Screening and assessment tools for older people

The 3MS is an extended version of the Mini-Mental State Examination (MMSE). It tests the following cognitive domains: orientation, attention, memory, visuoconstructional skills, language, and executive function.

The 3MS has been shown to accurately identify persons with dementia or mild cognitive impairment (MCI). It is among the highest-scoring cognitive screens from the DOMS review and is highly recommended.

The ACE-III is a comprehensive screening tool that is the recommended instrument for all dementias when shorter screens are inconclusive. It is useful for differential diagnosis between Alzheimer’s disease (AD), frontotemporal dementia (FTD), Parkinson’s disease dementia and related neurodegenerative conditions. The ACE-III is composed of tests of attention, orientation, memory, language, visual perceptual and visuospatial skills. Targeted to those aged 50 and over.

Superceded by ACE-III though remains in use as a brief bedside cognitive screening instrument which incorporates five sub-domain scores (orientation/attention, memory, verbal fluency, language and visuospatial).

The ACE-R is a valid dementia screening test, sensitive to early cognitive dysfunction, and used for people over the age of 50 with suspected cognitive decline/dementia.

Validated on adults aged 50-75 in Mioshi et al. (2006) original validation study; broader age range normative data available from New Zealand (ages 45-85) in Callow et al., 2015.

The ACLS is an assessment of functional cognition through a measure of global cognitive processing abilities, learning potential, performance abilities and ability to detect unrecognised or suspected problems. The normative data indicated that time taken and number of errors on the maze increases with age.

Target population is mental health, aged health/care, dementia, with some use in stroke and traumatic brain injury (TBI).

The AD8 is a very brief eight-item informant interview designed to differentiate between normal ageing and dementia. It has mostly been validated in high-prevalence settings such as emergency departments and dementia clinics, and has been adapted for many different languages.

The ADAS-COG is used for comprehensive cognitive assessment. It is recommended for second-stage or in-depth assessments and/or for particular research evaluations rather than for applications in routine care settings. ADAS-COG is widely used as an outcome measure in drug and therapy treatments aimed at delaying cognitive decline in dementia.

The AMT4 is a quick screening tool for the detection of delirium and cognitive impairment and is generally applied in Emergency Department and acute care settings and is used as an indicator for further cognitive testing.

Can be used for all people over 65 years (or over 45 years Aboriginal and Torres Strait Islander) or all with known predisposing factors and all with known related conditions.

The tester should take account of communication difficulties (hearing impairment, dysphasia, lack of common language) when carrying out the test and interpreting the score.

The AMTS is a validated, quick cognitive screen that has gained widespread acceptance over its many decades of use. Unlike many other cognitive screens it does not require the use of any physical materials, making it highly suitable for hospital or care settings where patients may have limited mobility or visual impairments.

The AMTS is administered in many settings though best used as a quick dementia screen in settings with a high prevalence of dementia (e.g. hospital inpatient).

The clock-drawing test (CDT) is a screening test for dementia and cognitive dysfunction: normal clock-drawing ability reasonably excludes cognitive impairment. There are variations in the administration of the test including using a pre-drawn circle and a clock-copying task. Clients are asked to draw a clock face and mark in the hours and then draw in the hands to indicate a particular time (e.g. 10 past 11, or 10 to two). The CDT assesses frontal and temporo-parietal functioning. It is easy to administer, is not threatening to the patient, takes very little time, is easy to document graphically in clinical records and can be used to document deterioration over time. The test has a high correlation with the MMSE and other test of cognitive dysfunction.

^* Also see Mini-Cog

The Cognistat rapidly assesses neurocognitive functioning in three general areas: orientation, attention, memory; and five major ability areas: language, constructional ability, memory, calculation skills and executive skills. Shows good test re-test reliability. Target population is adolescents, adults and seniors in three age groups: 60-64, 65-74 and 75-84. Used in patients with stroke, dementia, traumatic brain injury, major psychiatric disorders and substance abuse.

The CPT consists of 7 subtasks: medbox, shop, toast, phone, wash, dress and travel. Each subtask reviews working memory and executive function. Each subtask is labelled with a performance level score between two and six. On completion the scores are totalled and an average score is calculated. Subtask cues are more complex at higher levels and cues are simplified for lower scoring levels.

