Measuring awareness in people with mild to moderate Alzheimer's disease: development of the Memory Awareness Rating Scale--adjusted

Variations in level of awareness among people with Alzheimer's disease (AD) may impact on well-being for the person with dementia and their carer, and may influence outcomes of cognitive rehabilitation interventions. Awareness has often been assessed using discrepancies between self and proxy rating or between self-rating and objective task performance, with the latter considered to be preferable. Measures are available that are suitable for people with mild AD, for example the Memory Awareness Rating Scale (MARS). However, these may be less appropriate for people whose impairments are more advanced and who consequently have more difficulty with the objective task component. In order to provide a measure suitable for people with moderate AD, an adjusted Memory Awareness Rating Scale (MARSA) was developed by altering the objective task component of the MARS. The MARSA was piloted with 41 participants with mild to moderate AD. It was found to be suitable for use with a broader group of participants than the MARS. The component ratings were found to have good internal consistency. The component ratings and the two indices of awareness had high test-retest reliability. The extension of the original measure offers the opportunity to consider awareness throughout the course of the disease and provides a basis for longitudinal investigations of awareness.     

Memory impairment and awareness of memory deficits in early-stage Alzheimer's disease

Recognition memory of auditory verbal learning tests and awareness of memory deficits were examined in 24 individuals with early-stage Alzheimer's disease (AD) using a performance prediction-postdiction paradigm. Individuals with AD displayed impaired recognition memory, and recognition performance correlated positively with regional cerebral blood flow at rest in bilateral prefrontal areas and the left medial temporal area. In addition, underawareness of memory deficits was also marked even at this early stage. Individuals with AD retrospectively overestimated memory performance after actual performance, but appeared to benefit from feedback, and displayed intact online awareness of memory dysfunction, leading to normal prediction of the second session. However, individuals with AD failed to retrospectively incorporate incidents of memory failure into generalized self-belief systems. Brain/ behavior correlational analyses suggest that the prefrontal cortex and posterior dorsomedial regions including the precuneus may be involved in self-awareness.     

Awareness in early-stage Alzheimer's disease: relationship to outcome of cognitive rehabilitation

Awareness of difficulties may have an important impact on functioning and response to intervention in early-stage Alzheimer's disease (AD). Clinical reports and retrospective studies suggest an association, but this has not previously been tested in a prospective study. Using a new measure of awareness, the Memory Awareness Rating Scale (MARS), which was designed to take account of methodological limitations identified in a review of previous studies, the present study explored the relationship between awareness of difficulties and outcome of a cognitive rehabilitation (CR) intervention in 12 participants with a diagnosis of early-stage Alzheimer's disease. The relationship between awareness and mood, behaviour and executive function was also assessed. The results provide the first demonstration in a prospective study that higher levels of awareness are related to better CR outcomes. Awareness was associated with depression and reported behaviour problems, but not with performance on tests of executive function. These results suggest that variations in level of awareness in early-stage AD are influenced by psychological factors, and that explanatory models need to take these factors into account. Awareness of difficulties may serve as a useful predictor of the likely effectiveness of CR, andthis may assist clinicians in selecting appropriate interventions for individuals with early-stage AD.     

Differentiation of Alzheimer's disease and Huntington's disease with the Dementia Rating Scale

Patients with dementia of the Alzheimer type (DAT) and Huntington's disease (HD) were assessed with the Dementia Rating Scale, a brief mental status examination that provides a global dementia score and subtest scores for attention, initiation, construction, conceptualization, and memory capacities. Although the patients with DAT and the patients with HD were precisely matched in terms of total Dementia Rating Scale score, different subtest score profiles emerged. Patients with DAT were more impaired than patients with HD on the Memory subtest, whereas patients with HD were more impaired than patients with DAT on the initiation subtest. These results are indicative of qualitative differences in the cognitive impairment of the two disorders and demonstrate that such differences can be elucidated with brief mental status examinations.     

