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Barry Reisberg, M. D.

Professor of Psychiatry
Director, Fisher Alzheimer's Disease Program
Clinical Director, Aging & Dementia Research Center
Director, Clinical Core, NYU Alzheimer's Disease
Center
New York University School of Medicine
Agenda

3:00 PM Introduction to Workshop Barry Reisberg, M.D.

3:05 PM Cognitive dynamics: how variability in brain Kenneth Rockwood M.D., FRCPC, FRCP
function influences the risk of cognitive decline

3:35 PM Current Knowledge of Methodologies for Barry Reisberg, M.D.
Clinical Trials in Pre-MCI Persons with Subjective
Cognitive Impairment (SCI)

4:25 PM Discussion of Current Knowledge and Joel Sadavoy M.D., FRCPC
Methodologies

4:35 PM Discussion of Clinical Instrumentation for Barry Reisberg, M.D.
Subject Selection and Assessment

4:55 PM Subject Interview Workshop Faculty and Participants

5:25 PM Final Discussion Joel Sadavoy M.D., FRCPC
GLOBAL DETERIORATION SCALE (GDS)
Stage 1




1. No subjective complaints of memory
deficit.

No memory deficit evident on clinical
interview.


GLOBAL DETERIORATION SCALE (GDS)
Stage 2




2. Subjective complaints of memory deficit, most
frequently in following areas:
(a) forgetting where one has placed familiar
objects;
(b) forgetting names one formerly knew well.

No objective evidence of memory deficit on clinical
interview.

No objective deficit in employment or social situations.
Appropriate concern with respect to symptomatology.

GLOBAL DETERIORATION SCALE (GDS)
Stage 3
3. Earliest clear-cut deficits.

Manifestations in more than one of the following areas:
(a) patient may have gotten lost when traveling to an unfamiliar
location.
(b) co-workers become aware of patient's relatively poor
performance.
(c) word and/or name finding deficit become evident to intimates.
(d) patient may read a passage or book and retain relatively little
material.
(e) patient may demonstrate decreased facility remembering names
upon introduction to new people.
(f) patient may have lost or misplaced an object of value.
(g) concentration deficit may be evident on clinical testing.

Objective evidence of memory deficit obtained only with an intensive
interview.
Decreased performance in demanding employment and social settings.
Denial begins to become manifest in patient.
Mild to moderate anxiety frequently accompanies symptoms.
Abridged Global Deterioration Scale
Copyright 2008 Barry Reisberg, M.D. All rights reserved.
Abridged version published in Canadian Medical Association Journal, 2008; 179 (12); p. 1281. Modified from Reisberg, B., Ferris, S.H., de Leon, M.J, et al. The global
deterioration scale for assessment of primary degenerative dementia. Am J Psychiatry, 1982; 139: 1136-1139.
Stage 1 No subjective memory deficit (no cognitive impairment); no problems with activities of daily
living

Stage 2 Subjective memory complaints (subjective cognitive impairment): Complaints of being
forgetful, such as complaints of trouble with recall of names, complaints of misplacing objects

Stage 3 Earliest clear deficits (mild cognitive impairment): Difficulties often noted at work; may have
gotten lost; may have misplaced a valuable object

Stage 4 Clear deficits on clinical examination (moderate cognitive impairment): Decreased
knowledge of personal and/or current events; often trouble with travel and finances

Stage 5 Can no longer survive independently in the community without some assistance (moderately
severe cognitive impairment): Difficulty with recall of some important personal details (e.g.,
address, names of one or more important schools attended); may require cuing for activities of
daily living

Stage 6 Largely unable to verbalize recent events in their life (severe cognitive impairment): May forget
name of spouse; incontinence develops as this stage progresses; requires increasing assistance
with activities of daily living; increased behavioral problems (e.g., agitation, delusions)

