Severe Impairment Battery (SIB) in Korean Dementia Patients 507 Profile (SCIP) (5), the Preliminary Neuropsychological Battery (BNP) (6), the Test for

J Korean Med Sci 2006; 21: 506-17 ISSN 1011-8934 Copyright The Korean Academy of Medical Sciences Reliability and Validity of the Severe Impairment Battery (SIB) in Korean Dementia Patients This study was conducted to examine the reliability, validity and clinical utility of the Severe Impairment Battery (SIB) for a Korean population. 69 dementia patients with Clinical Dementia Rating (CDR) stages 2 or 3 were participated in this study. The SIB, Korean version-mini Mental State Examination (K-MMSE), CDR, and Seoul- Activities of Daily Living (S-ADL) were administered. The validity of the SIB was confirmed by evaluating the correlation coefficients between the SIB and K-MMSE, CDR, S-ADL, which were found to be significant. Cronbach s alpha for the total SIB score and each subscale score showed high significance, and the item-total correlation for each subscale was also acceptable. The test-retest correlation for the total SIB score and subscale scores were significant, except for the praxis and orienting to name. The total SIB score and subscale scores were examined according to CDR. The results suggest that the SIB can differentiate the poor performances of severely impaired dementia patients. On the basis of the receiver operating characteristic (ROC), it can be concluded that the SIB is able to accurately discriminate between CDR 2 and 3 patients. The results of this study suggest that the SIB is a reliable and valid instrument for evaluating severe dementia patients in Korean population. Key Words : Dementia; Neurophysiological Tests; Severe Impairment Battery; Reproducibility of Results; Reliability and Validity; ROC Curve Inn-Sook Ahn, Ji Hae Kim*, Hyoung Mo Ku, Judith Saxton, Doh Kwan Kim* Samsung Biomedical Research Institute, Samsung Medical Center; Department of Psychiatry*, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Department of Psychiatry, SunHospital, Daejeon, Korea; University of Pittsburgh, Pittsburgh, PA, U.S.A. Received : 2 August 2005 Accepted : 22 November 2005 Address for correspondence Doh Kwan Kim, M.D. Department of Psychiatry, Sungkyunkwan University, Samsung Medical Center, 50 Ilwon-dong, Gangnam-gu, Seoul 135-710, Korea Tel : +82.2-3410-3582, Fax : +82.2-3410-0050 E-mail : paulkim@smc.samsung.co.kr *This study was supported by a grant of the Korea Health 21 R&D Project, Ministry of Health & Welfare, Republic of Korea (A050079). INTRODUCTION Dementia is one of the most severe pathologies in old age, and as it progresses, it eventually leads to severe impairment of cognitive function, and activities of daily living, as well as behavioral problems. The progression of dementia results in global and severe impairment across all spheres of cognitive function. Therefore, it is important to evaluate the changes, which take place over time and the presence and extent of the preserved abilities as dementia progresses. This information may help in the management of severely demented patient, and could be used in the design of psychosocial and environmental interventions. The therapeutic efficacy can be also evaluated in severely demented patients if they are tested with more appropriate instruments. Many neuropsychological instruments have been developed which are designed to assess mild to moderate cognitive impairment and are in common usage. However, as dementia progresses to the advanced stages, the ability of these conventional neuropsychological and mental status assessments to measure cognitive functions becomes increasingly limited, because many dementia patients perform at floor levels (1). Moreover, since it can be difficult to test severely demented patients, due either to their refusal or the severity of deterioration, most of the instruments commonly used in cases of mild dementia show a limited range of scores and exhibit the floor effect in the advanced stages. One approach to the assessment of the cognitive functions of severely impaired dementia patients involves the use of observer-based rating scales. For example, the Clinical Dementia Rating Scale (CDR) (2) and Global Deterioration Scale (GDS) (3) enable the clinician to evaluate the severity of dementia and the presence or absence of symptoms on the basis of clinical interviews with family members or other informants. Another way to avoid the floor effect is to use neurologic procedures such as the Glasgow Coma Scale (4), which evaluates the presence of neurologic signs and symptoms rated in conjunction with basic cognitive and functional skills. Although these approaches adequately assess the global dementia severity, they do not provide a performance-based evaluation of the dementia patient s cognitive abilities and cannot detect relatively spared abilities in various cognitive domains. Therefore several instruments have been developed to overcome these limitations and to assess patients with severe dementia who are unable to complete standard neuropsychological tests, viz. the Severe Cognitive Impairment 506

