Article
The Lawton Instrumental Activities Daily Living/Activities Daily Living Scales: A Sensitive Test to Alzheimer Disease in Community-Dwelling Elderly People?
Journal of Geriatric Psychiatry and Neurology 2014, Vol. 27(2) 85-93 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0891988714522694 jgpn.sagepub.com
Pierre Koskas, MD1, Marie Ce´cile Henry-Feugeas, MD, PhD2, Jean Paul Feugeas, MD, PhD3, Aurore Poissonnet4, Ce´cile Pons-Peyneau, MD5, Yves Wolmark, MD4, and Olivier Drunat, MD5
Abstract Objective: To examine the diagnostic ability of the Lawton Instrumental Activities Daily Living (IADLs) scale and the Activities Daily Living (ADLs) scale as a sensitive tool to Alzheimer’s disease (AD) in community-dwelling elderly people. Design: In an old age memory outpatient center, among patients with a clinical diagnosis of AD dementia or no dementia supported by at least 6 months of follow-up, we looked back at the baseline Lawton IADL scale (short version IADL-4 item), ADL scale, Mini-Mental State Examination (MMSE), and Montreal Cognitive Assessment (MOCA) values. Results: There were 109 patients with AD and 53 nondemented individuals (81.4 + 4.6 years). The sensitivity of ADL scale or IADL-4 item or the MMSE was low (52%-57%). The most efficient AD classification used both the IADLs-4 item and the MOCA with a threshold score of 20. Besides age and memory scores, the main correlates of IADLs scale or ADLs scale were executive, neuropsychiatric, vascular, and extrapyramidal scores. Conclusion: Our results suggest that the Lawton IADLs-4 item scale and ADLs scale lack sensitivity to AD dementia in elderly people and support a better sensitivity of MOCA rather than MMSE and IADLs-4 item/ADLs at the expense of specificity. Keywords Alzheimer disease, MMSE, MOCA, IADLs, ADLs, old people
The recently revised definition of Alzheimer’s disease (AD) underlines the impact of cognitive impairment on activities of daily living (ADLs) and a decline from previous levels of functioning and performing1 as core clinical criteria. However, this recent consensus did not specifically recommend any clinical scale for functional assessment: there is a lack of agreement on the instruments and the norms used for measuring ADLs.2-4 Lack of normative data and the varying uses of the criterion (‘‘impact of cognitive impairment on activities’’) may still significantly complicate the diagnosing of nondemented individuals and patients with dementia. It may also contribute to the familiar heterogeneity in the prevalence rate of both nondemented individuals and patients with dementia, as well as patients having mild cognitive impairment (MCI), in population-based studies.5-7 There is variability in the use of assessment tools in European memory center.8 However, the ADLs9 and Instrumental Activities Daily Living (IADLs)10 scales and the combination of these scales with Mini-Mental State Examination (MMSE) remain the most often used screening instruments.11-13
These functional assessment scales may constitute an early marker of the disease in patients with MCI and AD.14-16 Longitudinal studies showed a predictive value of IADLs
1
Memory Center, Bretonneau Hospital, Assistance Publique-Hoˆpitaux de Paris, Paris, France 2 Department of Radiology, Bichat Claude Bernard University Hospital, Assistance Publique-Hoˆpitaux de Paris, Paris, France 3 UMR U722 INSERM Faculte´ de Me´decine Xavier Bichat, Paris Diderot University, Paris, France 4 Department of Geriatrics, Bretonneau Hospital, Assistance PubliqueHoˆpitaux de Paris, Paris, France 5 Department of Psycho-Geriatrics, Bretonneau Hospital, Assistance PubliqueHoˆpitaux de Paris, Paris, France
Received 09/15/2012. Received revised 06/18/2013. Accepted 10/09/2013. Corresponding Author: Pierre Koskas, Hoˆpital Bretonneau, Groupement Hospitalier Universitaire Nord, Assistance Publique-Hoˆpitaux de Paris, 23 rue Joseph de Maistre, 75018 Paris, France. Email: [email protected]
