A Compendium of Tests, Scales and Questionnaires

Psychology Press is part of the Taylor & Francis group, a trading division of Informa UK Ltd.Registered in England under no. 1072954Registered Office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH

Easy, one-stop reference for selecting and •evaluating both new and classic screening tests, rating scales and questionnaires

Includes more than 150 instruments, •providing a comprehensive overview of the functional consequences of all aspects of acquired brain impairment. There is a scale for every purpose!

Actual scale included (in most cases) giving •the reader ready access to the instrument

Uniform format lets the reader compare the •purpose, properties and specific features of the instruments

Includes classic scales and newly-developed •measures: more than one-third of the measures have been published in the last 10 years

Maps onto the ICF. The structure of the •book maps directly on to the influential International Classification of Functioning, Disability and Health (WHO, 2001) which links the book’s clinical concepts across health conditions.

New!

“Attention, brain injury researchers and clinicians! This unique compilation is a must-have for your bookshelf, as it brings order to the chaos wrought by the explosion of scales in this area. Professor Tate’s judiciously- and meticulously-selected collection of assessment instruments offers an optimal blend of comprehensiveness, brevity and detail required to help you quickly identify the measures you need.” - Bruce Caplan, Senior Editor, Journal of Head Trauma Rehabilitation, and Private Practitioner in Wynnewood, PA, USA

“This is a book that all neuropsychologists and clinical psychologists should have on their bookshelves – and within easy reach! Other professions, particularly occupational therapists, speech and language therapists, rehabilitation doctors and neurologists will also find it extremely useful. I believe it will prove to be a classic. To have all this information to hand in one volume is a treat and I am sure I will not be the only psychologist who will be referring to this treasure very frequently.” - Barbara Wilson, MRC Cognition and Brain Sciences Unit, University of Cambridge, UK

A Compendium of Tests, Scales and Questionnaires

The Compendium is a comprehensive reference manual containing an extensive selection of instruments developed to measure signs and symptoms commonly encountered in neurological conditions, both progressive and non-progressive. It provides a repository of established instruments, as well as newly-developed scales, and covers all aspects of the functional consequences of acquired brain impairment.

In particular, the text provides a detailed review of approximately 150 specialist instruments for the assessment of people with neurological conditions such as dementia, multiple sclerosis, stroke and traumatic brain injury. Part A presents scales examining body functions, including consciousness and orientation; general and specific cognitive functions; regulation of behaviour, thought, and emotion; and motor-sensory functions. Part B reviews scales of daily living activities and community participation. Part C focuses on contextual factors, specifically environmental issues, and Part D contains multidimensional and quality of life instruments.

Each instrument is described in a stand-alone report using a uniform format. A brief history of the instrument’s development is provided, along with a description of item content and administration/scoring procedures. Psychometric properties are reviewed and a critical commentary is provided. Up to a dozen key references are cited and in most cases the actual scale is included, giving the reader easy access to the instrument. The structure of the book directly maps onto the taxonomy of the influential International Classification of Functioning, Disability and Health (World Health Organization, 2001), enabling linkage of clinical concepts across health conditions.

The Compendium will be a valuable reference for clinicians, researchers, educators, and graduate students, and a practical resource for those involved in the assessment of people with brain impairment.

www.compendium-of-scales.com

31st March 2010: 8½x11: 720pp Hardcover: 978-1-84169-561-7

Dr Robyn Tate is a clinical psychologist and neuropsychologist with over 30 years of clinical and research experience. Her primary field of expertise is the rehabilitation of traumatic brain injury. She is currently Associate Professor in the Rehabilitation Studies Unit, Faculty of Medicine, University of Sydney, Australia, where, in addition to her own clinical and research work, she is involved in the teaching and research supervision of post-graduate medical and psychology students. She is also the founding co-editor of Brain Impairment, the official journal of the Australian Society for the Study of Brain Impairment.


Contents 1. Introduction. Background and Methodology. The International Classification of Functioning, Disability and Health (ICF). Placing Measuring Instruments for ABI within the ICF Taxonomy. References.