Validated and reliable for use with Alzheimer's population when used in standardised format, i.e. assessing at least five out of seven subtasks.

The FAB is a brief screen for executive dysfunction associated with damage to the frontal lobe. 

The FAB is sensitive to frontal lobe dysfunction (Dubois, et al 2000). There is also evidence that the FAB can accurately distinguish persons with frontal lobe dysfunction due to frontotemporal dementia from those with Alzheimer’s disease.

It can be administered in many settings and is well-accepted by consumers.

The GPCOG was developed to assist general practitioners and other primary healthcare workers to detect cognitive impairment and dementia. It consists of a short patient examination (<4 min) and an optional informant interview (2 min).

It has been translated to several languages and has been consistently shown to match or outperform longers scales in detecting dementia.

The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) (Jorm, 2004) is an Australian developed and widely used, informant based measure to screen for dementia. The short (and recommended version) of the questionnaire (IQCODE-SF) includes 16 items examining everyday cognitive abilities (e.g. remembering own telephone number and learning new things), with a few functional items (e.g. handling money for shopping) (Sansoni et al., 2008). It looks at changes in “the everyday cognitive function of an elderly person and aims to assess cognitive decline independently of pre-morbid ability” (Burns et al., 2004, page 348).

The informant or proxy rater needs to have known the patient for 10 years (Sansoni, et al 2010).

The IQCODE is an informant-based questionnaire that can supplement or replace cognitive testing. The abbreviated IQCODE-Short Form has been shown to perform as well as or better than the original version in detecting dementia, and both versions identify dementia at a similar rate to traditional cognitive testing.

The MET evaluates the effect of executive function deficits on everyday functioning through a number of real-world tasks (e.g. purchasing specific items, collecting and writing down specific information, arriving at a stated location). The MET comprised of eight items: six simple tasks, one task that is time-dependent, and one that comprises four subtasks.The test requires the participant to mobilise through a set environment. There are numerous versions for different settings and diagnostic populations (Shallice and Burgess, 1991):

• MET - Simplified Version (MET-SV) (Alderman et al., 2003)
• MET - Hospital Version (MET-HV) (Knight, Alderman & Burgess, 2002)
• Virtual MET (Rand, Rukan, Weiss & Katz, 2009)
• Baycrest MET (Dawson et al., 2009)
• Modified version of the MET-SV and MET-HV (including 3 alternate versions)

The Mini-Cog is a very brief cognitive screen designed for multi-lingual persons. It consists of a short memory test and a clock-drawing task. The Mini-Cog has been consistently shown to match or outperform longer scales in detecting dementia. The scale been translated into many different languages.

The MoCA is designed to detect mild cognitive impairment (MCI) but is also highly sensitive to dementia. It is a 16 item test that examines the following cognitive domains: orientation, attention, memory, visuoconstructional skills, language and executive function.

The MOCA has rapidly gained widespread acceptance and has many translations available. It is highly recommended. The original MoCA has been modified into different versions including the MoCA-Basic, aimed at those who are illiterate or have had limited years of education, and the MoCA-Blind, designed for those with serious visual impairments.

Validated tool in stroke, Parkinson's and Alzheimer's populations.

Versions 7.1-7.3 available for restesting. Version 8.1-8.3 also available for retesting. Excellent test/retest reliability.

Available in mulitple languages: ~ 46 languages and dialects. 

The Oxford Cognitive Screen (OCS) is a short and efficient cognitive screening tool for use in stroke - it can be used in both the acute and rehabilitation phase. OCS is easy to administer and score and importantly is inclusive for patients with aphasia and neglect. OCS returns a visual snapshot of a patient’s cognitive profile, in a ‘wheel of cognition’, which at a glance demonstrates the specific cognitive domain impairments in attention, language, praxis, number and memory.

The PAS-CDS is an informant measure designed to track changes in cognition over time. It was developed by the makers of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) and is designed to be suitable to assess cognition in persons in nursing home settings. The PAS-CDS can accurately distinguish persons with dementia from those with depression.

The Australian Department of Health requires testing with the PAS-CIS and PAS-CDS to assess eligibility for the Dementia and Cognition Supplement for in-home care, as part of the Australian Aged Care Funding Instrument (ACFI).

The Psychogeriatric Assessment Scales (PAS), of which the PAS-CDS is one part, is a collection of scales that include scales completed by the person assessed and scales completed by an informant.