86 disability7,14 and particularly the short IADLs-4 item (telephone use, use of means of transportation, responsibility for medication intake, and handling finances) using the 4 items best associated with cognitive performances in previous studies14,17-19 and recommended for the screening of dementia in community for the elderly patients.17,18,20 Several longitudinal studies also underlined the role of MMSE alone or combined with IADLs scales to predict daily activity.13,21 These studies were carried out on a rural population of mainly noneducated, elderly individuals. It was shown that ADLs and IADLs scales are even better screening tools in dementia diagnosis than the MMSE scores.22 In contrast, other authors have reported little or no disturbance3,4 in the IADLs scores in patients with a mild degree of cognitive deterioration measured with MMSE in high level, sociocultural individuals.5,23-25 Patients with cognitive impairment can successfully accomplish many of the ADLs and IALDs with the support of routines5 and the real efficiency of these screening processes is now being discussed.3,11 Indeed, there is a greater variability in the ADLs/IADLs performances than in the MMSE scores in dementia.26 Some authors suggested that both IADLs/ADLs and MMSE can assess the progression of AD in patients treated with acetylcholinesterase inhibitors27 while in other studies, only MMSE scores showed significant changes.28,29 Although the MMSE30 is the most commonly used, there is a growing body of evidence of the greater sensitivity of the Montreal Cognitive Assessment (MOCA)31,32 in the early stages of dementia. However, to our knowledge, the sensitivity of IADLs and ADLs for AD diagnosis, combined with the MOCA or with the MMSE, has not yet been explored in community-dwelling elderly patients. The ADLs9 and IADLs10 scales and the combination of these scales with MMSE remain the most often used screening instruments.12 However, there is conflicting data on their sensitivity to screening cognitive impairment.7,13 Some authors reported a link between the IADLs scale/ ADLs scale and global cognition or a larger panel of cognitive domains.33-35 Dodge et al33 used a global cognitive test, the Hasegawa Dementia Scale, and found that ‘‘cross-sectionally, the severity of cognitive impairment was significantly associated with disabilities in each ADL–IADL task . . . (p. 229)’’ In the same way, Hall et al34 reported a link with multiple cognitive domains, including memory, learning, executive functioning, and language. In contrast, other authors reported only a link with a limited number of specific cognitive domains—executive and frontal domains for Cahn-Weiner et al,36 memory and executive domains for Tomaszewski Farias et al.37 Nevertheless, several of these authors emphasized34 the limited number of studies on the cognitive associations of the IADLs/ADLs performances; as far as we are aware, no previous study used both global cognitive test and detailed specific cognitive domain tests. Therefore, the purpose of this study is to investigate whether the Lawton IADL-4 item and the ADLs everyday functioning
Journal of Geriatric Psychiatry and Neurology 27(2) questionnaire (ADLs; short tests that can be assessed by paramedical staff) can replace the more time-consuming examination by a trained clinician, for example, whether they are sensitive enough to early dementia diagnostic ability. Our objectives are: 1.
2.
to define the sensitivity and specificity of IADLs-4 item and ADLs, a secondary aim of this study being to compare the clinical ability of these scales with that of MMSE and MOCA either alone or in combination for the AD diagnosis; to define the main clinical, cognitive, and neuropsychiatric correlates of the IADLs-4 item and ADLs.
Methods Population Only community-dwelling patients consulting for the first time in our Old Age Memory outpatient center (Bretonneau Hospital, Paris) from 2009 to January 2012 were considered for this study. Exclusionary criteria at the time of enrollment included age < 75 years, non-French-speaking, severe illnesses, a Hachinski Ischemic Score < 7,28 depression Montgomery Assessment Depression Rating Scale (MADRS) score < 16,29 and medications likely to affect cognition or anticholinesterasic and memantine treatment (indeed, having AD medication suggested an already done diagnosis of AD). The inclusion criteria for the group of patients with AD were mild to moderate dementia (MMSE > 16) and revised AD criteria.1 The control group included not-cognitively impaired individuals and patients with MCI.
