분당서울대학교병원

CDR. GDS. FAST. 분당서울대학교병원 백민재

CDR clinical dementia rating GDS global deterioration scale FAST functional assessment staging of dementia

CDR 1979 - developed at Washington University School of Medicine 1982 - Hughes CP, Berg L, Danziger WL, Coben LA, Martin RL A new clinical scale for the staging of dementia British Journal of Psychiatry 14: 566-72. 1993 - Morris JC et al The CDR: current version and scoring rules. Neurology 43: 2412-3.

Level of impairment* None (0) Questionable (0.5) Mild (1) Moderate (2) Severe (3) Memory No memory loss or slight inconstant forgetfulness Consistent slight forgetfulness; partial recollection of events; "benign" forgetfulness Moderate memory loss; more marked for recent events; defect interferes with everyday activities Severe memory loss; only highly learned material retained; new material rapidly lost Severe memory loss; only fragments remain Orientation Fully oriented Fully oriented except for slight difficulty with time relationships Moderate difficulty with time relationships; oriented for place at examination; may have geographic disorientation elsewhere Severe difficulty with time relationships; usually disoriented to time, often to place Oriented to person only Judgment and problem solving Solves everyday problems and handles business and financial affairs well; judgment good in relation to past performance Slight impairment in solving problems, similarities, and differences Moderate difficulty in handling problems, similarities, and differences; social judgments usually maintained Severely impaired in handling problems, similarities, and differences; social judgment usually impaired Unable to make judgments or solve problems Community affairs Independent function at usual level in job, shopping, and volunteer and social groups Slight impairment in these activities Unable to function independently at these activities although may still be engaged in some; appears normal to casual inspection No pretense of independent function outside home Appears well enough to be taken to functions outside a family home Appears too ill to be taken to functions outside a family home Home and hobbies Life at home, hobbies, and intellectual interests well maintained Life at home, hobbies, and intellectual interests slightly impaired Mild but definite impairment of function at home; more difficult chores abandoned; more complicated hobbies and interests abandoned Only simple chores preserved; very restricted interests, poorly maintained No significant function in home Personal care Fully capable of self-care Needs prompting Requires assistance in dressing, hygiene, keeping of personal effects Requires much help with personal care; frequent incontinence

CDR-E & CDR-K 1996 - Fillenbaum GG et al Estimating the validity of the Clinical Dementia Rating Scale: the CERAD experience Aging Clinical Experimental Research 8: 379-385 2001 - 최성혜등한국판 Expanded Clinical Dementia Rating (CDR) 척도의타당도 The Korean Neurological Association 19: 585-591

