# The RUDAS, CSDD, and the SGA: Description, analyses and recommendations for practice

Title: The Rowland Universal Dementia Assessment Scale (RUDAS), the Cornell Scale for depression in Dementia (CSDD), and the Subjective Global Assessment (SGA): Description, analyses and recommendations for practice

## Abstract

Purpose
The purpose of this report is to describe how three assessment tools- the RUDAS, CSDD and SGA can be used to assess the abilities of a person with dementia. Three research articles are critically analysed on the development and use of RUDAS. Findings from this analysis are then synthesised into recommendations for practice.
Key Findings
RUDAS has both reliability and diagnostic accuracy for detecting dementia, is portable across cultures and easily used by primary health care clinicians. The assessment tool is also of benefit for its specificity in early diagnosis.
Conclusions
Assessment tools are subject to cultural, social, educational and physical factors which may influence findings. Further, while RUDAS was developed to overcome perceived biases in the MMSE it has also been found to have greater sensitivity and specificity in diagnosing dementia.
Recommendations
Users of assessment tools should be cognizant of factors which may affect results. A person-centred approach that considers the persons individual socio-cultural, educational and physical influences circumstances before selecting the most appropriate tool will produce a more reliable result. Being committed to person-centred care also requires a commitment to critical thinking, a multidimensional skill involving examination and analysis of all available ideas to inform clinical reasoning.

## Dementia and assessment

John has mixed type dementia and lives in a Residential Aged Care Facility (RACF). He was admitted to the facility one year previously following the death of his wife. Over the past several months, he has been actively refusing care, lost a significant amount of weight, appears to have difficulty swallowing and is subsequently refusing diet and fluids. Three assessment tools will be discussed to provide more information and determine the best course of action in John’s case. These are the Subjective Global Assessment (SGA) for nutritional assessment, the Cornell Scale for depression in Dementia (CSDD) and the Rowland Universal Dementia Assessment Scale (RUDAS). Three research articles will be analysed on the development and use of the RUDAS scale (Appendix 1). Findings from the analysis will then be synthesised into recommendations for practice.
The SGA assessment is used to investigate John’s difficulty in swallowing (dysphagia), loss of weight and refusal of diet and fluids. The process of swallowing involves complex coordination of voluntary and involuntary psychological, sensory and motor behaviours and is at risk of compromise from neurological disorders such as dementia (Ney et al. 2008). Dysphagia is characterised by difficulty in initiation of swallowing and impaired transfer of food from the mouth to the oesophagus (RACGP 2006, p.36). There is a strong correlation between dysphagia, malnutrition and poor clinical outcome (Ney et al. 2008). Patients with eating and swallowing disturbances are often at risk of malnutrition, dehydration, depression and aspiration pneumonia (Journal of the Dietitians Association of Australia (JDAA 2009; RACGP 2006, p.35). Aspiration pneumonia is the inhalation of food, saliva and gastric content and is the most common cause of death in patients with dysphagia associated with dementia (RACGP 2006, p.36). John’s chest infection may be a clinical indication of aspiration pneumonia (RACGP 2006, p.36).
Assessment using the SGA is a team approach that examines key areas such as functional capacity, gastrointestinal systems and dietary and weight changes. Speech Pathologists assess swallowing difficulties by judging the ability to safely and efficiently transfer the food bolus through the aero-digestive track (Ney et al. 2008). A medical officer will rule on other pathological processes such as xerostomia, sarcopenia or oesophageal motility. Consultation with a dietitian is also essential to ensure that adequate hydration and nutrition can be obtained within the texture and fluid modifications that may be recommended (JDAA 2009).
CSDD is designed for the assessment of depression in older people with dementia (Royal Australian College of General Practitioners (RACGP) 2006, p.34). John is at risk of depression due to recent life changes such as loss of independence and loss of a significant other (Alexopoulos et al. 1988). Late-onset depressive disorders are also often associated with pre-existing illnesses such as dementia due to cognitive vulnerability (RACGP 2006, p.34). Depression and dementia are the most frequent psychiatric syndromes in older people and are often found to co-exist (Alexopoulos et al. 1988). Depression, a treatable condition, may accompany symptoms of dementia and exacerbate psychological and behavioural issues. Clinical features include loss of interest, irritability, disinterest in food, fatigue, psychomotor slowing and social withdrawal (RACGP 2006, p.34). For John, the three assessment tools are used specifically because dementia, depression and dysphagia are often interrelated and symptomology can overlap. Differential diagnoses that identify, treat and modify the impact of one condition may also lead to improvement in other areas and an increase in overall function and well being (RACGP 2006, p.26).
RUDAS was developed in Australia to overcome recognised cultural, educational and age-related constraints of other cognitive assessment tools. It also assesses a wider range of cognitive domains, particularly frontal lobe function, an early sign of dementia (Storey at al. 2004). The rationale for assessing John’s cognitive function with RUDAS is to form a basis for evaluating the appropriateness of care and the need for, and effectiveness of, any interventions (Farrell 2007, pp. 32-34). Cognitive assessment is crucial in short and long term management and prognosis of dementia and its symptoms. Concurrent physical and mental illness, general deconditioning, and increased anxiety may also confound the clinical picture (Pang et al. 2008). The greater specificity of RUDAS in evaluating executive function and determining meaningful deficits will provide RACF staff with ongoing determination of the degree and progression of John’s dementia (Storey et al. 2004). This enables differential diagnosis with his current presentation and identification of collaborative problems, and determines appropriate therapeutic and psychosocial interventions (Pang et al. 2008).