The Dementia Rating Scale in Alzheimer's disease,Huntington's disease and progressive supranuclear palsy

The Dementia Rating Scale (DRS) comprises a series of five subtests which assess attention, memory, initiation/perseveration, construction, and conceptualisation. It can be delivered in full in approximately 30 min, making it a useful test for the detection and estimation of the overall level of dementia. We analysed the pattern of subscale test scores in patients with cortical and subcortical dementias, who were matched for their overall level of dementia on this scale. Patients with dementia of Alzheimer's type were more impaired than patients with Huntington's disease (HD) and progressive supranuclear palsy (PSP) on the memory subtest, whereas patients with HD and PSP were more impaired on the initiation/perseveration subtest. This is evidence in favour of the concept of cortical and subcortical dementias as separate, although overlapping, entities. Qualitative differences in the pattern of cognitive impairment in these disorders can be detected with a brief cognitive status examination.     

The clinical utility of the Mattis Dementia Rating Scale in assessing cognitive decline in Alzheimer's disease

The progression of cognitive decline in Alzheimer's disease (AD) was studied by examining patterns of test performance on successive administrations of the Mattis Dementia Rating Scale (DRS) in a sample of 63 participants who were diagnosed with probable AD. Assessments were performed at intervals ranging approximately from 3 to 38 months apart. Results indicated that the pattern of progression and sequence of neuropsychological decline in AD is influenced by sex and age of disease onset. Results offered support for the clinical staging of AD and further substantiated the clinical utility of the Mattis Dementia Rating Scale in staging degree of dementia.     

Dementia Rating Scale Performance: A Comparison of Vascular and Alzheimer's Dementia

Differences in the pattern of neuropsychological dysfunction associated with Alzheimer's disease (AD) and vascular dementia (VaD) were examined using the Dementia Rating Scale (DRS). We examined three groups of patients: (1) Patients with AD; (2) patients with single stroke (CVA); and (3) patients with multiple cerebral infarctions (MI). Comparisons of cognitive dysfunction were conducted on patients that met the DRS criteria for dementia. Dementia groups were similar in age, education, and severity of dementia. Comparisons of the AD and two VaD groups across the specific DRS-scales (Attention, Conceptualization, Construction, Initiation/Perseveration, and Memory) indicated that patients with AD were more impaired on the DRS-Memory while the patients with VaD were more impaired on the DRS-Construction. Additionally, patients with VaD related to MI scored lower on the DRS-Initiation/Perseveration as compared to patients with AD, and patients with AD scored lower on the DRS-Conceptualization as compared to patients with VaD related to CVA. These results are indicative of qualitative differences in the pattern of cognitive deficits associated with the two types of dementia.     

Longitudinal assessment of awareness in early-stage Alzheimer's disease using comparable questionnaire-based and performance-based measures: a prospective one-year follow-up study

Few studies of awareness in dementia have taken a longitudinal perspective, yet exploring the ways in which awareness changes over time may offer important information about the processes involved and the relationship between awareness and other variables. The present study explored in detail the patterns of change in awareness scores over time for a group of 12 participants with early-stage Alzheimer's disease using a multi-dimensional measure giving comparable participant-carer and post diction-performance discrepancy scores. There were small, non-significant increases in mean discrepancy scores for each of these components of the assessment, with similar patterns for questionnaire-based and performance-based ratings. The small changes that were observed reflected both participant and informant factors. The majority of participants showed only very minor changes; others showed changes in the direction of either reduced or increased awareness. There was no significant association between change in mean discrepancy score and change in MMSE score over time, although there was a significant decline in MMSE scores at follow-up. The observation of different longitudinal trajectories for awareness scores, reflecting increased or decreased awareness or no change, may indicate the operation of different processes affecting the expression of explicit awareness that can be understood within a biopsychosocial formulation of this complex construct.     

Disease-specific properties of the Rating Scale for Depression in patients with stroke,Alzheimer's dementia,and Parkinson's disease

To compare the psychometric properties of the Hamilton Rating Scale for Depression (Ham-D) in patients with stroke, Alzheimer's dementia (AD), and Parkinson's disease (PD), receiver operating characteristic curves were plotted for each group. The concurrent validity of the Ham-D with the DSM-IV criteria for major depressive disorder was high in each of these groups. However, optimal performance of the Ham-D requires the application of disease-specific cutoff scores for screening, diagnostic, and dichotomization purposes. These disease-specific cutoff scores were highest in PD, lower in AD, and lowest in stroke patients.     

