Clifton Assessment Procedures for the Elderly

Abstract

The Clifton Assessment Procedures for the Elderly (CAPE) is a comprehensive, multi-dimensional instrument developed for the rapid and reliable assessment of cognitive and behavioral functioning in older adults, particularly those requiring care or institutionalization. Introduced by Pattie and Gilleard in 1975, CAPE is specifically used in psychogeriatric settings to aid in diagnostic screening, placement decisions, and monitoring clinical progress. It consists of two primary, independently scorable components: the Cognitive Assessment Scale (CAS) and the Behavior Rating Scale (BRS).

Keywords

Clifton Assessment Procedures for the Elderly, CAPE, cognitive assessment, behavioral rating scale, functional status, dementia screening, psychogeriatric evaluation, geriatric assessment.

Authors

A. H. Pattie, C. J. Gilleard

Purpose

The primary purpose of the CAPE instrument is to provide clinicians and researchers with a quick, standardized, and objective method for assessing the degree of cognitive decline and associated behavioral problems in the elderly population. It was initially designed for use in inpatient and institutional settings to differentiate between organic brain syndromes, such as dementia, and functional psychiatric illnesses.

Furthermore, the scale is crucial for evaluating a patient’s overall functional capacity, which informs decisions regarding appropriate care placement, resource allocation, and planning for hospital discharge, ensuring that the patient receives a level of care commensurate with their needs.

Construct

CAPE measures two distinct but interrelated psychological and functional constructs. The first is Cognitive Function, assessed through the CAS, focusing on immediate recall, orientation, and basic mental processing speed. The second is Behavioral Function and Disability, assessed through the BRS, which measures daily living skills and the presence of socially disruptive or challenging behaviors.

These constructs combine to offer a holistic picture of the individual’s mental and physical status, which is vital in geriatric assessment. The BRS items reflect practical aspects of care needs, including physical dependency, social integration, and psychomotor skills, serving as an effective measure of observable functional impairment.

Validity

The validity of the CAPE has been established through several studies, particularly concerning its ability to discriminate between different diagnostic groups in psychogeriatric populations. Pattie and Gilleard (1975) validated the original schedule against psychiatric diagnosis and eventual discharge status from the hospital, demonstrating its clinical utility.

The scale shows strong construct validity, with the CAS correlating highly with established measures of cognitive impairment. Furthermore, the BRS subscales demonstrate criterion validity by correlating with observable measures of dependency and need for supervision, reinforcing its role as a predictor of functional outcome and care requirements.

Reliability

The CAPE exhibits satisfactory levels of psychometric reliability. Studies have confirmed the scale’s stability and internal consistency. Lesher and Whelihan (1986), for instance, confirmed the reliability of the mental status components when administered to nursing home residents, indicating its robustness in diverse care environments.

The Behavior Rating Scale (BRS), relying on observer reports, demonstrates high inter-rater reliability, suggesting that different staff members observing the patient arrive at consistent scores. The development of the survey version (Pattie, 1981) further supported its reliability for use in broader community and institutional surveys.

Factor Analysis

Factor analytical studies generally support the two primary scales of the CAPE: the Cognitive Assessment Scale and the Behavior Rating Scale. The CAS typically loads onto a strong single factor representing general cognitive impairment.

The BRS, being multi-dimensional, often reveals underlying factors related to key aspects of functional decline, such as physical dependence (bathing, walking, continence) and social disturbance (objectionable behavior, hoarding). This factor structure confirms that CAPE effectively measures distinct clinical domains required for comprehensive geriatric assessment.

Instrument

Test Type: Screening, diagnostic aid, and functional status measurement.

Format: Structured Interview and Performance Tasks (CAS); Observer/Staff Rating (BRS).

Language Available: Primarily English (UK context).

Population Group: Elderly/Geriatric patients.

Age Group: Older adults (typically 65 years and older).

Population Details: Institutionalized or community-dwelling elderly requiring comprehensive psychological or functional assessment, including those with suspected dementia or psychiatric illness.

Test Methodology: Administration of standardized cognitive tasks (timed where appropriate) and collection of observer ratings regarding daily functioning and behavior over a specified observation period.

Keywords

Psychomotor performance, functional disability, institutional care, mental ability, orientation, Pattie, Gilleard, psychometric assessment.

Authors

Author ORCID Identifier: N/A

Affiliation Email addresses: N/A

Correspondence Address: N/A (Historically associated with Clifton Hospital, York, UK)

Permissions & Fee and Test Year

The initial publication of the assessment schedule occurred in 1975, with the comprehensive manual published in 1979 by Hodder and Stoughton (Sevenoaks, Kent, UK). Specific fee structures and current commercial permissions must be sought directly from the current copyright holders or test distributors. The scale is widely referenced in academic literature and often used for research purposes.

Reference’s

McDowell, Ian. (2006). Measuring Health: A Guide to Rating Scales and Questionnaires, Third Edition. OXFORD UNIVERSITY PRESS.

Pattie, A.H., Gilleard, C.J. (1975). A brief psychogeriatric assessment schedule: validation against psychiatric diagnosis and discharge from hospital. The British Journal of Psychiatry, 127:489–493.

Pattie, A.H., Gilleard, C.J. (1976). The Clifton Assessment Schedule – further validation of a psychogeriatric assessment schedule. The British Journal of Psychiatry, 129 (1) 68-72.

