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Table 2 Summary of measure details, methods of administration, and feasibility and applicability in care

From: Measures to assess commonly experienced symptoms for people with dementia in long-term care settings: a systematic review

  Measures Number of items (range) Scoring (ranges) Methods of administration Rating period Time to compete (range) Training required
Pain APS 5–60 0–5 to 0–60 Observation over specified time period 1 minute specified observation time, observation during specified activities, observations during all personal care provision 30 seconds to 5–10 minutes Most measures do not require any formal training Two have been specifically developed for non-clinically trained care staff
CNPI Observation during specified activity  
CPAT Observation during routine care Training for raters in the studies ranged from 5 minute training video to 2 hours, or continued training throughout data collection period
Doloplus-2 From memory based on knowledge of resident
NOPPAIN Ratings of video recordings of activities or pain events
PAINAD Signs of pain including facial, behavioral, vocal, functional
Oral health BOHSE 8–10 0–16 to 0–20 Observation and examination Examination period 6–8 minutes 3–4 hours of training, with calibration
Neuropsychiatric NPI-Q 12–81 0–36 Observation and knowledge of person Last 4 weeks 5 minutes None
CDBQ 0–248
Depression BDI-modified 7–21 0–15 to 0–80 Observation, all available information sources, knowledge of person Last week to last 4 weeks No information No training, 30 minutes training or provision of instructions and instruction manual
CESD-modified MDS coordinator usually registered nurse
Hayes and Lohse Non-verbal Depression Scale
Anxiety GAI-modified 8–20 0–20 to 8–40 Modified to be self–administered by informal caregiver, based on knowledge of person Last week No information None
Psychological wellbeing PGCARS 5–11 0–90 Observation 5 minutes to last 24 hours 5–10 minutes Group and one-to-one teaching sessions with supervised practice
Ratings of video recordings    Training for raters in the studies ranged from none to 2 days
Discomfort DBS 9–17 0–17 to 0–102 Rated based on information from informants, observations and resident interactions Past week No information MDS coordinator, usually registered nurse
Observation over specified period and activity program 5 minute observation or specified activity program DS-DAT requires training and may have limited clinical applicability as complex to learn
Training for raters included continued training throughout data collection period
  1. APS, Abbey Pain Scale; CNPI, Checklist of Nonverbal Behaviors; CPAT, CNA Pain Assessment Tool; MPS, Mahoney Pain Assessment Tool; NOPPAIN, Non-communicative Patient’s Pain Assessment Instrument; PAINAD, Pain Assessment in Advanced Dementia; PACSLAC, Pain Assessment Checklist for Seniors with Limited Ability to Communicate; PACI, Pain Assessment in Communicatively Impaired; PADE, Pain Assessment for Dementing Elderly; PBOICIE, Pain Behaviors for Osteoarthritis Instrument for Cognitively Impaired Elders; BOHSE, Brief Oral Health Status Examination; OHAT, Oral Health Assessment Tool; NPI-Q, Neuropsychiatric Inventory Questionnaire; CDBQ, California Dementia Behavior Questionnaire; BDI-modified, Beck Depression Inventory – modified; CESD-Modified, Center for Epidemiologic Studies Depression Scale – modified; CSDD-modified, Cornell Scale for Depression in Dementia - modified; CSDD-M-LTCS, Cornell Scale for Depression in Dementia Modified for use by Long Term Care Staff; DDMS-modified, Depression in Dementia Mood Scale – modified; DSS-modified, Depression Signs Scale – modified; GDS, Geriatric Depression Scale; MDSDRS, Minimum Data Set Depression Rating Scale; GAI-modified, Geriatric Anxiety Inventory – modified; PSWQ-A-modified, Penn State Worry Questionnaire – Abbreviated – modified; PGCARS, Philadelphia Geriatric Center Affect Rating Scale; PWB-CIP, Psychological Wellbeing in Cognitively Impaired Persons; AARS, Apparent Affect Rating Scale; AER, Apparent Emotion Rating Instrument; DBS, Discomfort Behavior Scale; DS-DAT, Discomfort Scale for patients with Dementia of Alzheimer’s Type; MDS, Minimum Data Set