InterRAI

Scales: Status and Outcome Measures

Embedded within each interRAI instrument are various scales and indices that can be used to evaluate an individual's current clinical status. If longitudinal data is collected, changes in clinical status over time can also be evaluated and compared. These scales have been carefully researched to ensure that they are comparable to industry "gold standard” measures.

Following are descriptions (in alphabetical order by acronym / name) of some of the most widely used status and outcome measures developed by interRAI working groups.

Aggressive Behaviour Scale (ABS)

The Aggressive Behaviour Scale (ABS) is a measure of aggressive behaviour based on the occurrence of verbal abuse, physical abuse, socially disruptive behaviour and resistance of care. Scale scores range from 0-12 with higher scores indicative of greater frequency and diversity of aggressive behaviour. A score of 1 to 4 on the ABS indicates mild to moderate aggressive behaviour, whereas scores of 5 or more represents the presence of more severe aggression. This scale has been validated against the Cohen Mansfield Agitation Inventory.

Activities of Daily Living (ADL) Hierarchy

The ADL Hierarchy Scale groups activities of daily living according to the stage of the disablement process in which they occur. Early loss ADLs (for example, dressing)  are assigned lower scores than late loss ADLs (for example, eating). The ADL Hierarchy ranges from 0 (no impairment) to 6 (total dependence). Diagram

Social Withdrawal

Social Withdrawal is an indicator of withdrawal, based on the occurrence of anhedonia, withdrawal from activities of interest, lack of motivation and reduction in social interactions. Scores range from 0-12 with higher scores indicating higher levels of anhedonia. For persons with schizophrenia, this scale can also be used as a measure of negative symptoms. This scale has been validated against the Negative Symptoms Scale of the Positive and Negative Syndrome Scale (PANSS).

CHESS

The Changes in Health, End-Stage Disease, Signs, and Symptoms Scale was designed to identify individuals at risk of serious decline. It can serve as an outcome where the objective is to minimize problems related to declines in function, or as a pointer to identify persons whose conditions are unstable. CHESS, originally developed for use with nursing home residents, has been adapted for use with other instruments in the interRAI suite. It creates a 6- point scale from 0 = not at all unstable to 5 = highly unstable, with higher levels predictive of adverse outcomes such as mortality, hospitalization, pain, caregiver stress, and poor self-rated health. Diagram

CAGE

The CAGE acronym refers to 4 symptoms: Cutting down on substance use, being Angered by criticisms from others, feelings of Guilt about substance use and having an “Eye-opener” (drinking/using substances in the morning). Scores range from 0-4, with a score of 2 or higher considered to indicate a potential problem with substance addiction. The CAGE items in the interRAI mental health instruments have been validated against substance use disorder diagnoses.

Cognitive Performance Scale (CPS)

The Cognitive Performance Scale (CPS) combines information on memory impairment, level of consciousness, and executive function, with scores ranging from 0 (intact) to 6 (very severe impairment). The CPS has been shown to be highly correlated with the MMSE in a number of validation studies. Diagram

Cognitive Performance Scale 2 (CPS2)

The Cognitive Performance Scale 2 (CPS2) is an updated version for use with instruments that include Instrumental Activities of Daily Living (IADLS), such as the interRAI Home Care. The CPS2 is particularly sensitive to detect changes in early levels of cognitive decline. Diagram

Depression Rating Scale (DRS)

The Depression Rating Scale (DRS) is used as a clinical screen for depression. Validation studies were based on a comparison of the DRS with the Hamilton Depression Rating Scale and the Cornell Scale for Depression. Compared to DSM-IV major or minor depression diagnoses, the DRS was 91% sensitive and 69% specific at a cut-point score of 3 out of 7. Diagram

Depressive Severity Index (DSI)

The Depressive Severity Index (DSI) is an alternate measure to DRS for depressive symptoms based on: sad, pained facial expression; negative statements; self-deprecation; guilt/shame; and hopelessness. Scores range from 0 to 15; where higher scores indicate more depressive symptoms.  The DSI was derived in mental health samples based on comparisons with the Beck Depression Inventory and was found to be more predictive of self-harm ideation than the BDI.

DIVERT

The Detection of Indicators and Vulnerabilities for Emergency Room Trips Scale for was designed to classify the risk of emergency department use in frail community-dwelling older adults. It was developed from a multi-year, census-level cohort study of home care patients and was informed by a multi-national clinical panel. Previous emergency department use, cardio-respiratory symptoms, and cardio-respiratory conditions feature heavily in the DIVERT scale. It distinguishes 6 different risk levels (a score of 6 represents the highest level of risk). The DIVERT scale is intended to assist in case finding home and community care patients at risk of unplanned emergency department use. Also, the DIVERT scale may help prioritize communication and collaboration with primary care and relevant specialists. Beyond its use for case finding, it may also be used to stratify or adjust organizational, regional, and national level ED utilization metrics. Diagram

IADL Involvement Scale

The Instrumental ADL Scale is based on a sum of seven items: meal preparation, ordinary housework, managing finances, medications, phone use, shopping, and transportation. Individual items are summed to produce a scale that ranges from 0 to 48, with higher scores indicating greater difficulty in performing instrumental activities. Diagram

Mania Scale

The Mania Scale is a measure of frequency of symptoms of mania. The scale is based on 7 items: inflated self-worth; hyperarousal; irritability; increased socialability/hypersexuality; pressured speech; labile effect; and sleep problems due to hypomania. Scores range from 0-20, with higher scores indicative of more manic symptoms.