## Article 1

Storey, J, Rowland, J, Conforti, D and Dickson, H 2004 ‘The Rowland Universal Dementia Assessment Scale (RUDAS): a multicultural cognitive assessment scale’, International Psychogeriatrics, vol.16, no.1, pp.13–31 (online Cambridge Journals).
In this article Storey et al. (2004) describe the development of RUDAS. The objective was to design and validate a simple method of detecting dementia that was portable across cultures and easily used by primary health care clinicians (Storey et al. 2004). Stage 1 involved using cultural and health advisory groups to develop culturally fair cognitive items. In Stage 2, 42 items were clinically tested. Stage 3 involved random sampling to assess the predictive accuracy of the items. The result was the RUDAS, which comprises six items: body orientation, fist palm alternation, copying of a picture of a cube, judgment in relation to crossing a busy road, animal names and recall of grocery items presented at the beginning of the test. The items are designed to assess multiple cognitive domains such as executive function, recent memory, gnosis, praxis, and category fluency (Storey et al. 2004).
The rationale for developing this tool was that the current most common tool in use – the Folstein Mini-Mental State Examination (MMSE) (comments inclusive of the amended version, the Standardised Mini-Mental State Examination (SMME) – was developed in an English-speaking population with words and concepts that were not easily translated into other cultures (Escobar et al. 1986, cited in Storey et al. 2004, p. 14). While age and education normative values have been introduced for the MMSE, they are not widely in use (Pang et al. 2008). Rossellia et al. (2006) also found significant gender and educational bias when applying both the MMSE standard ‘serial 7s’ tasks and the apparently less difficult ‘backwards spelling’ task for those with lower educational levels.
Storey et al. (2004) therefore based their design premise primarily on the Escobar finding (1986, cited in Storey et al. 2004, p. 14) that the MMSE should be revised to diminish cultural, social, educational biases. RUDAS was the culmination of this design purpose and, in 2004, Storey and co-authors found that RUDAS had both reliability and diagnostic accuracy for detecting dementia based on DISM-IV criteria. The authors recommended further validation of RUDAS by random sampling in a community-based population with broader ranges of cognitive function (Storey et al. 2004). In 2006, this validation study was achieved with federal funding and RUDAS became an accepted assessment tool, recognised not only for its cross-cultural portability but also its predictive accuracy and sensitivity (Rowland et al. 2006).
It is this latter finding that offers the student of research particular interest in how ideas are developed, explored and expanded through research and designed study to consequently emerge, in refined form, into practice. For, while the stated objective by Storey et al. (2004) from the outset was to develop a ‘simple method...that is valid across cultures’ (2004, p.13), the conversation soon changed to recognise that another emerging benefit of RUDAS was its sensitivity in detecting earlier stages of dementia due to its focus on the executive function of the cognitive domains. In effect, while the authors set out to develop a tool to solve one issue, it became evident during the study, and in later research papers, that the tool was of equal if not more value in another area. Early detection and diagnosis of dementia is important as it allows for differential diagnoses and timely therapeutic and psychosocial interventions (Storey et al. 2004).