Part A. Body Functions.2. Scales of Consciousness and Orientation. Introduction. Section 1. Scales Measuring Coma, Vegetative and Minimally Conscious States. Coma/Near Coma (C/NC) Scale. Comprehensive Levels of Consciousness Scale (CLOCS). Glasgow Coma Scale (GCS). JFK Coma Recovery Scale – Revised (CRS-R). Rancho Los Amigos Levels of Cognitive Functioning Scale (LCFS). Wessex Head Injury Matrix (WHIM). Western Neuro Sensory Stimulation Profile (WNSSP). Section 2. Scales Measuring Delirium. Cognitive Test for Delirium (CTD). Confusion Assessment Method (CAM). Confusion Assessment Protocol (CAP). Delirium Rating Scale – Revised – 98 (DRS-R-98). Memorial Delirium Assessment Scale (MDAS). Section 3. Scales Measuring Orientation and Post-traumatic Amnesia. Galveston Orientation and Amnesia Test (GOAT). Orientation Group Monitoring System (OGMS). Orientation Log (O-Log). Post-traumatic Amnesia Questionnaire (PTAQ). Westmead Post-traumatic Amnesia Scale (WPTAS).

3. Scales of General Cognitive Functions. Introduction.Addenbrooke’s Cognitive Examination – Revised (ACE-R). Blessed Information-Memory-Concentration Test (BIMCT). Capacity to Consent to Treatment Instrument (CCTI). Clifton Assessment Procedures for the Elderly (CAPE). Cognitive Abilities Screening Instrument (CASI). Cognitive Failures Questionnaire (CFQ).

Cognitive Log (Cog-Log). General Practitioner Assessment of Cognition (GPCOG). Hopkins Competency Assessment Test (HCAT). Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Mini-Cog. Mini-Mental State Examination (MMSE). Montreal Cognitive Assessment (MoCA). Rowland Universal Dementia

Assessment Scale (RUDAS). Severe Mini-Mental State Examination (SMMSE).Telephone Interview for Cognitive Status (TICS). Test for Severe Impairment (TSI). 4. Scales of Specific Cognitive Functions. Introduction. Section 1. Scales Measuring Attention Functions. Moss Attention Rating Scale (MARS). Rating Scale of Attentional Behaviour (RSAB).

Section 2. Scales Assessing Executive Functions. Dysexecutive Questionnaire (DEX). Executive Interview (EXIT25). Frontal Assessment Battery (FAB).

Problem Solving Inventory (PSI). Section 3. Scales Assessing Language Functions. Communicative Effectiveness Index (CETI). Frenchay Aphasia Screening Test (FAST). La Trobe Communication Questionnaire (LCQ). Mississippi Aphasia Screening Test (MAST). Section 4. Scales Assessing Memory Functions. Comprehensive Assessment of Prospective Memory (CAPM).

Everyday Memory Questionnaire (EMQ). Memory Compensation Questionnaire (MCQ). Memory Functioning Questionnaire (MFQ). Memory Impairment Screen (MIS).

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Page 36

Page 36

Summary score sheet for the Glasgow Coma Scale

Teasdale and Jennett (1974)

Name:

Date:Time:

Assessor:

Spontaneous 4

EYE To speech 3

OPENING To pain 2

None 1

Oriented 5

BEST Confused 4

VERBAL Inappropriate words 3

RESPONSE Incomprehensible sounds 2

None 1

Obeys commands 6

BEST Localizes pain 5

MOTOR Withdraws 4

RESPONSE Flexion to pain 3

Extension to pain 2

None 1

TOTAL SCORE:

Acknowledgement: Adapted from Teasdale, G., & Jennett, B. (1974). Assessment of coma and impaired consciousness: A practical scale.The Lancet, 304(7872), 81–84, figure from p. 83, reprinted by permission of The Lancet, and Jennett, B. (1976). Assessment and prognosis ofcoma after head injury. Acta Neurochirurgica, 34(1–4), 45–55, reprinted by permission of Springer-Verlag.

36 Body functions

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Page 37

Items of the Amnesia Scale for Glasgow Coma Scale – Extended

Nell, Yates, and Kruger (2000)

Name: Assessor: Date:

7 No amnesia: client can remember impact, can remember falling and striking a solid surface, etc.

6 Amnesia for 30 minutes or less: client regained consciousness while still in vehicle, in street at scene of incident,etc.

5 Amnesia of ½ hour to 3 hours: remembers being loaded into ambulance, in ambulance on way to hospital,arriving at emergency room, admission to ward, etc.

