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10ournal ofNeurology, Neurosurgery, and Psychiatry 1994;57:1510-1517

A neuropsychological instrument adding to thedescription of patients with suspected corticaldementia: the Milan overall dementia assessment

M Brazzelli, E Capitani, S Della Sala, H Spinnler, M Zuffi

AbstractA new, short, neuropsychologically ori-ented test for dementia assessment-theMilan Overall Dementia Assessment(MODA)-is described.Age and education adjusted norms

based on 217 healthy controls are given.A validation study on 312 outpatients sus-pected of dementia (121 with probableAlzheimer's disease) showed that theMODA differentiated patients with cog-nitive impairment from normal subjectsmore effectively than did the DSM III-R.The correlation between the MODA

and the mini mental state examinationwas 0-63 in controls and 0*84 in patientswith Alzheimer's dementia. The MODAtest-retest reliability was 083. The testproved to be well suited to longitudinalstudies.

(3 Neurol Neurosurg Psychiatry 1994;57: 1510-1517)

Third NeurologicalDepartment,University ofMilan,St Paolo Hospital,ItalyE CapitaniH SpinnlerM ZuffiDepartment ofPsychology,University ofAberdeen, UKM BrazzelliS Della SalaCorrespondence to:Dr Hans Spinnler, ClinicaNeurologica III, Universitadi Milano, Polo Didatticodell' Ospedale San Paoloalla Barona, Via A StarabbaDi Rudini, 8 - 20142Milano, Italy.Received 8 September 1993and in final revised form31 May 1994.Accepted 8 June 1994

It is generally accepted that coping defects can

arise from a number of neurological, psychi-atric, and metabolic diseases.' When thesedefects take a chronic progressive course, theyare subsumed under the term of "dementia".In the diagnostic flow chart of patients withsuspected dementia it is useful to include a

step to verify the suspicion followed by one toestablish its nosology.'4

This study focuses on the steps necessary toconfirm and stage dementia. Because no invivo biological markers of either dementia or

its nosology are currently available, verifica-tion of the presence of dementia has to beneurobehavioural. A widely accepted, allembracing conceptual framework of the psy-chological breakdown of dementia remains tobe achieved, however. Therefore, the manyapproaches to the diagnosis of dementia are

based on standardised descriptions of copingfailures. These descriptions take the form ofenquiries or test batteries.

Behavioural and neuropsychological inves-tigations of patients with dementia yield datapertinent to the description and severity ratingof the disease. It is worth specifying the mainfeatures of these classes of instruments so as

to clearly establish those of the instrumentpresented in this paper.

BEDSIDE STANDARDISED INTERVIEWS

These are composed of heterogeneous items.The way in which they are assembled much

depends on the cultural background of theexaminer (geriatric, psychiatric, neurological),and the particular use for which they areintended (diagnostic, rehabilitative, experi-mental). There is often an array of items,exploring different topics, ranging from for-getfulness to psychotic traits, misperceptionsto confusion, breakdown of social rules tocommunication disorders, alterations in eat-ing and drinking habits to dizziness. The con-clusion that the patient is already in the throesof a dementing process is reached by compar-ing the present state with the presumptivepatient's premorbid state. The interview for-mat is continuously updated at consensusconferences5 with the aim of adding itemsbelieved relevant to the final decision andremoving those considered redundant.Bedside interviews yield semiquantitativemeasures, which are essentially a summationof checkmarks.6 Their main advantage is thatthey can be used to investigate patientsaffected by dementia due to different causes(for example, degenerative, metabolic, psychi-atric); however, even the most acclaimed ofthese guided interviews (for example, DSM-III-R)7 is not substantially more informativethan a carefully taken history.

