The Edinburgh Cognitive and Behavioural ALS Screen (ECAS)

Administration and Guidance Notes 2013

English Version
The ECAS is a practical screening tool that incorporates a range of short cognitive tests that have been shown to be
sensitive to cognitive impairment in ALS. The ECAS has been designed to differentiate between the different profiles
common with ageing including depression, Alzheimer’s disease and Fronto-Temporal Dementia. Executive Functions,
Memory, Language, Visuo-Spatial skills and Social cognition are specifically assessed whilst a Behavioural and
Psychosis brief interview can be carried out with carers or relatives. The ECAS is designed for ALS patients and answers
can be given verbally, or by a combination of writing or pointing. It is suitable for patients who are anarthric or patients
who have no hand motor function. The total score is 136 points and should take no longer than 15 minutes to administer.
Equipment required
To carry out the ECAS, you will need a clock or a watch with a second hand (though a stopwatch would be preferable).
A calculator is recommended for calculations (though these can also be carried out by hand). Answers can be written
or spoken, though should be spoken where possible. If answers are to be written, extra sheets of paper and a selection
of pens that will suit the person’s writing ability will be required.

Language – Naming: Score 0-8

Administration: There are eight pictures displayed. Ask the person to name the objects shown. No time limit is enforced
for the task. Incorrect answers are recorded and no prompt for alternative word is provided. A correct score will only be
given if the exact name is said or spelled correctly. Self-corrections are allowed; only the final answer is taken for scoring.
If the participant answers with the word of ribbon for bow and squeeze box for accordion, prompt once with “Do you
know another name for this object?”. If the person answers with a lower frequency name which is correct, such as
hatchet for axe, score as correct.
Scoring: One point is given for every correct name given. Correct answers are (left to right, top to bottom); scorpion,
bow, helicopter, fox, axe, squirrel, swan, accordion.

Language – Comprehension: Score 0-8

Administration: Using the pictures from the naming task, ask the person to correctly answer the questions. Questions
are either read by the person or to the person, depending on preference. Some questions will require the repetition of
an earlier item to serve as an answer; participants are not warned about this in advance but this can be clarified if
queried. If no answer is provided, answer space is to be left blank. Self-corrections are allowed; only the final answer is
taken for scoring.
Scoring: One point is given for every correct answer given. Correct answers are; helicopter, swan, squirrel, axe,
helicopter, axe, scorpion, squirrel.

Memory – Immediate Recall: Score 0-10

Administration: Say: “I am going to read you a short story. Please listen carefully. When I am finished, say or write as
much as you can remember.”
Story should be read at a steady pace of 2 words per second/the story should take around 20 seconds to read out.
When finished reading story aloud, say to participant “Now that’s the end of the story, what can you remember?”

© Copyright, The University Court of the University of Edinburgh, 2009 - 2013. All Rights Reserved. The authors being S. Abrahams & T. H. Bak
Time for recall is unlimited, until participants say that they can remember no more. Self-corrections are allowed; only
the final answer is taken for scoring.
Scoring: Score 1 point for each (either entire or part of) underlined section recalled.
For example “annual litter collection” recalled as ‘annual collection’ ‘litter collection’ or ‘annual rubbish collection’ would
each score 1 point. Number information must be recalled accurately, for example “Forty two people” recalled as ‘forty
something’ would score 0 points. This immediate recall score will also be used later on to calculate the percentage of
memory retained over time. No prompts should be given for specific information, only “is that everything you can
remember” should be asked to confirm participant is finished recall.

Language – Spelling: Score 0-12

Administration: Say “Spell, either by writing or speaking, the following words.”

If the person is using assistive technology, ask them to turn off any predictive text facility.
Unlimited time is given for spelling of each word. All words are assessed even if early words in the list are incorrect.
Move on to the next word if participant is unable or unwilling to attempt spelling of one word. For some patients it may
be easier to write these words than to keep track of spoken spellings, alternatively allow the patient to view as the tester
writes the spellings clearly.
Scoring: Score 1 point for each correct spelling. Self-corrections are allowed; only the final answer is taken for scoring.
Caution should be taken in interpretation where low premorbid IQ or a history of reading or spelling difficulties is reported.
It is recommended interviewer ask patient and/or carer about premorbid reading and writing abilities.
Fluency - Letter S: Score 0-12

Administration: The person can perform this task either by speaking or writing. Say: “I am going to give you a letter of
the alphabet and I would like you to say or write as different many words as you can beginning with that letter. But not
names of people or places, or numbers. If writing, say: “You will have two minutes and the letter is S.” If speaking,
say “You will have one minute and the letter is S.” Next the person copies/repeats these words.
 If writing, say: “Copy these words as fast as possible. I will time you. Ready? Begin.”
 If speaking, say: “Read aloud these words as fast as possible. Before you do this, check that you can read
them. I will time you. Ready? Begin.”
Scoring: All answers provided are recorded however the following rules apply for scoring items as correct.
Words must be varied for example: sugar, salt, slipper, snow, scream, shoot, scale, scissors….
Do not include repetitions, nonsense words or proper names in scoring items correct.
Repetitions where a second meaning is provided (e.g. ‘school - the educational institution’ or ‘school - collective name
of fish’) are scored as independent items. Likewise, when items are spoken and a different spelling/meaning is indicated
(e.g. slow and sloe) items are scored as independently correct. Where a meaning change is indicated (e.g. savour and
savoury) items are scored as independently correct.
Plural words will be accepted, only if they have not already been provided in singular form (e.g. slipper, slippers = score
1). Perseverations of words such as sit, sat, sitting… where meaning is not changed, are not accepted as correct (e.g.
sit, sat, sitting = score 1).
In order to account for differences in motor speed and speaking time variations, a Verbal Fluency Index (VFI) is
calculated using the equation below.

