Development of a minimum data set-based depression rating scale for use in nursing homes

BACKGROUND: depression is common but under-diagnosed in nursing-home residents. There is a need for a standardized screening instrument which incorporates daily observations of nursing-home staff. AIM: to develop and validate a screening instrument for depression using items from the Minimum Data Set of the Resident Assessment Instrument. METHODS: we conducted semi-structured interviews with 108 residents from two nursing homes to obtain depression ratings using the 17-item Hamilton Depression Rating Scale and the Cornell Scale for Depression in Dementia. Nursing staff completed Minimum Data Set assessments. In a randomly assigned derivation sample (n = 81), we identified Minimum Data Set mood items that were correlated (P < 0.05) with Hamilton and Cornell ratings. These items were factored using an oblique rotation to yield five conceptually distinct factors. Using linear regression, each set of factored items was regressed against Hamilton and Cornell ratings to identify a core set of seven Minimum Data Set mood items which comprise the Minimum Data Set Depression Rating Scale. We then tested the performance of the Minimum Data Set Depression Rating Scale against accepted cut-offs and psychiatric diagnoses. RESULTS: a cutpoint score of 3 on the Minimum Data Set Depression Rating Scale maximized sensitivity (94% for Hamilton, 78% for Cornell) with minimal loss of specificity (72% for Hamilton, 77% for Cornell) when tested against cut-offs for mild to moderate depression in the derivation sample. Results were similar in the validation sample. When tested against diagnoses of major or non-major depression in a subset of 82 subjects, sensitivity was 91% and specificity was 69%. Performance compared favourably with the 15-item Geriatric Depression Scale. CONCLUSION: items from the Minimum Data Set can be organized to screen for depression in nursing-home residents. Further testing of the instrument is now needed.     

Brief screening tests versus clinical staging in senile dementia of the Alzheimer type

Several brief screening tests of cognitive function were compared with a reliable and valid global rating of the presence and severity of senile dementia of the Alzheimer type, the Washington University Clinical Dementia Rating (CDR). The six-item Short Blessed Test, the Short Portable Mental Status Questionnaire, the 26-item Blessed Information-Memory-Concentration Test, the Blessed Dementia Scale, and the Blessed Dementia Scale-Cognitive were able to discern both the presence of dementia and its severity. The six-item Short Blessed Test is preferred as a screening test because of its brevity, administration to the subject only, inclusion of a learning task, reliability, and neuropathologic validity. Evidence is presented for the convergent validity of the Initial Subject Protocol, used to derive the Clinical Dementia Rating.     

Development and application of the extended scale for dementia.

As part of an interdisciplinary study of organic dementia, a psychologic test for assessing the degree of dementia--the Extended Scale for Dementia--was developed through the expansion and rescoring of the original Mattis Dementia Scale. Statistical analyses of the 23 test items resulted in a scoring scheme which includes the "weighting" of items for scoring purposes. The test was successfully administered to 90 subjects from 6 hospitals in the London (Ontario) region. With use of the Extended Scale, it was possible to discriminate between dementia and non-dementia groups of psychogeriatric inpatients and to correlate the findings closely with those of another measure of the degree of dementia, viz, the London Psychogeriatric Rating Scale (Ment.). Dementia patients who were retested after 6-month and 12-month intervals showed a significant decline in scores. No significant scoring differences were noted between males and females or between Alzheimer dementia and multi-infarct dementia.     

The detection of dementia in the primary care setting

BACKGROUND: Recognition and medical record documentation of dementia in the primary care setting are thought to be poor. To our knowledge, previous studies have not examined these issues in private practice office settings within the United States. OBJECTIVE: To determine the rate of unrecognized and undocumented dementia in a primary care internal medicine private practice. METHODS: This was a cross-sectional study of 297 ambulatory persons aged 65 years and older attending an internal medicine private group practice within an Asian American community of Honolulu, Hawaii. Of the subjects, 95% had been with their current primary care physician for at least 1 year. Each subject's primary care physician noted the presence or absence of dementia by questionnaire at the time of an office visit. An investigating physician (V.G.V.) subsequently assessed cognitive function using the Cognitive Abilities Screening Instrument, and confirmed the presence of dementia and its severity, if present, using Benson and Cummings' criteria and the Clinical Dementia Rating Scale, respectively. A trained research assistant completed telephone interviews to proxy informants for collateral information concerning cognition, behavior, and occupational or social function. Subjects' outpatient medical records were reviewed for documentation of problems with cognition. RESULTS: Twenty-six cases of dementia were identified. Of these 26, 17 (65%) (95% confidence interval, 44.3-82.8) were not documented in outpatient medical records; of 18 patients, 12 (67%) (95% confidence interval, 40.9-86.7) were not thought to have dementia by their physicians at the time of the office visit. Recognition and documentation rates increased with advancing stage of disease. CONCLUSION: Dementia is often unrecognized and undocumented in private practice settings. Arch Intern Med. 2000;160:2964-2968     

