What is the CDR?

The CDR is a 5-point scale used to characterize six domains of cognitive and functional performance applicable to Alzheimer disease and related dementias: Memory, Orientation, Judgment & Problem Solving, Community Affairs, Home & Hobbies, and Personal Care. The necessary information to make each rating is obtained through a semi-structured interview of the patient and a reliable informant or collateral source (e.g., family member). The CDR table provides descriptive anchors that guide the clinician in making appropriate ratings based on interview data and clinical judgment. In addition to ratings for each domain, an overall CDR score may be calculated through the use of an algorithm. This score is useful for characterizing and tracking a patient's level of impairment/dementia: 0 = Normal 0.5 = Very Mild Dementia 1 = Mild Dementia 2 = Moderate Dementia 3 = Severe Dementia Assignment of CDR rating Use all information available and make the best judgment. Score each category (M, O, JPS, CA, HH, PC) as independently as possible. Mark in only one box, for each category, rating impairment as decline from the persons usual level due to cognitive loss alone, not impairment due to other factors, such as physical handicap or depression. Occasionally the evidence is ambiguous and the clinicians best judgment is that a category could be rated in either one of two adjacent boxes, such as mild (1) or moderate (2) impairment. In that situation the standard procedure is to check the box of greater impairment. Aphasia is taken into account by assessing both language and non-language function in each cognitive category. If aphasia is present to a greater degree than the general dementia, the subject is rated according to the general dementia. Supply evidence of non-language cognitive function. The global CDR is derived from the scores in each of the six categories ("box scores") as

follows. Memory (M) is considered the primary category and all others are secondary. CDR = M if at least three secondary categories are given the same score as memory. Whenever three or more secondary categories are given a score greater or less than the memory score, CDR = score of majority of secondary categories on whichever side of M has the greater number of secondary categories. When three secondary categories are scored on one side of M and two secondary categories are scored on the other side of M, CDR=M. When M = 0.5, CDR = 1 if at least three of the other categories are scored one or greater. If M = 0.5, CDR cannot be 0; it can only be 0.5 or 1. If M = 0, CDR = 0 unless there is impairment (0.5 or greater) in two or more secondary categories, in which case CDR = 0.5. Although applicable to most Alzheimer's disease situations, these rules do not cover all possible scoring combinations. Unusual circumstances occur occasionally in Alzheimer's disease and may be expected in non-Alzheimer dementia as well are scored as follows: (1) With ties in the secondary categories on one side of M, choose the tied scores closest to M for CDR (e.g., M and another secondary category = 3, two secondary categories = 2, and two secondary categories = 1; CDR = 2). (2) When only one or two secondary categories are given the same score as M, CDR = M as long as no more than two secondary categories are on either side of M. (3) When M = 1 or greater, CDR cannot be 0; in this circumstance, CDR = 0.5 when the majority of secondary categories are 0. Morris, J.C. (1993). The clinical dementia rating (CDR): Current version and scoring rules. Neurology, 43(11), 2412-2414.

Clinical Dementia Rating On-line Training System

Alzheimers Disease Research Center (ADRC) John C. Morris, M.D., Principal Investigator & Co-Director

Washington University School of Medicine, St. Louis, Missouri, USA

What is the Clinical Dementia Rating (CDR)? The CDR is a clinical staging instrument for dementia. It characterizes six domains of cognitive and functional performance: Memory, Orientation, Judgment & Problem Solving, Community Affairs, Home & Hobbies, and Personal Care. The necessary information to make each rating is obtained through a semistructured interview of the patient and a reliable informant or collateral source (e.g., a family member). The CDR Table provides descriptive anchors that guide the clinician in making appropriate ratings based on interview data and clinical judgment. In addition to ratings on a 5-point scale for each domain (except Personal Care, which is rated on a 4-point scale) an overall CDR score is derived by standard algorithm. This score is useful for globally staging the level of impairment: 0 = No impairment, 0.5, 1, 2, and 3 indicate Very Mild, Mild, Moderate and Severe Dementia. Morris J.C. The Clinical Dementia Rating (CDR): Current version and scoring rules. Neurology,1993; 43:2412-2414. The scoring algorithm can be accessed at
http://www.biostat.wustl.edu/~adrc/cdrpgm/index.html.