Stage 7 Few intelligible words or no verbal abilities (very severe cognitive impairment): Loses the ability
to walk as this stage evolves
Stage 1: NCI. No Thinking (Cognitive) Impairment.
No self evident decline in memory or thinking abilities; no thinking related
problems with daily activities or work.
Stage 2: SCI. Subjective (Self Evident) Cognitive (Thinking) Impairment.
Personal belief that thinking abilities have declined in comparison with the
persons abilities five or ten year previously. Persons may notice that they are
forgetful, such as of having trouble with recall of names, and/or of misplacing
objects.
Stage 3: MCI. Mild Cognitive (Thinking) Impairment.
Earliest noticeable problems with memory and, or thinking abilities. For
example, problems or difficulties with thinking abilities and performance may
be noted at work; the person may have gotten lost; the person may have
misplaced a valuable object. Sometimes other people notice that the person
repeats things that the person has already said. Also, anxiety may be evident.
Stage 4: Mild Dementia.
Clear deficits on a doctors or other professionals examination of thinking
abilities. Decreased knowledge of personal and/or current events. For
example, the person may have gone away on a recent trip, perhaps to visit
relatives, and the person may have completely forgotten where they went.
Often difficulties with managing personal funds or shopping correctly, or with
independent travel or with meal preparation. Frequently, the person may
become more withdrawn or less active in a variety of ways. For example,
rather than preparing the holiday meal, the person may say Im just not up to
it this year, or Im getting old, or Im getting tired, or Im just not the person
I used to be. Generally, persons at this stage can still manage independently
in the community, although the difficulties mentioned may be evident.
Stage 5: Moderate Dementia.
Can no longer survive independently in the community without some
assistance. Difficulty with recall of some important personal details (for
example, the persons correct address; the names of one or more important
schools attended in childhood, adolescence, and early adulthood); may
require cuing for activities for daily living. Characteristically, persons at this
stage have difficulties selecting appropriate clothing to wear for the day,
considering the days events, weather conditions, etc. Therefore, the spouse
or other assistant will begin to counsel regarding choice of clothing. Also,
persons at this stage can still generally put on their clothing and shower
(bathe) without assistance.
Stage 6: Moderately Severe Dementia.
Largely unable to describe recent events in their life (severe thinking
problems): When asked, has little or no idea of their current address, the
current weather conditions, etc. May forget the name of their spouse. When
asked, may or may not be able to state their former job, their mothers name,
their fathers name, or their country of birth. Requires increasing assistance
with activities of daily living such as dressing (putting on their clothes) and
showering. Difficulty with control of urination and, generally later, bowel
movements, develops as this stage progresses. Increased behavioral
problems (for example, agitation or aggression) or other personality problems
are common.
Stage 7: Severe Dementia.
Few understandable words or no speaking abilities (very severe thinking
impairment). Incontinent of both urine and feces unless assistance is provided
to prevent toileting accidents,
such as frequent escorting to the bathroom. Loses the ability to walk as this
stage evolves. Later basic abilities such as the ability to sit-up independently,
to smile, and to move and/or to hold up the head independently, are
progressively lost.

.
Global Deterioration Scale for Concerned Persons, Families
and Friends
[Choose the most appropriate stage based mainly on thinking and functioning abilities]
Copyright 1983, 2008, 2009, 2010 Barry Reisberg, M.D. All rights reserved.
Abridged Global Deterioration Scale published in Canadian Medical Association Journal, 2008; 179(12); p. 1281. Modified from Reisberg, B., Ferris, S.H., de Leon, M.J. et al. The
global deterioration scale for assessment of primary degenerative dementia. American Journal of Psychiatry, 1982, 139:1136-1139.

Stage 1: NCI. No Thinking (Cognitive) Impairment.
No self evident decline in memory or thinking abilities; no thinking related
problems with daily activities or work.
Stage 2: SCI. Subjective (Self Evident) Cognitive (Thinking) Impairment.
Personal belief that thinking abilities have declined in comparison with the
persons abilities five or ten year previously. Persons may notice that they are
forgetful, such as of having trouble with recall of names, and/or of misplacing
objects.
Stage 3: MCI. Mild Cognitive (Thinking) Impairment.
Earliest noticeable problems with memory and, or thinking abilities. For
example, problems or difficulties with thinking abilities and performance may
be noted at work; the person may have gotten lost; the person may have
misplaced a valuable object. Sometimes other people notice that the person
repeats things that the person has already said. Also, anxiety may be evident.
Global Deterioration Scale for Concerned Persons, Families
and Friends

[Choose the most appropriate stage based mainly on thinking and functioning abilities]
Copyright 1983, 2008, 2009, 2010 Barry Reisberg, M.D. All rights reserved.
Abridged Global Deterioration Scale published in Canadian Medical Association Journal, 2008; 179(12); p. 1281. Modified from Reisberg, B., Ferris, S.H., de Leon, M.J. et al. The
global deterioration scale for assessment of primary degenerative dementia. American Journal of Psychiatry, 1982, 139:1136-1139.




BRIEF COGNITIVE RATING SCALE (BCRS)
INSTRUCTIONS
Each axis of the Brief Cognitive Rating Scale is scored independently.
Each axis is designed to be optimally concordant with the other axes
and with the numerically corresponding Global Deterioration Scale
stage. Consequently, each axis of the BCRS conveys important
staging related information.
For clinical purposes scores can be reported conveniently as consecutive
axis scores, e.g., 6,5,6,4,5". This reporting methodology indicates
relative capacity in each axis modality, i.e., concentration, recent
memory, etc.
For therapeutic trials the axes can be added and total scores for the five
axes can be utilized.
For staging, the Global Deterioration Scale stage is very closely
equivalent to the average score of the BCRS axes. Ideally, for staging
purposes, the BCRS can be used as a semistructured procedure for
guiding final GDS stage assignments.


BRIEF COGNITIVE RATING SCALE (BCRS)
1,2


AXIS I: CONCENTRATION (circle only one, i.e., the most appropriate level)

1 No objective or subjective evidence of deficit in concentration.

2 Subjective decrement in concentration ability.

3 Minor signs of poor concentration (e.g., subtraction of serial 7s from 100).

4 Definite concentration deficit for persons of their background (e.g., marked deficit
on serial 7s, frequent deficit in subtraction of serial 4s from 40).