Severe Impairment Battery (SIB) in Korean Dementia Patients 507 Profile (SCIP) (5), the Preliminary Neuropsychological Battery (BNP) (6), the Test for Severe Impairment (TSI) (7), and the Severe Impairment Battery (SIB) (8). The SIB is a particularly reliable, valid and useful instrument for evaluating cognitive changes in dementia patients whose level of functioning is in the moderate to severe range (1). The SIB was also more apt to identify differences in the performances in the 5-10 score region of the Mini Mental State Examination (MMSE) (9), thus avoiding the floor effect (10). The information provided by the SIB appeared to be fairly independent of that obtained from the CDR and GDS in the moderate to severe stages, although the utility of the SIB in milder dementia was limited (1). At present, the number of instruments that can be used in this country to evaluate patients with severe dementia who cannot complete conventional neuropsychological tests is very limited. Recently, Kim et al. developed the Severe Dementia Rating Scale (SDS) (11), which has a similar form to the Korean version-mini Mental State Examination (K- MMSE) (12). The SDS is composed 30 items that are independent of the education of the patients, and allows the various cognitive domains to be assessed within a shorter period of time. However, it has two main limitations, namely that it provides limited comprehensive information about the patient s cognitive functions and that the test-retest reliability interval is very short. This study was conducted to examine the reliability and validity of the SIB for a Korean population with the purpose of making a more comprehensive and appropriate instrument available for the evaluation of dementia patients with severe impairment. Also, the receiver operating characteristic (ROC) curve was used to determine the degree to which the SIB discriminates dementia severity and to examine its clinical utility. Subjects MATERIALS AND METHODS This study included 69 (male=19, female=50) patients with the diagnosis of dementia according to DSM-IV (13) and NINCDS/ADRDA (14) criteria treated at a Geropsychiatry Clinic, Department of Psychiatry, Samsung Medical Center. 54 had Alzheimer s disease (AD), 7 had the mixed type of dementia and 8 had other types of dementia, e.g., vascular dementia, dementia due to Parkinson s disease, dementia not otherwise specified. Only patients with CDR stages 2 or 3 and scores of less than 15 on the K-MMSE were included in this study. 25 subjects were rated as CDR stage 2, and 44 as stage 3. The mean K-MMSE total score was 5.49 (SD=3.91). The mean age of the subjects was 74.4 yr (SD=10.0), and their mean length of education was 7.91 yr (SD=5.78). Severe Impairment Battery (SIB) Saxton et al. developed the SIB to assess patients with severe dementia who cannot complete conventional neuropsychological tests. The SIB contains 51 questions which take a total of about 20 min to administer, and the possible scores range from 0 to 100. The SIB is divided into 9 subscales, viz. social interaction skills (score 0-6), memory (score 0-14), orientation (score 0-6), language (score 0-46), attention (score 0-6), praxis (score 0-8), visuospatial ability (score 0-8), construction (score 0-4) and orienting to name (score 0-2), each of which yields individual scores. There is no cut-off score for normal subjects as the test is only intended to be used with patients known to be severely impaired. However, it is possible to grade the severity of impairment by rating those who score less than 63 on the SIB (corresponding approximately to less than 4 on the MMSE). Also, in terms of its administration, the SIB is composed of very simple one-step commands, which are presented together with gesture cues and can be repeated several times to facilitate comprehension. The SIB used in this study was translated into Korean by three clinical psychologists, who made sure that all the characteristics and structure of the original SIB were maintained in the Korean version. Two items in the language subscale were modified. First, we changed the item recite the months of the year to recite the days of the week, because the original item was too easy for Koreans. Second, the phrase people spend money was not natural when it was translated into Korean, thus we changed it to I bought something. In terms of its administration, the original materials (photograph of spoon and cup, blocks) of the SIB were familiar to the patients. However, the patients mistook the color of certain blocks. For example, as sometimes occurs in normal elderly, those patients with severe cognitive impairment or a low educational level sometimes mistook a blue block for a green one. Thus, when they failed to indicate the correct color for the blue block, we informed them of their mistake before passing on to the next item. All of the items of the SIB are presented in the appendix. Korean version-mini Mental State Examination (K-MMSE) The MMSE was developed to evaluate the subject s orientation, memory, attention & calculation, and visuospatial and language abilities. Kang et al. conducted a study to examine the validity of newly constructed K-MMSE. It contains 30 questions, and the possible scores range from 0 to 30. Seoul-Activities of Daily Living (S-ADL) The S-ADL (15) was developed to assess basic activities of daily living, including self-care/hygiene, toileting, ambulation, and so on. It is composed of 12 items, and the possible scores range from 0 to 24. Using the S-ADL, the clinician eval-