NEUROPSYCHOLOGICAL SCREENINGINSTRUMENTSWithin this frame of reference, the- symptomsof dementia are purported to be of a neu-ropsychological nature.8 Dementia is thereforeconceived as an aggregation of deficits in sev-eral cognitive domains. The progressiveincrease in the number of these deficits con-tributes substantially to the ecological severityof dementia. It follows that diagnostic instru-ments are test batteries9 10 structured along thetraditional psychological taxonomy.311 Assuch, they are psychometrically sound,because patients' performances can be for-mally compared with norms adjusted for theinfluence of pathology independent variablessuch as age and education. Given the similari-ties between cognitive impairments due tofocal damage and cortical dementia, thisapproach is based on the longstanding corpusof neuropsychological knowledge. Accord-ingly, batteries include tests to assess retro-grade and anterograde memory processing,language, perceptual and spatial coping, andexecutive functions. Poor performances ofdemented patients are regarded as the resultof different cognitive breakdowns due toencroachment of the degenerative process on

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Assessment of dementia

specific cortical areas. Therefore, their use ispresently restricted to cortical dementias, themodel of which is Alzheimer's disease. A neu-ropsychologically oriented tool to ascertain"subcortical dementias" is still lacking.

Several neuropsychological instrumentshave been developed to assess cortical demen-tia, ranging from analytical batteries to briefscreening instruments.' The analyticalapproach provides insight into patients'spared and impaired cognitive abilities.3910 Itis useful for research purposes or when it isnecessary to demonstrate a specific cognitivepattern to confirm the diagnosis of a particu-lar neuropsychological syndrome (for exam-ple, the so called focal degenerative corticalimpairments). The analytical approach is,however, hampered by difficulties related toits administration"2 rendering it unsuitable inseverely deteriorated patients.'3 14

Brief screening instruments, on the otherhand, generally comprise a number of itemsthat are summed up in a global score. Theycan be easily given, scored, and analysed,without extensive prior training. Furthermore,they are suitable for large epidemiologicalstudies.'5 The inclusion of very easy itemswidens the metric window whereby evenseverely deteriorated patients may beassessed.The aim of this study was to present a new,

neuropsychologically oriented instrument:The Milan Overall Dementia Assessment(MODA). It is a rapid rating scale generating a

global score. The statistical procedureemployed allows the clinician to detect thepresence of an Alzheimer-like cognitivedecline and measure the severity of the condi-tion, although it provides no clues as to thenosology.The paper is divided into two parts. Part 1

focuses on the norms of the MODA and theanalysis of potentially influential variablessuch as age, education, and sex. Part 2 is avalidation study in which the MODA and theDSM III-R supported clinical diagnoses arecompared in a group of outpatients referredfor suspected dementia.

Part 1: normative study

Materials and methodsEXPERIMENTAL SUBJECTSNorms were provided by a sample of 217healthy controls, 114 women and 103 men,varying widely in age and education. Thesevolunteers were not paid to take part in the

experiment. We aimed at collecting data froman even number of subjects for each of thedemographic classes considered. They wererecruited in six different districts in the north ofItaly. Eighty per cent of the sample wasrecruited in rural or suburban areas, and theremaining 20% resided in city centres. Fifteenper cent of these subjects were recruitedamong healthy elderly people living in resi-dential homes.The mean age of the whole sample was

608 (SD 18-5, range 20-97) and their meaneducation was 9 1 (SD 4-9, range 1-17) years.Criteria for inclusion were minimal literacyand neurological and mental health. Also,every patient had to have a reliable "witness".Table 1 shows the demographic variables ofthe group.

TESTING PROCEDURESMilan Overall Dementia Assessment (MODA)The MODA' is a paper and pencil test com-posed of three sections: a behavioural scaleand two testing sections. The three sectionsare given in the same testing session in thesame sequence. They are detailed in theappendix. (The Italian version of the MODA isdistributed by the Organizzazioni Speciali, ViaScipione Ammirato, 37, Firenze, Italy.)The behavioural component (autonomy

scale) accounts for 15% ofthe score and com-

prises a set of items that aim to assess every-day coping skills. Information is provided by arelative and can therefore be collected even incases of severe deterioration. The cognitivecontribution in the MODA represents 85% ofthe score (orientation enquiry and neuropsy-chological testing yielding respectively 35%and 50% of the overall score).