5 Marked concentration deficit (e.g., giving months backwards or serial 2s from 20).

6 Forgets the concentration task. Frequently begins to count forward when asked o
count backwards from 10 by 1s.

7 Marked difficulty counting forward to 10 by 1s.
BRIEF COGNITIVE RATING SCALE (BCRS)
1,2

AXIS II: RECENT MEMORY (circle only one, i.e., the most
appropriate level)

1 No objective or subjective evidence of deficit in recent memory.
2 Subjective impairment only (e.g., forgetting names more than formerly).
3 Deficit in recall of specific events evident upon detailed questioning, (e.g.
about recent meals, current reading, recent appointments, etc). No deficit in
the recall of major recent events.
4 Cannot recall major events of previous weekend or week. Scanty
knowledge (not detailed) of current events, favorite TV shows, etc. May not
know telephone number and/or telephone area code and/or postal (zip) code.
5 Unsure of weather, and/or may not know current president and/or current
address.
6 Occasional knowledge of some recent events. Little or no idea of current
address, weather, etc. Given the current president's first name, may recall
their last name.
7 No knowledge of any recent events
BRIEF COGNITIVE RATING SCALE (BCRS)
1,2

AXIS III: PAST MEMORY (circle only one, i.e., the most appropriate level)

1 No subjective or objective impairment in past memory.
2 Subjective impairment only. Can recall two or more primary school teachers.
3 Some gaps in past memory upon detailed questioning. Able to recall at least
one childhood teacher and/or one childhood friend.
4 Clear-cut deficit. The spouse recalls more of the patient's past than the patient.
Cannot recall childhood friends and/or teachers but knows the names of schools
attended. Confuses chronology in reciting personal history.
5 Major past events sometimes not recalled (e.g., names of schools attended).
Characteristically, at this stage patients recall some schools attended, but not
others.
6 Some residual memory of past (e.g., may recall country of birth or former
occupation, may or may not recall mother's name, may or may not recall
father's name). Generally, patients do not recall any of the schools which they
attended.
7 No memory of past (cannot recall country, state, or town of origin, cannot recall
names of parents, etc.)

BRIEF COGNITIVE RATING SCALE (BCRS)
1,2

AXIS IV: ORIENTATION (circle only one, i.e., the most appropriate
level)
1 No deficit in memory for time, place, identity of self or others.
2 Subjective impairment only. Knows time to the nearest hour.
Knows location.
3 Any mistake in time of two hours or more, day of the week of 1
day or more, date of 3 days or more.
4 Mistakes day of the month by 10 days or more, and/or confuses
month of the year by 1 month or more.
5 Unsure of month and/or year and/or season, unsure of locale.
6 No idea of date. Identifies spouse but may not recall name.
Knows own name.
7 Cannot identify spouse. May be unsure of personal identity.

BRIEF COGNITIVE RATING SCALE (BCRS)
1,2

AXIS V: FUNCTIONING AND SELF-CARE a (circle only one, i.e., the
most appropriate level)
1 No difficulty, either subjectively or objectively.
2 Complains of forgetting location of objects. Subjective work difficulties.
3 Decreased job functioning evident to co-workers. Difficulty in traveling to new
locations. Decreased organizational capacity.*
4 Decreased ability to perform complex tasks, e.g., planning dinner for guests,
handling personal finances (such as forgetting to pay bills), difficulty marketing,
etc.*
5 Requires assistance in choosing proper clothing to wear for the day, season, or
occasion, e.g. patient may wear the same clothing repeatedly, unless supervised.*
6 Requires assistance in putting on clothing, and/or bathing, and/or toileting, and/or
feeding.
7 Requires constant assistance in all activities of daily life.*
*Scored primarily on the basis of information obtained from a knowledgeable informant and/or caregiver.

a
The Functional Assessment Staging (FAST) scale can be utilized in lieu of Axis V for more precise staging.

1
Adapted from Reisberg, B. and Ferris, S.H., Brief Cognitive Rating Scale (BCRS). Psychopharmacology Bulletin, 1988;
24:629-636.
2
Copyright 1984 Barry Reisberg, M.D. All rights reserved.

Agenda

3:00 PM Introduction to Workshop Barry Reisberg, M.D.

3:05 PM Cognitive dynamics: how variability in brain Kenneth Rockwood M.D., FRCPC, FRCP
function influences the risk of cognitive decline

3:35 PM Current Knowledge of Methodologies for Barry Reisberg, M.D.
Clinical Trials in Pre-MCI Persons with Subjective
Cognitive Impairment (SCI)

4:25 PM Discussion of Current Knowledge and Joel Sadavoy M.D., FRCPC
Methodologies

4:35 PM Discussion of Clinical Instrumentation for Barry Reisberg, M.D.
Subject Selection and Assessment

4:55 PM Subject Interview Workshop Faculty and Participants

5:25 PM Final Discussion Joel Sadavoy M.D., FRCPC


Workshop Moderator


Joel Sadavoy M.D., FRCPC

Professor of Psychiatry, University of Toronto,
Sam and Judy Pencer Chair in Applied General Psychiatry,
Director Cyril & Dorothy, Joel & Jill Reitman Institute for
Alzheimer's Support and Training,
Head Geriatric and Community Psychiatry Programs
Mount Sinai Hospital

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