The PRPP Assessment is a standardised, client centred, criterion referenced, occupational therapy assessment of occupational performance. It is used with clients of any age, gender, diagnosis or cultural background whose performance is compromised by difficulties with the cognitive demands of occupations. The assessment yields information about performance mastery and cognitive strategy application capacity. Strategy application behaviours assessed align with dimensions of attention and perception (P), learning, memory and recall (R), planning, decision-making and judgment (P), and the capacity to act on decisions and follow-through with plans (P).

It has established validity in a variety of practice domains including neurology, mental health, learning disabilities, autism, chronic pain, HIV-associated neurocognitive disorders, and dementia. Acceptable reliability has been demonstrated following training.

It is used with clients of any age, gender, diagnosis, or cultural background whose performance is compromised by difficulties with the cognitive demands of occupations.

It is used in multiple settings where the child or adult performs daily routines and tasks (home, hospital, school, work).

The RBMT was designed to provide an objective measure of a range of everyday memory problems. The test tries to detect impairment of everyday memory function by providing test items that resembled activities in everyday life, e.g. remembering to deliver a message, remembering to retrieve a personal belonging after an interval. Its goal was also to predict everyday memory problems in people with acquired, non-progressive brain injury and monitor change over time. The original test was used to detect moderate to severe impairments and did not detect mild memory impairment. The Extended Rivermead Behavioral Memory Test (ERBMT) is designed to detect more subtle memory impairments.

The S-MMSE is a version of the MMSE for which the administration and scoring of the test is standardised. The S-MMSE has a detailed manual describing how to administer and score each item, with evidence that this method improves the reliability and diagnostic capacity of the test.

This scale has been designed for the geriatric population (Burns, 2004).

The paper by Vertesi et al. (2001) provides detailed clinical interpretation guidelines. This includes looking at the relationship between different scale items and scores (i.e. pattern analysis) with the following diseases: Alzheimer’s disease, Vascular Dementia, Dementia with Lewy bodies, and Depression. Descriptions of the relationship between SMMSE scores and functional and cognitive impairment are also provided. Vertesi et al. (2001) advises how the SMMSE can be adapted for people with physical impairments (for example, problems with a person’s dominant hand due to stroke, or problems due to blindness).

The TMT is a measure of attention, speed and mental flexibility. It requires the subject to connect, by making pencil lines, 25 encircled numbers randomly arranged on a page in proper order (Part A) and 25 encircled numbers and letters in alternating order (Part B). Numerous versions and adaptations exist (e.g. Oral Trail Making Test, Color Trails, Symbol Trail Making Test, Comprehensive Trail Making Test, Arabic version, Hebrew version, and D-KEFS subtests modelled on original).

The AES is an 18-item rating scale designed to assess symptoms of apathy. It has clinician (AES-C), informant (AES-I) and self-rated (AES-S) versions, as well as an abbreviated version (AES-10). The AES is a well-validated scale for measuring apathy in people with dementia and has been applied in many settings. It has also contributed to the development of many alternative apathy scales.

The BEHAVE-AD is a global measure of BPSD with 25 items grouped into seven major categories: paranoid and delusional ideation, hallucinations, activity disturbance, aggressiveness, diurnal rhythm disturbances, affective disturbances, and anxieties and phobias. It can detect clinically significant changes in BPSD and has become widely adopted for drug trials.

The revised BEHAVE-AD-FW adds a frequency-weighted severity score to improve the accuracy of identifying abnormal BPSD. The E-BEHAVE-AD is an adaptation that allows the clinician or staff member to rate the person’s behaviour based on direct observation.

The CMAI is a comprehensive measure of agitation which has been well-validated in people with dementia. It assesses three domains: aggressive behaviour, non-aggressive behaviour and verbally aggressive behaviour. The CMAI is frequently used to measure change in agitation following non-pharmacological interventions. The original 'Long Form' CMAI has 29 items and there is also a 'Short Form' with 14 items (CMAI-Short) and an extended Community form with 37 items (CMAI-C).

The CSDD is specifically designed to measure depression in persons with dementia. It uses an interview of the person and an informant and is designed to overcome the potential unreliability of reports by persons with dementia. The CSDD can detect depression in persons with a range of dementia severities and can discriminate persons with depression from those with dementia. It is preferred to the GDS particularly for persons with higher degrees of cognitive impairment.

