.
Instrumental Activities of Daily Living as a
Screening Tool for Cognitive ImpairGent and
Dementii in Elderlv Communitv Dwellers J J
Pascale Barberger-Gateau, MD, PhD, Daniel Commenges, PhD, Michile Gagnon, MA, Luc
Letenneur, MA, Claire Sauvel, MD, and Jean-Frangois Dartigues, MD, PhD
Objective:To identify which Instrumental Activities of Daily
Living (IADL) are related to cognitive impairment, independ-
ent of age, sex, and education; to assess the performance of an
IADL score using these items in screening for cognitive
impairment and dementia in elderly community dwellers.
Design: Survey based on the baseline interview of the
PAQUID study on functional and cerebral aging.
Setting: Community survey in 37 randomly selected parishes
in Gironde, France.
Subjects: Random sample of 2,792 community dwellers aged
65 and over (participation rate: 69%).
Measurements: Two-phase screening: (1) functional assess-
ment, Mini-Mental State Examination (MMSE) and DSM-111
criteria for dementia; (2) in DSM-111-positive patients,
NINCDS-ADRDA criteria applied by a neurologist. Func-tional
assessment: IADL scale of Lawton and Brody. Criterion
C ognitive decline is one of the major features of aging
and may, in some individuals, be a prel-ude to
irreversible dementia. Unfortunately
clinical assessment of cognitive impairment lacks sen-
sitivity.' Moreover, general practitioners are generally not
accustomed to the use of psychometric tests for
evaluating cognitive functioning, and the conditions of
stress or brevity of the consultation are not suitable for a
thorough assessment. Patients referred to specialists such
as geriatricians, neurologists, and psychiatrists are often
too deteriorated for management and treatment to be
effective.
The problem of sensitivity in the clinical assessment of
cognitive impairment also affects epidemiologic studies of
dementia, which require precise identifica-tion of
prevalent and/or incident cases, whose etiology must be
ascertained by the use of standard criteria. A two-step
screening procedure is generally used poten-tially
demented subjects are first screened by the use of general
tests of cognitive functioning such as the Mini-Mental
State Examination (MMSE),' and all the subjects scoring
under a given cut-off value of the MMSE are then
reviewed by a psychologist and a neurologist to verify the
diagnosis of dementia and
From INSERM U.330, Universit6 de Bordeaux 11,146, rue
~
Saignat,
33076
Bordeaux Cedex, France.This research was conducted at the INSERM unit
U330 in Bordeaux. The PAQUID program is funded by the Fondation de
France, Sandoz Laboratories, AXA Insurance Company, the French Ministry of
Research and Technology, the National Medical Insurance Companies
CNAMTS and MSA, the Brain Institute, the Regional Council of Aquitaine, the
General Councils of Gironde and Dordogne, the Regional Direction of
Sanitary and Social Affairs, the Inter-Firms Pension Aid Fund, CAPIMMEC, 2010
Media and the National Institute of Medical Research (INSERM).
Part of this paper was presented at the 44th annual meeting of the Geronto-
logical Society of h e r i c a in San Francisco, November 22-26,1991.
]AGS 40:2229-1134, 1992
Q 2992 by tke American Geriam'cs Socieg
T .
standards cognitive impairment: MMSE score lower than 24;
dementia: DSM-I11 and NINCDS-ADRDA criteria.
Results: Four IADL items are correlated with cognitive im-
pairment independent of age, sex, and education: telephone
use, use of means of transportation, responsibility for medi-
cation intake, and handling finances. A score adding the
number of IADL dependencies has a sensitivity of 0.62 and
a specificity of 0.80 at the lowest cut-off point (score > 0)
for the diagnosis of cognitive impairment. The same score
at the same cut-off has a sensitivity of 0.94 and a specificity
of 0.71 for the diagnosis of dementia. The prevalence of
dementia (2.4%)is reduced by a factor of 12 in subjects
independent for the four IADL.
Conclusion: The four IADL score could be incorporated into
the screening procedure for dementia in elderly community
dwellers. J Am Geriatr SOC401129-1134,1992
ascertain its cause. However, this protocol is very ex-
pensive: psychometric testing requires an interview of
each subject by a trained psychologist or specialized
interviewer^.^ Moreover, general tests of cognitive
functioning like the MMSE are sensitive at the usual cut-
off point of 24 but lack specificity for the diagnosis of
dementia, especially among poorly educated thus
many individuals who are free of dementia are
classified as cognitively impaired at the
first step of the procedure.