Who uses the CDR and for what purposes? The CDR is used in both research and clinical settings to characterize the level of cognitive and functional performance in patients at risk for or suspected of having Alzheimers Disease or another dementing disorder. Common applications include patient evaluation in memory assessment clinics, research studies of normal elderly and those with dementia, and clinical trials of therapeutic agents that might influence dementia progression. Is special training needed? The CDR is based on information elicited through a semi-structured interview standardized in an

assessment protocol. Clinical skills to elicit appropriate information and judge its relevance are required. Physicians and advanced practice nurses administer the protocol and score the CDR in our center. Physicians and non-physician health professionals demonstrate good reliability in administering the CDR after appropriate training. (Morris JC, Ernesto C, Schafer K, et. al. Clinical Dementia Rating training and reliability in multi-center studies: The Alzheimer's Disease Cooperative Study experience. Neurology 1997; 48:1508-1510.) The Brief Training and Reliability Protocol (BTRP) includes an introduction to the CDR by Dr. John Morris, three videotaped patient interviews for training purposes, and six videotaped interviews for reliability certification. Successful completion of the 6 reliability tapes is achieved with agreement with a gold standard on at least 5 out of the 6 tapes. Alternatively, the ADRC offers minifellowships in the CDR where in on-site observations of the CDR with actual patients by a CDR-experienced clinician permits individual instruction. Become a CDR Rater On-line The Brief Training & Reliability Protocol (BTRP) for the CDR is available for browsing and formal reliability training through the ADRC Website. Individual health professionals and researchers are welcome to use this system free of charge. Fees may apply for commercial and group users, however. To access the system and related documentation, go to http://alzheimer.wustl.edu/adrc2, click on the Clinical Dementia Rating link in the Education Menu, and then follow the instructions to access the training modules. Full training through the BTRP requires 6-9 hours, but this can be broken up over multiple sittings. This system is made possible through funding from the National Institute on Aging (P50-AG05681).

Questions? Contact the ADRC Education Director at adrcedu@abraxas.wustl.edu or call 314-286-2882.

WASHINGTON UNIVERSITY CLINICAL DEMENTIA RATING

The Washington University Clinical Dementia Rating Scale (CDR) is widely used in longitudinal and clinical studies to gauge Alzheimer's Disease progression. The CDR is also helpful as a guide in the clinical care of Alzheimer's Disease patients and their family care providers.

A specially trained physician, nurse, psychologist or other health professional administers the CDR semistructured interview to both patient and informant (usually a close family member). Impairment levels are determined in six cognitive-functional categories:

1- Memory 2- Orientation 3- Judgment 4- Community Affairs 5- Home & Hobbies 6- Personal Care

Click HERE to view the CDR grid.

A five-point scale is used to rate function in each category:

0 = Normal (no significant problem) 0.5 = Questionable Impairment (more than just normal aging) 1 = Mild Impairment (mildly impaired relative to peers) 2 = Moderate Impairment 3 = Severe Impairment

Interview data from the patient and informant are reviewed to determine functional impairment ratings in each cognitive category. These category scores (or "box scores") are then analyzed using special scoring rules to determine a final, overall CDR score. Click HERE to utilize the CDR Scoring Algorithm.

Individuals who receive a score of 1 or greater show clear signs of a dementing illness, in most cases Alzheimer's Disease. Those who score O.5 may be experiencing the very early manifestations of dementia. Repeated evaluation over time allows the illness process to be tracked and diagnostic clarifications to be made.

CLINICAL DEMENTIA RATING (CDR)

Impairment Level and CDR Score (0, 0.5, None 0 Memory No memory loss or slight inconsistent forgetfulness Questionable 0.5 Consistent slight forgetfulness; partial recollection of events; "benign" forgetfulness Mild 1 Moderate memory loss; more marked for recent events; defect interferes with everyday activities

1, 2, 3) Moderate 2 Severe 3

Severe memory loss; Severe memory loss; only highly learned material retained; new only fragments remain material rapidly lost Severe difficulty with Oriented to person time relationships; only usually disoriented to time, often to place

Orientation

Fully oriented

Fully oriented except Moderate difficulty for slight difficulty with time with time relationships relationships; oriented for place at examination; may have geographic disorientation elsewhere Slight impairment in solving problems, similarities, and differences

Judgment & Problem Solving

Solves everyday problems & handles business & financial affairs well; judgment good in relation to past performance Independent function at usual level in job, shopping, volunteer and social groups

Moderate difficulty in Severely impaired in handling problems, handling problems, similarities, and similarities, and differences; social differences; social judgment usually judgment usually maintained impaired Unable to function No pretense of independently at these independent function activities although outside home may still be engaged in some; appears normal Appears well enough to casual inspection to taken to functions outside a family home

Unable to make judgments or solve problems

Community Affairs

Slight impairment in these activities

No pretense of independent function outside home Appears too ill to be be taken to functions outside a family home No significant function in 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

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

Score only as decline from previous usual level due to cognitive loss, not impairment due to other factors. http://www.adrc.wustl.edu/cdrGrid.html

http://alzheimer.wustl.edu/adrc2/Education/CDR%20Inter-Page.html