CIBIS. (Clinician Interview Based Impression of Severity)

CIBIS (Clinician Interview Based Impression of Severity)

Baseline CIBIS Examination Instructions This semi-structured interview is based, in part, upon the ADCS Global Impression of Change instrument. It identifies four major categories for evaluation: General, Mental/Cognitive State, Behaviour, and Activities of Daily Living. Each of these four categories is subdivided into Domains. General Mental/Cognitive State Behaviour Activities of Daily Living Relevant History Observation / Evaluation Arousal / Alertness / Attention / Concentration Orientation Memory Language / Speech Praxis Judgement / Problem Solving / Insight Thought Content Hallucinations / Delusions / Illusions Behaviour / Mood Sleep / Appetite Neurological / Psychomotor Activity Basic and Complex (instrumental activities) Social Function Each Domain is assessed by the use of Probes. For all Domains, some suggested Probes are provided. The Interviewer is encouraged to choose additional Probes, as necessary, to enhance the comprehensiveness of the interview. The amount of time required for this Interview is not specified. It is estimated that 30 to 45 minutes may be necessary. Instructions for Assessing Severity at Baseline After completing the interview, the clinician should examine all other relevant information. This will include scores from the MMSE or ADAS-cog. Severity (the CIBIS score) is graded on the 7-point scale. After the recording of Severity, the clinician is asked to indicate, on an analog scale, the extent to which information from each of the four categories helped to determine the CIBIS score. A vertical hash mark should be drawn on scale at the point most closely approximating what the clinician feels is best answer. Each category should be evaluated independently. The scores will not be summed.

MODIFIED CLINICIAN'S INTERVIEW BASED IMPRESSION OF SEVERITY (CIBIS) BRIEF INSTRUCTIONS: DOMAINS be evaluated in any particular order. However, it is essential that each DOMAIN be examined and that observations be recorded in sufficient detail to facilitate assessment of change at 3-6 months. DOMAIN PROBES NOTES GENERAL Relevant History Recent relevant clinical events, illnesses of the patient, caregiver or other family members, significant social or personal events. Major fluctuations in clinical state Observation / Evaluation Appearance - general cleanliness and hygiene, clothing (correctness of clothing for season, neatness, matching colors/prints, fasteners done) DOMAIN PROBES NOTES MENTAL/COGNITIVE STATE - Specify Structured Exam, If Used: Arousal/ Alertness/ Attention/ Concentration Confusion/Clarity Excitement/Reactivity State of consciousness Distractability

DOMAIN PROBES NOTES MENTAL/COGNITIVE STATE (continued) Orientation MODIFIED CLINICIAN'S INTERVIEW BASED IMPRESSION OF SEVERITY (CIBIS) Time (Day, Year) Place (City, State, Clinic) Person Knows relationship to caregiver? Memory Registration Recall Long term/remote/past events Language/ Speech Fluency/Expressive Language Comprehension/Receptive Language Naming Repetition Follows directions (1 step, 2 steps) Praxis Constructional ability (i.e., pentagon, circle) Ideational praxis Ideomotor/Imitation Gait apraxia described/observed Judgement/ Problem Solving/ Insight Patient's behaviour in situations requiring judgement (i.e., electrical power loss in home, locked out of house, etc.) Awareness of self (i.e., of mistakes, inappropriate behaviour, poor judgement) Attempts to correct errors (i.e., of judgements, mistakes)

DOMAIN PROBES NOTES BEHAVIOUR Thought Content MODIFIED CLINICIAN'S INTERVIEW BASED IMPRESSION OF SEVERITY (CIBIS) Organisation appropriateness Relevant to current situation Hallucinations Delusions/ Illusions Auditory/Visual Misperceptions Systematised/Developed Behaviour/Mood Affect/Lability; Unusual/Bizarre Uninhibited; Motivation/Energy Wandering/Getting Lost Agitation/Aggression; Hostility Depression-related Anxiety-related Appropriateness Cooperativeness Sleep/Appetite Sleep disorder Insomnia (type?) Nocturnal activity Hyper-, hyposomnia Appetite/Weight change Food preferences Is patient aware of any problems? Neurological/ Psychomotor Activity Overall motor activity Posture/Gait Movement disorder Unusual motor behaviour/pacing Daily patterns of activity Purposeless Activity

DOMAIN PROBES NOTES ACTIVITIES OF DAILY LIVING Basic and Complex (instrumental) Functional Ability MODIFIED CLINICIAN'S INTERVIEW BASED IMPRESSION OF SEVERITY (CIBIS) Mobility (walking, getting around inside and/or outside of home) Hygiene/Grooming Bowel/Bladder Control Dressing/Choosing clothing Self-feeding, preparing food Household chores Hobbies and personal pursuits (i.e., painting, television) Telephone Is patient aware of any problems? Social Function Participation in: Social interactions Home activities (i.e., family gatherings) External activities (i.e., visiting home of a friend, dining out) Community activities (i.e., religious, day center) Spectator events (i.e., sports, movies) Independence Helplessness Is patient aware of activities? Notes, Comments, Summary Statement: Information from other sources:

MODIFIED CLINICIAN'S INTERVIEW BASED IMPRESSION OF SEVERITY (CIBIS) Enter Test Scores in Boxes: Test Baseline MMSE SEVERITY OF ILLNESS Considering your total clinical experience with this particular population, how mentally ill is this patient now? 0 = Not assessed 4 = Moderately ill 1 = Normal, not at all ill 5 = Markedly ill 2 = Borderline mentally ill 6 = Severly ill 3 = Mildly ill 7 = Among the most extremely ill patients SCORE

CIBIC-plus (Clinician Interview Based Impression of Change plus Caregiver Input)

