Table 3.
Summary of scales and algorithms in interRAI mental health instruments.
| interRAI scale | Domain | Type of scale | Scale components | Range | Included in |
|---|---|---|---|---|---|
| Aggressive Behavior Scale | Aggressive behavior | Parallel form Sum of items |
Verbal abuse; Physical abuse; Socially inappropriate/disruptive; Resists care | 0–8 | MH, CMH, ESP |
| Activities of Daily Living (ADL) Scale | Basic physical function | Parallel form Sum of items |
Personal hygiene; Locomotion; Toilet use; Eating |
0 to 16 | MH, CMH, ESP |
| Negative Symptoms Scale | Negative symptoms | Parallel form Sum of items |
Anhedonia;Withdrawal from activities of interest; Lack of motivation; Reduced social interactions | 0 to 12 | MH, CMH, ESP |
| CAGE-Crosswalk | Behavioral signs of addiction | Parallel form Sum of items |
Need to cut down substance use; Angered by criticisms from others; Guilt; Drinking/using in am | 0 to 4 | MH, CMH |
| Cognitive Performance Scale | Cognitive function | Decision tree | Daily decision making; Short-term memory; Making self understood; Performance in eating | 0 to 6 | MH, CMH, ESP |
| Depressive Severity Index | Depressive symptoms | Parallel form Sum of items |
Sad, pained facial expressions; Negative statements; Self-deprecation; Guilt/shame; Hopelessness | 0 to 15 | MH, CMH, ESP |
| Instrumental Activities of Daily Living Capacity | Higher level physical functioning | Parallel form Sum of items |
Meal preparation; Ordinary housework; Managing finances; Managing medications; Phone use; Shopping; Transportation |
0 to 30 | MH, CMH, ESP |
| Mania | Mania symptoms | Parallel form Sum of items |
Inflated self-worth; Hyperarousal; Irritability Increased sociability/hypersexuality; Pressured speech; Labile affect; Sleep problems—hypomania |
0 to 20 | MH, CMH, ESP |
| PAIN | Frequency and intensity of pain | Parallel form Sum of items |
Pain frequency; Pain intensity | 0 to 4 | MH, CMH |
| Positive Symptoms Scale | Positive symptoms | Parallel form Sum of items |
Hallucinations; Command hallucinations; Delusions; Abnormal thought process |
0 to 12 | MH, CMH, ESP,BMHS |
| Risk of Harm to Others | Harm to others | Decision tree | Violence/Extreme Behavior; Violent Ideation; Intimidation/threats; Aggressive Behavior Scale; Positive Symptoms Scale; Insight; Delusions; Sleep | 0 to 6 | MH, CMH, ESP |
| Self-Care Index | Self-care | Decision tree | Cognition; Positive Symptoms; Insight; Decreased Energy; Expressive Communication; Hygiene; Mania Scale; Anhedonia | 0 to 6 | MH, CMH, ESP |
| Severity of Self-harm Scale | Self-harm | Decision tree | Self-harm ideation; Suicide attempts; Suicide plan; Others concerned; Depressive severity scale; Positive Symptoms Scale; Cognitive Performance Scale | 0 to 6 | MH, CMH, ESP |