The FBI is a questionnaire developed to improve the differential diagnosis of people with frontotemporal dementia (FTD) from those with Alzheimer’s disease (AD) or other types of dementia. For this purpose it has been shown to have superior diagnostic efficiency to that of cognitive testing.

Designed as a brief screening tool to be used specifically within the older age group to fill the perceived gap in valid tools for use with older people with anxiety disorders. It is a 20 item self-reported questionnaire or may be administered by a clinician such as a nurse. Designed to measure symptom severity rather than a diagnostic tool and to measure potential changes in that severity after an intervention. The tool covers a range of anxiety disorders rather than being diagnostic of any one specific anxiety disorder and takes the format of agree or disagree answers to 20 questions about themselves.

The GDS is a brief scale that measures depression in geriatric populations. Users respond in Yes/No format. The GDS  was developed as a 30-item questionnaire but a 15-item questionnaire was developed in 1986 and has been validated.

It is able to discriminate people with Alzheimer’s disease from those with Parkinson’s disease based on higher reports of depression in the latter. Due to its requirement to self-report symptoms over the previous week, the GDS is most appropriate for the early stages of dementia where potential problems with memory are less confounding. A short version, the GDS-15, has also been developed with similar psychometric properties to the original full version.

The HADS is a frequently used self-rating scale developed to assess psychological distress in non-psychiatric patients. It consists of 14 items with seven items for the anxiety subscale and seven for the depression subscale.

HADS has been validated in many languages, countries and settings including hospital, general practice and community settings.

The K10 is a simple measure of general distress without identifying its cause. It is a screening instrument to identify people in need of further assessment for anxiety and depression. The K10 measurement of a client's psychological distress levels can also be used as an outcome measure and to assist in treatment planning and monitoring. Can be difficult to use with consumers with dementia.

The MADRS is a ten-item questionnaire used to measure the severity of depressive symptoms. A self-reported version the MADRS-S was developed in 1994 by Svanborg and Asberg. This has nine items based on the client's feelings over the previous three days. In 2008, Williams and Kobak developed the SIGMA-Structured Interview Guide for the Montgomery and Asberg Depression Rating Scale. By providing a structured interview guide inter-rater reliability can be improved.

The NPI was developed to assess behaviour and psychosocial symptoms of dementia (BPSD) in people with dementia and to help distinguish BPSD in different types of dementia. It covers the following types of BPSD, each of which has its own subscale that can be administered on its own: delusions, hallucinations, agitation or aggression, dysphoria or depression, anxiety, euphoria or elation, apathy or indifference, disinhibition, irritability or lability, aberrant motor behaviours, sleep/nighttime behaviour disorders and appetite/eating disturbances. The NPI includes both symptom frequency and severity ratings.

The NPI has been very well validated and is highly popular worldwide. It is able to discriminate people with frontotemporal dementia (FTD) from those with Alzheimer’s disease based on their symptom profile, and detect clinically significant changes in BPSD over the course of dementia.

The NPI-Questionnaire (NPI-Q) is a shorter version of the NPI and is useful for briefly surveying BPSD. The NPI with Caregiver Distress Scale (NPI-D) adds an additional question on each domain specifically addressing the level of distress caused to carers by each specific symptom.

The Neuropsychiatric Inventory-Nursing Home (NPI-NH) is designed for completion by care staff in residential care settings. The NPI-Clinician (NPI-C) includes an expanded set of items and domains not present in the original NPI.

The PAS is a very brief measure of agitation that is particularly useful as an initial screen of BPSD in nursing home and hospital settings. It measures the severity of agitation in four general categories: aberrant vocalisation, motor agitation, aggressiveness and resisting care. The PAS has been frequently used to measure change in agitation following non-pharmacological interventions, and to distinguish people with dementia from those with depression.

The RAGE is a very brief scale specifically designed to measure aggressive behaviour. It was developed so that nurses could objectively measure aggressive behaviours in residential settings and to enable researchers to test the effects of therapeutic interventions. The RAGE has been shown to accurately detect clinically significant changes in aggressive behaviours over time, in a range of settings and in people with dementia.

There must be a three-day (or week long) observation period. It is very suitable for a nursing home settings.