The screening procedure for cognitive impairment or
dementia could be greatly improved if it were possible to
use a very simple, reliable, and sensitive screening
instrument before the MMSE in order to eliminate
patients who are definitely not demented and to focus
psychometric testing only on suspected cases.
The Instrumental Activities of Daily Living (IADL)
scale' is a very simple and efficient assessment instru-
ment for elderly patients and is recommended both at an
individual level and in epidemiologic studies.'-" Its
validity has been demonstrated in various popula-tions,'
and it is especially suitable for community dwellers. The
instrumental tasks involve a higher level of complexity
than the Activities of Daily Living (ADL), to which they
are hierarchically related.12 The IADL are strongly
correlated with cognitive functioning,' in particular when
measured by the MMSE.13 IADL items were found to
explain 23.3% of the variance in MMSE score and to be
the main explanatory variable when age, sex, race, and
education were ~ontrolled.'~
Moreover, functional impairment in social and oc-
cupational activities is one of the DSM-I11 criteria for
dementing syndrome,15 and the effects of cognitive
impairment and dementia on activities of daily living
~
OOO2-8614/92/$3.50
1130 BARBERGER-GATEAU ET AL
have been well Murden et a15 rec-ommended
considering functional decline for improv-ing the
accuracy of the diagnosis of dementia in poorly educated
subjects scoring between 18 and 23 on the MMSE.’
Therefore, as suggested by Fillenbaum et al,I4 it might be
possible to use specific IADL items to improve
discrimination between cognitively impaired and normal
older subjects.
The present study first identifies which IADL items
are more specifically related to cognitive impairment
assessed by the MMSE in a representative sample of
French elderly community dwellers. The selected items
are then used to compute a global score. In a second step
the ability of this IADL score to predict a diagnosis of
“cognitive impairment” measured by the MMSE is
assessed. Finally, the contribution of the IADL score to
the screening of dementia is addressed.
METHODS
Sample The data come from the baseline data col-
lection of the PAQUID (Personnes Agies QUID) epi-
demiologic project, which investigates cerebral and
functional aging. A sample of 5,555 community resi-
dents aged 65 and over was randomly selected from the
electoral rolls of 75 districts of two administrative areas
of southwestern France (Gironde, 1,127,546 in-habitants,
and Dordogne, 377,356 inhabitants) by a three-step
procedure stratified by age, sex, and size of township. In
Gironde, 68.9% agreed to participate, resulting in 2,792
subjects, representative of the age-sex distribution of the
elderly in the area. These sub-jects form the study
sample.
The general methodology of PAQUID has been de-
scribed elsewhere.21~22In brief, in 1988 all subjects
underwent a 1 -hour home interview by a trained psy-
chologist. The initial questionnaire included questions
relating to socio-demographic characteristics, social
support, functional assessment, medication intake, main
symptomatology, depressive symptomatology, and
psychometric testing. A similar interview was con-ducted
1 year later, and all the subjects are followed-up for at
least 5 years. Events of interest for follow-up are death,
institutionalization, cognitive decline (espe-cially
dementia of the Alzheimer type), and loss of autonomy.
Assessment of Cognitive Functioning The French
version of Folstein’s MMSE’ was used as a general
measure of cognitive functioning. The validity of the test
for the screening of cognitive impairment has been
proved in clinical series’ and in population ~tudies.’’~ 23
A score between 0 and 30 was derived by summing the
scores on each item. Among the 2,792 subjects, 65
(2.3%) could not be administered the MMSE: 0.8%
because of physical impairment, 1.3% refused, and in
0.2% the conditions of the interview were not suitable
for a reliable assessment; these subjects were excluded
from the present study. Subjects scoring less than 24
were considered as “cognitively impaired” in the pres-ent
study, according to the most recommended and widely
used threshold.’, 24 However, this threshold leads to a
high rate of false positive cases for the
JAGS-NOVEMBER 1992-VOL 40, NO. 11
diagnosis of dementia, mainly because of low educa-
tional level.”