4 Amnesia of 3 to 24 hours: determine duration by content of the first memory, which will be for an event in theward or other hospital procedure

3 Amnesia of 1 to 7 days



0 Amnesia greater than 3 months

X Cannot be scored, e.g., can speak but responses are inappropriate or unintelligible, cannot speak becauseunconscious, intubated, facial fractures, etc.

Acknowledgement: From Nell, V., Yates, D. W., & Kruger, J. (2000). An extended Glasgow Coma Scale (GCS-E) with enhanced sensitivity tomild brain injury. Archives of Physical Medicine and Rehabilitation, 81(5), 614–617, Table 1, p. 615, reprinted with permission of the AmericanCongress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation and Elsevier.

Consciousness and orientation 37

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Confusion Assessment Method

Inouye, van Dyck, Alessi, Balkin, Siegal, and Horwitz (1990)

Name: Assessor: Date:

Yes/No1. ACUTE ONSETIs there evidence of an acute change in mental status from the patient’s baseline?

2. INATTENTION*a) Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty

keeping track of what was being said?Not present at any time during interviewPresent at some time during interview, but in mild formPresent at some time during interview, in marked formUncertain

b) (If present or abnormal) Did this behaviour fluctuate during the interview, that is, tend to come and go or increaseand decrease in severity?

YesNoUncertainNot applicable.

c) (If present or abnormal) Please describe this behaviour:

3. DISORGANIZED THINKINGWas the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear orillogical flow of ideas, or unpredictable switching from subject to subject?

4. ALTERED LEVEL OF CONSCIOUSNESSOverall, how would you rate this patient’s level of consciousness?

Alert (normal)Vigilant (hyperalert, overly sensitive to environmental stimuli, startled very easily)Lethargic (drowsy, easily aroused)Stupor (difficult to arouse)Coma (unarousable)Uncertain

5. DISORIENTATIONWas the patient disoriented at any time during the interview, such as thinking that he or she was somewhereother than the hospital, using the wrong bed, or misjudging the time of day?

6. MEMORY IMPAIRMENTDid the patient demonstrate any memory problems during the interview, such as inability to remember events inthe hospital or difficulty remembering instructions?

7. PERCEPTUAL DISTURBANCESDid the patient have any evidence of perceptual disturbance, for example, hallucinations, illusions, ormisinterpretations (such as thinking something was moving when it was not)?

8. PSYCHOMOTOR ACTIVITY:Part 1: PSYCHOMOTOR AGITATIONAt any time during the interview, did the patient have an unusually increased level of motor activity, such asrestlessness, picking at bedclothes, tapping fingers, or making frequent sudden changes of position?Part 2: PSYCHOMOTOR RETARDATIONAt any time during the interview, did the patient have an unusually decreased level of motor activity, such assluggishness, staring into space, staying in one position for a long time, or moving very slowly?

9. ALTERED SLEEP–WAKE CYCLEDid the patient have evidence of disturbance of the sleep–wake cycle, such as excessive daytime sleepinesswith insomnia at night?

* The questions listed under this topic (Inattention) were repeated for each topic where applicable.

56 Body functions

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Confusion Assessment Method – Diagnostic Algorithm

Inouye, van Dyck, Alessi, Balkin, Siegal, and Horwitz (1990)

Feature Definition

1. Acute onset andfluctuating course

This feature is usually obtained from a family member or nurse and is shown by positiveresponses to the following questions: Is there evidence of an acute change in mental status fromthe patient’s baseline? Did the (abnormal) behaviour fluctuate during the day, that is, tend tocome and go, or increase and decrease in severity?

2. Inattention This feature is shown by positive response to the following question: Did the patient havedifficulty focusing attention, for example, being easily distractible, or having difficulty keepingtrack of what was being said?

3. Disorganized thinking This feature is shown by a positive response to the following question: Was the patient’s thinkingdisorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flowof ideas, or unpredictable switching from subject to subject?

4. Altered level ofconsciousness

This feature is shown by any answer other than “alert” to the following question: Overall, howwould you rate this patient’s level of consciousness? (alert [normal], vigilant [hyperalert],lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [unarousable])

Diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4.