508 I.-S. Ahn, J.H. Kim, H.M. Ku, et al. uates the subject s functional disability by conducting interviews with the caregivers. Clinical Dementia Rating (CDR) The CDR assesses the cognitive performance in six categories; memory, orientation, judgment and problem solving, community affairs, home and hobbies, and personal care. The information needed to evaluate each category is obtained by semi-structured interviews with both the patient and a reliable informant. The CDR provides descriptors for each category and a global CDR score of five levels of impairment (0=no dementia, 0.5=questionable, 1=mild, 2=moderate, 3=severe). Data analysis Statistical analyses were performed with SPSS 11.0 for WINDOWS. The Mann-Whitney U test and Spearman correlation were used to test for significant differences in the total SIB, K-MMSE and S-ADL scores according to sex, age and education. The validity of the SIB was determined by calculating the Spearman correlation coefficients between the SIB and the K-MMSE, CDR, and S-ADL. Cronbach s coefficient alpha and item-total correlation coefficients were generated to examine the internal consistency of the SIB. Also, Spearman correlation coefficients were generated to evaluate the 3 months test-retest reliability. The Mann-Whitney U test was used to assess the differences in the mean SIB total score for the various CDR stages. Finally, a ROC curve was used to compare the sensitivity, specificity and probability Table 1. Correlations between the SIB and other variables K-MMSE CDR S-ADL SIB 0.875* -0.678* -0.661* SIB, Severe Impairment Battery; K-MMSE, Korean version-mini Mental State Examination; CDR, Clinical Dementia Rating; S-ADL, Seoul-Activities of Daily Living. *p<0.01. Table 3. Test-retest reliability of the SIB (n=15) SIB, Severe Impairment Battery. *p<0.05, p<0.01. Spearman s SIB total score 0.79 Social interaction 0.71 0.69 Orientation 0.63* 0.74 Attention 0.53* Praxis 0.45 Visuospatial ability 0.58* Construction 0.88 Orienting to name 0.00 of correctly discriminating dementia severity in the case of the SIB, K-MMSE and S-ADL. RESULTS Demographical characteristics Sex and education had no significant effect on the K-MMSE, SIB, S-ADL or CDR, but significant correlations were found between age and the total K-MMSE score ( (69)=0.26, p<0.05) and age and the total SIB score ( (69)=0.27, p<0.05). Validity The construct validity of the SIB was examined by comparing the total SIB score with the total K-MMSE, CDR and S-ADL scores (Table 1). The Spearman correlation coefficient between the SIB and the K-MMSE was 0.875 (p< 0.01); between the SIB and the CDR was -0.678 (p<0.01); and between the SIB and the S-ADL was -0.661 (p<0.01). Table 2. Internal consistency of the SIB SIB, Severe Impairment Battery. Cronbach s SIB total score 0.97 Social interaction 0.77 0.76 Orientation 0.57 0.94 Attention 0.77 Praxis 0.90 Visuospatial ability 0.83 Construction 0.86 Table 4. Means and standard deviations of the SIB for each CDR group CDR 2 (n=25) Mean (SD) CDR 3 (n=44) Mean (SD) SIB total score 71.48 (12.28) 33.91 (22.94) 0.000 Social interaction 4.92 (1.29) 3.58 (1.65) 0.001 7.36 (2.77) 2.65 (3.04) 0.000 Orientation 3.44 (1.39) 1.88 (1.52) 0.000 34.20 (6.56) 15.74 (11.29) 0.000 Attention 4.88 (1.33) 1.98 (1.88) 0.000 Praxis 6.28 (2.49) 2.19 (2.66) 0.000 Visuospatial ability 5.68 (2.38) 2.93 (3.03) 0.001 Construction 3.72 (0.61) 1.63 (1.60) 0.000 Orienting to name 1.52 (0.65) 1.49 (0.69) 0.861 SIB, Severe Impairment Battery; CDR, Clinical Dementia Rating. Total scores of the SIB subscale: Social interaction (6), (14), Orientation (6), (46), Attention (6), Praxis (8), Visuospatial (8), Construction (4), Orienting to name (2). p

Severe Impairment Battery (SIB) in Korean Dementia Patients 509 Reliability The Cronbach s coefficient alpha and item-total correlation coefficients were generated to examine the internal consistency of the SIB (Table 2). The internal consistency of the total SIB score was 0.97, and that of the SIB subscales ranged from 0.57 (orientation) to 0.94 (language). The item-total correlation for the SIB subscales was also acceptable (p<0.01). Data from those 15 subjects who were tested again after an interval of 3 months allowed the assessment of the testretest reliability using Spearman correlation coefficients (Table 3). The test-retest correlation for the total SIB score was statistically significant. Significant subscale correlations were observed for social interaction, memory, orientation, language, attention, visuospatial ability and construction. However, the test-retest correlation for the praxis and the orienting to name subscales did not reach significance. SIB score according to dementia severity The subjects were separated into two groups according to their dementia severity using the CDR with the aim of measuring the total SIB score and subscale scores (Table 4). As a result, the difference in the total SIB score and its subscale scores between the CDR 2 and CDR 3 groups was significant, except for the orienting to name subscale. Despite their pervasive deficits, the more severely demented patients belonging to the CDR 3 group showed a wide range of total SIB score and subscale scores. In the analysis of impairment in the individual cognitive domains, the CDR 2 patients had greater impairment in the individual cognitive domains, especially in memory and Table 5. Sensitivity and specificity of the SIB, K-MMSE and S- ADL AUC, Area Under Curve. *p<0.01. AUC Cut-off Sensitivity Specificity SIB 0.906 62/63 88% 88% K-MMSE 0.900 5/6 86% 88% S-ADL 0.881 6/7 84% 82% SIB, Severe Impairment Battery; K-MMSE, Korean version-mini Mental State Examination; S-ADL, Seoul-Activities of Daily Living; AUC, Area Under Curve. Table 6. AUC of the K-MMSE subtests AUC Time orientation 0.623 Place orientation 0.857* Registration 0.874* Attention and Calculation 0.548 Recall 0.517 and Visuospatial 0.820* orientation, as compared with that in the full score of each subscale. On the other hand, their construction, attention and social interaction