Diagnosis of Dementia At the end of the inter-view,
DSM-I11 criteria for dementia syndrome were
filled in by the psychologist. The DSM-I11 positive cases
were reviewed by a neurologist to confirm the diag-nosis
and ascertain the etiology of the dementing syn-drome
with the National Institute of Neurological
Communicative Disorders and Stroke-Alzheimer’s Dis-
ease and Related Disorders Association (NINCDS-
ADRDA) criteria.” The neurologist was unaware of the
aims of the present study and did not have access to the
IADL assessment made by the psychologist. These
subjects were then classified as possible or prob-able
Alzheimer‘s disease, vascular dementia, Parkin-son’s
disease dementia, other dementia, or false posi-tive. Only
the subjects whose dementing syndrome had been
confirmed by the neurologist were considered as
demented in the present study. The subjects who refused
the neurologist’s visit or died before were excluded from
the analyses. All the demented subjects scored less than
24 on the MMSE in our sample, although this was not a
compulsory condition.”
Functional Assessment The Instrumental Activi-ties of
Daily Living scale of Lawton and Brody6involves eight
tasks: telephone use (A), shopping (B), meal preparation
(C), housekeeping (D), laundry (E), use of transportation
(F), responsibility for medication intake (G), and
handling finances (H). Tasks C, D, and E are usually
excluded when assessing men. Each task is graduated in
a 3, 4, or 5-level scale. The validity and reliability of
IADL items have been assessed in various
In the PAQUID study the assessment
was conducted by the psychologist during the face-to-
face interview. If the patient was unable to answer, help
of a proxy was required.
Association between IADL Dependency and Cog-
nitive Impairment The association between the per-
formance achieved for each IADL item and the classi-
fication of cognitively impaired (MMSE < 24) was
tested by chi-square. Two separate logistic regressions
were then performed in women and men to identify the
IADL items that were independently related to the
classification of ‘cognitively impaired” (MMSE < 24
coded 1; MMSE > 23 coded 0), with adjustment for age
and educational level (model 1). The IADL items (8 in
women, 5 in men) were entered simultaneously as
independent variables in the model and coded on a 3,4,
or 5-level scale, the score increasing with the level of
dependence. Age was entered as a continuous vari-able.
Educational level was dichotomized in a lower group
coded 1 (subjects having less than 6 years of formal
education, ie, the primary school level; 67% of the
sample) and an upper group coded 0.
Construction of an IADL Score In order to com-bine
all the sigruficant items weighted by their regres-sion
coefficients into one score, another logistic regres-sion
was performed on the classification “cognitively
impaired” (MMSE < 24) using only the significant IADL
items of model 1 as explanatory variables. In this second
model, the IADL items were dichotomized as
IAGS-NOVEMBER 1992-VOL. 40, NO. 17 IADL, COGNITIVE IMPAIRMENT AND DEMENTIA 1131

follows: in order to achieve the highest sensitivity, a RESULTS

subject was coded 0 if he could perform the IADL item Association between IADL Items and Cognitive
without any help; otherwise he was coded 1. The Impairment Of the 2,792 PAQUID subjects who were
respective p, regression coefficients were then used as seen in Gironde, 2,780 completed all IADL items, 2,716
weights for each Xi variable and a score, S, was com- of them received the MMSE, and 2,713 (97.2% of the
puted for each subject: total sample) could also provide their educational level.
s = cpixi Prevalence of cognitive impairment (MMSE <
I 24) was 27.8% in the 1,614 women and 19.7% in the
The score increased with increasing IADL dependency. 1,099 men.
Performances of the IADL Score for the Screening of The performance achieved on each IADL item was
Cognitive Impairment and Dementia The crite-rion significantly associated with the classification of 'cog-
standard for cognitive impairment was defined by MMSE nitively impaired" (MMSE < 24) (P < 0.001 for all chi-
square tests).
score. As the use of lowered cut-off points for MMSE in
Two separate logistic regressions were then per-
the less educated or older subjects remains controversial, formed, entering eight IADL for women and five for
the performances of the IADL score de-scribed above men, with adjustment for age and educational level
were compared for three different cut-off values of the (model 1). The results are displayed in Table 1. Only
MMSE score: 4 8 (severe cognitive impairment), <21 three items are independently related to the classifica-
(moderate impairment), <24 (mild im~airment)24.~, tion of "cognitively impaired" for men: telephone (A),
The criterion standard for dementia was the diag-nosis medication (G), and budget (H). The same items are
given by the neurologist, according to NINCDS-ADRDA significant for women, too, in addition to use of trans-
criteria. The specific IADL items related to dementia portation (F).