The RAID is a rating scale to measure anxiety in people with dementia. It contains five out of the six DSM-IV criteria for Generalised Anxiety Disorder (GAD), excluding symptoms that overlap with dementia (“difficulty concentrating or mind going blank”), with excellent diagnostic efficiency for GAD. Scores on RAID have been shown to be unrelated to the level of dementia severity or cognitive impairment.

The Revised Algase Wandering Scale - Long Term Care Version (RAWS-LTC) was developed to estimate the intensity and type of wandering behaviour exhibited by people with dementia in Long Term Care (LTC). Derived from the Algase Wandering Scale, the RAWS-LTC has three validated sub-scales: persistent walking, spatial disorientation and eloping behavior.

The RAWS is a 19-item tool. Values for each item range from 1 to 4: value 1 is assigned to the first response listed for each item and so on. A total score (add up the score for each item) and a subscale score can be computed to give a total and average score for each subscale (total subscale score/number of items in the subscale).

A higher score indicates the person walks with greater intensity and exhibits more characteristics of wandering behavior than those with lower scores. The responses can also be used to determine times of the day when the person is most active (Q7, 8 and 9). The subscale with the highest average score indicates the characteristic of wandering of most concern for that individual and their care and support.

The Revised Algase Wandering Scale - Community Version (RAWS-CV) was developed from the Algase Wandering Scale and includes items that have been re-worded to be relevant to the community setting. The RAWS-CV has 39 items and six sub-scales to identify characteristics of wandering exhibited: persistent wailing, repetitive walking, eloping behaviour, spatial disorientation, negative outcomes and meal time impulsivity.

Values for each item range from 1 to 5 (1 = never/unable; 2 = seldom; 3 = sometimes; 4 = usually; 5 = always). A total score (add up the score for each item) and a subscale score can be computed to give a total and average score for each subscale (total subscale score / number of items in the subscale).

A higher score indicates the person walks with more intensity and exhibits more characteristics of wandering behavior. The responses can also be used to determine times of the day when the person is most active (Q 8, 10 and 12). The subscale with the highest average score indicates the characteristic of wandering of concern for that individual.

The SAD-Q was developed to assess depressed mood in aphasic clients in hospital and community settings.

Community (SADQ 10) and Hospital (SADQ-H 10) clients, specifically with stroke and significant aphasia.

The VAMS was developed to assess mood disturbance in neurologically impaired patients who cannot complete lengthy or verbally demanding measures of mood states, due to cognitive and/or communication deficits (e.g. aphasia). The VAMS is a brief measure of a patient's mood state and includes assessment of eight distinct moods: sad, afraid, tired, angry, confused, tense, happy and energetic. It is validated for use in neurological populations as well as neurotypical populations. Target population group is adults and older adults with cognitive and/or communication impairments.

This tool was developed to link the deterioration of intelligence and personality with the underlying neuropathology in dementia. It looks at the biological, psychological and social changes in dementia. It involves the clinical rating of changes in activities of daily living, self-care abilities and behaviour. This is identified in 22 items across the three areas and rating range between 0 (normal) to 28 (extreme incapacity), with cognitive relatability of normal (0) to severe/advanced dementia (17). Information is gained from relatives or friends in the preceding six months; yet medical records have also been used.

Population group: Older people (over 65) with assumed cognition loss.

The CDR is a comprehensive dementia staging scale that has become a worldwide standard for assessing the severity and progression of dementia. Two different scores can be calculated from the CDR:

• the Global score which is the standard regularly used in clinical and research settings but requires an algorithm to calculate
• the Sum of Boxes score which provides more comprehensive information, particularly in patients with mild dementia, and does not require an algorithm to calculate.

The DSRS is a brief staging instrument that is completed by the carer. It has a multiple-choice format. The DSRS has excellent ability to discriminate people without cognitive impairment from those with mild cognitive impairment (MCI) or Alzheimer’s disease (AD).

The FAST is a very brief dementia staging scale with a focus on functional decline at the moderate to severe stages of dementia. It was developed by the makers of the Global Deterioration Scale.

The GDS is a brief dementia staging scale designed for carers and clinical staff to assess the current stage of dementia and its progression over time. The GDS has been extensively validated, and has a long history of use worldwide.