Korean version of expanded CDR CDR 0 CDR 0.5 CDR 1 CDR 2 CDR 3 CDR 4 CDR 5 기억력 Memory 기억장애가전혀없거나경미한건망증이때때로나타남. 경하지만지속적인건망증 ; 사건의부분적인회상만가능 ; 양성건망증 중등도의기억장애 ; 최근것에대한기억장애가더심함 ; 일상생활에지장이있음 심한기억장애 ; 과거에반복적으로많이학습한것만기억 ; 새로운정보는금방잊음. 심한기억장애 ; 부분적이고단편적인사실만보존됨. 부분적인사실조차도보통잊어버림. 난해하거나부적절한말을사용하기때문에기억력을검사하기힘든경우가잦음. 의미있는기억기능이전혀없음. 이해력이없거나둔한경우가잦음. 지남력 Orientation 정상 시간에대한경미한장애가있는것외에는정상 시간에대해중등도의장애가있음 ; 사람과장소에대해서검사상으로는정상이나실생활에서길찾기에장애가있을수있음 시간에대한지남력은상실되어있고장소에대한지남력역시자주손상됨. 사람에대한지남력만유지되고있음. 자신의이름에대해서만때때로반응함 자신에대한인식이전혀없음. 판단력과문제해결능력 Judgment and Problem solving 일상생활의문제를잘해결하고사업이나재정문제도잘처리함 ; 과거에비해판단력은아직좋음 문제해결능력, 유사성, 상이성해석에대한경미한장애 문제해결능력, 유사성, 상이성해석에대한중등도의장애 ; 사회생활에대한판단력은대부분유지되어있음. 문제해결, 유사성, 상이성해석에심한장애 ; 사회생활에서의판단력이대부분손상됨. 판단이나문제해결이불가능함. 단순한지시나명령에대해서도수행할능력이없음. 문제에대한인식이나주변환경에대한이해가전혀없음. 사회활동 Community Affairs 직장생활, 물건사기, 자원봉사, 사회적활동등에서보통수준의독립적기능이가능함. 이와같은활동에있어서의장애가의심되거나약간의장애가있음. 이와같은활동의일부에아직참여하고있고언뜻보기에는정상활동을수행하는것처럼보이나사실상독립적인수행이불가능함. 집밖에서독립적인활동을할수없으나외견상으로는집밖에서도기능을잘할수있어보임. 집밖에서독립적인활동을할수없고외견상으로도가정을떠나외부에서는정상적인기능을할수없어보임. 어떠한사회적상황에서도의미있는참여를할수없음. 어떠한활동에도참여할수없음. 집안생활과취미 Home and Hobbies 집안생활, 취미생활, 지적인관심이잘유지되어있음. 집안생활, 취미생활, 지적인관심이다소손상되어있음. 집안생활에경하지만분명한장애가있고, 어려운집안일은포기된상태임. 복잡한취미나흥미 ( 예를들어바둑 ) 는포기됨 아주간단한집안일만할수있고, 관심이나흥미가매우제한됨. 집안에서의미있는기능수행이없음. 어떠한취미활동이나집안일에도의미있는참여를할수없음. 어떠한활동에도전혀참여할수없음. 위생및몸치장 Personal Care 정상 정상 가끔개인위생에대한권고가필요함. 옷입기, 개인위생, 개인소지품의유지에도움이필요함. 개인위생과몸치장의유지에많은도움이필요하며, 자주대소변의실금이있음. 옷입기나식사를하려는시도는있음. 도움없이는이동하지못함. 식사시먹여주어야함. 누워지내는상태임.

CDR Rating through a semi-structured interview Interview of the patient & a reliable informant or collateral source (e.g., a family member) Rating base on interview data & clinical judgment 5-point scale - 0: none - 0.5: questionable - 1: mild - 2: moderate - 3: severe

CDR 1. Memory 2. Orientation 3. Judgment & Problem solving 4. Community affairs 5. Home & hobbies 6. Personal care

CDR Global CDR score - synthesis of the individual ratings in each of the six domains (clinical scoring rules: Morris, 1993) - the Washington University online algorithm (http://www.biostat.wustl.edu/~adrc/cdrpgm/index.html) CDR Sum of Boxes (CDR-SOB) - more detailed quantitative general index - providing more information than the global CDR score to track the progression of dementia

CDR Rating Worksheet Clinical Dementia Rating Worksheet This is a semi-structured interview. Please ask all of these questions. Ask any additional questions necessary to determine the subject s CDR. Please note information from the additional questions. Memory Questions for Informant: 1. Does he/she have a problem with his/her memory or thinking? Yes ( ) No ( ) 1a. If yes, is this a consistent problem (as opposed to inconsistent)? Yes ( ) No ( ) 2. Can he/she recall recent events? Usually( ) Sometimes( ) Rarely( ) 3. Can he/she remember a short list of items (shopping)? Usually Sometimes Rarely 4. Has there been some decline in memory during the past year? Yes( ) No( ) 5. Is his/her memory impaired to such a degree that it would have interfered with his/her activities of daily life a few years ago (or pre-retirement activities)? (collateral sources opinion) Yes ( ) No ( ) 6. Does he/she completely forget a major event (e.g., trip, party, family wedding) within a few weeks of the event? Usually( ) Sometimes( ) Rarely( ) 7. Does he/she forget pertinent details of the major event? Usually ( ) Sometimes ( ) Rarely ( ) 8. Does he/she completely forget important information of the distant past (e.g., birthdate, wedding date, place of employment)? Usually ( ) Sometimes ( ) Rarely ( ) 9. Tell me about some recent event in his/her life that he/she should remember. (For later testing, obtain details such as location of the event, time of day, participants, how long the event was, when it ended and how the subject or other participants got there). Within 1 week: Within 1 month: 10. When was he/she born? 11. Where was he/she born? 12. What was the last school he/she attended? Name Place Grade 13. What was his/her main occupation/job (or spouse s job if subject was not employed)? 14. What was his/her last major job (or spouse s job if subject was not employed? 15. When did he/she (or spouse) retire and why?