Methods to improve the detection of mild cognitive impairment

We examined whether the performance of the National Institute of Aging's Consortium to Establish a Registry for Alzheimer's Disease's 10-word list (CWL), part of the consortium's neuropsychological battery, can be improved for detecting Alzheimer's disease and related disorders early. We focused on mild cognitive impairment (MCI) and mild dementia because these stages often go undetected, and their detection is important for treatment. Using standardized diagnostic criteria combined with history, physical examination, and cognitive, laboratory, and neuroimaging studies, we staged 471 community-dwelling subjects for dementia severity by using the Clinical Dementia Rating Scale. We then used correspondence analysis (CA) to derive a weighted score for each subject from their item responses over the three immediate- and one delayed-recall trials of the CWL. These CA-weighted scores were used with logistic regression to predict each subject's probability of impairment, and receiver operating characteristic analysis was used to measure accuracy. For MCI vs. normal, accuracy was 97% [confidence interval (C.I.) 97-98%], sensitivity was 94% (C.I. 93-95%), and specificity was 89% (C.I. 88-91%). For MCI/mild dementia vs. normal, accuracy was 98% (C.I. 98-99%), sensitivity was 96% (C.I. 95-97%), and specificity was 91% (C.I. 89-93%). MCI sensitivity was 12% higher (without lowering specificity) than that obtained with the delayed-recall total score (the standard method for CWL interpretation). Optimal positive and negative predictive values were 100% and at least 96.6%. These results show that CA-weighted scores can significantly improve early detection of Alzheimer's disease and related disorders.     

Brief screening tool for mild cognitive impairment in older Japanese: Validation of the Japanese version of the Montreal Cognitive Assessment

Aim: The Montreal Cognitive Assessment (MoCA), developed by Dr Nasreddine (Nasreddine et al. 2005), is a brief cognitive screening tool for detecting older people with mild cognitive impairment (MCI). We examined the reliability and validity of the Japanese version of the MoCA (MoCA‐J) in older Japanese subjects. Methods: Subjects were recruited from the outpatient memory clinic of Tokyo Metropolitan Geriatric Hospital or community‐based medical health check‐ups in 2008. The MoCA‐J, the Mini‐Mental State Examination (MMSE), the revised version of Hasegawa's Dementia Scale (HDS‐R), Clinical Dementia Rating (CDR) scale, and routine neuropsychological batteries were conducted on 96 older subjects. Mild Alzheimer's disease (AD) was found in 30 subjects and MCI in 30, with 36 normal controls. Results: The Cronbach's alpha of MoCA‐J as an index of internal consistency was 0.74. The test–retest reliability of MoCA, using intraclass correlation coefficient between the scores at baseline survey and follow‐up survey 8 weeks later was 0.88 (P < 0.001). MoCA‐J score was highly correlated with MMSE (r = 0.83, P < 0.001), HDS‐R (r = 0.79, P < 0.001) and CDR (r = ?0.79, P < 0.001) scores. The areas under receiver–operator curves (AUC) for predicting MCI and AD groups by the MoCA‐J were 0.95 (95% confidence interval [CI] = 0.90–1.00) and 0.99 (95% CI = 0.00–1.00), respectively. The corresponding values for MMSE and HDS‐R were 0.85 (95% CI = 0.75–0.95) and 0.97 (95% CI = 0.00–1.00), and 0.86 (95% CI = 0.76–0.95) and 0.97 (95% CI = 0.00–1.00), respectively. Using a cut‐off point of 25/26, the MoCA‐J demonstrated a sensitivity of 93.0% and a specificity of 87.0% in screening MCI. Conclusion: The MoCA‐J could be a useful cognitive test for screening MCI, and could be recommended in a primary clinical setting and for geriatric health screening in the community. Geriatr Gerontol Int 2010; 10: 225–232.     