Scoring procedures-MODA total scoreranges from a worst of 0 to a best of 100. Inall items a score of zero is given if the patientfails to provide an answer or responds inap-propriately. Instructions may be repeated foreach item, so as to elicit the patient's best pos-sible performance. The overall time requiredto administer MODA ranges from 30 minutesin healthy controls to 45 minutes in deterio-rated patients. The subsequent analysis andadjustment of scores takes minutes.

Mini mental state examination (MMSE).One hundred and ninety healthy subjects ofthe whole sample were also given theMMSE,16 which yields a score from 0 to 30.The missing data for 27 subjects are not fromany systematic bias: they are simply the resultof some organisational problems.

Table 1 Distribution according to age, education, and sex of the control subjects included in the study (n = 217)

Age

Sex Education 20-34 35-44 45-54 55-59 60-64 65-69 70-74 75-79 80-84 > 85

Women(n= 114) <8years(n=73) 7 6 7 7 7 6 9 7 9 8>8years (n = 41) 6 3 4 3 6 4 6 3 3 3

Men (n = 103) <8 years (n = 64) 7 7 8 7 7 7 5 5 7 4>8years(n=39) 6 6 2 5 3 8 2 4 2 1

Total (n= 217) 26 22 21 22 23 25 24 19 21 16

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Table 2 Means (SD) of the MODA total scores in the different age groups

Age No Total score Orientation Autonomy Tests

20-29 21 97 5 (2 7) 35 0 (0-0) 15-0 (0 0) 47-5 (2 7)30-39 16 96-6 (23) 349 (03) 15-0 (00) 467 (22)40-49 19 95 7 (3-1) 34-8 (0-7) 15-0 (0 0) 45-9 (2 7)50-59 35 95-1 (3 7) 349 (02) 15-0 (00) 45-2 (37)60-69 48 94-1 (3 8) 34-8 (04) 14-9 (0 3) 44-2 (3 9)70-79 41 92-8 (4 5) 34-9 (0-2) 14-8 (0 6) 43 0 (4 4)80-85 21 88-9 (7 2) 34-6 (0 8) 14-8 (0 6) 39-6 (6-8)

>85 16 87-4 (7 7) 33-7 (2 9) 15-0 (0 0) 38-6 (5-6)

Total 217 93-7 (5 2) 34-8 (0 8) 14-9 (0 3) 43-9 (4 9)

ResultsInstructions were easily understood by allsubjects. Tetrachoric correlation coefficients17were calculated between the MODA subsec-tions, due to the high incidence of top scores.

Test subsection scores were split according tothe median value, whereas the criterion usedto dichotomise autonomy and orientation wasmaximum v non-maximum scores. Compu-tations were calculated with the Prelis pro-

gramme.'8 Correlation coefficients were 0O42between orientation and autonomy, 047between orientation and tests, and 047between autonomy and tests. An analysisshowed that these coefficients were all differ-ent from zero (p < 0001).

Table 2 reports the means of the MODAscores according to age.

In the normal sample, the total variance ofMODA was accounted for almost entirely byperformance on the test section.The MODA total score was submitted to

multiple regression analysis to study the effectof age, education, and sex. The effects of theconcomitant variables were first assessed indi-vidually and then studied within a simultane-ous regression model to partial out theiroverlap. Effects were included in the finalmodel only if they were still significant afterthis adjustment. Age and education were

Table 3 Linear regression models

Independent variables:transformations, and

Test statistical significance

Regioin wherecontrolled 'jLdgernme'

is possible

Below oLItertoleranicelimit

85.5 t5th centile ofthe sample

. :t lt)rI r>) I4;e rear

Scheme for the interpretation of the inner and outertolerance limits. A performance above 89-0 is consideredabove the chosen thresholdfor normnality. A score lowerthan 85 5 indicates a performance below the chosen cut offfor normality. Age and education adjusted score between85 5 and 89-0 cannot be unequivocally judged as beingabove or below the normality threshold.

