Jeffrey T. J. Rowland

The Rowland Universal Dementia Assessment Scale (RUDAS): a multicultural cognitive assessment scale.

OBJECTIVE To develop and validate a simple method for detecting dementia that is valid across cultures, portable and easily administered by primary health care clinicians. DESIGN Culture and Health Advisory Groups were used in Stage 1 to develop culturally fair cognitive items. In Stage 2, clinical testing of 42 items was conducted in a multicultural sample of consecutive new referrals to the geriatric medicine outpatient clinic at Liverpool Hospital, Sydney, Australia (n = 166). In Stage 3, the predictive accuracy of items was assessed in a random sample of community-dwelling elderly persons stratified by language background and cognitive diagnosis and matched for sex and age (n = 90). MEASUREMENTS A research psychologist administered all cognitive items, using interpreters when needed. Each patient was comprehensively assessed by one of three geriatricians, who ordered relevant investigations, and implemented a standardized assessment of cognitive domains. The geriatricians also collected demographic information, and administered other functional and cognitive measures. DSM-IV criteria were used to assign cognitive diagnoses. Item validity and weights were assessed using frequency and logistic regression analyses. Receiver-operating characteristic (ROC) curve analysis was used to determine overall predictive accuracy of the RUDAS and the best cut-point for detecting cognitive impairment. RESULTS The 6-item RUDAS assesses multiple cognitive domains including memory, praxis, language, judgement, drawing and body orientation. It appears not to be affected by gender, years of education, differential performance factors and preferred language. The area under the ROC curve for the RUDAS was 0.94 (95% CI 0.87-0.98). At a cut-point of 23 (maximum score of 30), sensitivity and specificity were 89% and 98%, respectively. Inter-rater (0.99) and test-retest (0.98) reliabilities were very high. CONCLUSIONS The 6-item RUDAS is portable and tests multiple cognitive domains. It is easily interpreted to other languages, and appears to be culturally fair. However, further validation is needed in other settings, and in longitudinal studies to determine its sensitivity to change in cognitive function over time.

The Rowland Universal Dementia Assessment Scale (RUDAS) and the Folstein MMSE in a multicultural cohort of elderly persons

OBJECTIVE To compare the accuracy of the Rowland Universal Dementia Assessment Scale (RUDAS) and the Folstein Mini-mental State Examination (MMSE) for diagnosis of dementia in a multicultural cohort of elderly persons. METHODS A total of 129 community-dwelling persons were selected at random from a database of referrals to an aged-care team. Subjects were stratified according to language background and cognitive diagnosis, and matched for age and gender. The RUDAS and the MMSE were administered to each subject in random order. Within several days, a geriatrician assessed each subject for dementia (DSM-IV criteria) and disease severity (Clinical Dementia Rating Scale). All assessments were carried out independent and blind. The geriatrician also administered the Modified Barthel Index and the Lawton Instrumental Activities of Daily Living Scale, and screened all participants for non-cognitive disorders that might affect instrument scores. RESULTS The area under the receiver operating characteristic curve (AUC) for the RUDAS [0.92, 95% confidence interval (95%CI) 0.85-0.96] was similar to the AUC for the MMSE (0.91, 95%CI 0.84-0.95). At the published cut-points (RUDAS < 23/30, MMSE < 25/30), the positive and negative likelihood ratios for the RUDAS were 19.4 and 0.2, and for the MMSE 2.1 and 0.14, respectively. The MMSE, but not the RUDAS, scores were influenced by preferred language (p = 0.015), total years of education (p = 0.016) and gender (p = 0.044). CONCLUSIONS The RUDAS is at least as accurate as the MMSE, and does not appear to be influenced by language, education or gender. The high positive likelihood ratio for the RUDAS makes it particularly useful for ruling-in disease.

Accuracy of the clock drawing test for detecting dementia in a multicultural sample of elderly Australian patients.