Pattie, A.H., Gilleard, C.J. (1979). Manual of the Clifton Assessment Procedures for the Elderly (CAPE). Sevenoaks, Kent, UK: Hodder and Stoughton.

Pattie, A. H. (1981). A survey version of the Clifton Assessment Procedures for the Elderly (CAPE). British Journal of Clinical Psychology, 20: 173–178.

Smith, A.H.W., Ballinger, B.R., Presly, A.S. (1981). The reliability and validity of two assessment scales in the elderly mentally handicapped. The British Journal of Psychiatry, 138:15–16.

Lesher, E.L., Whelihan, W.M. (1986). Reliability of mental status instruments administered to nursing home residents. J Consult Clin Psychol, 54:726–727.

The original PDF detailing the instrument components can be downloaded here: www.a4ebm.org/sites/default/files/Measuring%20Health.pdf

Items of the Clifton Assessment Procedures for the Elderly

COGNITIVE ASSESSMENT SCALE

Information and Orientation

Correct recall of: Name, Hospital/address, Colour of British flag, Age, City, Day, D.o.B., P.M., Month, Ward/place, U.S. President, Year

Mental Ability

• Ability to count 1 to 20 (timed)
• Reciting alphabet (timed)
• Write name
• Reading a list of pre-selected words

Psychomotor

The patient is asked to draw around a pre-printed spiral maze, avoiding “obstacles” drawn in the pathway; performance is timed.

BEHAVIOR RATING SCALE

Physical Disability, Bathing and dressing, Walking ability, Continence, Staying in bed during the day, Confusion (unable to find way around, loses things), Appearance, Apathy, Would need supervision if allowed outside, Helps out in the home or ward, Keeps occupied, Socializes, Accepts suggestions to do things, Communication Difficulties, Understands what is communicated to him/her, Able to communicate, Social Disturbance, Objectionable to others during day, Objectionable to others during night, Accuses others of wrongdoing, Hoards apparently meaningless items, Sleep pattern

1. When bathing or dressing, he/she requires
   • no assistance (0)
   • some assistance (1)
   • maximum assistance (2)
2. With regard to walking, he/she:
   • shows no sign of weakness (0 )
   • walks slowly without aid, or uses a stick (1)
   • is unable to walk, or if able to walk, needs frame, crutches or someone by his/her side (2)
3. He/she is incontinent of urine and/or faeces (day or night):
   • never (0)
   • sometimes (once or twice per week) (1)
   • frequently (3 times per week or more) (2)
4. He/she is in bed during the day (bed does not include couch, settee, etc):
   • never (0)
   • sometimes (1)
   • almost always (2)
5. He/she is confused (unable to find way around, loses possessions, etc):
   • almost never confused (0)
   • sometimes confused (1)
   • almost always confused (2)
6. When left to his/her own devices, his/her appearance (clothes and/or hair) is:
   • almost never disorderly (0)
   • sometimes disorderly (1)
   • almost always disorderly (2)
7. If allowed outside, he/she would:
   • never need supervision (0)
   • sometimes need supervision (1)
   • always need supervision (2)
8. He/she helps out in the home/ward:
   • often helps out (0)
   • sometimes helps out (1)
   • never helps out (2)
9. He/she/keeps him/herself occupied in a constructive or useful activity (works, reads, plays games, has hobbies, etc):
   • almost always occupied (0)
   • sometimes occupied (1)
   • almost never occupied (2)
10. He/she socialises with others:
    • does establish a good relationship with others (0)
    • has some difficulty establishing good relationships (1)
    • has a great deal of difficulty establishing good relationships (2)
11. He/she is willing to do things suggested or asked of him/her:
    • often goes along (0)
    • sometimes goes along (1)
    • almost never goes along (2)
12. He/she understands what you communicate to him/her (you may use speaking, writing or gesturing):
    • understands almost everything you communicate (0)
    • understands some of what you communicate (1)
    • understands almost nothing of what you communicate (2)
13. He/she communicates in any manner (by speaking, writing or gesturing):
    • well enough to make him/herself easily understood at all times (0)
    • can he understand sometimes or with some difficulty (1)
    • can rarely or never be understood for whatever reason (2)
14. He/she is objectionable to others during the day (loud or constant talking. pilfering, soiling furniture, interfering with affairs of others):
    • rarely or never (0)
    • sometimes (1)
    • frequently (2)
15. He/she is objectionable to others during the night (loud or constant talking, pilfering, soiling furniture, interfering with affairs to others):
    • rarely or never (0)
    • sometimes (1)
    • frequently (2)
16. He/she accuses others of doing him/her bodily harm or stealing his/her personal possessions – if you are sure the accusations are true, rate zero, otherwise rate one or two:
    • never (0)
    • sometimes (1)
    • frequently (2)
17. He/she hoards apparently meaningless items (wads of paper, string, scraps of food, etc):
    • never (0)
    • sometimes (1)
    • frequently (2)
18. His/her sleep pattern at night is:
    • almost never awake (0)
    • sometimes awake (1)
    • often awake (2)

Sensory Status

Eyesight:

(tick which applies)

• can see (or can see with glasses)
• partially blind
• totally blind

Hearing:

(tick which applies)

• no hearing difficulties, without hearing aid
• no hearing difficulties, though requires hearing aid
• has bearing difficulties which interfere with communication
• is very deaf