included in the regression equation aftermathematical transformations that explaineda greater percentage of the test variance withrespect to the original ones. Table 3 reportsthe linear models of the experimental vari-ables and the adopted transformations, withthe significance levels. For the model of theMODA subsections, age and education were

significant for the test section, and age was

significant for the orientation scale. No cor-

rection of the autonomy scale was required.Table 3 also reports the statistical analysis

of the influence of age, education, and sex on

the MODA scores. Age was significant andlikewise education, whereas sex did not play a

significant part.The model of the MODA total score pro-

vides a means of adjusting the raw scores

according to age and education; this adjust-ment can be made by reversing the signs ofthe regression coefficients.'9 On the adjustedscores we calculated the inner and the outertolerance limits for the best 95% of the popu-lation, with 95% confidence.20 If a subjectscores between the inner and outer tolerancelimits, no unequivocal assignment is possible,and the subject is more appropriately labelled

MODA (Overall)Age: log (100-age)Education: square rootSex

F (1, 214) = 62-969, p < 0-0001F (1, 214) = 139-366, p < 0-0001F (1, 215) < 1, NS

Final model: 93-72 + 3-64 [log(100-age)-3-53] + 3-33 (V;education -291)

OrientationAge: log (100-age)Education: square root(adjusted for age:Sex

Final model: 34 80 + 0-53 [log(100-age)-3-53]

AutonomyAge: no transformationsEducation: square rootSex

Final model: 14 93-0-003 (age-60-82)

TestsAge: log (100-age)Education: square rootSex

F (1, 215) = 32-178, p < 0-0001F (1, 215) = 7 305, p = 0 007F (1, 214) = 1-505, NS)F (1, 215) < 1, NS

F (1, 215) = 5-932, p = 0-016F (1, 215) = 2-742, NSF (1, 215) < 1, NS

F (1, 214) = 50-203, p < 0-0001F (1, 214) = 124-011, p < 0-0001F (1, 215) = <1, NS

Table 4 Correction grid and tolerance limits ofMODAtotal score. The correction values have to be added to orsubtractedfrom each patient's raw score. No correctionshould be applied to a raw score of 100 (the maximum)

Education (y)

Age 3 5 8 13 17

25 1.1 -0-6 -2-6 - 5.1 -6.930 1-3 -0 3 -2-3 -4-9 -6 635 1-6 0 -2-0 -4-6 -6-340 1.9 0-2 -1-7 -4-3 -6-045 22 05 -1-4 -40 -5750 2-5 09 -1.1 -37 -5-455 29 1-3 -07 -3.3 -5060 3.4 1-7 -0-3 -2-9 -4-665 3.9 22 0-2 -24 -4.170 4-4 2-7 0-8 - 1-8 - 3 575 5-1 3.4 1-4 -1.1 -2-980 5.9 42 2-2 -03 -2-185 6-9 5-3 3-3 0.7 -1 0

Exact adjustment can be calculated from the formula:adjusted score = original score - 3-64 [log (100- age)-3- 53]- 3.33 (,/education - 2-91) One sided tolerance limits for theupper 95% of the population (adjusted scores) with 95%confidence: outer region = <85-5; inner region = >89-0;"uncertain" = 85-5 to 89-0.

Final model: 43 95 + 3 03 [log(100-age)-3-53] + 3 29 ('Iieucaition -2-91)

The degrees of freedom (1, 215) apply to the unadjusted test scores; the values (1, 214) areappropriate when the other variable has been partialled out.

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Table S Mean (SD) age andyears ofeducation of the sample in the validation study

Groups No Sex (MIF) Age Education

Non-demented 138 72/66 60-7 (14-6) 7-7 (4-2)Demented: 174 67/107 68-0 (10-6) 7-1 (4-3)

Probable Alzheimer's disease 121 39/82 68-8 (9 2) 6-7 (4-1)Other dementias 53 28/25 66-3 (13-0) 7-9 (4 5)

Overall 312 139/173 64-8 (13-0) 7-3 (4 2)

as a "borderline" case. The outer limits indi-cate the score under which there should be atmost 5% of the normal population, and curbthe risk of spuriously declaring that a subjectis not normal. The inner limits indicate thescore above which there should be at most95% of the normal population, and are usefulfor curbing the risk of spuriously declaring asubject to be normal. For the MODA totalscore, the inner tolerance limit was 89-0 andthe outer tolerance limit was 85-5 (see figure).The inner and outer tolerance limits (toler-

ance regions) for the subscales of the MODAwere respectively 34-3 and 33-8 for the orien-tation scale, 15-0 and 14 1 for the autonomyscale, and 38&8 and 36-2 for the tests section.

