. Author manuscript; available in PMC: 2015 Apr 7.

Published in final edited form as: Dement Geriatr Cogn Disord. 2014 Apr 7;38(1-2):89–146. doi: 10.1159/000357839

Table 4.

The BEHAVE-AD-FW: conceptual framework, methodology, construct validity, reliability, criterion validity, and utility ^*

A Conceptual framework
The BEHAVE-AD has been demonstrated to be a valid, reliable, and sensitive scale. The BEHAVE-AD has demonstrated sensitivity to both nonspecific psychological interventions and further sensitivity to the additional effects of pharmacological intervention with two classes of pharmacological medications, i.e., anxiolytic medication and antipsychotic medication. Despite the success of the BEHAVE-AD and its clear utility, there is a need for increased sensitivity of the measure, if possible. We therefore developed a frequency-weighted scale dimension for concurrent assessment with the BEHAVE-AD.

B Methodology
The elements of the previously developed BEHAVE-AD assessment are used in their entirety. These elements include the 2-week time frame of symptomatic assessment. They also include the 25 BEHAVE-AD questions assessed in the 7 symptomatic categories on the 4-point severity scale. Additionally, a frequency-weighted score is added for each item of the traditional BEHAVE-AD. For 24 of the 25 BEHAVE-AD symptomatic items, the frequency dimension is assessed on a 4-point scale. One symptomatic item, ‘day/night disturbance’, is assessed on a 3-point frequency score. The frequency ratings are all referenced to the prior 2-week interval, and the information is obtained from the same knowledgeable informant from whom the severity information is obtained, immediately after the severity level is established. The frequency is referenced to the symptomatic item severity level. The frequency scoring is: 1 = once (over the preceding 2-week interval); 2 = every several days; 3 = daily, and 4 = more than once daily. Conceptually and procedurally, the frequency level ‘4’ is not applicable for day/ night disturbance, hence this item is scored on a 3-point frequency scale. The frequency-weighted score for each item is obtained by multiplying the severity item score by the frequency score. The frequency-weighted score for each BEHAVE- AD-FW category is obtained by adding the frequency-weighted scores for the category items. Similarly, the total scale frequency-weighted score is the sum of the frequency-weighted scores of the 25 BEHAVE-AD items.

C Construct validity
For spouses, professional caregivers, friends, and others in contact with individuals with dementia or with the antecedents of dementia, such as MCI, the frequency of a behavioral disturbance adds to the severity of the disturbance in terms of the actual burden of their social contact. Therefore, a reliably obtained frequency dimension should add to the severity assessment in terms of the full measure of social burden (disturbance). For treatment trials, frequency-weighted symptomatic assessments together with severity symptomatic assessments should potentially provide greater sensitivity to therapeutic efficacy.

D Reliability
Authors [Ref.]	Methodology	Findings
Monteiro et al. [2]	Informants of 28 subjects with MCI (n = 5) or dementia (n = 23) were interviewed. The dementia subjects had probable AD (n = 22) or possible AD (n = 1). The subjects consisted of 14 men and 14 women, with a mean age of 73.5 (SD = 7.9) years. The MMSE scores ranged from 28 to 0 (mean 18.8 ± 7.8). The informants were from one of the following categories: spouse (n = 12), one or more adult children (n = 10), a close friend of the subject (n = 3), or a paid professional caregiver (n = 3). Subjects were baseline or follow-up participants in longitudinal studies at the New York University (NYU) School of Medicine’s Aging and Dementia Research Center and the NYU US National Institute on Aging (NIA)-supported Alzheimer’s Disease Center. Two experienced clinicians interviewed the informants, generally on an alternating basis.	For all 3 methodologies studied, all 7 symptomatic categories and total scores showed significant correlations between the scores for the 2 clinicians (all p values <0.001). For the traditional BEHAVE-AD severity scores, the correlations between the ratings of the 2 clinicians for the 7 BEHAVE-AD symptomatic categories ranged from 0.74 (for Diurnal Rhythm Disturbances) to 0.97 (for Hallucinations) (all p values <0.001). For the total BEHAVE-AD severity scores, the ICC for the scores of the 2 raters was 0.90 (p < 0.001). For the unweighted frequency scores, the correlation between the ratings of the 2 clinicians for the 7 symptomatic categories ranged from 0.86 (for Activity Disturbances) to 0.97 (for Affective Disturbances). For the total BEHAVE-AD-FW absolute frequency scores, the ICC for the 2 raters was 0.96 (p < 0.001).
Monteiro et al. [2]	Both clinicians were present for all informant interviews and independently rated the responses based upon the information obtained by the designated interviewer. The observing clinician had an opportunity to clarify responses from the informant at the conclusion of the designated clinician interview. No discussion of scoring was permitted between the clinicians. The reliability study examined ICCs with respect to 3 components of the BEHAVE-AD-FW scoring: (1) traditional BEHAVE-AD severity scores, (2) absolute frequency values, and (3) frequency-weighted severity scores for the BEHAVE-AD-FW.	Finally, for the frequency-weighted severity scores, the correlation for the 7 symptomatic categories of the scores of the 2 clinicians ranged from 0.69 (for Diurnal Rhythm Disturbances) to 0.98 (for Hallucinations). For the entire BEHAVE-AD-FW, the correlation between the scores of the 2 raters was 0.91 (p < 0.001). Hence, in absolute terms, the reliability of the BEHAVE-AD-FW was found to be even greater than that of the traditional BEHAVE-AD. Furthermore, since the BEHAVE- AD-FW adds an additional dimension of observation and results to the total scores, which are approximately 2.5 times greater than those of the traditional BEHAVE-AD, we hypothesize that the BEHAVE-AD-FW is approximately 2.5 times as sensitive to therapeutic effects of interventions as the traditional, BEHAVE-AD without the frequency dimension.

E Criterion validity
The BEHAVE-AD-FW assessment instrument contains all elements of the traditional BEHAVE-AD assessment. Therefore, all studies which have demonstrated the criterion validity of the traditional BEHAVE-AD instrument in terms of sensitivity to both nonpharmacological (e.g., placebo related) and pharmacological intervention [e.g., 24-28, 100] apply to the BEHAVE- AD-FW. Additionally, the BEHAVE-AD-FW adds a frequency rating dimension which has been demonstrated to be reliable [2] and which should add an approximately 2.5 times greater sensitivity to the traditional BEHAVE-AD [2].

F Utility
The BEHAVE-AD-FW has been used to identify the relationship between an individual delusional symptom and the cognitive course of AD [5]. The BEHAVE-AD-FW has also been used to uncover the relationship between a particular delusional symptom in AD and changes in blood flow in a brain region associated with emotionality [6]. Hence, the BEHAVE-AD-FW assessment is beginning to fulfill the goals and promise of this instrument in the sensitive identification of individual delusional symptoms in AD. However, perhaps the greatest promise of the BEHAVE-AD-FW assessment is the more sensitive identification of treatment responsiveness in AD. The BEHAVE-AD-FW has apparently not yet been utilized for this important purpose, which can serve to advance treatment possibilities for AD.