could not be identified by logistic regressions as to Each of these four IADL items was dichotomized into
cognitive impairment owing to the small number of fully independent (coded 0) or at least partly dependent
demented subjects in the sample. Thus the same IADL (coded 1).These dichotomized items were entered, as the
items were used, with the same weights. This procedure only independent variables, in a second logistic
regression on the classification of "cognitively impaired"
is justified since cognitive impairment is a major feature
(MMSE < 24): the results showed that the regression
of the clinical diagnosis of dementia, and all the
demented subjects scored less than 24 on the MMSE in coefficients /3 were all near one (PA = 1-02, PF = 1.03,
our study. PG = 0.86, PH = 1.02). Thus a very simple score was
In both cases the sensitivity and specificity were computed by summing the number of IADL
computed for each cut-off point of the IADL score. dependencies for these items.
Performance of the Four IADL Score for Detecting
Sensitivity (Se) was equal to the proportion of depend-
Cognitive Impairment The distribution of the scores
ent subjects among the cognitively impaired or de-
among the Gironde residents is given in Table 2. The
mented. Specificity (Sp) was equal to the proportion of prevalence of cognitive impairment diagnosed by the
independent subjects among the cognitively normal or
not demented for a given cut-off point of the IADL score.
Reliability of the IADL Score Internal consistency of TABLE 1. LOGISTIC REGRESSION OF IADL ITEMS
the IADL score was assessed by Cronbach's alpha.26 The ON BEING CLASSIFIED AS 'TOGNITIVELY
reliability of a phone evaluation of the dichotomized IMPAIRED" (MMSE < 24), ADJUSTED FOR
IADL items was assessed in an additional test sample of AGE AND EDUCATIONAL LEVEL
34 subjects living in two districts of Gironde. These Women (n= 1614) Men (n = 1099)
subjects were randomly selected, inter-viewed, and n Significance OR
followed up in the same manner as the PAQUID cohort, Significance OR
but they were used as a pre-test sample and never *** 1.07 ***
Age 1.06
included in the results. These sub-jects were contacted by
Education *** 3.88 *** 5.39
the secretary by phone to make an appointment for the
IADL * 1.35 ** 1.65
third year follow-up; one was hospitalized and could not A
be reached. Another was deaf and could not answer. The B ns ns
remainder were inter-viewed by phone for the selected C ns Not Tested
IADL items dicho-tomized as described above. Another D ns Not Tested
assessment of the full IADL scale was made by the E ns 1.33 Not Tested
psychologist during the face-to-face interview with 26 F *** ns
G ** 2.61 * 1.94
subjects (6 refused) a few days later, and the results were **
H a*
1.72 1.74
compared with the former evaluation for the selected
items. Because of the small sample size and the very ns = not significant.
OR = odds ratio.
asymmetric distribution of the scores in a few classes, * = P < 0.05, ** = P < 0.01,*** = P < 0.001.
concordance between the two measures was assessed by A = telephone, B = shopping, C = meal preparation, D =
Cohen's kappa." housekeeping, E = laundry, F = transportation, G =
medi-cation, H = handling finances.
1132 BARBERGER-GATEAU ET AL IAGS-NOVEMBER 1992-VOL 40, NO. 1 1

TABLE2.DISTRIBUTION OF THE FOUR IADL SCORE AND PREVALENCE OF COGNITIVE

IMPAIRMENT AND DEMENTIA FOR EACH VALUE OF THE SCORE AMONG COMMUNITY
RESIDENTS
Score 0 1 2 3 4 Total
n 1927 458 183 104 108 2780
(%I (69.3) (16.5) (6.6) (3.7) (3.9) (100)
MMSE: 1903 442 180 99 92 2716
n l administered
(w+ (98.8) (96.5) (98.4) (95.2) (85.2) (97.7)
MMSE score < 24 13.4 36.4 52.8 75.8 87.0 24.5
(%)** 6.1 15.8 27.8 48.5 76.1 13.8
MMSE score < 22
(%y 0.7 2.7 8.9 14.1 58.7 4.0
MMSE score < 18
(%)**
NINCDS-ADRDA 0.2 1.1 3.3 11.0 37.5 2.4
Demented: (%I*
* percentage of n in fh e column
* percentage of nl in the column

MMSE is strongly correlated with the score. The fre-
quency of severe cognitive impairment (58.7% for
MMSE < 18) is increased by 14.5-fold in people scoring
4 on the IADL compared with its frequency in the whole
sample (4%). Conversely, in the subjects scoring zero,
the percentage of slightly cognitively impaired subjects
(MMSE < 24) is approximately divided by two and that
of severely impaired subjects (MMSE < 18) by 6.