Table 4 presents a correction grid for theadjustment of the total raw scores of MODAaccording to age and education. The correc-tion values, which are reported only for somecombinations of age and education, have tobe added to or subtracted from the raw scoreof each patient. Exact adjustments for inter-mediate values may be calculated directlyfrom the formula reported in table 4.The reliability of the MODA was assessed

by retesting 32 subjects (by a different exam-iner) after three weeks. The correlationbetween the performance in the two testingsessions was 0-83 (df= 30, p < 0.001). Onthis basis, it was estimated that the 90% confi-dence limits for the true value of the singleunadjusted score2' were 22 4, and that the95% confidence limits were i 2-9.The MMSE mean (SD) score was 28-45

(2 02), range 16-30. The correlation betweenthe MMSE and the MODA was 061 (df=188, p < 0-001).

DiscussionThe MODA was modelled on the cognitivepicture of Alzheimer's disease." Therefore itassesses so called cortical deficits, and is ofvalue in ascertaining whether the cognitiveperformance of a subject is below the norm.Even so, it cannot be regarded as a compre-hensive instrument for the diagnosis ofdementia.

Table 6 MODA total and section scores of the 312 patients studied in our outpatientdementia units, classified according to the DSM-III-R.

MODA Autonomy Orientation Tests

Non-demented: (n = 138) 87-3 (8-3) 14-2 (1-4) 33-3 (2-9) 39-8 (6-0)Alzheimer's disease (n = 121) 51-1 (19-4) 13-2 (2-0) 19-9 (8-3) 18-0 (11-1)Other dementias: (n = 53) 69-5 (18-2) 13-0 (2-4) 27-9 (7-3) 28-6 (11-4)

Results are mean (SD).

The MODA proved to be sensitive to ageand education. With few exceptions22 23screening tests and rating scales that use hardcut offs disregard influential variables such asage and education and result in a many falsepositives.22425 The statistical analysis of theMODA circumvents the risk of considering asubject not normal simply because he or she isold or poorly educated. This is of particularrelevance given that several recent studieshave reported a higher risk of dementia inthose with lower educational levels.2S28The correlation between the MODA total

score and the MMSE was significant, but nothigh enough to support the view that thesetests share the same structure.

Given the great variability in the neuropsy-chological profile of patients affected byAlzheimer's disease,29 30 the MODA, whichassesses independent areas of cognition,should add sensitivity to the dementingprocess. Furthermore, granted the differentrates of progression of the disease31-33 the par-ticular composition of the MODA shouldprove useful for longitudinal studies or phar-macological investigations.34 A validationstudy (part 2) was performed with the aim ofverifying these predictions.

Part 2: validation study

Materials and methodsThe testing material is as reported in part 1.

EXPERIMENTAL SUBJECTSThree hundred and twelve patients werereferred to the Dementia Research Units ofthe University of Milan or the Medical centreof Veruno, with suspected dementia, first sig-nalled by relatives and not immediately ruledout by a physician (usually a general practi-tioner). Table 5 shows features of the patientgroups.Two clinicians, who, although aware of the

purpose of the study, had not been given theMODA score achieved by each patient,attempted a diagnosis of dementia on thebasis of the dementia criteria of the DSM-III-R.7 Cognitive deterioration was ruled out in138 of the 312 subjects. Of the remaining174, 121 (38-8% of the whole sample, and69-5% of the demented patients) were given adiagnosis of probable Alzheimer's diseaseaccording to the formal criteria of theNINCDS-ADRDA.35 A further 53 patientswere deemed to be affected by different formsof dementia.