OBJECTIVE To assess the accuracy of clock drawing for detecting dementia in a multicultural, non-English-speaking-background population. DESIGN A prospective cohort study. SETTING A general geriatric medical outpatient clinic in southwest Sydney, Australia. PARTICIPANTS Ninety-three consecutive new patients to the clinic who had a non-English-speaking-background country of birth (mean age 78.0 years). MEASUREMENTS The clock drawing test was conducted at the beginning of each clinic visit by a blinded investigator. Each patient was then assessed by a geriatrician who collected demographic data, administered the Modified Barthel Index, the Geriatric Depression Scale, and the Folstein Mini-Mental State Examination, and categorized each patient as normal or demented, according to DSM-IV criteria. Interpreters were used for participants who spoke a language other than English or who requested them. Each clock drawing was scored according to the 4-point CERAD scale and the previously published methods of Mendez, Shulman, Sunderland, Watson, and Wolf-Klein. Scoring was evaluated for reliability and predictive accuracy, using receiver operating characteristic (ROC) curve analysis. Logistic regression analysis was used to assess the potential interaction between level of education and each of the clock scoring methods. RESULTS Using ROC curve analysis, there was no significant difference between the clock scoring methods (area under the curve varied from 0.60 to 0.72). The most sensitive was the Mendez scoring method (98%), with a specificity of 16%. Specificity above 50% was found only for the Wolf-Klein method, with an intermediate sensitivity of 78%. CONCLUSIONS There were no significant differences in the clock scoring methods used to detect dementia. Performance of the clock drawing test was modest at best with low levels of specificity across all methods. Scored according to these methods, clock drawing was not a useful predictor of dementia in our multicultural population.

The Validity of the Rowland Universal Dementia Assessment Scale (RUDAS) in a Multicultural Cohort of Community-dwelling Older Persons With Early Dementia

The 6-item Rowland Universal Dementia Assessment Scale (RUDAS) is a simple, portable multicultural scale for detecting dementia. Items address executive function, praxis, gnosis, recent memory, and category fluency. It can be directly translated to other languages, without the need to change the structure or the format of any item. The RUDAS was administered to 151 consecutive, consenting, culturally diverse community-dwelling subjects of mean age 77 years, 72% of whom had an informant. Subjects were recruited from various clinics and healthcare programs. All were evaluated for cognitive impairment in a blinded manner by experienced clinicians in geriatric medicine. According to Diagnostic and Statistical Manual of Mental Disorder-IV criteria, 40% of the subjects were normal, 22% had cognitive impairment (not otherwise specified), and 38% had dementia; 84% of whom had questionable or mild dementia. In the primary analysis (normal subjects vs. those with definite dementia), the RUDAS accurately identified dementia, with an area under the receiver operating characteristic curve of 0.94 (95% confidence interval, 0.88-0.97); at the published cut point of less than 23/30, the positive likelihood ratio (LR) for dementia diagnosis was 8.77, and the negative likelihood ratio was 0.14. Additional analyses showed that the RUDAS performed less well when subjects with cognitive impairment (not dementia) were included. In all logistic regression models, the RUDAS was an independent predictor of dementia (odds ratio 0.64, 95% confidence interval, 0.52-0.79, primary analysis model), after adjusting for age, sex, years of education, and cultural diversity, none of which were independent predictors. Further studies are needed across the full spectrum of early dementia syndromes, and in additional ethnic minority groups.

Emergency department admissions, older people, functional decline, and length of stay in hospital

Objective:  Early identification of patients at risk of a prolonged admission to the hospital may allow targeted management decisions and discharge planning to begin in the emergency department. The aim of this study was to evaluate the effect of recent decline in function, measured in the emergency department, on length of stay (LOS) in the hospital.

Breaking the mould without breaking the system: the development and pilot of a clinical dashboard at The Prince Charles Hospital

There is a vast array of clinical and quality data available within healthcare organisations. The availability of this data in a timely and easy to visualise way is an essential component of high-performing healthcare teams. It is recognised that good quality information is a driver of performance for clinical teams and helps ensure best possible care for patients. In 2012 the Internal Medicine Program at The Prince Charles Hospital developed a clinical dashboard that displays locally relevant information alongside relevant hospital and statewide metrics that inform daily clinical decision making. The data reported on the clinical dashboard is driven from data sourced from the electronic patient journey board in real time as well as other Queensland Health data sources. This provides clinicians with easy access to a wealth of local unit data presented in a simple graphical format that is being captured locally and arranged on a single screen so the information can be monitored at a glance. Local unit data informs daily decisions that identify and confirm patient flow problems, assist to identify root causes and enable evaluation of patient flow solutions.

Hospital care of people living in residential care facilities : Profile, utilization patterns and factors impacting on quality and safety of care

Background:  Residents in residential care facilities (RCF) are frequent users of acute hospital services. However, the interface between the two sectors remains relatively unexplored. Our objective was to determine the patterns of utilization, characteristics and experiences of RCF residents accessing a tertiary referral center (TRC).