abilities were comparatively maintained. The CDR 3 patients had more severe impairment than the CDR 2 patients in all cognitive domains, and this greater impairment was especially notable for construction, attention and praxis. Receiver Operating Characteristic (ROC) Curve The ROC curve was used to determine the degree to which the SIB allows the dementia severity to be discriminated (CDR 2 vs. CDR 3). The sensitivity and specificity levels of the SIB were also compared with those of the K-MMSE and S-ADL (Table 5). The sensitivity and specificity of the SIB in the differentiation of the CDR 2 and CDR 3 patients were both 88% when the cut-off score was 62.5. When the cutoff score of the K-MMSE was 5.5, the corresponding sensitivity and specificity were 86% and 88%, respectively. The sensitivity and specificity of the S-ADL were 84% and 82%, respectively, when the cut-off score was 6.5. Grossly, the sensitivity and specificity of the SIB were higher than those of both the K-MMSE and S-ADL. The Area Under the Curve (AUC) for each test revealed that the SIB (AUC=90.6%) was more accurate than both the K-MMSE (AUC=90%) and S-ADL (AUC=88.1%) in the differentiation of the CDR 2 and CDR 3 patients. The diagnostic accuracy of the K-MMSE was similar to that of the SIB. However, as a result of the diagnostic accuracy of the K-MMSE subscales, it was found that only the place orientation, registration, language and visuospatial subscales could be usefully discriminated between the CDR 2 and CDR 3 patients using this instrument (Table 6). The diagnostic accuracy of the S-ADL was lower than that of both the SIB and K-MMSE. Fig. 1 shows the results in the form of the ROC curve. Sensitivity 1.00 0.75 0.50 0.25 0.00 0.00 0.25 0.50 0.75 1.00 1-Specificity Fig. 1. ROC curves of the SIB and K-MMSE. Source of curve Reference line SIB total score K-MMSE total score

510 I.-S. Ahn, J.H. Kim, H.M. Ku, et al. DISCUSSION In this study, the reliability and validity of the SIB were examined, and its clinical utility for discriminating dementia severity was proved using the ROC curve. The results of this study suggest that the SIB is a reliable, valid, and useful instrument for evaluating severely impaired dementia patients. The significant correlation that was obtained between the SIB and the K-MMSE, CDR and ADL suggests that the SIB has appropriate construct validity, as was previously observed. In particular, the high correlation between the total SIB and K-MMSE scores indicates that the SIB evaluates global cognitive functioning in patients with severe dementia. Cronbach s coefficient alpha for the total SIB score and each subscale score and the item-total correlation for the SIB subscales showed high significance, indicating that the SIB has excellent internal consistency. The test-retest correlation for the total SIB score and each subscale scores was relatively significant. This result suggests that the performance on this instrument has acceptable stability over time. However, the testretest correlation for the praxis subscale was not significant in this study, whereas the one month test-retest correlation for this subscale was 0.63 (p<0.01) in a previous study (1). This discrepancy may be attributed to the change in the functioning of the patients caused by the long retest interval. The test-retest correlation for the orienting to name subscale was not significant either, possibly due to the fact that the difference in the orienting to name subscale score was not notable, because almost all of the patients were successful in this subscale. The total SIB score and the SIB subscale scores were compared according to the dementia severity using the CDR. It was found that the difference in the total SIB score and its subscale scores between the CDR 2 and CDR 3 patients was significant, except for the orienting to name subscale. Despite their pervasive deficits, the more severely demented patients belonging to CDR 3 showed a wide variation in both the total SIB scores and the scores on each subscale. These results suggest that the SIB is useful for evaluating dementia patients with a moderate to severe range of functioning, and can differentiate between the poor performances of very severely impaired dementia patients. The SIB can also avoid the floor effect that was frequently observed in conventional neuropsychological tests used for evaluating patients in the advanced stages. In the analysis of the impairment in individual cognitive domains according to dementia severity, the CDR 2 patients had greater impairment in memory and orientation than other cognitive domains. On the other hand, the construction, attention and social interaction abilities were comparatively maintained. The CDR 3 patients showed more severe impairment than the CDR 2 patients in all cognitive functions. In particular, greater impairment was observed in the construction, attention and praxis subscales. However, the difference in the orienting to name subscale score between the CDR 2 and CDR 3 patients was not significant. This result indicates that recognition of self is relatively maintained until the advanced stages of dementia. These aspects of the comparative decline in various cognitive domains are consistent with the clinical course of AD, so the result of this study should provide us with a better understanding of natural history in AD. However, there is a limitation in that this study included not only AD patients but also patients with other forms of dementia. Therefore, it is necessary to compare the different aspects of cognitive