ResultsTables 6 and 7 report the MODA findings forthe sample of outpatients with suspecteddementia compared with the outcome of theDSM-III-R classification.On the whole, more patients were classified

by the MODA as being affected by cognitivedeterioration than by the DSM-III-R asdemented, as in the same sample the MODArated 71 (22-8%) as normal, v 138 (44 2%)

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Table 7 Diagnostic categorisation of the neurogeriatric sample (n = 312) according tothe DSM-III-R and the MODA

MODA

Normal Uncertain Not normal

DSM-III-R:Non-demented 67 (48-5) 28 (20 3) 43 (31-2)(n = 138)Demented: Alzheimer's disease 0 (0) 3 (2 5) 118 (97 5)(n = 121)Demented: non-Alzheimer's disease 4 (7 5) 8 (15-1) 41 (77 4)(n = 53)

71 (22 8) 39 (12-5) 202 (64 7)

Results are number (%).

according to the DSM-III-R. Even ifwe allowfor the presence of the uncertain category inthe MODA classification, 43 subjects whowere definitely outside the norm with theMODA were considered normal according tothe DSM-III-R, whereas only four showed theopposite pattern. Table 8 gives details of the43 subjects.

Thirty five of the 121 patients with proba-ble Alzheimer's disease were retested with theMODA after a mean interval of 15-3 months.These patients were less severely affected thanthose who could not be re-examined (meanMODA score = 66-2 (SD 18), v 44 9 (SD19-2), but were of similar age and education.This selection is presumably due to the factthat the compliance of patients who weremost severe at the first examination decreasedwith the disease progression. We think thatthis selection does not, however, make follow-ing up patients with moderately severeAlzheimer's disease any less interesting. Table9 shows the results.The MODA is well suited to monitoring

the disease progression. The average monthlydeterioration of patients' performance on the

Table 8 Subjects judged non-demented by theDSM-III-R (n = 43) who scored below the norm on thesections of theMODA (autonomy, orientation, and tests)

No of subjects

Subjects outside the norm on:Autonomy only 2Orientation only 9Tests only 9

Orientation and autonomy 3Orientation and tests 7Tests and autonomy 6

All sections: 7

Overall:Autonomy 18Orientation 26Tests 29

Table 9 MODA follow up of35 patients with Alzheimer's disease who underwent asecond testing session (mean interval 15.5 months)

MODAoverall Autonomy Orientation Tests

First examination 66-1 14-6 26-1 25-4Second examination 49-6 12-8 20.1 16-7Student's t value 5-847 5 054 4 979 5-367p Value (df = 34) <0-0001 <0-0001 <0-0001 <0-0001

Average monthly deterioration 1-059 0-114 0-385 0-560

MODA was 1-06 (SD 1'25), range -0-06 to5-44. This should be useful for gauging theeffect of treatments in clinical trials. On anannual basis, 28 patients out of 35 worsenedto an extent greater than the confidence limitsof the score (2.9 points). Average worseningon the autonomy scale is less informative, asits course is likely to be non-linear.Interestingly, the mean estimated duration ofillness of the 42 patients with Alzheimer's dis-ease with pathological scores on both the testand orientation sections, but not on auton-omy, was 3-12 (SD 2-51) years, whereas thatof the 67 patients with all three sections belowthe norm was 4-33 (SD 3-31) years. This dif-ference was significant (t = 2-03, p = 004).

Thirty one patients with Alzheimer's dis-ease were given both the MODA and theMMSE. The correlation coefficient with theMMSE was 0-84 (p < 0O001).

DiscussionThe MODA meets the requirements for areliable bedside cognitive screening instru-ment,2 given that a large group of unselectedpatients entered the validity study and a stan-dardised diagnostic procedure was employed.As shown in table 7, only four of the

patients who were classified as demented(although not of the Alzheimer's type) by theDSM III-R achieved a normal MODA score.Conversely, 31 2% of the subjects who werenot demented according to the DSM-III-Rscored below the MODA chosen cut off (and203% were classed as uncertain).