Awareness dimensions and associated factors in Alzheimer's disease

ObjectivesWe recently reported the major role depression and apathy in awareness among Alzheimer patients, using the stage of the disease as an exposure factor and exploring different assessment methods. Using the same patient data, we aimed here to explore the different dimensions of awareness assessed by different sub-scales in awareness scales.MethodSixty-one Alzheimer patients were examined using four awareness scales relating to three assessment methods: (a) patient-caregiver discrepancy; (b) clinical rating; and (c) prediction of performance discrepancy. Global cognition, executive functioning, autonomy, depression and apathy were also assessed. Multivariate logistic models were performed using disease stage as an exposure factor for awareness scales and sub-scales. Correlations across the different factors and patient and caregiver awareness ratings were computed.ResultsThe patient-caregiver discrepancy and clinical rating methods (a, b) both identified the factors associated with awareness in the overall scales and the sub-scales as being depression and/or apathy. Depression correlated with patient self-ratings while apathy correlated with caregiver ratings. The prediction of performance discrepancy method (c) identified different factors in the overall scale, executive factors in three sub-scales involving executive domains and the memory factor in a sub-scale involving the mnesic domain.DiscussionThe awareness scales using a referential based on a human rating (a, b) suggest that awareness is unidimensional, with depression impacting self-reports and apathy influencing caregiver/clinical reports. Scales based on a test rating (c) appear to be more closely associated with the dimensions assessed. This highlights the role of the reference system for awareness assessment in Alzheimer's disease.     

The clinical validity of the Mattis Dementia Rating Scale in staging Alzheimer's dementia

Considerable heterogeneity exists in the criteria used for the establishment of stages of impairment for patients with dementia. The valid distinction of stages is important both for clinical interpretation and the study of dementia. This study reports on the use of the Mattis Dementia Rating Scale (DRS) in staging dementia. Using a sample of 42 patients diagnosed with Alzheimer-type dementia, DRS performance and a rating of Instrumental Activities of Daily Living (IADL) were compared with clinical ratings of dementia severity. Total DRS score provides a clinically valid measure of stage of impairment and appeared to provide a better distinction among stages than IADL score. However, use of the IADL score in conjunction with total DRS may improve correspondence with clinical staging over use of the total DRS score alone. Normative data for the DRS are also provided.     

Mini-Mental State Examination and Mattis Dementia Rating Scale performance differs in Hispanic and non-Hispanic Alzheimer's disease patients.

Little information exists regarding the performance of Spanish-speaking versus English-speaking patients with Alzheimer's disease (AD) on the Mini-Mental State Examination and the Mattis Dementia Rating Scale. In an attempt to identify culturally biased MMSE items or DRS subscales, we matched Spanish-speaking Hispanic and English-speaking non-Hispanic White community-dwelling AD patients by their MMSE scores and examined specific items within each scale. Our findings indicate that Hispanic AD patients perform significantly worse than non-Hispanics in terms of total DRS score, scores on the DRS subscales for Conceptualization and Memory, and on serial subtraction (or backward spelling item) of the MMSE. While mildly to moderately demented Hispanic and non-Hispanic patients obtained comparable scores on the DRS, severely impaired Spanish-speaking participants obtained considerably lower DRS scores than their English-speaking counterparts. The discrepancy in the DRS scores of the severely impaired Hispanic and non-Hispanic examinees might reflect a cultural bias in the test or educational differences between the groups. Alternatively, the DRS may be more sensitive than the MMSE for detecting severe cognitive impairment in Hispanic patients.     

Memory for choices in Alzheimer's disease

Despite their cognitive impairment, patients with mild Alzheimer's disease (AD) often make important life choices. When making choices, people frequently attempt to directly compare the features of different options, rather than evaluating each option separately. Not every feature has an analogous (or alignable) feature in the other option, however. In 2005, Mather's group found that both younger and older adults filled in such gaps when remembering, creating features in the other option to contrast with existing features. In the present study, such effects of alignability on recognition memory were not found in patients with mild AD. This finding suggests that patients with mild AD are less likely to engage in feature-by-feature comparison processes across choice options, a change that may lead them to make qualitatively different choices than healthy older adults.     

Memory processing in Alzheimer's disease.

