Mohammed T. Abou-Saleh

170 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYphysical and instrumental autonomy of elderly subjects. It takes5 min to deliver and has been used as a base instrument for morerecent developments in this field. Both the IADL and the PADLare task-based scales using simple scoring systems.The Stockton and other scales 20 inspired the Physical andMental Impairment of Function Evaluation in the Elderly(PAMIE). The assessment is completed with the aid of simplyformulated items not requiring rater interpretation. It measuresbehavioural characteristics in patients suffering from chronicdiseases, with particular reference to the elderly. Two other scales,the Psychogeriatric Dependency Rating Scale (PGDRS) 21 and theGeriatric Behavioural Scale 22 , have been developed by nurses,psychologists and psychiatrists. Both scales have been used for theassessment of dementia and physical incapacity. They have beenwell validated in the context of prognostic ability over a period of1–2 years. The only scale designed to examine behaviour in elderlyschizophrenic subjects is the Nurses’ Observation Scale forInpatient Evaluation (NOSIE) 23 . The scale consists of 30 itemsand takes about 20 min to complete. It is based on 3-dayconsecutive observation of the patient and has a frequency scaleof 0–4 for each item.A number of scales designed to be completed by nurses andcarers address disruptive, antisocial and aggressive behaviour indementia sufferers. These include the Overt Aggression Scale 24 ,The Disruptive Behaviour Rating Scale 25 , The Nursing HomeBehaviour Problem Scale 26 and the Brief Agitation Rating Scale 27 .The Caretaker Obstreperous-Behaviour Rating Assessment(COBRA) 28 and the Ryden Aggression Scale 29 are slightly longer,taking up to 30 min to complete.SCALES ASSESSING CARERS AND ENVIRONMENTThe Multiphasic Environment Assessment Procedure 30 is arelatively well-validated questionnaire for the assessment of theenvironment in which dementia sufferers are nursed. It enables theassessment of the complex relationships existing between physicalenvironment, the policies and the characteristics of the staff andresidents. Adaptations have to be made for its use in the UK, as itwas designed and validated in North America 31 . The SocialNetwork Assessment Scale 32 has been used in typing socialnetworks of older dementia sufferers.SCALES ASSESSING CARERSGilleard 33 developed the Problem Checklist and Strain Scale,designed to assess problems experienced by carers. Other less wellknowninstruments include those designed to assess psychologicalproblems facing the carer: the Ways of Coping Check List 34 andthe Burden Interview 35 . The Relatives’ Stress Scale 36 enables therelatives to make a standard assessment of stress they areexperiencing as a result of having to care for an elderly dementedperson living at home. The Caregiver Activity Survey 37 quantifiesthe time a caregiver devotes to the patient, and the MaritalIntimacy Scale 38 specifically examines the psychological andemotional consequences of caring for an ill spouse.RATING SCALES FOR MORALE AND MOODThe Measurement of Morale in the Elderly Scale consists of itemsextracted from empirical observations 39 . It is a long, structuredinterview lasting 2–4 h. A degree of training and knowledge of theinstrument is required before it is used, in order to achievesatisfactory levels of reliability. A shorter morale scale, ThePhiladelphia Geriatric Centre Morale Scale 40 , takes 10 min andrequires no training. The questions are of a forced-choice type andare read to the respondent. There is an internal consistency offactors and the scale has had fairly wide use. It is a multidimensionalinstrument for use in the very old and wasparticularly designed not to provoke fatigue or excessiveinattention.Depression rating scales should only be employed in ratingdepression in older people if validation studies have beenreported. Some rating scales have been specifically designed forthis age group, accommodating the issues of concomitant physicalillness and cognitive change. The Self Care (D) 41 is a selfadministeredscale. It has been used in the community for thescreening and rating of severity of depression in the elderly. It wasfound to be a sensitive indicator of depression. It may havepotential use in the monitoring of change as a consequence ofantidepressant medication. The scale has been validated in a pilotstudy in elderly, continuing-care patients 42 . The Geriatric DepressionScale (GDS) 43 was devised by compiling 100 questions usedby professionals in the diagnosis of depression. O’Riordan et al. 44recently used the scale in a large survey of patients admitted to anacute medical geriatric assessment unit, where there was a highprevalence of physical illness and cognitive impairment. Theyfound that the GDS appeared to be a sensitive test for depressionin this group, but was sufficiently non-specific to requirepsychiatric evaluation of patients with high scores to establishthe accurate prevalence of depressive illness. The instrument existsin 15-item 45 , 10-item and four-item versions 46 . Other scales thatare used by clinicians include the Cornell Scale for depression indementia 47 , the Brief Assessment Schedule Depression Cards 48and the ELDRS 49 designed to be used with an informant as well asthe patient. The Centre for Epidemiological Studies DepressionScale (CES-D) 50 is a self-rating scale that has been found to be ofvalue in screening community samples.CONCLUDING REMARKSThis chapter does not provide a comprehensive account of thewide variety of instruments that are available for the assessmentof the elderly mentally ill. Attention has been given to thoseinstruments that have been relatively well validated, with evidenceof reliability, that are easy to use with little or no training. Theyhave been loosely categorized by function and use. Care must betaken in their application, with appropriate supervision andstandardization in view of frequent problems of inter-raterreliability. In isolation, these instruments are of limited clinicalvalue, but in the context of a multi-professional team they do haveimportant potential in screening, clinical audit, examining issuesof service need and rating change.REFERENCES1. Kendrick DC, Gibson AJ, Moyes ICA. The Kendrick Battery; clinicalstudies. Br J Soc Clin Psychol 1978; 18: 329–39.2. Folstein MF, Folstein SE, McHugh PR. Mini-Mental State; a practicalmethod for grading the cognitive state of patients for the clinician. JPsychiatr Res 1975; 12: 189–98.3. Dick JPR. The Mini-Mental State Examination in neurologicalpatients. J Neurol Neurosurg Psychiat 1984; 471: 491–8.4. Li G, Shen YC, Chen CH et al. An epidemiological survey of agerelated dementia in an urban area of Beijing. Acta Psychiat Scand1989; 79: 557–63.5. Molley DW, Alemayehu E, Roberts R. Reliability of a standardisedMini-Mental State Examination compared with the traditional Mini-Mental State Examination. Am J Psychiat 1991; 148: 102–5.