Many different assessment instruments could be used to measure the concepts in the CLASS Program benefit triggers that are most important for people with cognitive impairment. The CLASS Program legislation says that the eligibility determinations based on the benefit triggers will be made by “a licensed health care practitioner.” Procedures for determining eligibility for CLASS Program services and supports have not yet been developed, and it is unclear whether there will eventually be a single organization that conducts eligibility determinations or, more likely, many organizations and individuals that determine eligibility, as is the case with most existing long-term care insurance plans. In this context, this contractor believes that no specific assessment instruments or procedures should be required to determine eligibility for CLASS Program services and supports. On the other hand, it is important to provide information about such instruments and their use to anyone who is responsible for implementing the CLASS Program benefit trigger. Some organizations and individuals may choose to use certain instruments. Equally important, awareness of the content of the instruments could help such organizations and individuals better understand and implement the intent and meaning of the concepts in the benefit triggers.
This section lists assessment instruments that measure concepts in CLASS Program benefit triggers that are most important for people with cognitive impairment. Further analysis of these instruments will be needed, but the objective of the analysis will differ depending on the decision that is made about whether specific assessment instruments and procedures will be required to determine eligibility for CLASS Program services and supports.
A. Measuring “Substantial Assistance”
The CLASS Program benefit trigger requires that an individual must be unable to perform at least the minimum number (which may be 2 or 3) of activities of daily living as are required under the plan for the provision of benefits without substantial assistance (as defined by the Secretary) from another individual. As noted earlier, this contractor recommends that “substantial assistance” should be defined to include not only hands-on and standby assistance but also the assistance needed by a person with cognitive impairment who cannot perform the ADL independently, that is, assistance to initiate the ADL at the right time and in the right place and to complete the steps required to perform the ADL successfully.
Need for assistance to perform ADLs is usually determined with generic assessment instruments developed by Katz et al. (1963), Lawton and Brody (1969) and others. Some researchers and clinicians have developed assessment instruments intended specifically for people with cognitive impairment and dementia. Many of these instruments measure IADLs as well as ADLs, and many provide potentially useful wording to identify the kinds of difficulties people with cognitive impairment often experience in performing ADLs, and therefore the kinds of assistance they need to perform the ADLs successfully.
Assessment Instruments To Measure ADLs and IADLs in People with Cognitive Impairment and Dementia
- AD Situational Test (Skurla et al. 1988)
- Dependence Scale (Rating based on informant responses to 13 questions about functional activities) (Stern et al., 1994)
- Direct Assessment of Functional Status (DAFS) (Observation and rating on tasks in 7 functional areas) (Lowenstein et al., 1989)
- Dressing Performance Scale (Observation and rating on 34 steps in dressing) (Beck 1988)
- Functional Activities Questionnaire (Informant report on 10 functional activities (Pfeffer et al. 1982)
- Refined ADL Assessment Scale (Observation and rating on 14 tasks) (Tappen 1994)
- Self-Care Performance Tool (Observation and rating on 4 self-care activities (Thralow and Rueter1993)
B. Measuring “Substantial Cognitive Impairment”
The CLASS Program benefit trigger requires that the individual must need substantial supervision to protect him or her from threats to health and safety due to substantial cognitive impairment. As noted earlier, this contractor recommends that “substantial cognitive impairment” be defined in the context of the CLASS Program benefit trigger specifically, as the level of cognitive impairment that results in threats to health and safety to which the individual is not able to respond effectively.
Many assessment instruments have been developed to measure cognitive impairment, and some of these instruments may be particularly useful for organizations and individuals that are implementing the CLASS Program benefit triggers. The lists of assessment instruments below include brief mental status tests, performance tests, and instruments for informant interviews.