The sensitivity and specificity of the four IADL score
for predicting cognitive impairment are displayed in
Table 3 for each value of the score and three different
MMSE cut-off points. The sensitivity of the score for
detecting a slight or moderate cognitive impairment is
weak, even for a cut-off value of zero. However, the
specificity of the indicator is high whatever the cut-off
point.
These results suggest that the four IADL score might
be used with a satisfactory sensitivity (0.88) for the
further screening of severe cognitive impairment de-
tected by MMSE.
Performance of the Four IADL Score for the Di-
agnosis of Dementia One hundred one subjects were
diagnosed as demented by the psychologist with the
DSM-I11 criteria. Among them, 15 refused the neurol-
ogist’s visit and two died before the investigation; 15 of
these subjects were dependent for at least one of the four
IADL. Of the remaining subjects, 66 were classi-fied as
demented by the neurologist: 51 possible or probable
Alzheimer‘s diseases, five vascular dementias, five
Parkinson’s disease dementias, and five other de-mentias.
There were 18 false-positive cases. Hence the
prevalence of dementia according to NINCDS-ADRDA
criteria was 2.4% in the sample. In one demented
subject, information about item G (medication intake)
was not available, and he was excluded from the
computations; this subject was dependent for items A
and H.
The performances of the scores for the diagnosis of
dementia are displayed in Tables 2 and 4. The preva-
lence of dementia increased considerably with the IADL
score from 0.2% in the independent subjects to 37. 5%
in those dependent for the four IADL. Among the
demented subjects, 94% were dependent for at least one
IADL, whereas among the non-demented, 71 % were
fully independent (Table 4).
Reliability of the Four IADL Score Cronbach’s alpha
was 0.76 in the sample, reaching the lower boundary of
acceptable reliability.
Among the 26 subjects interviewed by phone about
their IADL performance, 22 scored similarly at the face-
to-face and phone assessments. Sixteen of these were
fully independent. None was classified as dependent on
all four IADL. The overall agreement between meas-
ures was good, with a kappa statistic of 0.70.
DISCUSSION
IADL items are strongly correlated with MMSE clas-
sification in cognitively impaired subjects. When age,
sex, educational level, and all Lawton’s scale items are
simultaneously taken into account, only items A (tele-
phone), G (medication) and H (budget), adding F
(transportation) for women, are significant. Despite a
high specificity, the performance of the four IADL

TABLE3.PERFORMANCE OF THE FOUR IADL SCORE FOR DETECTING COGNITIVE IMPAIRMENT

AMONG COMMUNITY RESIDENTS
ScoreMMSEe24MMSE>23MMSEe22MMSE>21 MMSEc18 MMSE>17
cut- b = 666) (n = 2050) (n = 354) (n = 2362) (n = 109) (n = 2607)
Off Sensitivity Specificity Sensitivity Specificity Sensitivity Specificity
>O 062 0.80 0.67 0.76 0.88 0.73
>1 0.37 0.94 0.47 0.91 0.77 0.89
>2 0.23 0.98 0.33 0.97 0.62 0.95
>3 0.12 0.99 0.20 0.99 0.49 0.99
IAGS-NOVEMBER 1992-VOL 40, NO. 11
TABLE4.PERFORMANCE OF THE FOUR IADL
SCORE FOR DETECTING A DIAGNOSIS OF
DEMENTIA (NINCDS-ADRDA CRITERIA) AMONG
COMMUNITY RESIDENTS
Demented Non-demented
Score (n = 65) (n = 2698)
Sensitivity Specificity
>O 0.94 0.71
>1 0.86 0.88
>2 0.77 0.94
>3 0.60 0.98
score in detecting cognitive impairment defined by an
MMSE score lower than 24 is weak, owing to the lack of
sensitivity of the measure. An acceptable sensitivity
(0.88) is achieved only for an MMSE score lower than 18,
ie, severe cognitive impairment. In contrast, the
performance of the score in ruling out subjects who are
not demented is particularly interesting. The risk of being
demented in the A, F, G, H independent group is only
about 2%, with a prevalence of 2.4% for de-mentia in the
sample. A more complex model involving age and
educational level did not improve the discrim-inating
performances. In severely demented subjects, these four
items can be interpreted as part of the "C" criterion of the
DSM-IIIR for dementia: the loss of intellectual ability
must significantly interfere with so-cial or occupational
f~nctioning.'~
The four items identified as independently correlated
with the MMSE are very near the tasks proposed by
Loewenstein et alZ8for the assessment of Alzheimer
patients, although the methodology varied consider-ably.
