out a copy of the CAP to refer to as you review these instructions.
The sources for CAP items are indicated on the protocol. Complete
references are cited in the Reference section.
with any other neuropsychological test, the examiner should develop
some rapport prior to starting administration. The patient should
be examined in a quiet room as free of distractions as possible.
Some confused patients can only tolerate very brief testing sessions.
For such patients it is acceptable to break up administration into
more than one session on the same day. The CAP can be administered
as part of a longer, comprehensive bedside assessment. For the typical
patient, CAP examination requires less than 30 minutes. Some parts
of the CAP have alternative forms (CTD Vigilance, CTD Visual Picture
Memory Test, CTD Comprehension Test). These forms should be alternated
on successive administrations of the CAP.
to respond on any CAP item is given the lowest possible score. If
the patient discontinues or avoids items due to agitation or drowsiness,
the lowest possible score is given. Test completion codes are provided
on the protocol to allow the examiner to indicate whether each item
was completed in a standard administration or could not be completed
due to decreased level of arousal, motor impairment, visual impairment,
inability to phonate, aphasia, or agitation.
Attentional Subtest: Items are read to the patient as indicated
on the protocol. Cuing (20, 19, 18) is permitted for the counting
backwards item. No other cuing is permitted. Items are scored as
correct or incorrect; there is no partial credit. When cued for
counting backwards, the patient may pick up with 17 and count down
to 1 and still be scored correct. Some patients may repeat their
responses which may indicate perseveration. For example the patient
may count to 20 and then start counting to 20 again. The first time
this happens, the patient should be instructed to perform each task
only once. Subsequent repetitions are scored as errors.
Vigilance: After reading the instructions, the set of letters
is read to the patient. The patient can indicate that he/she has
heard the letter H in any manner (raised hand, head nod, the word
“yes”, etc.) as long as the indication is clear to the
examiner. The number of hits (correctly identified targets is calculated
and multiplied by 2. Next the number of commissions (incorrectly
identified targets, that is letters other than H that are responded
to) is calculated. The Vigilance score is calculated by subtracting
the number of commissions from the number of hits multiplied by
2. Thus the score is (hits X 2) – commissions.
The GOAT is administered in the standard manner. See Levin, O’Donnell,
and Grossman (1979) for additional information.
Visual Picture Memory Test: Pictures of 5 common objects
are shown to the patient. Each picture is displayed for 3 seconds.
The CTD Comprehension Test is administered to create a brief delay.
Next, pictures of 10 objects are shown to the patient. This set
of 10 pictures includes the 5 previously displayed pictures and
5 novel pictures. The patient is asked to indicate which pictures
he/she has seen before. The patient may indicate in any manner.
One point is given for each correct recognition of a previously
displayed picture (a yes response) and each correct recognition
of a novel picture (a no response). The highest possible score is
picture stimuli are provided in the original CTD paper by Hart and
colleagues (1996). We created our stimuli by enlarging the stimuli
from the article. Pictures were then individually cut-out and laminated.
Note that 2 copies of the 2 sets of 5 target pictures are needed.
This allows the examiner to have a set of 5 pictures to be displayed
and then a separate set of 10 pictures (5 targets and 5 novel pictures)
for the recognition trial.
Comprehension Test: As indicated in the instructions on
the protocol, the 4 questions are read to the patient. The patient
may answer yes or no in any manner (head nods/shakes, the word yes/no,
thumbs up/down, etc.) as long as the indication is clear to the
examiner. Some patients may attempt to discuss the question rather
than giving a yes/no response. The examiner should firmly insist
on a yes or no response.
The ABS is administered as described by Corrigan (1989). For CAP
scoring, ABS ratings should be based on the direct observations
of the examiner as well as the input from nursing staff and therapists
who have worked with the patient in the 8 hour period during which
the CAP was administered. For examiners who do not have previous
ABS rating experience, we find it helpful to have a more experienced
examiner co-rate some patients initially to help the novel examiner
learn a standard way of rating the scale.
Rated Items: The fluctuation, perceptual disturbances and
hallucinations, delusions, and thought process abnormalities items
were taken from the DRS-R. The DRS-R sleep-disturbance item is rated
based on both nighttime and daytime sleep disturbance. Based on
our clinical experience, we thought that it was important to separate
nighttime and daytime sleep disturbance. The DRS-R sleep-disturbance
item was modified so that it is just rated based on nighttime sleep
pattern. We recommend that nighttime sleep graphs are completed
by nursing staff to assist with rating this item. A new item was
created to capture decreased daytime level of arousal. For each
of the Clinician Rated Items, as with the ABS, the examiner should
rate the item based on direct observations as well as input from
nursing staff and therapists who have worked with the patient in
the 8 hour period during which the CAP was administered.
are calculated on the final page of the protocol. Correct performances
on TOTART items are given various point values based on the difficulty
of the items. All incorrect performances are scored 0. Point values
are assigned to CTD Vigilance scores. Recall that the CTD Vigilance
score = (hits X 2) – commissions. CTD Comprehension and CTD
Recognition scores are assigned points in a similar manner. The
cognitive points are totaled (the maximum point total is 28). Totals
< 18 indicate cognitive impairment of sufficient severity to
possibly indicate confusion and such a total would count as one
symptom of confusion. If the cognitive total is < 18, a 1 should
be put in the far right column by Cognitive Impairment.
is determined by the GOAT. A GOAT error score > 24 (indicating
a GOAT score < 76) indicates disorientation and a 1 should be
put in the far right column by Disorientation.
(restlessness) is assessed with the ABS. Scores > 17 indicate
significant restlessness and a 1 should be put in the far right
column by Agitation.
of Symptoms is assessed with the first clinician rated item. A rating
of 1 or 2 on that item indicates significant fluctuation and a 1
should be put in the far right column by Fluctuation.
Disturbance is assessed with the second clinician rated item. Scores
of 2 or 3 indicate significant sleep disturbance and a 1 should
be put in the far right column by Sleep Disturbance.
Daytime Arousal is assessed with the third clinician rated item.
Scores of 2 or 3 indicate significantly decreased daytime arousal
and a 1 should be put in the far right column by Decreased Daytime
Symptoms are assessed with clinician rated items 4, 5, and 6. Scores
of 1, 2, or 3 on item 4 (Perceptual Disturbances and Hallucinations)
or scores of 1, 2, or 3 on item 5 (Delusions) or scores of 2 or
3 on item 6 (Thought Process Abnormalities) are indications of psychotic-type
symptoms and a 1 should be put in the far right column by Psychotic-type
scores of 1 or 0 are assigned for each of the 7 symptoms of confusion,
these scores are summed. CAP totals of 4 or higher indicate that
the patient is in PCS. CAP totals of 3 indicate that the patient
is in PCS if one of the 3 symptoms present is disorientation.