Clinical Assessment Patients were first tested on the MOCA and the MMSE. Threshold (cutoff) scores
The Lawton Instrumental Activities Daily Living/Activities Daily Living Scales: A Sensitive Test to Alzheimer Disease in Community-Dwelling Elderly People?
Journal of Geriatric Psychiatry and Neurology 2014, Vol. 27(2) 85-93 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0891988714522694 jgpn.sagepub.com
Pierre Koskas, MD1, Marie Ce´cile Henry-Feugeas, MD, PhD2, Jean Paul Feugeas, MD, PhD3, Aurore Poissonnet4, Ce´cile Pons-Peyneau, MD5, Yves Wolmark, MD4, and Olivier Drunat, MD5
Abstract Objective: To examine the diagnostic ability of the Lawton Instrumental Activities Daily Living (IADLs) scale and the Activities Daily Living (ADLs) scale as a sensitive tool to Alzheimer’s disease (AD) in community-dwelling elderly people. Design: In an old age memory outpatient center, among patients with a clinical diagnosis of AD dementia or no dementia supported by at least 6 months of follow-up, we looked back at the baseline Lawton IADL scale (short version IADL-4 item), ADL scale, Mini-Mental State Examination (MMSE), and Montreal Cognitive Assessment (MOCA) values. Results: There were 109 patients with AD and 53 nondemented individuals (81.4 + 4.6 years). The sensitivity of ADL scale or IADL-4 item or the MMSE was low (52%-57%). The most efficient AD classification used both the IADLs-4 item and the MOCA with a threshold score of 20. Besides age and memory scores, the main correlates of IADLs scale or ADLs scale were executive, neuropsychiatric, vascular, and extrapyramidal scores. Conclusion: Our results suggest that the Lawton IADLs-4 item scale and ADLs scale lack sensitivity to AD dementia in elderly people and support a better sensitivity of MOCA rather than MMSE and IADLs-4 item/ADLs at the expense of specificity. Keywords Alzheimer disease, MMSE, MOCA, IADLs, ADLs, old people
The recently revised definition of Alzheimer’s disease (AD) underlines the impact of cognitive impairment on activities of daily living (ADLs) and a decline from previous levels of functioning and performing1 as core clinical criteria. However, this recent consensus did not specifically recommend any clinical scale for functional assessment: there is a lack of agreement on the instruments and the norms used for measuring ADLs.2-4 Lack of normative data and the varying uses of the criterion (‘‘impact of cognitive impairment on activities’’) may still significantly complicate the diagnosing of nondemented individuals and patients with dementia. It may also contribute to the familiar heterogeneity in the prevalence rate of both nondemented individuals and patients with dementia, as well as patients having mild cognitive impairment (MCI), in population-based studies.5-7 There is variability in the use of assessment tools in European memory center.8 However, the ADLs9 and Instrumental Activities Daily Living (IADLs)10 scales and the combination of these scales with Mini-Mental State Examination (MMSE) remain the most often used screening instruments.11-13
These functional assessment scales may constitute an early marker of the disease in patients with MCI and AD.14-16 Longitudinal studies showed a predictive value of IADLs
1
Memory Center, Bretonneau Hospital, Assistance Publique-Hoˆpitaux de Paris, Paris, France 2 Department of Radiology, Bichat Claude Bernard University Hospital, Assistance Publique-Hoˆpitaux de Paris, Paris, France 3 UMR U722 INSERM Faculte´ de Me´decine Xavier Bichat, Paris Diderot University, Paris, France 4 Department of Geriatrics, Bretonneau Hospital, Assistance PubliqueHoˆpitaux de Paris, Paris, France 5 Department of Psycho-Geriatrics, Bretonneau Hospital, Assistance PubliqueHoˆpitaux de Paris, Paris, France
Received 09/15/2012. Received revised 06/18/2013. Accepted 10/09/2013. Corresponding Author: Pierre Koskas, Hoˆpital Bretonneau, Groupement Hospitalier Universitaire Nord, Assistance Publique-Hoˆpitaux de Paris, 23 rue Joseph de Maistre, 75018 Paris, France. Email: [email protected]