Loewenstein et a1 selected from the literature and opinion
of expert geriatricians a group of domains including,
among others, telephone use, transportation, and handling
finances. Skurla et alZ9also derived a performance score
from four tasks: dressing, meal preparation, telephone
use, and purchasing. The total score did not correlate well
with the Short Portable Mental Status Questionnaire in
nine Alzheimer pa-tients. Very similar items are also used
in the Blessed and Roth Dementia Scale.30Our approach
was, on the contrary, to start from a well validated and
widely used instrument and to test its ability to detect
patients who may be demented in a community sample.
The consequences of using such an IADL score in
medical practice and epidemiologic studies of dementia
could be important. With the four IADL score defined in
the present study, only 21.5% of the men and 35.8% of
the women of the sample are dependent for at least one
IADL (score > 0) and, therefore, suspected of cognitive
impairment. The remaining 70% are classi-fied as
independent and mostly free of cognitive dete-rioration. A
new strategy for obtaining a proxy esti-mation of the
prevalence of dementia in the community could use the A,
F, G, and H items as a first screen. If the subject is
dependent in at least one of the four activities or unable to
answer himself, a psychologist could do a thorough
interview and psychometric test-ing of the subject to
ascertain if the handicap is related
to cognitive impairment. Other pathologies which might
affect the ability of the person to perform IADLs,
IADL, COGNITIVE IMPAIRMENT AND DEMENTIA 1133
such as arthritis or depre~sion,'~could be diagnosed at
this step. This strategy has now been implemented at the
3-year follow-up of the PAQUID study. The IADL score
is assessed by a phone interview of the subjects who
refuse the home visit in order to identify those who are
potentially demented.
The same strategy can be used by a general practi-
tioner on an individual basis: if a patient is fully inde-
pendent in using the telephone, means of transporta-tion,
taking medication, and handling finances, he is probably
not demented. The others should undergo a complete
assessment, including MMSE, to specify if the etiology
of the loss of independence is related to physical
ailments or to cognitive impairment. Particular attention
should also be paid to depressive symptom-atology,
which is associated with poor performance in
IADLs.I3,31 These results meet the general recommen-
dations for health status assessment of elderly patients
made by Rubenstein.'
Adding the IADL score to the diagnostic strategy of
dementia considerably improves the predictive value of
MMSE alone. Of the 666 subjects scoring less than 24
on the MMSE, only 10% were demented in the sample;
however, of the subjects scoring less than 24 and
dependent for the four IADL, 49% were demented
versus only 1.6% in the same MMSE group who were
fully independent for the four IADL.
Validation studies should be undertaken on other
samples of community dwellers to assess the sensitivity
and specificity of the screening procedure and the
reliability of the IADL score in different socio-cultural
environments. We assessed the validity of the IADL
score in the Dordogne part of the PAQUID study. The
sensitivity and specificity of the score were very similar
to those found in the Gironde sample for the different
levels of cognitive impairment defined by the MMSE
score, as well as for the diagnosis of dementia (unpub-
lished data, available from authors on request). The
reliability of a phone or mail assessment of these IADL
items should also be tested in various populations and
interview conditions. One point to solve, among others,
is how to treat missing data. Additional items or ques-
tioning of the proxies could also be added in order to
improve the sensitivity of the score in slightly cogni-
tively impaired elderly. Further validation of the four
IADL score will be undertaken according to the same
procedure at the first year of follow-up of the Gironde
subjects. Repeated measures of IADL performance in the
same subjects will be needed to assess how their
evolution is correlated with cognitive decline, and this
may be predictive of the onset of dementia.