Assessment and treatment of patients with dementia of the Alzheimer type]

Recently more than a dozen clinical trials for dementia of the Alzheimer type (DAT) have been conducted in Japan using almost the same diagnostic criteria and assessment procedures. Cholinomimetic drugs such as AChE or M1 agonist are the most common in the current clinical drug trials. DSM-IIIR and NINCDS-ADRDA are usually employed as diagnostic criteria. In the recent report on the sensitivity and specificity of these diagnostic criteria, it has been indicated that the clinician or researcher who wishes to ensure that patients classified as DAT are more likely DAT should choose DSM-III, whereas the investigator who wishes to include the greatest number or DAT cases, seldom assigning a diagnosis of no DAT to a true case, should choose NINCDS-ADRAD. Also, development of exclusion criteria for DAT would be essential to improve interrater reliability of these diagnostic criteria. In the recent clinical trials outside Japan, a dual assessment procedure consisting of objective psychometric test(s) to assess cognitive impairment and global clinical impression of change is a standard method to evaluate the clinical efficacy of drugs for DAT. In psychometric tests, Alzheimer's Disease Assessment Scale (ADAS) is the most common in the US and Hasegawa's Dementia Scale (HDS) in Japan. A Japanese version of ADAS-cog. has been already developed for use in clinical trials in Japan. Also, HDS has recently been revised to improve the sensitivity of the test. In addition, Clinical Dementia Rating (CDR) that is one of the common measures staging severity of dementia in Japan might be a better alternative to the conventional Clinical Global Impression of Change (CGIC) in the US.(ABSTRACT TRUNCATED AT 250 WORDS)     

The short human figure drawing scale for evaluation of suspect cognitive dysfunction in old age

Human figure drawings have been widely used to assess cognitive development in children. In the present study, free-hand human figure drawings were examined for 62 demented patients, and 60 normal elderly subjects. The drawings were scored for 53 body details using a method derived from work with children. A short scale of 15 details was developed by selecting body details with high item-total correlations which are simple to score even for untrained staff. This short scale had excellent interscorer and test-retest reliability and excellent concurrent validity as well. It correlated highly with the Mini-Mental State Examination, a commonly used screening test for dementia. The short scale discriminated demented and non-demented subjects and different levels of dementia severity as graded by the Clinical Dementia Rating Scale. However, no differences were observed between Alzheimer patients and patients with vascular dementia concerning presence of details in human figure drawings.     

Cut-off values of blessed dementia rating scale and its clinical application in elderly Taiwanese

Although the Blessed Dementia Rating Scale (BDRS), a clinical screening instrument, has been applied extensively, no suitable cut-off values and clinical application have been proposed, particularly in mild cognitive impairment (MCI), the precursor of dementia. The BDRS, Mini Mental State Examination (MMSE), and Clinical Dementia Rating Scale (CDR) were administrated in people aged 65 years and above, who were enrolled from southern Taiwan with multistep stratified random sampling and followed-up for 2 years. All subjects (total number = 3,027), with new onset of MCI (defined as CDR = 0.5) in the first year and dementia (defined as CDR > or = 1) in the second and third years were subjected to statistical analysis. In distinguishing normal from MCI, except in the literate group aged 65-74 years, MMSE was superior to BDRS, with cut-off values of 1 in both literate groups aged 65-74 years and > or = 75 years, and 1.5 and 2 in less educated groups aged 65-74 and > or = 75 years, respectively. In distinguishing MCI from dementia, BDRS had cut-off values of 2.5 in both literate groups aged 65-74 and > or = 75 years, and 2.5 and 3 in less educated groups aged 65-74 and > or = 75 years, respectively. These values were better than those for MMSE in all groups. BDRS might be considered as a better tool than MMSE to screen for MCI and dementia in the increasing proportion of literate elderly aged 65-74 years in the aging population.     

Iofetamine I 123 single photon emission computed tomography is accurate in the diagnosis of Alzheimer's disease

To determine the diagnostic accuracy of iofetamine hydrochloride I 123 (IMP) with single photon emission computed tomography in Alzheimer's disease, we studied 58 patients with AD and 15 age-matched healthy control subjects. We used a qualitative method to assess regional IMP uptake in the entire brain and to rate image data sets as normal or abnormal without knowledge of subjects'clinical classification. The sensitivity and specificity of IMP with single photon emission computed tomography in AD were 88% and 87%, respectively. In 15 patients with mild cognitive deficits (Blessed Dementia Scale score, less than or equal to 10), sensitivity was 80%. With the use of a semiquantitative measure of regional cortical IMP uptake, the parietal lobes were the most functionally impaired in AD and the most strongly associated with the patients' Blessed Dementia Scale scores. These results indicated that IMP with single photon emission computed tomography may be a useful adjunct in the clinical diagnosis of AD in early, mild disease.     