CLINICIAN'S INTERVIEW BASED IMPRESSION OF CHANGE - CIBIC-PLUS INSTRUCTIONS: Use this form to record the CIBIC-Plus rating after interviewing the Caregiver and Subject. CAREGIVER INTERVIEW INTERVAL HISTORY Clinical events since Baseline Changes? Illnesses? Effects? COMPLIANCE MENTAL / COGNITIVE STATE AROUSAL/ALERTNESS/ ATTENTION/ CONCENTRATION Confusion/Clarity Excitement/Reactivity State of consciousness ORIENTATION Time relationship Travel Finds his/her way? Recognises: Self/Others/Objects Reacts appropriately? MEMORY Recall Memory Past events

CLINICIAN'S INTERVIEW BASED IMPRESSION OF CHANGE - CIBIC-PLUS CAREGIVER INTERVIEW MENTAL / COGNITIVE STATE - Continued LANGUAGE Expression Comprehension Word finding Naming, amount Repetition Follows direction MOTOR ACTIVITY Overall activity Daily pattern Ambulation Movement disorder Unusual movements JUDGMENT PROBLEM SOLVING Subject's behaviour in situations requiring judgement BEHAVIOUR THOUGHT CONTENT Organisation Appropriateness Hostile expression HALLUCINATIONS/ DELUSIONS/ILLUSIONS Auditory/Visual Misperceptions BAHAVIOUR/MOOD Affect/Lability Unusual/Bizarre/Uninhibited Motivation/Energy Wandering Agitation/Aggression/Hostility Depression - related Anxiety - related Appropriateness/Cooperativeness

CLINICIAN'S INTERVIEW BASED IMPRESSION OF CHANGE - CIBIC-PLUS CAREGIVER INTERVIEW BEHAVIOUR - continued SLEEP/APPETITE Sleep disorder Insomnia (type?) Nocturnal activity Hypersomnia - hyposomnia Appetite/Weight change FUNCTIONING BASIC AND COMPLEX (Instrumental) FUNCTIONAL ABILITY PRAXIS SOCIAL FUNCTION Mobility Hygiene/Grooming Dressing Self-feeding Shopping Household chores/hobbies Finances Participation in: - social interactions - community - activity Independence Helplessness NOTES, COMMENTS, SUMMARY STATEMENT: The clinical interview-based impression of change scale used in this study is from the Clinical Global Impression of Change, developed and currently undergoing validity studies by the National Institute on Aging Alzheimer's Disease Study Units Program (1 UO1 AG10483; Leon Thal, Principal Investigator), and is in the public domain.

CLINICIAN'S INTERVIEW BASED IMPRESSION OF CHANGE - CIBIC-PLUS INSTRUCTIONS: Use this form to record the CIBIC-Plus rating after interviewing the Caregiver and Subject. SUBJECT INTERVIEW INTERNAL HISTORY Clinical events since Baseline OBSERVATION/ EVALUATION Appearance MENTAL / COGNITIVE STATE (Refer to Mini-Mental Assessment Packet from this visit only) AROUSAL/ALERTNESS/ ATTENTION/ CONCENTRATION Confusion/Clarity Excitement/Reactivity State of consciousness ORIENTATION Time Place Person MEMORY Registration Recall Long term/remote

CLINICIAN'S INTERVIEW BASED IMPRESSION OF CHANGE - CIBIC-PLUS SUBJECT INTERVIEW MENTAL / COGNITIVE STATE - continued LANGUAGE/SPEECH Fluency/Expressive language Receptive language Comprehension Paraphasis/Word finding PRAXIS Constructional ability Ideational praxis Ideomotor/imitation JUDGMENT PROBLEM SOLVING BEHAVIOUR THOUGHT CONTENT Organisation Appropriateness HALLUCINATIONS/ DELUSIONS/ILLUSIONS Auditory/Visual Misperceptions Systemised/Developed BEHAVIOUR/MOOD Affect/Lability Motivation/Energy Agitation/Aggression/Hostility Depression - related Anxiety - related Uninhibited Appropriateness/Cooperative

CLINICIAN'S INTERVIEW BASED IMPRESSION OF CHANGE - CIBIC-PLUS SUBJECT INTERVIEW BEHAVIOUR - continued SLEEP/APPETITE Sleep disorder Nocturnal activity Appetite/Weight change NEUROLOGICAL/ Overall motor activity PSYCHOMOTOR ACTIVITY Posture/Gait Movement disorder Unusual motor behaviour FUNCTIONING BASIC AND COMPLEX (Instrumental) FUNCTIONAL ABILITY Mobility Hygiene/Grooming Dressing Self-feeding Shopping SOCIAL FUNCTION Interactions Community activities NOTES, COMMENTS, SUMMARY STATEMENT: The clinical interview-based impression of change scale used in this study is from the Clinical Global Impression of Change, developed and currently undergoing validity studies by the National Institute on Aging Alzheimer's Disease Study Units Program (1 UO1 AG10483; Leon Thal, Principal Investigator), and is in the public domain.

CLINICIAN INTERVIEW BASED IMPRESSION OF CHANGE SUMMARY SHEET THREE SIX MONTH VISIT Subject s Interview Clinical Impression of Change: Very Much Improved Much Improved Minimally Improved No change Minimal worsening Moderate worsening Marked worsening Informant s Interview Clinical Impression of Change: Very Much Improved Much Improved Minimally Improved No change Minimal worsening Moderate worsening Marked worsening Overall Score Clinical Impression of Change: Very Much Improved Much Improved Minimally Improved No change Minimal worsening Moderate worsening Marked worsening *** A patient will need to have a score of Much Improved or Very Much Improved to qualify for ongoing treatment with a cholinesterase inhibitor. For a full list of the Prescribing Guidelines, please refer the Schedule of Pharmaceutical Benefits Book.