The percentage of subjects who could not be admin-
istered the MMSE is higher in the dependent than
independent group. If these subjects were considered as
"cognitively impaired" from the MMSE testing, it would
increase the performances of the four IADL score even
more. A sample of 17 DSM-III-positive subjects refused
the neurologist's investigation or died before the
investigation; 15 of these were dependent for at least one
IADL. These refusals may slightly bias the performance
of the four IADL score: if the two refusals in the fully
independent group were all de-mented, the sensitivity
would be lowered to 0.91 for a
1134 BARBERGER-GATEAU ET AL
cut-off point at 0. If some of the refusals among the
"dependent" group were demented, it would on the
contrary increase the sensitivity of the score.
Some subjects may have over- or underestimated
their actual IADL performance, and there may be some
disagreement between proxy and self- respondent^.^'
The percentage of proxy respondents was not regis-tered
at baseline. Among the 1,053 first interviews for the
third year follow-up, 94.4% of the subjects could answer
the four items by themselves without any help, 3.8%
needed help, and in 1.8% the answer was given by a
proxy. Of the 367 subjects dependent in at least one of
the four IADLs, the percentages are respectively, 84.7%,
10.6%, and 4.7%. As expected, the percentage of
subjects needing help for answering increases with the
four IADL score.
Another limitation of the study is the use of MMSE as
a criterion for cognitive impairment. The MMSE has a
high rate of false-positive cases for the diagnosis of
dementia, especially among poorly educated people."
Hence, the MMSE cannot be considered in itself as a
criterion for dementia, because it would lead to very high
levels of prevalence. This may partly explain the better
performances of the IADL score for the diagnosis of
dementia than for the diagnosis of cognitive impair-ment
defined by an MMSE score lower than 24.
The present data are limited to community dwellers. In
institutions, the prevalence of cognitive impairment is
probably much higher, and the IADL are not really
suitable for the patient's assessment, owing to the low
"autonomy#left to the majority of those who live in an
institutional setting. We are now conducting the same
study on institutionalized elderly, and we will try to
identify the indicators that are the most relevant for that
population.
In conclusion, the four instrumental activities of daily
living identified here could be a very helpful instru-
ment, allowing an inexpensive and easy first step
screening in epidemiologic studies, leading to a proxy
measure of the prevalence of dementia. If all the sub-
jects can undergo the psychometric phase, the IADL
score could be used as an additional criterion in the full
clinical screening procedure for dementia. These items
are probably less biased by educational level
than specific instruments of cognitive functioning, such
as the MMSE, and could therefore be used in poorly
educated populations after additional validation stud-ies.
REFERENCES
1. Pinholt EM,Kroenke K, Hanley JF et al. F ~ n c t i assessment~~l of the
elderly. A comparison of standard instruments with clinical judgment.
Arch Intern Med 1987;147484-488.
2. Folstein MF, Folstein SE, McHugh PR. Mini-Mental-State: A practical
method for grading the cognitive state of patients for the cliniaan. J
Psychiatr R e 1975;12189-198.
3. Fdenbaum GG, Heyman A, Williams K et al. Sensitivity and specificity of
standardized screens of cognitive impairment and dementia among elderly
black and white community residents. J Clin Epidemiol1990;43:651-660.
JAGS-NOVEMBER 1992-VOL 40, NO.
11
4.Anthony JC. Leresche L, Niaz V et al. Limits of the 'Mini-Mental
State' as a screening test for dementia and delirium among hospital
patients. Psychol Med 1982;12:397-408.
5.Murden RA, McRae TD, Kaner S et al. Mini-Mental-State exam
scores vary with education in Blacks and Whites. J Am Geriatr Soc
1991;39:149-155.
6. Lawton MP, Brody EM. Assessment of older people: Self-maintaining and
instrumental activities of daily living. Gerontologist 1969;9:179-186.
7.Fillenbaum GG. Screening the elderly: A brief instrumental activities
of daily living measure. J Am Geriatr SOC1985;33698-706.
8. Rubenstein LV, Calkins DR, Greenfield S et al. Health status
assessment for elderly patients. Report of the Society of General Internal
Medicine Task Force on Health Assessment. J Am Geriatr Soc
1988;37:562-569.
9. Applegate WB, Blass JP, Williams TF. Instruments for the functional
assessment of older patients. N Engl J Med 1990;322:1207-1214.