impairment by dementia subtype in a further study. On the basis of the ROC curve, it can be concluded that the SIB was very useful for discriminating between CDR 2 and CDR 3 patients, as was the total K-MMSE score. However, the time orientation, attention/calculation and recall subscale scores were at floor and consequently, these subscales were not apt to discriminate dementia severity in the moderate to severe stages of dementia. The S-ADL had a somewhat lower sensitivity, specificity and diagnostic accuracy than those of the SIB and K-MMSE. These results indicate that the SIB has greater clinical utility than the K-MMSE and S-ADL, because it can provide comprehensive information about the changes in various types of cognitive functioning (i.e. social functioning, memory, language, and so on) of the patients and can discriminate between the relative impairment in the cognitive domains in the final stages of the disease. This study has several limitations. First, the dementia subtype was not taken into consideration. Because those cognitive functions that are more impaired or spared may differ according to dementia subtype, it is important that the different aspects of cognitive impairment be examined by dementia subtype in a further study. Second, there is a possibility that the change in the functioning of the patients caused by the long retest interval may have affected the test-retest correlation coefficient. REFERENCES 1. Schmitt FA, Ashford W, Emesto C, Saxton J, Schneider LS, Clark CM, Ferris SH, Mackell JA, Schafer K, Thal LJ. The severe impairment battery: concurrent validity and the assessment of longitudinal change in Alzheimer s disease. The Alzheimer s disease cooperative study. Alzheimer Dis Assoc Disord 1997; 11: 51-6. 2. Morris JC. The Clinical Dementia Rating (CDR): Current version and scoring rules. Neurology 1993; 43: 2412-4. 3. Reisberg B, Ferris SH, DeLeon MJ, Crook T. The Global Deterioration Scale for assessment of primary degenerative dementia. Am J Psychiatry 1982; 139: 1136-9. 4. Benesch CG, McDaniel KD, Cox C, Hamill RW. End-stage Alzheimer s disease: Glasgow Coma Scale and the neurologic examination. Arch Neurol 1993; 50: 1309-15. 5. Peavy GM, Salmon DP, Rice VA, Galasko D, Samuel W, Taylor

Severe Impairment Battery (SIB) in Korean Dementia Patients 511 KI, Ernesto C, Butters N, Thal L. Neuropsychological Assessment of severely demented elderly: The Severe Cognitive Impairment Profile. Arch Neurol 1996; 53: 367-72. 6. Cossa FM, Fabiani M, Farinato A, Laiacona M, Capitani E. The preliminary neuropsychological battery: An instrument to grade the cognitive level of minimally responsive patients. Brain Inj 1999; 13: 583-92. 7. Albert M, Cohen C. The test for severe impairment an instrument for assessment of patients with severe cognitive dysfunction. J Am Geriatric Soc 1992; 40: 449-53. 8. Saxton J, McGoingle-Gibson K, Swihart A, Miller M, Boller F. Assessment of the severely impaired patient: description and validation of a new neuropsychological test battery. Psychol Assess 1990; 2: 298-303. 9. Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: a practical method for grading the cognitive state of patients for clinician. J Psychiatr Res 1975; 12: 189-98. 10. Barbarotto R, Cerri M, Acerbi C, Molinari S, Capitani E. Is SIB or BNP better than MMSE in discriminating the cognitive performance of severely impaired elderly patients? Arch Neurol 2000; 15: 21-9. 11. Kim TY, Kim SY, Kim JW, Lim BH. Severe Dementia Rating Scale: The mental status examination for moderate to severe Alzheimer s disease patients. J Korean Dementia Assoc 2002; 1: 113-6. 12. Kang Y, Na DL, Hahn S. A validity study on the Korean Mini-Mental State Examination (K-MMSE) in dementia patients. J Korean Neurol Assoc 1997; 15: 300-8. 13. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder (4th ed): 1994. 14. McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan E. Clinical diagnosis of Alzheimer s disease: report of the NINCDS- ADRDA Work group under the auspices of Department of Health and Human Services Task Force on Alzheimer s disease. Neurology 1984; 34: 939-44. 15. Ku HM, Kim JH, Lee HS, Ko HJ, Kwon EJ, Ahn SM, Kim DK. A study on the reliability and validity of Seoul-Activities of Daily Living (S-ADL). J Korean Geriatr Soc 2004; 8: 206-14.

512 I.-S. Ahn, J.H. Kim, H.M. Ku, et al. Appendix The Severe Impairment Battery (SIB) 명시된경우를제외하고, 필요하다면지시를반복할수있다. Social Interaction 1 (SI) a 피검자에게다가가인사를한다. 2점 : 자발적으로고개를숙이며인사하거나 안녕하세요. 제이름은 OOO입니다 안녕하세요 라며인사함 1점 : 검사자를바라보지만, 인사를하지는않음 b 손을내밀어검사실이나책상을가리킨다. 2점 : 가리킨방향으로자발적으로가거나, 몇가지물어볼게있습니다. 질문에대답해주십시오 (alternative) 자발적으로일어나앉음 저와같이검사실로갑시다 1점 : 격려후반응 반응이없으면피검자의팔을잡고격려한다. 저와같이갑시다 Alternative: 피검자가걸을수없다면, 몇가지물어볼게있습니다. 질문에대답해주십시오. 일어나앉아주시겠어요? 피검자의팔을잡고격려한다. 일어나앉아주세요 c 손을내밀어의자를가리킨다. 2점 : 자발적으로의자에앉거나, (alternative) 자발적 여기앉으세요 으로책상쪽으로오거나, (alternative) 자발적으 피검자의팔을잡고, 의자가있는쪽으로 로책상을잡아당김 안내를한다. 1점 : 격려후반응 여기앉으세요 Alternative: 피검자가휠체어를타고있다면, 이쪽으로와서책상가까이에앉으세요 살짝피검자의어깨를밀면서격려한다. 이쪽으로와서책상가까이에앉으세요 Alternative: 피검자가고정의자에앉아있고, 이동할수없다면, 작은책상을피검자가까이에두고, 책상을 OOO 님쪽으로당기세요 지시를반복하면서책상을만진다. 2 (M) 제이름은 OOO입니다 2점 : 자발적으로정답 이름을반복해서말해준다. 1점 : 정답에근접한반응 ( 예 ) 고혜정 을 고희정 으로 제이름이뭔지물어볼테니까기억하고있으세요 제이름이무엇입니까? 정답여부에상관없이, ( 예 ) 제이름은 OOO입니다 Orientation 3 (O) 당신의이름은무엇입니까? 2점 : 전체이름을말함. 한번의격려는허용 피검자가성만말하면, 전체이름을말하도록격려한다. 1점 : 성만말함 예 ) 김, 뭐요? 4 (L) a 여기에이름을쓰세요 2점 : 자발적으로맞게씀 ( 약간의오류는허용 ) 1점 : 부분적으로맞음 ( 성만쓴경우 ) b 피검자가 4a에서 2점을받으면이문항은생략하고, 2점 : 자발적으로맞게씀. 또는 4a에서 2점을받음 2점을준다. 1점 : 부분적으로맞음 빈종이에피검자의이름을쓴다 이걸베껴서쓰세요 Orientation 5 (O) 오늘이몇월입니까? 2점 : 자발적으로정답 오늘이 O, O, 또는 O입니까? 1점 : 예를들어준후정답 6개월전의월, 현재의월, 전월을예로들어준다.