Sensitivity and specificity of cognitive and functional screening instruments for dementia: the Indo-U.S. Dementia Epidemiology Study

There is a shortage of adequate screening instruments for dementia in poorly educated populations and non-English-speaking groups. An epidemiological survey was conducted in a population-based, largely illiterate, sample of 5,126 individuals aged 55 and older in 28 villages in the rural community of Ballabgarh in northern India. All participants were administered a general mental status test, the Hindi Mental State Examination (HMSE), and a brief battery of neuropsychological tests. Their informants answered a questionnaire assessing functional ability, the Everyday Abilities Scale for India (EASI). Six hundred thirty-two participants underwent clinical diagnostic evaluation for dementia. We investigated whether the sensitivity, specificity, and predictive value for dementia of the mental status test could be improved by the addition of the brief neuropsychological test battery or the functional questionnaire, comparing the instruments alone and in combination. In participants who could be tested cognitively, the HMSE, the neuropsychological battery, and EASI had sensitivities of 81.3%, 81.3%, and 62.5%, respectively, with specificities of 60.2%, 74.5%, and 89.7%, respectively. The combination of all three was 93.8% sensitive and 41.8% specific. The sensitivity of the HMSE alone was nonsignificantly improved by the addition of either the EASI or the neuropsychological battery, whereas its specificity was significantly decreased by either addition. An advantage of the EASI was that it could also be administered to informants of subjects who were cognitively untestable. In this largely illiterate community, with a low prevalence of dementia, the combination of cognitive tests and a functional ability questionnaire had substantial value for population screening.     

Longitudinal change in three brief assessments of SDAT

Previous research has shown that there is considerable interest in the development of brief indices for use in the diagnosis and staging of senile dementia of the Alzheimer's type (SDAT). Examples of such measures include the Blessed Dementia Scale (BDS) and Pfeiffer's Short Portable Mental Status Questionnaire (SPMSQ). A third measure used in the assessment of organic cognitive impairment is the Face-Hand Test (FHT). This study, which was part of a large longitudinal investigation of SDAT, examined the performance of 43 subjects with SDAT and 57 healthy controls over 30 months. The subjects were assessed three times during this period. In addition to the brief measures (BDS, SPMSQ, and FHT) all subjects were rated on a Clinical Dementia Rating (CDR) Scale based on a lengthy clinical interview. The data were analyzed by means of a series of univariate, repeated measures ANOVAs, and discriminant analysis. Results indicate: control scores did not change over time on any of the measures; when classified according to severity of SDAT, different patterns of performance emerged over time for each measure; and it is difficult to accurately predict progression of SDAT from the three scores.     

Self-rated depression scales and screening for major depression in the older hospitalized patient with medical illness

Until now, no self-rated depression scale had been validated as a screening measure for major depression in the older patient hospitalized with medical illness. The present report establishes the validity of two brief, easily administered depression screening tests, the Geriatric Depression Scale (GDS) and the Brief Carroll Depression Rating Scale (BCDRS), in this population. Structured psychiatric interviews were performed and self-rated depression measures administered to 128 men, aged 70 and over, consecutively admitted to medical and neurological services of a VA hospital. The GDS and BCDRS were both shown to have high sensitivity and specificity for detecting major depression in this setting. Optimal cut-off scores determined by the receiver operating curve characteristics of these tests were 11 for the GDS and 6 for the BCDRS. At a cutoff score of 11, the GDS had a sensitivity of 92%, a specificity of 89%, and a negative predictive value of 99%; lowering the break point to 8 did not increase sensitivity. At a cutoff score of 6, the BCDRS achieved a 100% sensitivity, 93% specificity, and 100% negative predictive value. Whether clinicians decide to implement either of these depression screens in their practice will depend to a large degree on the importance ascribed to the detection of these disorders and on attitudes toward the benefits of treatment.     