This 12-item screening tool has been developed to screen for risk of cognitive impairment in an Alcohol and Other Drugs (AOD) treatment population. If a person scores positive on the screening tool it is recommended the BEAT be administered.

This tool has been validated and trialled in over 500 AOD clients.

Population group: 18 years and older AOD treatment population. Likely to be applicable to other settings but not yet trialled. For use in primary health, inpatient and outpatient settings.

The BEAT is a cognitive test developed to detect cognitive impairment, especially executive function impairment, in an AOD treatment population.

This tool has been validated and trialled in over 500 AOD clients.

Population group: 18 years and over. Likely to be applicable to other settings but not yet trialled. For use in primary health, inpatient and outpatient settings.

Requires a systematic assessment of:

• cultural identity
• cultural conceptualisations of distress, psychosocial stressors and cultural features of vulnerability and resilience
• cultural features of the relationship between the individual and clinician
• overall cultural assessment.

The glossary contains cultural concepts of distress to describe ways that cultural groups experience, understand and communicate suffering, behavioural problems, or troubling thoughts and emotions.

The RUDAS is developed for the assessment of cognitive impairment and dementia in culturally and linguistically diverse (CALD) people, and in those with limited levels of education. It is easily translatable into different languages and has been shown to detect dementia regardless of the language spoken or the educational level of the person tested.

The RUDAS is a short cognitive screening instrument that was designed to minimise the effects of educational level, cultural background, gender and language on cognitive screening. The six-item RUDAS assesses multiple cognitive domains including memory, praxis, language, judgement, visuoconstructional drawing and body orientation.

It is a validated tool, based on evidence from multiple studies conducted in 2004, 2006 and 2007.

Targeted mostly for older adults suspected of having dementia or mild cognitive impairment.

Can be used in any clinical setting such as in-hospital, out-patient clinic and community-based. Also can be used in any clinical speciality but commonly used by geriatricians, psychogeriatricians, neuropsychologists and neurologists.

The RUDAS is part of the Australian Aged Care Funding Instrument (ACFI). It is used in the Aged Care Application to assess eligibility for the Dementia and Cognition Supplement for in-home care in people that are from a culturally or linguistically diverse background.

The KICA-Cog is developed to assess cognitive performance in for older Indigenous Australians living in rural and remote areas.

The KICA also has multiple versions:

• the original KICA-Cog is designed for remote Indigenous populations
• the Modified KICA (mKICA) is tailored for urban and rural Indigenous Australians
• the KICA-Carer is an informant scale
• the KICA-Screen is an abbreviated version of the KICA-Cog.

The 4AT is designed to be used by any Healthcare professional at first contact with the patient, and at any other time when delirium is suspected. It is a short tool for delirium assessment, designed to be easy to use in clinical care and specifically for routine clinical practice.

It is suitable for use by all practitioners with a basic knowledge of delirium. All patients can be assessed, including those unable to speak (e.g. with severe drowsiness), so no patients are 'unable to assess'.

It has built-in brief cognitive tests.

The CAM is a structured questionnaire developed as a brief screen for delirium. It is designed for use in older people at high risk of developing delirium (e.g. older medical and surgical inpatients). Scores on the CAM agree favourably with a diagnosis of delirium based on DSM-IV criteria. It can also distinguish people with delirium-only from those with delirium superimposed on dementia, a clinically important distinction since the latter strongly predicts a worse medical outcome. When the CAM is used alongside cognitive testing the differential diagnosis of dementia from delirium can be enhanced.

The DRAT is used to assess delirium risk for hospitalised older people and is performed in conjunction with cognitive screening. This tool identifies key risk factors that predispose an older person to delirium and risk factors that may precipitate delirium and recommends further investigations, if there is a change in behaviour.

Population group: for all people over 65 (all over 45 ATSI) or all with known predisposing factors and all with known related conditions.

The DRS-R-98 is a comprehensive scale designed to measure delirium and its severity. It is a revised version of the original DRS scale and be applied to people with or without dementia. It has excellent inter-rater reliability and can distinguish people with delirium versus illness due to other causes (e.g., schizophrenia, dementia, depression). The DRS-R-98 can also distinguish people with delirium-only from those with delirium superimposed on dementia, an extremely important distinction since the latter strongly predicts a more adverse medical outcome.

The DRS-R-98 has been translated into several languages. For more rapid testing by non-specialists the CAM may be more appropriate.