Acknowledgement: From Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., & Horwitz, R. I. (1990). Clarifying confusion: TheConfusion Assessment Method: A new method for detection of delirium. Annals of Internal Medicine, 113(12), 941–948, Appendix Tables 1 & 2with permission of Dr Sharon Inouye.

Consciousness and orientation 57

Sample Pages


Prospective and Retrospective Memory Questionnaire (PRMQ). Section 5. Scales Assessing Self-awareness. Awareness Questionnaire (AQ). Patient Competency Rating Scale (PCRS). Self-awareness of Deficits Interview (SADI). 5. Scales Assessing the Regulation of Behaviour, Thought and Emotion. Introduction. Agitated Behavior Scale (ABS). Apathy Evaluation Scale (AES). Behavioral Dyscontrol Scale (BDS). Behavioral Pathology in Alzheimer’s Disease Rating Scale (BEHAVE-AD). Behavior Rating Inventory of Executive Function (BRIEF). Cohen-Mansfield Agitation Inventory (CMAI). Fatigue Impact Scale (FIS). Fatigue Severity Scale (FSS). Frontal Behavioral Inventory (FBI). Frontal Systems Behavior Scale (FrSBe). Harmful Behaviours Scale (HBS). Katz Adjustment Scale – Form R1 (KAS-R1). Neuropsychiatric Inventory (NPI). Neuropsychology Behavior and Affect Profile (NBAP). Overt Aggression Scale – Modified for Neurorehabilitation (OAS-MNR). Overt Behaviour Scale (OBS).

6. Scales of Sensory, Ingestion and Motor Functions. Ian D. Cameron, Introduction. Section 1. Scales Assessing Sensory Functions. Seeing Functions. Snellen Chart. Hearing Functions. Whispered Voice Test (WVT). Smell Functions. San Diego Odor Identification Test (SOIT). Touch Functions. Semmes Weinstein Monofilament (SWM). Pain Functions. Visual Analogue Pain Scale

(VAS), Numeric Rating Scales (NRS), and Other Pain Scales. McGill Pain Questionnaire (MPQ). Section 2. Scales Assessing Ingestion Functions. Bedside Swallowing Assessment (BSA). Section 3. Scales Assessing Motor Functions. Muscle Power Functions. Medical Research Council Motor Scale (MRC-MS). Muscle Tone Functions. Ashworth Scale (AS). Tardieu Scale (TS). Movement Functions. Berg Balance Scale (BBS). Fugl-Meyer Assessment (FMA). High-level Mobility Assessment Tool (HiMAT). Motor Assessment Scale (MAS). Motricity Index (MI). Rivermead Mobility Index (RMI). Timed Gait Pattern Function Tests.

Part B. Activities and Participation. 7. Scales Assessing Activities of Daily Living. Introduction. Activities of Daily Living Questionnaire (ADLQ). Assessment of Living Skills and Resources (ALSAR). Barthel Index (BI). Bristol Activities of Daily Living Scale (BADLS). Frenchay Activities Index (FAI). Functional Independence Measure (FIM). Functional Independence Measure and Functional Assessment Measure(FIM+FAM). Functional Independence Measure for Children (WeeFIM). Katz Index of Activities of Daily Living (KIADL). Instrumental Activities of Daily Living Scale (IADLS) and Physical Self-Maintenance Scale (PSMS). Northwick Park Dependency Score (NPDS). Nottingham Activities of Daily Living Scale (NADLS).

Nottingham Extended Activities of Daily Living (NEADL). Rivermead Activities of Daily Living (RADL). Systeme de Mesure de l’Autonomie Fonctionnelle (SMAF; English version:Functional Autonomy Measurement System). 8. Scales Assessing Participation and Social Role. Introduction. Child and Adolescent Scale of Participation (CASP). Community Integration Measure (CIM). Community Integration Questionnaire (CIQ). Community Outcome Scale (COS). Craig Handicap Assessment and Reporting Technique (CHART). Impact on Participation and Autonomy (IPA) Questionnaire. Leeds Assessment Scale of Handicap (LASH). London Handicap Scale (LHS). Nottingham Leisure Questionnaire (NLQ). Participation Objective, Participation Subjective (POPS). Reintegration to Normal Living (RNL) Index. Sydney Psychosocial Reintegration Scale (SPRS). World Health Organization Disability Assessment Schedule II (WHODAS II).