CDR Rating Worksheet Orientation Questions for Informant: How often does he/she know of the exact: 1. Date of the Month? ( )Usually ( )Sometimes ( )Rarely ( )Don t Know 2. Month? ( )Usually ( )Sometimes ( )Rarely ( )Don t Know 3. Year? ( )Usually ( )Sometimes ( )Rarely ( )Don t Know 4. Day of the Week? ( )Usually ( )Sometimes ( )Rarely ( )Don t Know 5. Does he/she have difficulty with time relationships (when events happened in relation to each other)? ( )Usually ( )Sometimes ( )Rarely ( )Don t Know 6. Can he/she find his/her way about familiar streets? ( )Usually ( )Sometimes ( )Rarely ( )Don t Know 7. How often does he/she know how to get from one place to another outside his/her neighborhood? ( )Usually ( )Sometimes ( )Rarely ( )Don t Know 8. How often can he/she find his/her way about indoors? ( )Usually ( )Sometimes ( )Rarely ( )Don t Know

CDR Evaluating decline from the patient s premorbid level of performance Rating only impairment caused by cognitive loss Not including physical disability or other noncognitive factors

CDR One of the gold standards of global rating of dementia in trials of patients with AD Validation against neuropathological information Excellent inter-rater reliability (McCulla et al., 1989) - Correlation coefficient 0.89 Correlation with neuropsychological measures (Fillenbaum et al., 1996)

Global CDR vs. CDR SOB O Bryant & Doody et al. (2008) CDR Sum of Boxes range Staging Category 0 Normal 0.5 4.0 Questionable cognitive impairment 0.5 2.5 Questionable impairment (MCI) 3.0 4.0 Early Stage of dementia 4.5 9.0 Mild dementia 9.5 15.5 Moderate dementia 16.0 18.0 Severe dementia

CDR In both research & clinical settings Characterize the level of cognitive & functional performance in older patients AD or another dementing disorders

GDS. BCRS. FAST Global Deterioration Scale Staging System Global Deterioration Scale (GDS) Brief Cognitive Rating Scale (BCRS) Functional Assessment Staging (FAST) Inter-rater and test/retest reliability > 0.90

GDS 1982 Reisberg B, Ferris SH, de Leon MJ, Crook T The Global Deterioration Scale (GDS) for assessment of primary degenerative dementia. American Journal of Psychiatry 139: 1136-9.

GDS 1. No Cognitive Decline 2. Very Mild Cognitive Decline 3. Mild Cognitive Decline 4. Moderate Cognitive Decline 5. Moderately Severe Cognitive Decline 6. Severe Cognitive Decline 7. Very Severe Cognitive Decline

GDS Inter-rater and test/retest reliability > 0.90 Accurately reflecting the progression of the disorder of the primary degenerative dementia Not influenced by educational, cultural, socioeconomic, and other biases More simple than CDR

FAST Functional Assessment Staging of Dementia 1988 - Reisberg B Functional Assessment Staging (FAST). Psychopharmacology Bulletin 24: 653-9 more detailed version of the 7-point functioning and self care axis of the Brief Cognitive Rating Scale (BCRS: Reisberg et al., 1983) 16-item scale

FAST Scale Stage Characteristics 1. Normal adult No functional decline 2. Normal older adult Personal awareness of some functional decline 3. Early AD Noticeable deficits in demanding job situations 4. Mild AD Requires assistance in complicated tasks such as handling finances, planning parties etc 5. Moderate AD Requires assistance in choosing proper attire 6. Moderately severe AD 7. Severe AD Requires assistance dressing, bathing, toileting, experiences urinary & fecal incontinence (a-e) Speech ability declines, loss of abilities to walk, sit up, smile, holding head up (a-f)

CDR GDS FAST MMSE Normal Adult 0 0.5 1 2 1 2 3 4 5 6 7 3 Early stage of AD Mild AD Moderate AD SMI MCI 29 29 29 25 19 14 5 0 Severe AD

CDR GDS FAST MMSE Normal Adult 0 0.5 1 2 3 1 2 3 4 5 6 4 7 5 Early stage of AD Mild AD Moderate AD Severe AD Profound AD Terminal AD SMI MCI 29 29 29 25 19 14 5 0

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