Severe Impairment Battery (SIB) in Korean Dementia Patients 513 6 (L) 요일을순서대로얘기해보세요 2점 : 자발적으로정답 1점 : 격려후에맞게반응하거나, 요일하나를빼고 월요일, 화요일, 수요일, 그리고...? 반응한경우 (2번의격려허용 ) Orientation 7 (O) 이도시의이름은무엇입니까? 2점 : 자발적으로정답을말함 1점 : 예를들어준후정답 여기가 ( ), ( ), 또는 ( ) 입니까? 정답과다른도시이름두개를예로들어준다. 8 (L) a 커피같은뜨거운차는어디에마시나요? 2점 : 컵, ( 찻 ) 잔, 머그잔 1점 : 관련된다른대답. 예 : 유리컵, 커피포트, 또는 커피를담아서마실수있는그릇의이름은뭐죠? 격려후에정답 0점 : 관련없는물건. 예 : 접시 b 국은무엇으로먹나요? 2점 : 숟가락 1점 : 관련된다른대답. 예 : 대접, 국그릇, 또는격려후에정답 국을먹을때사용하는도구를뭐라고하죠? 0점 : 관련없는물건. 예 : 칼 9 (L) a 다음이적힌카드를제시한다. 손을주세요 2점 : 자발적으로손을내밈 피검자가카드에주의를기울이고있는지확인한다. 1점 : 정답에근접한반응. 예 : 손을들어올리거나, 카드에적힌것을읽고, 쓰여있는대로행동해보세요 격려후에정답반응 지시사항을반복하고, 동시에검사자가 0점 : 검사자가읽어준경우 손바닥이위로향하게피검자앞에놓는동작을해서 ( 참고 ) 두손을내밀면한손만내밀라고얘기해줌 반응을격려한다. 그래도 카드에적힌문장을큰소리로읽어준다. b 이번엔다른손을주세요 2점 : 자발적으로정답 지시사항을반복하거나손바닥을펴서 1점 : 정답에근접한반응. 예 : 손을들기는하지만, 보여주는동작을해서반응을격려한다. 검사자쪽으로내밀지않는경우, 같은손을내밀거나격려후반응한경우 c 손을주세요 라고쓰여진카드를다시제시한다. 2점 : 자발적으로카드를읽음 여기에뭐라고쓰여있죠? 1점 : 부분적으로맞음. 예 : 잘못읽거나, 다음과같이격려한다 : 문장의일부분만읽음, 격려후맞음. 이카드에쓰여진것을큰소리로읽어보세요 카드를치운다. 10 (M) 죄송하지만, 뭐라고말했죠? 2점 : 자발적으로 9c에서말한것을정확하게반복 지시사항을일상적인대화를할때쓰는언어로제시한다. 1점 : 부분적으로맞음. 예 : 문장의일부분만읽거나, 다음과같이격려한다 : 격려후맞음 뭐라고말했죠? 11 (L) 따라해보세요 2점 : 각문항을정확하게반복 a 나는물건을샀다 1점 : 각문항을부분적으로정확하게반복하거나단어를사용한말을함. 예 : 나는아기들을 b 아기 좋아해요 Attention 12 (ATT) 따라해보세요 2점 : 3, 4, 또는 5개의숫자조합을정확하게반복 2 1점 : 1개나 2개의숫자조합을정확하게반복 5 87 41 582 694 6439 7286 42731 75836 같은길이의숫자조합에서모두실패하면중단한다.

514 I.-S. Ahn, J.H. Kim, H.M. Ku, et al. 13 (L) 먹고싶은것들을모두말씀해주세요 또는 2점 : 4개이상의항목 아침에먹고싶은 / 점심에먹고싶은 / 저녁에먹고 1점 : 3개이하의항목 싶은것 / 또는요리하고싶은것들을모두말씀해주세요 필요할때마다격려하며, 1분안에답한항목들을모두기록한다. 14 (M) 제이름을기억하십니까? 2점 : 자발적으로정답 ( 예 ) 제이름은 OOO입니다 1점 : 정답에근접한반응. 예 : Karen 을 Carol 로, 앞서와같은이름을정확하게사용한다. 또는 Smith 를 Schmitt 로 15 (L) 컵그림을보여주며, 이것이무엇입니까? 2점 : 컵, ( 찻 ) 잔 1점 : 비슷한것. 예 : 유리컵, 머그잔 Praxis 16 (PR) 이것을어떻게사용하는지보여주십시오 2점 : 분명하게실연 1점 : 정답에근접한반응. 예 : 컵을위로들어올리지만확실하게입으로가져가지는않음 17 (L) 15에서 2점을받았다면, 이문항은 2점을준다. 2점 : 자발적으로옳은반응을하거나, 15번에서 그러나회상시필요하기때문에이과제를반드시실시한다. 2점을받은경우 이것을잡아보세요 ( 컵을준다 ) 1 점 : 정답에근접한반응 이것이뭐죠? Praxis 18 (PR) 피검자가계속컵을잡고있도록한다. 2점 : 분명하게실연 이것을어떻게사용하는지 ( 다시 ) 보여주세요 1점 : 정답에근접한반응. 예 : 컵을위로들어올리지만확실하게입으로가져가지는않음. 19 (L) 15번이나 17번을맞췄다면이질문은하지않고, 1점을준다. 1점 : 컵, 또는 15번이나 17번을맞춘경우 이것이모자인가요, 컵인가요? 0점 : 모자 이컵을기억하도록해보세요 ( 컵을집어든다 ) (2점답은없음) 제가몇분후에다시물어볼테니까, 기억하려고노력해보세요 20 (L) 숟가락그림을보여주며, 이것이무엇입니까? 2점 : 숟가락 1점 : 정답에근접한반응. 