86 disability7,14 and particularly the short IADLs-4 item (telephone use, use of means of transportation, responsibility for medication intake, and handling finances) using the 4 items best associated with cognitive performances in previous studies14,17-19 and recommended for the screening of dementia in community for the elderly patients.17,18,20 Several longitudinal studies also underlined the role of MMSE alone or combined with IADLs scales to predict daily activity.13,21 These studies were carried out on a rural population of mainly noneducated, elderly individuals. It was shown that ADLs and IADLs scales are even better screening tools in dementia diagnosis than the MMSE scores.22 In contrast, other authors have reported little or no disturbance3,4 in the IADLs scores in patients with a mild degree of cognitive deterioration measured with MMSE in high level, sociocultural individuals.5,23-25 Patients with cognitive impairment can successfully accomplish many of the ADLs and IALDs with the support of routines5 and the real efficiency of these screening processes is now being discussed.3,11 Indeed, there is a greater variability in the ADLs/IADLs performances than in the MMSE scores in dementia.26 Some authors suggested that both IADLs/ADLs and MMSE can assess the progression of AD in patients treated with acetylcholinesterase inhibitors27 while in other studies, only MMSE scores showed significant changes.28,29 Although the MMSE30 is the most commonly used, there is a growing body of evidence of the greater sensitivity of the Montreal Cognitive Assessment (MOCA)31,32 in the early stages of dementia. However, to our knowledge, the sensitivity of IADLs and ADLs for AD diagnosis, combined with the MOCA or with the MMSE, has not yet been explored in community-dwelling elderly patients. The ADLs9 and IADLs10 scales and the combination of these scales with MMSE remain the most often used screening instruments.12 However, there is conflicting data on their sensitivity to screening cognitive impairment.7,13 Some authors reported a link between the IADLs scale/ ADLs scale and global cognition or a larger panel of cognitive domains.33-35 Dodge et al33 used a global cognitive test, the Hasegawa Dementia Scale, and found that ‘‘cross-sectionally, the severity of cognitive impairment was significantly associated with disabilities in each ADL–IADL task . . . (p. 229)’’ In the same way, Hall et al34 reported a link with multiple cognitive domains, including memory, learning, executive functioning, and language. In contrast, other authors reported only a link with a limited number of specific cognitive domains—executive and frontal domains for Cahn-Weiner et al,36 memory and executive domains for Tomaszewski Farias et al.37 Nevertheless, several of these authors emphasized34 the limited number of studies on the cognitive associations of the IADLs/ADLs performances; as far as we are aware, no previous study used both global cognitive test and detailed specific cognitive domain tests. Therefore, the purpose of this study is to investigate whether the Lawton IADL-4 item and the ADLs everyday functioning
Journal of Geriatric Psychiatry and Neurology 27(2) questionnaire (ADLs; short tests that can be assessed by paramedical staff) can replace the more time-consuming examination by a trained clinician, for example, whether they are sensitive enough to early dementia diagnostic ability. Our objectives are: 1.
2.
to define the sensitivity and specificity of IADLs-4 item and ADLs, a secondary aim of this study being to compare the clinical ability of these scales with that of MMSE and MOCA either alone or in combination for the AD diagnosis; to define the main clinical, cognitive, and neuropsychiatric correlates of the IADLs-4 item and ADLs.
Methods Population Only community-dwelling patients consulting for the first time in our Old Age Memory outpatient center (Bretonneau Hospital, Paris) from 2009 to January 2012 were considered for this study. Exclusionary criteria at the time of enrollment included age < 75 years, non-French-speaking, severe illnesses, a Hachinski Ischemic Score < 7,28 depression Montgomery Assessment Depression Rating Scale (MADRS) score < 16,29 and medications likely to affect cognition or anticholinesterasic and memantine treatment (indeed, having AD medication suggested an already done diagnosis of AD). The inclusion criteria for the group of patients with AD were mild to moderate dementia (MMSE > 16) and revised AD criteria.1 The control group included not-cognitively impaired individuals and patients with MCI.
Clinical Assessment Patients were first tested on the MOCA and the MMSE. Threshold (cutoff) scores