Part C. Contextual Factors. 9. Scales of Environmental Factors. Introduction. Care and Needs Scale (CANS). Craig Hospital Inventory of Environmental Factors (CHIEF). Home and Community Environment (HACE) Instrument. Interpersonal Support Evaluation List (ISEL). Lubben Social Network Scale (LSNS). Measure of Quality of the Environment (MQE). Northwick Park Care Needs Assessment (NPCNA). Social Support Survey (SSS). Supervision Rating Scale (SRS).

Survey of Unmet Needs and Service Use (SUNSU).

Part D. Multi-domain Scales. 10. Global, Multidimensional and Quality of Life Scales. Introduction. Section 1. Global Scales. Clinical Dementia Rating (CDR) Scale. Expanded Disability Status Scale (EDSS). Glasgow Outcome Scale (GOS). Global Deterioration Scale (GDS) and Functional Assessment Staging (FAST). Modified Rankin Scale (mRS). Section 2. Multidimensional and Quality of Life Scales. Disability Rating Scale (DRS). European Brain Injury Questionnaire (EBIQ). Functional Status Examination (FSE). Health of the Nation Outcome Scales (HoNOS). Mayo-Portland Adaptability Inventory – 4 (MPAI-4). Neurobehavioral Functioning Inventory (NFI). Neurobehavioral Rating Scale – Revised (NRS-R). Rivermead Post-concussion Symptoms Questionnaire (RPQ). Satisfaction with Life Scale (SWLS). Short-Form 36 Health Survey (SF-36). World Health Organization Quality of Life (WHOQOL). Appendices. A. Clinical Populations for Which Scales Were Originally Designed and With Which They Have Been Used. B. List of Abbreviations. C. Listing of ICF Categories and Codes Pertinent to Instruments Included in the Compendium. D. Items from Scales of Activity/Participation Mapped to ICF Domains. E. Item Content of Scales of Activity/Participation. Alphabetical List of Scales. Indexes.

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“Tate’s Compendium is an extraordinary and comprehensive work. Concise syntheses of each measure’s psychometric qualities, utility, applications, and clear linkages to the International Classification of Functioning (ICF) greatly facilitate comparison and selection of measures. This landmark volume will find a welcome home on the shelf of any student, clinician, or researcher involved in the assessment of the sequelae of acquired brain disorders.” - James F. Malec, Research Director, Rehabilitation Hospital of Indiana, Indianapolis, USA, and Professor Emeritus, Mayo Clinic, USA

“With this book, Professor Tate is not only providing an incredibly valuable service in creating a compendium of what measures are currently available; she has also done much of the groundwork for improving evidence-based practice for the future.” - Huw Williams, Associate Professor of Clinical Neuropsychology, University of Exeter, UK

“The time-consuming hunt to identify and understand the pros and cons of available outcome measures is over. Dr. Tate has compiled a comprehensive, scholarly, and eminently useful guide to help clinicians select screening tests, rating scales and questionnaires matched to their clinical needs. This book will be one of the most well-used resources by clinicians concerned with documenting and measuring neurologically-based impairments.” - McKay Moore Sohlberg, Professor of Communication Disorders & Sciences at University of Oregon, USA, and author of Cognitive Rehabilitation: An Integrated Neuropsychological Approach

“Tate has identified the relevant information on a huge number of scales to save us much of the work and for that we should be extremely grateful. The book is an incredibly useful resource. I am sure clinicians, therapists and researchers working in the field of acquired brain injury will consult this book frequently – I know I will.” - Jonathan Evans, Professor of Applied Neuropsychology, University of Glasgow, UK


A Compendium of Tests, Scales and Questionnaires by Robyn L. Tate

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Tests, Scales and Questionnaires OnlineThe Practitioner’s Guide to Measuring Outcomes after Acquired Brain Impairment

The majority of the tests, scales and questionnaires in the book will be available online from 1st April 2010.

The book includes a voucher for you to fill in and return to us. For a one-off payment of £100, you can gain online access to the majority of tests, scales and questionnaires featured in the book as downloadable PDFs on a password-protected website.

Tests, Scales and Questionnaires Online: The Practitioner’s Guide to Measuring Outcomes after Acquired Brain Impairment is available only to buyers of the book.

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A Compendium of Tests, Scales and Questionnaires