What is the CDR?

The CDR is a 5-point scale used to characterize six domains of cognitive and functional
performance applicable to Alzheimer disease and related dementias: Memory, Orientation,
Judgment & Problem Solving, Community Affairs, Home & Hobbies, and Personal Care. The
necessary information to make each rating is obtained through a semi-structured interview of the
patient and a reliable informant or collateral source (e.g., family member).

The CDR table provides descriptive anchors that guide the clinician in making appropriate
ratings based on interview data and clinical judgment. In addition to ratings for each domain, an
overall CDR score may be calculated through the use of an algorithm. This score is useful for
characterizing and tracking a patient's level of impairment/dementia:
0 = Normal
0.5 = Very Mild Dementia
1 = Mild Dementia
2 = Moderate Dementia
3 = Severe Dementia
Assignment of CDR rating
Use all information available and make the best judgment. Score each category (M, O, JPS, CA,
HH, PC) as independently as possible. Mark in only one box, for each category, rating
impairment as
decline from the persons usual level due to cognitive loss alone, not impairment due to other
factors,
such as physical handicap or depression. Occasionally the evidence is ambiguous and the
clinicians
best judgment is that a category could be rated in either one of two adjacent boxes, such as mild
(1) or
moderate (2) impairment. In that situation the standard procedure is to check the box of greater
impairment.
Aphasia is taken into account by assessing both language and non-language function in each
cognitive category. If aphasia is present to a greater degree than the general dementia, the
subject is
rated according to the general dementia. Supply evidence of non-language cognitive function.
The global CDR is derived from the scores in each of the six categories ("box scores") as follows.
Memory (M) is considered the primary category and all others are secondary. CDR = M if at least
three
secondary categories are given the same score as memory. Whenever three or more secondary
categories are given a score greater or less than the memory score, CDR = score of majority of
secondary categories on whichever side of M has the greater number of secondary categories.
When
three secondary categories are scored on one side of M and two secondary categories are
scored on the
other side of M, CDR=M.
When M = 0.5, CDR = 1 if at least three of the other categories are scored one or greater. If M =
0.5, CDR cannot be 0; it can only be 0.5 or 1. If M = 0, CDR = 0 unless there is impairment (0.5 or
greater) in two or more secondary categories, in which case CDR = 0.5.
Although applicable to most Alzheimer's disease situations, these rules do not cover all possible
scoring combinations. Unusual circumstances occur occasionally in Alzheimer's disease and
may be
expected in non-Alzheimer dementia as well are scored as follows:
(1) With ties in the secondary categories on one side of M, choose the tied scores closest to M
for
CDR (e.g., M and another secondary category = 3, two secondary categories = 2, and two
secondary categories = 1; CDR = 2).
(2) When only one or two secondary categories are given the same score as M, CDR = M as
long as
no more than two secondary categories are on either side of M.
(3) When M = 1 or greater, CDR cannot be 0; in this circumstance, CDR = 0.5 when the majority
of
secondary categories are 0.
Morris, J.C. (1993). The clinical dementia rating (CDR): Current version and scoring rules.
Neurology,
43(11), 2412-2414.

Clinical Dementia Rating
On-line Training System
Alzheimers Disease Research Center (ADRC)
John C. Morris, M.D., Principal Investigator & Co-Director
Washington University School of Medicine, St. Louis, Missouri, USA
What is the Clinical Dementia Rating (CDR)?
The CDR is a clinical staging instrument for dementia. It characterizes six domains of
cognitive and
functional performance: Memory, Orientation, Judgment & Problem Solving, Community
Affairs, Home &
Hobbies, and Personal Care. The necessary information to make each rating is
obtained through a semistructured
interview of the patient and a reliable informant or collateral source (e.g., a family
member). The
CDR Table provides descriptive anchors that guide the clinician in making appropriate
ratings based on
interview data and clinical judgment. In addition to ratings on a 5-point scale for each
domain (except
Personal Care, which is rated on a 4-point scale) an overall CDR score is derived by
standard algorithm.
This score is useful for globally staging the level of impairment: 0 = No impairment, 0.5,
1, 2, and 3 indicate
Very Mild, Mild, Moderate and Severe Dementia.
Morris J.C. The Clinical Dementia Rating (CDR): Current version and scoring rules.
Neurology,1993;
43:2412-2414. The scoring algorithm can be accessed at
http://www.biostat.wustl.edu/~adrc/cdrpgm/index.html.
Who uses the CDR and for what purposes?
The CDR is used in both research and clinical settings to characterize the level of
cognitive and functional
performance in patients at risk for or suspected of having Alzheimers Disease or
another dementing
disorder. Common applications include patient evaluation in memory assessment
clinics, research studies
of normal elderly and those with dementia, and clinical trials of therapeutic agents that
might influence
dementia progression.
Is special training needed?
The CDR is based on information elicited through a semi-structured interview
standardized in an
assessment protocol. Clinical skills to elicit appropriate information and judge its
relevance are required.
Physicians and advanced practice nurses administer the protocol and score the CDR in
our center.
Physicians and non-physician health professionals demonstrate good reliability in
administering the CDR
after appropriate training. (Morris JC, Ernesto C, Schafer K, et. al. Clinical Dementia
Rating training and
reliability in multi-center studies: The Alzheimer's Disease Cooperative Study
experience. Neurology 1997;
48:1508-1510.)
The Brief Training and Reliability Protocol (BTRP) includes an introduction to the CDR
by Dr. John Morris,
three videotaped patient interviews for training purposes, and six videotaped interviews
for reliability
certification. Successful completion of the 6 reliability tapes is achieved with agreement
with a gold
standard on at least 5 out of the 6 tapes. Alternatively, the ADRC offers
mini-fellowships in the CDR where
in on-site observations of the CDR with actual patients by a CDR-experienced clinician
permits individual
instruction.
Become a CDR Rater On-line
The Brief Training & Reliability Protocol (BTRP) for the CDR is available for browsing
and formal reliability
training through the ADRC Website. Individual health professionals and researchers are
welcome to use
this system free of charge. Fees may apply for commercial and group users, however.
To access the
system and related documentation, go to http://alzheimer.wustl.edu/adrc2, click on
the Clinical Dementia
Rating link in the Education Menu, and then follow the instructions to access the training
modules. Full
training through the BTRP requires 6-9 hours, but this can be broken up over multiple
sittings. This system
is made possible through funding from the National Institute on Aging (P50-AG05681).
Questions? Contact the ADRC Education Director at adrcedu@abraxas.wustl.edu or
call 314-286-2882.