The aim of the present research was to examine automatic and controlled influences on memory processing in patients with Alzheimer's disease using the process-dissociation procedure. In Experiment 1, a source recognition procedure was used, and the patients were found to have significantly reduced estimates of automatic processing and capacity to recognise words seen during the study phase of the procedure. In Experiment 2, a detection of repetition procedure was used to determine whether automatic influences on memory decline as a dementia progressed. The patients showed the expected inability to detect repetition in their responding, but there was no evidence that estimates of automatic processing were predicted by mental status scores or by ratings of the severity of dementia. In the third study, a novel method for estimating parameters in the process-dissociation model, developed from the task used in Experiment 2, was tested in a student sample. In this procedure, participants first produce semantic associates with either high or low relatedness to a list of cue words. These responses are subsequently used in a paired associate learning paradigm to determine independent estimates of recollection and automatic processing. Evidence for the validity of this procedure was found in Experiment 3 and the procedure used to examine memory processing in a sample of persons with dementia (Experiment 4). The patient group was found to have a substantial deficit in controlled recollection and a reduced capacity for automatic memory processing.     

Development and validity of the Family Stigma in Alzheimer's disease Scale (FS-ADS)

Although it is widely assumed that persons with Alzheimer disease (AD) and their family caregivers are victims of stigmatization, family stigma in the area of AD has received surprisingly limited attention. Reliable, valid, and user-friendly scales are a first step in expanding this body of knowledge. The aim of this study was to develop and examine the validity of the Family Stigma in Alzheimer's disease Scale. Interviews were conducted with 185 children of persons with AD. A pool of 100 items was identified from the literature and an earlier qualitative study including 3 dimensions (caregivers' stigma, lay persons' stigma, and structural stigma). Exploratory factor analyses, theoretical relevance, and internal reliability analyses allowed us to reduce the pull to 62 items. Regarding construct validity, statistically significant associations were found between family stigma and caregivers' burden and behavioral problems, in most of the scales. Although further testing is warranted, these findings indicate that the Family Stigma in Alzheimer's disease Scale is a reliable and valid instrument for assessing stigma in the context of AD.     

Behavior Rating Scale for Dementia: development of test scales and presentation of data for 555 individuals with Alzheimer's disease

We studied 555 Alzheimer's disease patients on the Behavior Rating Scale for Dementia (BRSD), which uses informant interviews to measure behavioral pathology in demented patients. For the 45 items, ratings of present ranged from 5% to 66% of the subjects, with 39 rated present in at least 10%. Twenty-nine items were significantly correlated with dementia severity. The mean number of items present per subject was 13.5; only two subjects had none rated present. Factor analysis identified six factors common to mildly and moderately demented subjects. Six subscales were developed: Depressive Symptoms, Inertia, Vegetative Symptoms, Irritability/Aggression, Behavioral Dysregulation, and Psychotic Symptoms. Interitem consistency was high for three subscales (alpha's from .75 to .80) and moderate for three (alpha's from .48 to .56). Four subscale scores and total scores were significantly but weakly correlated with dementia severity. Detailed results and test instructions are presented in the BRSD manual, available from The Consortium to Establish a Registry for Alzheimer's Disease.     

Examination of the Lille Apathy Rating Scale in Parkinson disease

Apathy is a unique, multidimensional syndrome commonly encountered in patients with Parkinson disease (PD). Recently, the Lille Apathy Rating Scale (LARS), a semistructured interview yielding a global score, and composite subscores for different domains of apathy (i.e., cognitive, behavioral, affective, self awareness), was developed and given to a sample of patients with PD in France. This study is the first outside of its original developers to examine the English language version of the LARS in PD. We found the LARS to be a coherent instrument demonstrating both convergent and divergent validity, as compared to the Apathy Scale (AS) and Beck Depression Inventory (BDI‐II). Using a receiver operating characteristic (ROC) analysis comparing the LARS to the AS, a validated and widely‐used measure, we identified a cut‐off score (sensitivity = 64%, specificity = 92%, PPV = 88%, NPV = 75%) that was higher than that proposed by the original authors, who derived their cut‐off by comparing LARS global scores to clinical judgments of apathy. Although the present study does not compare the LARS to a diagnostic gold standard or promote its utility for diagnosing apathy, it provides further support for the LARS as a promising instrument to examine apathy in PD. © 2009 Movement Disorder Society