of Age DRS raw scores Scaled “ile Initiation Conceptual score range Attention Perseveration Construction ization Memory Total Score 18 >99 - - - - - - vw 99 = - z = = = 16 98 - - - — - - 15 9597 = = = = = 143144 14 9094 = - — = - - 3 8289 7 Z = 39 25 142, 2 7281 - 37 - - — 14041 ui O71 36 = 3 38 - 139 10 4159 35 36 6 36372324 136138 9 29.40 = 2 ~ 35 = 134135 8 1928 3334 3435 = 34 22 132.133 7 11418 32 3233 5 3233 = 130131 6 610 31 31° - 3031 2 127-129 5 35 0 2930 4 2829 20 12226 4 2 29 27-28 - 27 1819 120-121 3 i 2728 2426 3 2526 7 no-119 2 <1 27 <24 02 25 <7 <110 ote: Age range = 68-78 years, n =222. MOANS = Mayo Oldet American Notmative Studies, From “Normative Data for the Matis Pementia Rating Scale,” by J. A. Lucas, R. J lik, G. E. Smith, D. L, Bohac, E. G, Tangalos, E. Kekmen, N. R. Graff-Radford, and RC Petersen, 1998, Journal of Clinical and Experimental Neuropsychology, 20, . 540. Copyright 1998 by Swets & Zeitinger Adapted with permission, 38 Table A4 DRS-2 MOANS Scaled Scores and Percentile Ranges for Persons 75 to 77 Years of Age DRS raw scores Scaled Shile Initiation/ Coneeptual- score range Attention Perseveration Construction ization Memory Total Score 18 >99 = — - = — - iz 99 = = = eg = _ 16 98 _ = = = _ 144 5 9597 = = = = = 143 14 90-94 _ - — - = = 8 82.89 37 = = 39 2B 141-142 12 7281 36 37 _ 38 = 140 i 60-71 2 = - = Py 138-139 10 4159 35 36 6 3637 23 135-137 9 29-40 = 35 = 35 = 133-134 8 19.28 33:34 34 = 33.34 22 131-132 7 1148 32 32:33 5 32 at 129130 6 610 31 31 _ 3031 - 126-128 5 35) 30, 29:30 4 28:29 1920 122125 4 2 29 27-28 - 27 18 120-121 3 i 2728 24-26 a 23:26) 7 1Os119 2 1 99 _ - ~ _ - - a7 99) = = = = = = 16 98 - — - — _ 144 15 95.97 = = = = = 143, 14 90-94 37 - - 39 _ 142, B 82:89 = - = = 25 141 12 72-81 36 37 - 38 — 139-140 iW 60-71 = z = 37. 24 137-138 10 4159 35 35:36 6 36 23 135-136 9 29.40 34 = = 5) — 132134 8 19-28 33 33:34 = 33:34 22 130-131 7 1148 32) 32. a 3132 21 127129, 6 610 31 31 - 29:30 - 123-126 5 35, 30 29:30 4 27-28 1920 120-122 4 2 29 27-28 - 26 18 116-119 es 26-28 24.26 3 1925 7 108-115 2 <1 <26 <24 02 <19 <7 <108 Note. Age range = 7484 years, n = 338, MOANS = Mayo Older American Normative Studies, From “Normative Data for the Matis Dementia Rating Scale,” by J. A. Lucas, R. J. lnk, G. E. Smith, D. L. Bohac, E. G, Tangalos, E. Kokmen, N. R. GraffRadford, and R. C. Petersen, 1998, Journal of Clinical and Experimental Neuropsychology, 20, p. 540. Copyright 1998 by Swets 6 Zeitinger. ‘Adapted with permission, 40 Table AG DRS-2 MOANS Scaled Scores and Percentile Ranges for Persons 81 to 83 Years of Age DRS raw scores Scaled ile Initiation Conceptual score range Attention Perseveration Construction _ ization Memory Total Score 18 >99 - - - - - - 7 99 = = te = 2 144 16 98 ~ - - - - 143 15 9597 S S a = = 142 14 90-94 7 = - 39 25 - 13 82-89 = 37 = = = 140-141 12 7281 36 - ~ 38 24 138139 if 60-71 ss 36 = 37 = 137 10 4159 35 35 6 3536 23 134-136 9 29.40 cy = = 3a = 131133 8 19.28 33 3334 - 3 22 129.130 z 1118 32 3132 5 3132 2 127-128 6 610 31 30 - 28:30 20 122-126 5 35 30) 2829 4 2627 9 118-121 4 2 29 26.27 - 25 1718 115417 2 1 2628 2425 3 19:24 16 108-114 2 <1 <26 <24 02 <19 <16 <108 Piste. Age range = 77-87 years, n =333. MOANS= Mayo Older American Normative Studies. From “Normative Data for the Matis Romentia Rating Seale," by J. A. Lucas, R. J. Ivnik, G. . Smith, D. L Bohae, E.G. Tengelos, E. Koknten, N. R. Graff Radiord, and a rapeeieesen, 1998, Journal of Clinical and Experimental Neuropsychology, 20, . 540. Copytight 1998 by Swets & Zelinge ‘Adapted with permission 41 Table A7 DRS-2 MOANS Scaled Scores and Percentile Ranges for Persons 84 to 86 Years of Age DRS raw scores Scaled %ile Initiation Conceptual- score range Attention Perseveration Construction ization Memory Total Score 18 >99 - - - = - — 7 99 = = a = - 143-144 16 98 - = - - - - 15 9597 = - = = 142, 14 90.94 37 - - 39 25 141 3) e289 = 37 = = = 1395140 12 7281 36 - - 38 24 138 W 60-71 = 36 - 37 = 136-137 10 4159 3435 35 6 35:36 2B 133-135, 9 2940 34 = 4 2 130-132 8 19.28 33 32.33 5 3233, a 128-129 7 1118 2 31 = 3031 = 125127, 6 610 31 2930 - 2129 20 12-124 5 35 30 27.28 4 25:26 19114120 4 2 29 26 - 24 16 13 3 i 2628 2425) 3 1923 15 07412 2 <1 <26 <24 02 <19 <15 <107 ‘Note. Age range = 80:90 years, n = 292. MOANS = Mayo Older American Normative Studies, From “Normative Data for the Mats Dementia Rating Seale,” by J. A. Lucas, R. J lnk, G. E. Smith, D. L Bohae, E. G. Tangalos, E. Kokmen, N. R. Graf-Radford, and R.C. Petersen, 1998, Journal of Clinical and Experimental Neuropsychology, 20, p. 40. Copyright 1998 by Swets & Zeillinger, ‘Adopted with permission 42 Table A8 DRS-2 MOANS Scaled Scores and Percentile Ranges for Persons 87 to 89 Years of Age DRS raw scores Initiation Conceptua- Scaled score range Attention Perseveration Construction ization Memory Total Score 18 >99 = - _ - - 144 17 99, = = = = = 143, 16 98 - _ - = - - 15 9597 = = Bs = = 142, 14 90-94 37 _ - 39 25 140-141 13 82-89 = 7 = 38 = 139 12 7281 36 - - - 24 137-138 a 60-71 - 36 = Ec = 135-136 10 4159 34:35 35 6 3536 23 132-134 9 29-40 33 34 = 33:34 22 130-131 8 19.28 - 32:33 5 3132 2 127-129 7 1118 32. 3031 = 29:30 20 1235126 6 10 31 27-29 4 27:28 17-19 116-122 5 35 30 24:26 = 2526 16 13115 4 2 29 22:23 3 23-24 - 110-112 a i 2628 1921 2 1922 1415 104109 2

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