This MODA/DSM-III-R inconsistencypossibly stems from the greater sensitivity tocognitive decline of neuropsychological itemsthan of general behavioural issues. This is notto be read as a fault of the DSM-III, butrather it points to a lack of overlappingbetween the different nosographic categoriesconsidered by the two instruments. TheMODA in fact, is designed to detect andscore cognitive deterioration, whereas theDSM-III is thought of as a clinical tool guidingthe diagnosis of dementia.The opposite pattern, patients who were

normal on the MODA and demented on theDSM-III-R, was seldom seen (only four casesout of 174 (2 3%)). This discrepancy mayhave arisen as a result of a defect in specificityof the DSM-III, the patients at issue couldindeed be non-demented, or a lack of sensitiv-ity of the MODA. In the last case, the MODAenquiry could have failed to detect a behav-ioural defect in non-Alzheimer's diseasepatients, with a poor neuropsychologicalcounterpart (for example, heterogeneous psy-chiatric traits). Anyhow, this error rate seemsacceptable.

In short the MODA seems to be a fairlysensitive screening instrument for cdementia,and this may be of importance as all too oftenthe screening tests used in dementia studiesshow a high rate of false negative classifica-tions.

This has been confirmed in a populationstudy we recently carried out, with a view to

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determining the prevalence of dementia.36 Inthat study we compared the outcome ofMODA with that of the MMSE in serving as a"red flag" for further investigation of a sampleof elderly subjects selected from the commu-nity. The two tests were given to 782 subjects.The correlation between the two measureswas 0-67 (p < 0-001), similar to the onereported in the present study. Subjects with ascore below the cut off on either of the twotests (n = 219) entered a standardised twostage diagnostic procedure that included clini-cal, neuropsychological, and when needed,neuroradiological investigation and a followup period of at least one year, aimed at detect-ing cognitive problems. The results demon-strated a higher sensitivity (95 5% v 67A4%)and a higher specificity (100% v 94-1%) ofthe MODA compared with the MMSE indetecting subjects with cognitive deficits. Theprice of this higher sensitivity is of course agreater number of subjects to be considered inthe follow up; however, this did not exceed4% of the whole sample. Therefore, we arefairly confident in stating that MODA is moresatisfactory than MMSE as a screening test.

General discussionThe need in both clinical practice andresearch for standardised instruments able tograde the cognitive ability of dementedpatients is undeniable. Nevertheless, a limita-tion inherent in many of the rating scalesspecifically designed to assess dementedpatients is that they are appropriate for onlycertain subgroups such as very severely or verymildly deteriorated patients.37 Instrumentsthat disclose abnormalities only when the dis-ease is manifest add little to the diagnosis andstaging of the disease.38 On the other hand,sophisticated neuropsychologically orientedinstruments are of little use in the later stagesof the disease.39

Recently Rebok and Folstein40 maintainedthat the development of "more sensitive andspecific criteria for the diagnosis are needed".Their contention was directed towards theforthcoming revision of DSM-III-R (DSM-IV). We could not agree more. Our approachto this widely felt need has been different,however, in as much as we deem that improv-ing the diagnostic keenness is likely to belinked to a psychometric fine grained elabora-tion (for example, score adjustable for age andeducation) of a standardised instrument pos-sibly framed in a clear cut theoretical commit-ment. In our view most of the phenomenashown by demented patients achieve adescriptive coherence in a neuropsychologicalcontext.The MODA does not rule out the need for

an accurate collection of the history, as onlythis gives the clinician the opportunity to for-mulate the suspicion of dementia and recom-mend psychometric assessment. The testcannot be used as a comprehensive instru-ment for the diagnosis of dementia. A normalMODA score, however, makes true dementia avery unlikely diagnosis.

Other instruments have been devised bychecklisting neuropsychological items, such asthe CAMCOG section in the CAMDEX.'0The guidelines of Roth et al10 do not, how-ever, conceive dementia as a neuropsychologi-cal disease. Accordingly, Roth et al'0 do notrely heavily on CAMCOG, to any greatextent, to stage and diagnose dementia. TheMODA is also a handier instrument and,unlike the CAMCOG, provides a means toadjust the scores for age and education.

