What is the CDR

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 = Normal0.5 = Very Mild Dementia1 = Mild Dementia2 = Moderate Dementia3 = Severe Dementia Assignment of CDR ratingUse 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 asdecline 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 cliniciansbest judgment is that a category could be rated in either one of two adjacent boxes, such as mild (1) ormoderate (2) impairment. In that situation the standard procedure is to check the box of greaterimpairment.Aphasia is taken into account by assessing both language and non-language function in eachcognitive category. If aphasia is present to a greater degree than the general dementia, the subject israted 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 threesecondary categories are given the same score as memory. Whenever three or more secondarycategories are given a score greater or less than the memory score, CDR = score of majority ofsecondary categories on whichever side of M has the greater number of secondary categories. Whenthree secondary categories are scored on one side of M and two secondary categories are scored on theother 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 orgreater) 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 possiblescoring combinations. Unusual circumstances occur occasionally in Alzheimer's disease and may beexpected 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 forCDR (e.g., M and another secondary category = 3, two secondary categories = 2, and twosecondary categories = 1; CDR = 2).(2) When only one or two secondary categories are given the same score as M, CDR = M as long asno 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 ofsecondary categories are 0.Morris, J.C. (1993). The clinical dementia rating (CDR): Current version and scoring rules. Neurology,43(11), 2412-2414.

Clinical Dementia RatingOn-line Training SystemAlzheimers Disease Research Center (ADRC)John C. Morris, M.D., Principal Investigator & Co-DirectorWashington University School of Medicine, St. Louis, Missouri, USAWhat is the Clinical Dementia Rating (CDR)?The CDR is a clinical staging instrument for dementia. It characterizes six domains of cognitive andfunctional performance: Memory, Orientation, Judgment & Problem Solving, Community Affairs, Home &Hobbies, and Personal Care. The necessary information to make each rating is obtained through a semistructuredinterview of the patient and a reliable informant or collateral source (e.g., a family member). TheCDR Table provides descriptive anchors that guide the clinician in making appropriate ratings based oninterview data and clinical judgment. In addition to ratings on a 5-point scale for each domain (exceptPersonal 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 indicateVery 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 functionalperformance in patients at risk for or suspected of having Alzheimers Disease or another dementingdisorder. Common applications include patient evaluation in memory assessment clinics, research studiesof normal elderly and those with dementia, and clinical trials of therapeutic agents that might influencedementia progression.Is special training needed?The CDR is based on information elicited through a semi-structured interview standardized in anassessment 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 CDRafter appropriate training. (Morris JC, Ernesto C, Schafer K, et. al. Clinical Dementia Rating training andreliability 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 reliabilitycertification. Successful completion of the 6 reliability tapes is achieved with agreement with a goldstandard on at least 5 out of the 6 tapes. Alternatively, the ADRC offers mini-fellowships in the CDR wherein on-site observations of the CDR with actual patients by a CDR-experienced clinician permits individualinstruction.Become a CDR Rater On-lineThe Brief Training & Reliability Protocol (BTRP) for the CDR is available for browsing and formal reliabilitytraining through the ADRC Website. Individual health professionals and researchers are welcome to usethis system free of charge. Fees may apply for commercial and group users, however. To access thesystem and related documentation, go to http://alzheimer.wustl.edu/adrc2, click on the Clinical DementiaRating link in the Education Menu, and then follow the instructions to access the training modules. Fulltraining through the BTRP requires 6-9 hours, but this can be broken up over multiple sittings. This systemis 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 RATINGThe 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 semi-structured interview to both patient and informant (usually a close family member). Impairment levels are determined in six cognitive-functional categories: 1- Memory 2- Orientation3- Judgment4- Community Affairs5- Home & Hobbies6- 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 Impairment3 = 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, 1, 2, 3)

None0Questionable0.5Mild 1Moderate2Severe3

MemoryNo memory loss or slight inconsistent forgetfulnessConsistent slight forgetfulness; partial recollection of events; "benign" forgetfulnessModerate memory loss; more marked for recent events; defect interferes with everyday activitiesSevere memory loss; only highly learned material retained; new material rapidly lostSevere memory loss; only fragments remain

OrientationFully orientedFully oriented except for slight difficulty with time relationshipsModerate difficulty with time relationships; oriented for place at examination; may have geographic disorientation elsewhereSevere difficulty with time relationships; usually disoriented to time, often to placeOriented to person only

Judgment & Problem SolvingSolves everyday problems & handles business & financial affairs well; judgment good in relation to past performanceSlight impairment in solving problems, similarities, and differencesModerate difficulty in handling problems, similarities, and differences; social judgment usually maintainedSeverely impaired in handling problems, similarities, and differences; social judgment usually impairedUnable to make judgments or solve problems

Community AffairsIndependent function at usual level in job, shopping, volunteer and social groupsSlight impairment in these activitiesUnable to function independently at these activities although may still be engaged in some; appears normal to casual inspectionNo pretense of independent function outside homeAppears well enough to taken to functions outside a family home No pretense of independent function outside home Appears too ill to be be taken to functions outside a family home

Home and HobbiesLife at home, hobbies, and intellectual interests well maintainedLife at home, hobbies, and intellectual interests slightly impairedMild but definite impairment of function at home; more difficult chores abandoned; more complicated hobbies and interests abandonedOnly simple chores preserved; very restricted interests, poorly maintainedNo significant function in home

Personal CareFully capable of self-careNeeds promptingRequires assistance in dressing, hygiene, keeping of personal effectsRequires 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.

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http://www.biostat.wustl.edu/~adrc/cdrpgm/index.html