예 : 수저, 먹는도구 Praxis 21 (PR) 이것을어떻게사용하는지보여주십시오 2점 : 분명하게실연 1점 : 정답에근접한반응. 예 : 숟가락을입쪽으로올리지만, 확실하게숟가락쪽으로입을움직이지않음 22 (L) 20번에서 2점을받았다면, 이문항은 2점을준다. 2점 : 자발적으로옳은반응을하거나, 20번에서 2점을 그러나회상시필요하기때문에이과제를반드시실시한다. 받은경우 이것을잡아보세요 ( 숟가락을준다 ) 1점 : 정답에근접한반응 이것이뭐죠? Praxis 23 (PR) 피검자가계속숟가락을잡고있도록한다. 2점 : 분명하게실연 이것을어떻게사용하는지 ( 다시 ) 보여주세요 1점 : 정답에근접한반응. 예 : 숟가락을입쪽으로올리지만, 확실하게숟가락쪽으로입을움직이지않음 24 (L) 20번이나 22번을맞췄다면실시하지않고, 1점을준다. 1점 : 숟가락, 또는 20번이나 22번을맞춘경우 이것이구두인가요, 숟가락인가요? 0점 : 구두 다시컵과숟가락을피검자에게보여준다. (2점답은없음) 이숟가락을기억하도록해보세요 ( 숟가락을집어든다 ) 이컵도요 ( 컵을집어든다 ) 제가몇분후에다시물어볼테니까잘보시고기억하려고노력해보세요

Severe Impairment Battery (SIB) in Korean Dementia Patients 515 25 (M) 두가지다른물건과컵을보드판위에다음순서로놓는다 : 검사자왼쪽 가운데 검사자오른쪽 2점 : 컵, 숟가락모두말함 플라스틱용기 접시 컵 1점 : 컵, 숟가락중하나만말함 이것중에서어떤것이제가기억하라고했던거죠? 모든물건들을거둔다. 두가지다른물건과숟가락을보드판위에다음순서로놓는다 : 검사자왼쪽 가운데 검사자오른쪽 숟가락 국자 포크 이것중에서어떤것을제가기억하라고했었어요. 어떤거였죠? 피검자에게컵과숟가락을다시보여준다. 이숟가락을기억하도록해보세요 ( 숟가락을집어든다 ) 이컵도요 ( 컵을집어든다 ) 제가나중에다시물어볼테니까잘보시고기억하려고노력해보세요 26 (L) 피검자에게파란색토막을보여주며, 2점 : 자발적으로정답 무슨색깔입니까? 1점 : 파란색과가까운색을말하는경우 ( 예 : 자주색, 남 색 ), 혹은둘중에고르라고했을때맞추는경우 이것이파란색입니까, 빨간색입니까? Visuospatial ability 27 (VS) 파란색, 녹색, 빨간색토막을보드판위에다음과같은 2점 : 자발적으로정답순서로놓는다. 1점 : 격려후정답검사자왼쪽가운데검사자오른쪽 0점 : 검사자가답을말한경우파란색초록색빨간색파란색자극토막을들고, 피검자가볼때까지토막을움직여서피검자가토막을보도록한다. 이토막들중에서어느것이.. ( 보드판을가리키거나책상을두드리며 ) 이것과색깔이같습니까? 이것은저의파란색토막이구요. 당신앞에있는토막들중에서파란색토막을보여주세요 ( 자극토막과보드판위의토막들을가리킨다 ) 옳지않은반응을하거나반응을하지않는경우, 피검자의파란색토막을집어들고 이것입니다-이것이파란색토막이예요 28 (M) 다음과같은순서로토막의순서를바꾼다. 2 점 : 자발적으로정답검사자왼쪽가운데검사자오른쪽 1 점 : 격려후정답녹색파란색빨간색 0 점 : 검사자가답을말한경우 저한테줬던것 ( 제가보여드렸던것 ) 과똑같은것을저에게돌려주세요 어떤토막을저한테줬었죠?- 이거입니까? 이거요? 아니면이거요? ( 보드판에있는토막을가리킨다 ) 옳지않은반응을하거나반응을하지않는경우, 이것입니다 - 이게그거예요 ( 파란색토막집어든다 ) Visuospatial ability 29 (VS) 이번엔저에게다른토막을주세요. 좀전에 2점 : 자발적으로정답 제가보여드렸던토막이아니라다른토막이요 1점 : 격려후정답 이것은파란색토막입니다 ( 파란색토막을집어든다 ) 다른색깔토막을주세요 30 (L) a 빨간색토막을보여주며, 2점 : 자발적으로정답 이것은무슨색깔입니까? 1점 : 빨간색과가까운색을말하는경우 ( 예 : 분홍색, 주황색 ), 혹은둘중에고르라고했을때맞추는 파란색입니까, 빨간색입니까? 경우

516 I.-S. Ahn, J.H. Kim, H.M. Ku, et al. b 초록색토막을보여주며, 2점 : 자발적으로정답 이게무슨색인가요? 1점 : 피검자가원래색과비슷하게대답할경우 ( 예 : 올리브색, 풀색, 청록색등 ) 혹은둘중에 이게초록색입니까, 파란색입니까? 고르라고했을때맞추는경우 c 검정색네모토막을보여주며 2점 : 자발적정답 이게무슨모양이죠? 1점 : 힌트후정답 이게네모입니까, 동그라미입니까? Visuospatial ability 31 (VS) 보드판위에다음과같은순서로검정색토막을놓는다. 2점 : 자발적정답 검사자의왼쪽 중앙 검사자의오른쪽 1점 : 힌트후정답 세모 동그라미 네모 0점 : 검사자가알려준경우 검정색의네모토막을집어들고피검자가볼때까지토막을움직여서피검자가토막을보도록한다. 여기있는토막들중에서 ( 보드판을가리키거나책상을두드리며 ) 이것과같은모양의토막이어떤것인가요? 제가가지고있는건네모입니다. 