Brief Mental Status Tests
- Alzheimer’s Disease Assessment Scale: Cognitive Behavior (ADAS-Cog) (11 items) (Rosen et al., 1984)5
- Blessed Information-Memory-Concentration Test (BIMC) (26 items) (Blessed et al., 1968)
- Blessed Information-Memory-Concentration Test (BIMC) (26 items) (revised by Katzman et al., 1983).
- Blessed Orientation-Memory-Concentration Test(BOMC) (Also called the Short Blessed Test (SBT) (6 items) (Katzman et al., 1983)
- Clock Drawing Tests (many sources for scoring clock drawing tests
- CLOX (an executive clock drawing test (Royall et al., 1998b)
- Cognitive Abilities Screening Instrument (CASI) (25 items) (Teng et al., 1994)
- Cognitive Abilities Screening Instrument-Short form (CASI-Short)(4 items) (Teng et al., 2001)
- Community Screening Interview for Dementia (CSI ‘D’) (28 items for the person and other items for an informant (Hall et al., 1993)
- EXIT (The Executive Interview) (Royall et al., 1992) This is a 25-item bedside measure
- General Practitioner Assessment of Cognition (GPCOG) (6 items for the person and other items for an informant (Brodaty et al., 2002).
- Isaacs Set Test (IST) (4 category verbal fluency test) (Isaacs et al., 1973)
- Memory Impairment Screen (MIS) (4 items)(Buschkeet al., 1999)
- Mental Status Questionnaire (MSQ) (10 items) (Kahn et al., 1960)
- Mini-Cog (3 items) (Borson et al., 2000)
- Mini-Mental State Examination (MMSE) (~12 items) (Folsteinet al., 1975)
- Montreal Cognitive Assessment (MoCA) (30 points) (Nasreddine et al., 2005)
- Modified Mini-Mental State Examination (3MS) (~ 16 items )(Tengand Chui 1987)
- Ottawa 3D and Ottawa 3DY (3 items and 4 items, respectively) (Molnar et al. 2008)
- Saint Louis University Mental Status Examination (SLUMS) (11 items) (Banks and Morley 2003)
- Seven-Minute Screen (includes 4 tests: cued recall: naming animals for 1 minute; the Benton Temporal Orientation Test, and Clock Drawing) (Solomon and Pendlebury, 1998)
- Short Portable Mental Status Questionnaire (SPMSQ) (10 items (Pfeiffer 1975)
- Drug Regimen Unassisted Grading Scale (DRUGS) (Edelberget al., 1999)
- Everyday Problems Test for Cognitively Challenged Elderly (EPCCE) (Willis et al., 1996)
- Face-Hand Test (FHT) (Fink et al., 1952)
- The Home Visit (Kapust and Weintraub, 1988)
- The Medication Management (MM) Test (Gurlandet al., 1994)
- The Time and Change Test (Inouye et al., 1998)
Instruments for Informant Interviews
- AD8(8 items) (Galvin et al., 2005)
- Blessed Dementia Scale (22 items) (Blessed et al., 1968)
- Dementia Severity Rating Scale (11 domains) (Clark and Ewbank 1996)
- Everyday Cognition Scale (E-Cog) (39 items) (Fariaset al., 2008)
- General Practitioner Assessment of Cognition (GPCOG) (6 items for the informant and other items for the person) (Brodaty et al., 2002).
- Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) (26 items) (Jorm and Jacomb1989)
- The Community Screening Interview for Dementia (CSI’D’) (3o items for the informant and other items for the person) (Hall et al., 1993)
C. Measuring “Substantial Supervision”
The CLASS Program benefit trigger requires that the individual must need substantial supervision to protect him or her from threats to health and safety due to substantial cognitive impairment. This contractor recommended earlier that “substantial supervision” should be defined specifically as the amount of supervision needed to protect an individual from threats to health and safety. The concepts and wording in the Supervision Rating Scale, described earlier, and in the two studies of amount of supervision provided and perceived need for supervision for older people with cognitive impairment and people with dementia may be useful for organizations and individuals that are implementing the CLASS Program benefit triggers