## Article 2

Lype, T, Ajitha, B, Antony, P, Ajeeth, N, Job, S & Shaji S 2006, ‘Usefulness of the Rowland Universal Dementia Assessment Scale in South India’, Journal of Neurology, Neurosurgery & Psychiatry, vol. 77, pp. 513-514 (online PubMed).
In this study Lype et al. (2006) sought to compare RUDAS with the MMSE in assessing a sample population and also to gauge how well RUDAS performed in an entirely different socio-cultural population. A total of 58 patients with mild to moderate dementia and 58 with age and sex matched controls were screened with years of formal education also correlated to the findings (Lype et al. 2006). The rationale behind the study was the concern that people without dementia but with less education, or who are illiterate and innumerate, may be screened positive for dementia (Lype et al. 2006). The study found that while RUDAS and MMSE had similar sensitivity, RUDAS had greater specificity. In other words, while both tests were similarly sensitive to detecting dementia, RUDAS was better able to identify those who did not have the condition. It was determined that the inclusion of frontal executive function tests gave RUDAS an advantage. In other areas, the authors found RUDAS to be user-friendly, easy to administer but retaining some educational bias. In conclusion, the RUDAS was of benefit in addressing the authors’ concerns of misdiagnosis of dementia due to its specificity and was usable in different socio-cultural environment. However, concerns lingered about the use of screening tools from educationally developed countries in populations with much lower levels of education (Lype et al. 2006).

## Article 3

Pang, J, Yu, H, Pearson, K, Lynch, P & Fong, C 2009, ‘Comparison of the MMSE and RUDAS cognitive screening tools in an elderly inpatient population in everyday clinical use’, Internal Medicine Journal, vol. 39, no.8, pp.560-564 (online Web of Science).
Pang et al. (2008) conducted a pilot study to validate RUDAS in a clinical setting, determine patient satisfaction and gain an impression of clinicians’ views of each test’s utility. Moreover, the population setting – a convenience sample of 48 inpatients of Eastern Health in Victoria – is a heavily culturally and linguistically diverse (CALD) environment – another test of the claim made by Storey et al. (2004) that RUDAS is multicultural. In reading these objectives, there is immediate concern about lack of specificity in the research question and that the breadth may lend itself to superficiality and lack of investigative depth (Draper 2004, pp. 69-70). However, the paper does seek to answer three pertinent and very real questions for the clinician working in the pressured inpatient setting: Which test is better? Which is more user-friendly? And how do my peers regard it?
The study found that MMSE and RUDAS correlated well, took the same amount of time and had similar levels of patient satisfaction. Clinicians generally preferred the MMSE owing to lack of familiarity with RUDAS. However, RUDAS was preferred specifically in the CALD environment as there was no need to adjust normative language values as with the MMSE. The authors also recognised the specific challenges of the inpatient setting such as delirium, physical and mental illness, anxiety and environmental distractions. Where patients are bed-bound or immobile, the MMSE is easier to perform as it requires no movement.
In conclusion, this report by analysing the three articles finds that RUDAS was developed primarily to overcome perceived biases in the MMSE. It has also been found that due to its focus on the executive function of the cognitive domains, RUDAS can have a greater sensitivity and specificity in diagnosing dementia and is easily used by clinicians. However, when using any assessment tool the clinician should be mindful of the cultural, social, educational and physical factors which may influence findings and also question whether there are other tools available which may provide more accurate data. These conclusions are synthesised in the following recommendations for practice as person-centred care and critical thinking.
Person-centred care is the notion that we do not regard our patients as a collection individual of diseases but, instead, view them holistically with regard to exogenous influences such as age, education and socio-cultural differences- the human factors (Pelzang 2010; Farrell 2007, p. 25). Most important, when using assessment tools like RUDAS, is ensuring that the tool is appropriate for the patient’s situation rather than make the patient fit the parameters of the tool. A recent example from clinical placement is of a patient who scored consistently low on his Glasgow Coma Scale unless his son was present during assessment to translate into their first language, when the patient would then exhibit distinct motor responses, moving all four limbs on request. As a nurse, there is an obligation to identify when assessment tools need to be attenuated by situational awareness of cultural and other social issues (ANMC 2006). Using such tools without being holistically aware of the patient’s needs may lead to misdiagnosis.
Being committed to person-centred care also requires a commitment to critical thinking, a further recommendation for practice. Critical thinking is a multidimensional skill involving examination and analysis of all available ideas to inform clinical reasoning (Farrell 2007, p. 25). It is also about questioning whether the assessment tools being used in a particular clinical environment are providing the most accurate and valuable of data to help identify and solve the patient’s problems (ANMC 2006). Thus it may have been established that the client has dementia using the MMSE, but using the RUDAS may enable the nurse to develop a care plan specific to the functionality of the individuals’ cognitive domains and therefore better meet their needs. Collecting more cues from a wider range of informational sources enables proactive nursing that better predicts and manages a patients needs rather than reacting to a singular set of patient problems (Levett-Jones et al. 2009).