Use of the Geriatric Depression Scale in dementia of the Alzheimer type

The Geriatric Depression Scale (GDS) has been shown to be an effective screening test for depression in selected geriatric populations. However, it has not been evaluated as a screening test for depression among elderly adults with dementia of the Alzheimer type. Over a two-year period 283 patients were seen in a geriatric assessment center and were screened for depression using the Geriatric Depression Scale. They also received a clinical psychiatric diagnosis by one of two geropsychiatrists. Patients with a Clinical Dementia Rating (CDR) of 0 (cognitively intact) (n = 70) and those with mild Alzheimer's disease (CDR of 1) (n = 72) were selected for comparison. The data were analyzed using Receiver Operating Characteristic Curves (ROCs) in order to compare the utility of the Geriatric Depression Scale in these two groups. ROC curves, which plot sensitivity against false positives, have come into increasing use as a method of examining the clinical performance of tests. The area lying beneath the curve (AUC) can be estimated and used as a quantitative measure of test performance (equivalent to the Wilcoxon rank sum). In the intact group, the Geriatric Depression Scale produced a ROC curve with an AUC of 0.85 (percent score = 1), which is significant (z = 7.28, P less than .0001). In the group composed of those with Alzheimer's disease, the Geriatric Depression Scale yielded a ROC curve with an AUC of 0.66, which was not significantly different from chance (z = 1.92, P = NS). This study provides empirical evidence that while the Geriatric Depression Scale is an accurate screening test for depression in cognitively intact geriatric populations, it does not maintain its validity in populations that contain large numbers of patients with dementia of the Alzheimer type.     

Symptoms as predictors of functioning in the community-dwelling elderly

This survey was carried out to explore the relationship between symptoms and functional status in the elderly living at home. The setting is an urban area of Turin (Northern Italy). A cross-sectional screening for 20 symptoms was completed in 747 subjects, aged 75 and older. Dependence in basic Activities of Daily Living (ADL) and in Instrumental Activities of Daily Living (IADL), Short Portable Mental Status Questionnaire and Cumulative Illness Rating Scale were also ascertained. A discriminant analysis was performed to determine the potential value of symptoms in predicting functional impairment. The mean number of symptoms was 6.0 per subject (+/-S.D. 3.3) and dependence in ADLs was 8.2%. Amongst a 20-symptom list, six symptoms (fatigue, memory loss, indigestion, nutrition, hearing and speaking problems), either alone or in association, showed sufficient discriminatory power to identify dependence in ADLs (sensitivity=72%), mental impairment (72%), psychological distress (80%), but not dependence in IADLs (48%). Symptoms are common in the free-living elders, but their functional status is good. A short (6 items) formal screening for symptoms may be a simple way to predict functioning and to rapidly manage problems.     

Long-term cognitive and functional decline in late onset Alzheimer's disease: therapeutic implications

BACKGROUND: National Institute of Clinical Excellence guidelines advocate the use of the Mini-Mental Test Examination and a functional assessment as a means of measuring treatment response. However, there is little knowledge of the change expected in those with Alzheimer's disease in clinical practice. OBJECTIVE: to describe the long-term variability of the Mini-Mental Test Examination and Blessed Dementia Rating Scale. METHOD: 374 Alzheimer's disease patients referred to psychiatric services in southeast London were followed annually over a 3-year period. RESULTS: the mean Mini-Mental Test Examination score for the total group at baseline was 9.9 points. Individual variability in the rate of cognitive and functional decline is large and around 40% of patients after 1 year, and up to one-quarter of patients after 3 years who survived, show no change or an improvement in scores compared with baseline measures. CONCLUSIONS: in the evaluation of individual treatment response the rate of change, as measured by the Mini-Mental Test Examination and Blessed Dementia Rating Scale, is of limited value.     

A screening instrument for a Sicilian neuroepidemiological survey in the elderly

We evaluated the sensitivity and specificity of a screening instrument developed for use in a two-phase neuroepidemiological survey in Sicily. The Sicilian Epidemiological Dementia Study (SEDES) project will evaluate the prevalence and incidence of dementia, parkinsonisms and essential tremor in four Sicilian municipalities. It is a two-phase door-to-door survey. To identify subjects with possible neurological disorders, in this study, we developed a screening instrument including a symptoms questionnaire and simple physical tasks for parkinsonisms and essential tremor. The Mini-Mental State Examination (MMSE) was chosen for screening dementia. The symptoms questionnaire and simple tasks developed to identify possible patients with parkinsonism and essential tremor, was tested in a hospital setting. To evaluate sensitivity, we selected 20 patients with essential tremor and 40 with Parkinson's disease (20 with Stages I-II and 20 with Stages III-V) [Neurology 17 (1967) 427]. To evaluate specificity we also selected 20 healthy subjects. The screening instrument was administered in a hospital setting by trained interviewers. Sensitivity of the screening instrument (questionnaire plus simple tasks) was 100% for essential tremor and parkinsonisms regardless of the stage. Specificity of the instrument was 90% (95% CI 66.9-98.2); the predictive positive value was 90.9%, while the negative predictive value was 100%. Even if validity was assessed in a hospital setting, the high sensitivity and specificity obtained suggest that the instrument could be an appropriate screening tool for parkinsonisms and essential tremor in a two-phase neuroepidemiological survey.     