Pain Scale

The Pain Scale was originally developed for use with nursing home residents and later translated for use with other interRAI instruments. The scale uses two items to create a score from 0 to 3. It has been shown to be highly predictive of pain as measured by the Visual Analogue Scale.  Diagram

Positive Symptoms Scale (PSS)

The Positive Symptoms Scale (PSS) consists of two measures (short and long version of the scale) of the frequency of positive symptoms. Both scales have been validated against the Positive and Negative Syndrome Scale (PANSS).

PSS_short scale is based on presence of hallucinations; command hallucinations; delusions; and abnormal thought process/form. Based on a sum of these 4 items scale scores range from 0 to 12; with higher scores represent elevated levels of positive psychotic symptomotology.

PSS_long scale is based on presence of hallucinations; command hallucinations; delusions; abnormal thought process/form; inflated self-worth; hyperarousal; pressured speech; and abnormal/unusual movements. Based on the sum of these 8 items scale scores range from 0 to 24; where higher scores indicate higher levels of positive symptoms.

Revised Index of Social Engagement (RISE)

The Revised Index of Social Engagement (RISE) is a measure of social engagement based on being at ease interacting with others, being at ease doing planned activities, accepting invitations, pursuing involvement in life of facility, initiating interactions and reacting positively to interactions. Scale scores range from 0-6 with higher scores indicative of greater social engagement in the life of the facility. The index is a revised version of the Index of Social Engagement (ISE) that was developed for an earlier version of the RAI for long term care facilities.

Risk of Harm to Others (RHO)

The Risk of Harm to Others (RHO) is a predictive algorithm for risk of harm to others based on the presence of delusions; insight into one’s own mental health; difficulty falling asleep; aggressive behaviour scale; sleep problems due to hypomania; and indicators of violence (violence towards others, intimidation, violent ideation, extreme behaviour disturbance and police intervention for violent crime). Scale scores range from 0 to 6, where higher scores indicate a person is at increased risk of harming someone else. The RHO was derived using clinician ratings of severity of risk of harm to others and validated against reasons for admission and inpatient incident reports for violence.

Self-Care Index (SCI)

The Self-Care Index (SCI) is a predictive algorithm for risk of inability to care for self due to psychiatric symptoms. The SCI is based on daily decision making; insight into one’s own mental health; decreased energy; abnormal thought process; and expression (for example, making self understood). Scale scores range from 0 to 6, where higher scores indicate decreased ability to care for self due to psychiatric symptoms. The SCI was derived using clinician ratings of severity of risk of adverse health outcomes due to inability to care for self and validated against reasons for admission in independent samples.

Severity of Self-harm (SoS)

The Severity of Self-harm (SoS) is a predictive algorithm for risk of harm to self and is based on consideration of self-injurious act; intent of any self-injurious act was to kill self; depressive severity index (DSI); family/others concerned about person’s risk for self-injury; pss_short_ESP((Emergency Screener for Psychiatry version of the PSS_short) ; cognitive performance scale (CPS); and suicide plan. Scale scores range from 0 to 6, where higher scores indicate increased risk for self-harm. The SoS was derived using clinician ratings of severity of risk of harm to self and validated against reasons for admission and future self-harm events in inpatient settings.

References

Burrows A, Morris JN, Simon S, Hirdes JP, Phillips C. 2000. Development of a Minimum Data Set-Based Depression Rating Scale for Use in Nursing Homes. Age and Ageing 29(2): 165–72.

Fries BE, Simon SE, Morris JN, Flodstrom C, Bookstein FL. 2001. Pain in U.S. Nursing Homes: Validating a Pain Scale for the Minimum Data Set. Gerontologist 41(2): 173–79.

Hirdes JP, Frijters D, Teare G. 2003. The MDS CHESS Scale: A New Measure to Predict Mortality in the Institutionalized Elderly. Journal of the American Geriatrics Society51(1): 96–100.

Morris JN, Carpenter I, Berg K, Jones RN. 2000. Outcome Measures for Use with Home Care Clients. Canadian Journal on Aging 19(2): 87–105.

Morris JN, Fries BE, Mehr DR, Hawes C, Philips C, Mor V, Lipsitz L. 1994. MDS Cognitive Performance Scale. Journal of Gerontology: Medical Sciences 49(4): M174–M182.

Morris JN, Fries BE, Morris SA. 1999. Scaling ADLs within the MDS. Journal of Gerontology: Medical Sciences 54(11): M546–M553.