WASHINGTON UNIVERSITY CLINICAL DEMENTIA RATING
The Washington University Clinical Dementia Rating Scale (CDR) is widely used in longitudinal and clinical studies to
gauge Alzheimer's Disease progression. The CDR is also helpful as a guide in the clinical care of Alzheimer's
Disease patients and their family care providers.
A specially trained physician, nurse, psychologist or other health professional administers the CDR
semi-structured interview to both patient and informant (usually a close family member). Impairment levels are
determined in six cognitive-functional categories:
1- Memory
2- Orientation
3- Judgment
4- Community Affairs
5- Home & Hobbies
6- Personal Care
Click HERE to view the CDR grid.
A five-point scale is used to rate function in each category:
0 = Normal (no significant problem)
0.5 = Questionable Impairment (more than just normal aging)
1 = Mild Impairment (mildly impaired relative to peers)
2 = Moderate Impairment
3 = Severe Impairment
Interview data from the patient and informant are reviewed to determine functional impairment ratings in each
cognitive category. These category scores (or "box scores") are then analyzed using special scoring rules to
determine a final, overall CDR score. Click HERE to utilize the CDR Scoring Algorithm.
Individuals who receive a score of 1 or greater show clear signs of a dementing illness, in most cases Alzheimer's
Disease. Those who score O.5 may be experiencing the very early manifestations of dementia. Repeated evaluation
over time allows the illness process to be tracked and diagnostic clarifications to be made.


CLINICAL DEMENTIA RATING (CDR)

Impairment Level and CDR Score (0, 0.5, 1, 2, 3)
None
0
Questionable
0.5
Mild
1
Moderate
2
Severe
3
Memory No memory loss or
slight inconsistent
forgetfulness
Consistent slight
forgetfulness; partial
recollection of events;
"benign"
forgetfulness
Moderate memory
loss; more marked for
recent events; defect
interferes with
everyday activities
Severe memory loss;
only highly learned
material retained; new
material rapidly lost
Severe memory loss;
only fragments remain
Orientation Fully oriented Fully oriented except
for slight difficulty
with time
relationships
Moderate difficulty
with time
relationships; oriented
for place at
examination; may have
geographic
disorientation
elsewhere
Severe difficulty with
time relationships;
usually disoriented to
time, often to place
Oriented to person
only
Judgment &
Problem
Solving
Solves everyday
problems & handles
business & financial
affairs well; judgment
good in relation to
past performance
Slight impairment in
solving problems,
similarities, and
differences
Moderate difficulty in
handling problems,
similarities, and
differences; social
judgment usually
maintained
Severely impaired in
handling problems,
similarities, and
differences; social
judgment usually
impaired
Unable to make
judgments or solve
problems
Community
Affairs
Independent function
at usual level in job,
shopping, volunteer
and social groups
Slight impairment in
these activities
Unable to function
independently at
these activities
although may still be
engaged in some;
appears normal to
casual inspection
No pretense of
independent function
outside home
Appears well enough
to taken to functions
outside a family home
No pretense of
independent function
outside home
Appears too ill to be
be taken to functions
outside a family home
Home and
Hobbies
Life at home, hobbies,
and intellectual
interests well
maintained
Life at home, hobbies,
and intellectual
interests slightly
impaired
Mild but definite
impairment of
function at home;
more difficult chores
abandoned; more
complicated hobbies
and interests
abandoned
Only simple chores
preserved; very
restricted interests,
poorly maintained
No significant
function in home
Personal Care Fully capable of self-care Needs prompting Requires assistance in
dressing, hygiene,
keeping of personal
effects
Requires much help
with personal care;
frequent incontinence

Score only as decline from previous usual level due to cognitive loss, not impairment due to other
factors.
http://www.adrc.wustl.edu/cdrGrid.html

http://alzheimer.wustl.edu/adrc2/Education/CDR%20Inter-Page.html

http://alzheimer.wustl.edu/

http://www.biostat.wustl.edu/~adrc/cdrpgm/index.html