10.Kak S.Assessing self-maintenance: Activities of daily living. mobility and
instrumental activities of daily living. J Am Geriatr Soc 1983;31:721-727.
11.Katz S, Stroud MW. Functional assessment in geriahics. A review of progress
and directions. J Am Geriatr Soc 1989;37267-271.
12.Spector WD, Kak S,Murphy JB et al. The hierarchicalrelationship between
activities of daily living and instrumental activitiesof daily living. J Chronic
Dis 1987;40481-489.
13.Barberger-Gateau P, Chaslerie A, Dartigues JF et al. Health measures correlates
in a French elderly community population: the Paquid Study. J Gerontol: Social
Sciences 1992;47588-95.
14.Fillenbaum GG, Hughes DC, Heyman A et al. Relationship of health and
demographic characteristics to Mini-Mental State Examination score among
community residents. Psychol Med 1988;18:719-726.
15.American Psychiatric Association Committee on Nomenclature. Manuel
diagnostique et statistique des troubles mentaux. DSMllI Paris: Masson,
1983.
16. Winograd CH. Mental status tests and the capacity for self-care. J Am
Geriatr Soc 1984;32:49-55.
17.Vitaliano PP,Breen AR, Albert MS et al. Memory, attention and functional
status in community-residing Alzheimer type dementia patients and opti-mally
healthy aged individuals. J Gerontol 1984;39:58-64.
18.Griffiths RA, Good WR, Watson NP et al. Depression, dementia and disability
in the elderly. Br J Psychiatry 1987;150:482-493.
19.Scherr PA, Albert MS, Funkenstein HH et al. Correlates of cognitive function in
an elderly community population. Am J Epidemiol
1988;128:1084-1101.
20.Reed BR, Jagust WJ, Seab JP. Mental status as a predictor of daily function
in progressive dementia. Gerontologist 1989;29:804-807.
21. Dartigues IF, Barberger-Gateau P, Gagnon M et al. PAQUID: Etude
6pidbiolgique du vieillissement normal et pathologique. Rev Geriatr
1991;165-15.
22. Gagnon M, Letenneur L, Dartigues JF et al. The validity of the Mini-
Mental State Examination (MMS) as a screening instrument for cognitive
impairment and dementia in French elderly community residents. Neuro-
epidemiology 1990;9:143-150.
23.Commenges D, Gagnon M, Letenneur L et al. Statistical description of the
Mini-Mental Status Examination (MMS) for French elderly community
residents. J Nerv Ment Dis 1992;18028-32.
24.Folstein MF, Anthony JC, Parhad I et al. The meaning of cognitive
impairment in the elderly. J Am Geriatr Soc 1985;33:228-235.
25.McKhann G, Drachman D, Folstein M et al. Clinical diagnosis of Alz-
heimer's disease: Report of the NINCDS-ADRDA Work Group under the
auspices of Department of Health and Human Services Task Force on
Alzheimer's disease. Neurology 1984;34939-944.
26.Bravo G, Potvin L. Estimating the reliability of continuous measures
with Cronbachs alpha or the intraclass correlation coeffiaent: Toward the
integration of two traditions. J Clin Epidemiol1991;44381-390.
27.Fermanian J. Measure of concordance between two observers. The
quali-tative case. Rev Epidemiol et Sant.5 Pub1 1984;32:140-147.
28.Loewenstein DA, Amigo E, Duara R et al. A new scale for the a-ment
of functional status in Alzheimer's disease and related disorders.J Gerontol
1989;44114-121.
29.Skurla E, Rogers JC, Sunderland T. Direct assessment of activities of daily
living in Alzheimer's disease. A controlled study. J Am Geriatr Soc
19863697-103.
30. Blessed G, Tomlinson BE, Roth M. The assodation between
quantitative measures of dementia and of senile change in the cerebral grey
matter of elderly subjects. Br J Psychiatry 1968;114:797-811.
31. Fuhrer R, Antonuca TC, Gagnon M et al. Depressive symptomatology
and cognitive functioning: An epidemiologic survey in an elderly com-munity
sample in France. Psychol Med 1992;22159-172.
32.Rubenstein U,Schairer C, Willard GD, et al. Systematic biases in func-tional
status assessment of elderly adults. Effects of different data sou~es.
J Gerontol 1984;39:686-91.