당신앞에있는토막들중에서네모가어떤것인지보여주세요 그래도 정답을가리키며, 이게네모입니다 32 (M) 다음과같이보드판위의토막순서를바꾼다. 2점 : 자발적정답 검사자의왼쪽 중앙 검사자의오른쪽 1점 : 힌트후정답 동그라미 네모 세모 0점 : 부적절한대답또는검사자가알려준경우 좀전에제가보여드렸던것과같은토막을제게주세요 제가보여드렸던것이이것입니까, 아니면이것입니까? ( 보드판위에있는토막들을가리키면서 ) 틀린답을말하거나, 이게제가보여드렸던것입니다 ( 네모토막을들어서보여준다 ) Visuospatial ability 33 (VS) 이번에는좀전에보여드렸던것과는다른모양을저에게 2점 : 자발적정답 보여주세요 1점 : 힌트후정답 이게네모입니다 ( 네모토막을집어든다 ) 제게다른모양을보여주세요 34 (L) a 동그란토막을보여주며, 이건무슨모양인가요? 2점 : 자발적인정답 ( 원, 동그란 ) 1점 : 힌트후정답 이게네모입니까, 동그라미입니까? b 세모모양의토막을보여주며, 이건무슨모양인가요? 2점 : 자발적인정답 1점 : 힌트후정답또는 피라미드 이건세모입니까, 네모입니까? Construction 35 (C) a 동그라미를그리세요 2점 : 자발적으로그린둥근모양, 달걀모양, 동그라미가그려진그림을보여주면서 타원모양 ( 약간의실수는인정 ) 이렇게그려보세요 1점 : 비슷한모양. 예 : 적어도반원정도는그린원모양, 또는힌트후그린원이나원을그리려고시도한경우 0점 : 직선, 점등 b 네모를그리세요 2점 : 사각형, 직사각형 ( 약간의실수는인정, 하지만 네모가그려진그림을보여주면서 4면이있어야함 ) 이렇게그려보세요 1점 : 비슷한모양. 예 : 네모모양이기는하나한쪽끝이열려져있는경우 ( 세모는틀린것으로간주 ), 또는힌트후그린경우나네모를그리려고시도한경우 0점 : 직선, 점등

Severe Impairment Battery (SIB) in Korean Dementia Patients 517 Attention 36 (ATT) 이제제가책상을두드릴것입니다. 그러면제가몇번을 2점 : 자발적으로 5까지셌을때 두드리는지세어보세요. 잘들어보세요 1점 : 한번의기회를더주고나서야 5까지셌을때 1초에 1번두드리는속도보다더빨리책상을세번 0점 : 두번이상의기회를주어야하거나, 두드린다. 아니면 5까지세지못하는경우 그리고두드리면서 1-2-3 이라고수를센다. 이제제가두드릴테니까, OOO님께서직접세보세요 5번을두드린다. 딱한번의기회를더줄수있다. 37 (ATT) 피검자의주의를끌기위해손가락을흔든다. 2점 : 다섯번모두정확하게셌을경우 자, 제손가락을보세요. 세개의손가락을올리고있습니다 1점 : 다섯번모두세기는했지만, 검지, 중지, 약지손가락을치켜든다. 한번멈춰서한번의기회를더주었을경우 그리고나서검지손가락을치켜든다. 0점 : 틀렸거나, 두번이상의추가적인기회를주어 지금저는손가락하나를올리고있습니다 야한경우 그리고나서검지와새끼손가락을편다. 자, 제가손가락을몇개펴고있는지세어보세요 ( 예 ) 두개입니다 그런다음검지손가락만올리고있는다. 피검자가검사자의손가락을자발적으로세지못한다면, 제가손가락을몇개올리고있는지세어보세요. 멈추지마시고계속세어보세요 딱한번의기회를더줄수있다. ( 여기서부터채점하기시작한다 ) 다음순서대로손가락을편다. 검지와새끼 ( 정답 2) 검지 ( 정답 1) 검지, 중지, 약지 ( 정답 3) 새끼 ( 정답 1) 검지, 중지, 약지, 새끼 ( 정답 4) 38 (M) 보드판위에컵과두개의다른물건을다음과같은순서로 2점 : 컵, 숟가락둘다대답 놓는다. 1점 : 컵이나숟가락중하나만대답 검사자의왼쪽 가운데 검사자오른쪽 계량컵 컵 대접 이물건들중에서제가기억하라고했던것이어떤것이었나요? 세가지물건을모두치운다. 보드판위에숟가락과두개의다른물건을다음과같은순서로놓는다. 검사자의왼쪽 가운데 검사자오른쪽 칼 주걱 숟가락 이번에도제가기억하라고했던것이있는데그게무엇인가요? 여기서공식적인면대면검사는끝이나며, 피검자에게이제는집에갈준비를하라고말한다. Orienting to name 39 (ON) 대기실로돌아가는동안이나, 집에갈준비를하는동안 2점 : 자발적인반응 ( 피검자가뒤돌아보는경우 ) 피검자의뒤에서서피검자의이름을불러본다. 1점 : 약간의반응 ( 언어적이든비언어적이든. 하지만소리가들리는방향을확실하게모르고있음 ) 0점 : 무반응 40 (L) 만약피검자가 39번문항에서반응을보인다면몇가지 2점 : 두질문중어느한가지에대한적절한대답. 대화를시도한다. 하나의완전한문장으로말해야함 오늘어떠셨나요? 피검자가한단어로반응을한다면 ( 예 : 좋았어요 ) 1점 : 적절한대답이긴하나한두단어로대답함. 더많은얘기를할수있도록격려한다. ( 예 : 괜찮았어요, 예, 그래요 ) 이번주말에뭐하실건가요?, 오늘손님이오시나요? Alternative: 피검자가 39 번문항에서아무런반응을보이지않 2 았다면이와같은질문들은피검자가떠나기전적절한시기에물어보아야한다.