The time and change test: a simple screening test for dementia

BACKGROUND: Although dementia screening tests are available, they have not gained widespread use in hospital or primary care settings. Our goal was to develop a simple, standardized, performance-based test incorporating real-world activities to augment screening efforts in older populations: the Time and Change (T&C) Test. METHODS: The study followed a prospective cohort design, involving medicine and surgery services at an urban teaching hospital. From consecutive admissions, 776 participants aged 70-98 years, 14% with dementia, were enrolled. T&C ratings were validated against a reference standard based on the modified Blessed Dementia Rating Scale and the Mini-Mental State Examination (MMSE). Convergent validity with other cognitive measures, test-retest agreement, and interobserver reliability were assessed. RESULTS: The T&C Test had a sensitivity of 86%, specificity of 71%, and negative predictive value of 97%. The T&C Test demonstrated convergent agreement with three cognitive measures, agreeing most strongly with the MMSE (r = .58). Test-retest and interobserver agreement rates were 88% and 78%, respectively. Education explained 3% of the variance of the T&C Test, compared with 13% of the MMSE. The T&C Test took a mean of 22.9 seconds to complete and was acceptable to participants. Refusal of any test component occurred in 39 individuals (5%). CONCLUSIONS: The T&C Test is a simple, accurate, reliable, performance-based tool for detection of dementia. With its quick, easy-to-use, real-world nature, we hope the T&C Test will be used for widespread cognitive screening in older populations.     

Comparing the Montreal Cognitive Assessment and Rowland Universal Dementia Assessment Scale in a multicultural rehabilitation setting

In Australia it is recommended that all older people undergoing rehabilitation have a cognitive screen. We performed a longitudinal study comparing the correlation of two cognitive screening tools – the Rowland Universal Dementia Assessment Scale (RUDAS) and Montreal Cognitive Assessment (MoCA) with discharge outcomes in a geriatric inpatient setting. The RUDAS cut‐off (<23/30) was associated with discharge to a nursing home (sensitivity 52%, specificity 70%). This was also noted with a MoCA cut‐off <18/30 (sensitivity 57%, specificity 69%). Furthermore the association between the RUDAS and discharge destination was independent of its association with the Functional Independence Measure (r = 0.116; P = 0.275) and had a shorter administration time. Both RUDAS and MoCA scores could be used as predictors of discharge destination in a multicultural population.     

The International HIV Dementia Scale: a new rapid screening test for HIV dementia

OBJECTIVE: HIV dementia is an important neurological complication of advanced HIV infection. The use of a cross-cultural screening test to detect HIV dementia within the international community is critical for diagnosing this condition. The objective of this study was to evaluate the sensitivity and specificity of a new screening test for HIV dementia, the International HIV Dementia Scale (IHDS) in cohorts from the US and Uganda. DESIGN: Two cross-sectional cohort studies designed to evaluate for the presence of HIV dementia. METHODS: Sixty-six HIV-positive individuals in the US and 81 HIV-positive individuals in Uganda received the IHDS and full standardized neurological and neuropsychological assessments. The sensitivity and specificity of varying cut-off scores of the IHDS were evaluated in the two cohorts. RESULTS: In the US cohort, the mean IHDS score for HIV-positive individuals without dementia and with dementia were 10.6 and 9.3 respectively (P < 0.001). Using the cut-off of < or = 10, the sensitivity and specificity for HIV dementia with the IHDS were 80% and 57% respectively in the US cohort, and 80% and 55% respectively in the Uganda cohort. CONCLUSIONS: The IHDS may be a useful screening test to identify individuals at risk for HIV dementia in both the industrialized world and the developing world. Full neuropsychological testing should then be performed to confirm a diagnosis of HIV dementia.