Each of the heterogeneous sets of toolsdesigned for the "global" assessment of mentalstate has proved to be highly sensitive to cog-nitive impairment, despite vast differences incomposition and theoretical background.Thus it is tempting to suggest that the crucialcontribution to the resulting score is fairlycontent free. Such a state of affairs would bedisappointing. Given that the genuine neuro-psychological requirements are those thatsubstantially enhance the sensitivity of theinstruments that include them, we believe thatthe overall sensitivity of the many tools pro-posed stems from their neuropsychologicaloverlaps. A neuropsychologically orientedstaging instrument such as MODA is a furtherstep towards generating instruments within acognitive frame of reference. Turning now toseverity one might refer to an all encompass-ing cognitive defect (a Grundstorung) andrange severity accordingly. On the other hand,it could be suggested that the behaviouralincompetence seen in demented peoplederives from several assembled deficits in con-ceptually independent cognitive realms. Wefavour this second view, hence the MODAscore is merely the sum of graded impair-ments in a large array of cognitive domains.The accuracy of a global score in describingthe severity of dementia would therefore beachieved notwithstanding the heterogeneouspattern of the disease.29 Therefore, we main-tain that the MODA is a successful compro-mise between comprehensive, but impracticalneuropsychological test batteries and bedsideinstruments that fail to tap important aspectsof cortical dementias.

We are grateftil to Colin Grey who has taken time to discusswith us the results reported in this article, and to Gilian Jarviswho revised the English. The research was partly supported bya grant to HS of the Consiglio Nazionale delle Ricerche(N:CT 87-00233-04-115-12235). Authors are listed in alpha-betical order, and this does not imply differential contributionto the paper.

Preliminary data were presented at the Meeting of theEuropean Federation of Neurological Societies (EFNS).Berlin, 8-11 December 1993.

AppendixAUTONOMY SCALEThis scale measures everyday coping skillsand is the only non-neuropsychological sec-tion of the MODA. As it is predicted that per-formance on this section will be hamperedonly in the later stages of the dementia, itshould enable us to score even the most dete-riorated patients. The examiner needs the col-laboration of someone who is able to provideinformation about the subject's presentbehaviour. The section considers five aspects

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of everyday living: walking, dressing, personalhygiene, control of sphincters, and eating.The score for each question ranges from 0 (inneed of total supervision) to 3 (total auton-omy). Answers are sought from a close rela-tive. The overall score range is 0-15.

ORIENTATION ENQUIRYThis section is made up of four different setsof items. The items require the subject to pro-duce information that either changes (forexample, age) or remains the same (forexample, date of birth) over time. An answeris accepted when checked against the "truth"(documents or witnesses). The score range ofthe entire section is 0-35. The four sets ofitems are:

Temporal orientation-Five question areasked: the day of the week, the date of themonth, the month, the year, and the time ofday, following the procedure of Benton et al.41The score ranges from 0 to 10.

Spatial ortientation42 -Three questionsrequiring topographical information on townand country are asked. The score ranges from0 to 3.

Personal orientation42 -Seven questionsregarding personal background are asked.Standardised items are weighted differentlyaccording to face value difficulty. The scoreranges from 0 to 10.

Family orientation42 The subject is askedthe name and age (+ 5 years) of four differentfamily members, and whether they are alive ordead. The score ranges from 0 to 12.

NEUROPSYCHOLOGICAL TESTSAll tests are drawn from an Italian standard-ised series4' of formal, currently employed,neuropsychological tests. Only the easiestitems have been chosen to avoid, as far as pos-sible, a "floor performance" in dementedpatients. The score range for the whole sec-tion is 0-50.

Tests assess attention (digit cancellation;reversal learning), intelligence (logical reason-ing), memory (prose memory), language (ver-bal comprehension; fluency), space cognition(finger agnosia; constructional apraxia), andvisual perception (figure completion). Theyare detailed here in the order of administra-tion:

Test No of items Score range

Reversal learning" 5 0-5Digit cancellation test45 10 0-10Logical reasoning43 2 0-6*Prose memory43 16 units 0-8Semantic word fluency46

(names of animals) 0-5tToken test47 5 0-5Finger agnosia4' 5 0-5Construction apraxia49 3 0-3Street completion test50 3 0-3

*Subjects are requested to say what is different between atruck and a coach and the meaning of a well known proverb.The scoring system accounts for norms.43tScore is categorised according to the number of wordsproduced in two minutes and weighted against norms.43

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