For example, a participant given 60 seconds to complete the

VFI = (test time – time taken to repeat words))
task who generates 5 words and then takes 15 seconds to
Number of correct words generated read these words aloud would have a VFI of 9:
60-15 = VFI of 9
5
A participant’s VFI is converted to a Fluency score using the conversion table provided in ECAS.

© Copyright, The University Court of the University of Edinburgh, 2009 - 2013. All Rights Reserved. The authors being S. Abrahams & T. H. Bak
 Executive – Reverse Digit Span: Score 0-12

Administration: Numbers should be read out at a pace of 1 number per second. Say: “I am going to say some
numbers and I would like you to say them back to me in reverse order. For example, if I say ‘2 3 4’, you should say ‘4
3 2’. Let’s have a practice. If I say ‘7 1 9’, what would you say?”If participant cannot complete the practice trial, another
practice trial is provided at the level of two digits, before moving on to test items. If a participant cannot complete a
practice trial at the level of two items, the test is scored as 0 out of 12 and no further test items are attempted.
Advance warning that the number sequences will increase in length is provided at the start of each line of a trial. In
order to score a trial of a line as correct, participant must accurately recall all items in reverse order. No score is given
for individual numbers correctly recalled in an incorrectly recalled sequence. If person gets at least one trial of a line
correct, move on to the next line. Self-corrections are allowed; only the final answer is taken for scoring. Stop when
person gets both trials of a line wrong.

Score: Score is total number of trials achieved correctly (out of 12).

Executive – Alternation: Score 0-12

Administration: Say: “I want you to alternate between numbers and letters, starting with 1-A, then 2-B, 3-C, and so on.
Please continue from there, alternating between numbers and letters, in order, without skipping any until I tell you to
stop”. Say: “1-A, 2-B, 3-C...” with the patient and then let them continue the sequence alone.
Score: One point is given for every correct trial.

Fluency - Letter T: Score 0-12

Administration: The person can perform this task either by speaking or writing. Say: “I am going to give you a letter of
the alphabet and I would like you to say or write as many different words as you can beginning with that letter. But not
names of people or places, or numbers. This time the word must only be four letters long. No more or less than
four letters.” Note: Plurals are accepted in order to create four letters – for example, Toes.
 If writing, say: “You will have two minutes and the letter is T.”
 If speaking, say “You will have one minute and the letter is T.”
Next the person copies/repeats these words.
 If writing, say: “Copy these words as fast as possible. I will time you. Ready? Begin.”
 If speaking, say: “Read aloud these words as fast as possible. Before you do this, check that you can read
them. I will time you. Ready? Begin.”
Scoring: See scoring criteria from previous Fluency task to produce VFI, and conversion table provided in ECAS.

Visuospatial – Dot counting: Score 0-4

Administration: Say “I would like you to count how many dots are in each box, but without pointing to them”. Progress
from left to right and top to bottom to move through the squares. All squares should be attempted.
Score: One point for each correct box. Correct answers are: Top left 10, top right 8, bottom left 7, bottom right 9.

Visuospatial – Cube counting: Score 0-4

Administration: Ask the person “How many cubes are in each structure, including the ones you may not be able to
see?” Progress from left to right and top to bottom to move through the cube structures. All structures should be
attempted.
Score: one point for each correct answer. Correct answers are top left 5, top right 6, bottom left 10 and bottom
right 7.

Visuospatial – Number location: Score 0-4

© Copyright, The University Court of the University of Edinburgh, 2009 - 2013. All Rights Reserved. The authors being S. Abrahams & T. H. Bak
Administration: Ask the person “Which number corresponds to the position of the dot?’ Progress from left to right and
top to bottom to move through the squares. All squares should be attempted. If the patient does not understand the
instructions explain further “Imagine this box (point to the lower box) is placed on top of this box (point to the top box),
on which number would the dot fall?
Score: One point for each correct answer. Correct answers are top left 6, top right 5, bottom left 2, bottom right 3

Executive – Sentence completion: Score 0-12

Administration: Say “Listen carefully to these sentences and as soon as I have finished reading them, please tell me, or
write, a word that finishes the sentence as quickly as possible.” For example, ‘She was so tired that she went straight
to…bed’. Do not score the first two questions.
Now say: “ I’d like you to do that again, but this time the word you give should not make sense whatsoever in the context
of the sentence. It must not be related to the word that actually completes the sentence. For example, ‘John cut his
hand with the sharp…orange’. If person answers with a word which completes the sentence in context then remind
them that the requirement is to provide an answer that bears no significance to the context of the sentence. Progress
through all questions, even when incorrect answers are provided. If the person does not respond within 20 seconds,
move onto the next question.
Score: Give 2 points for completely unconnected word, 1 for related word (e.g. associated or opposite meaning) and
0 for exact word. See table below for scoring examples. Note: sentences can be ungrammatical.

Question 2 points 1 point 0 points

1 The postman knocked on the... Car, potato... Window, gate, Door
mailbag...
2 He brought his umbrella with Rubber, Sunshine, wind, ice... Rain
him in case of... parachute...
3 Sally spread her toast with Earth, sand... Cereal, egg, oranges... Jam, Marmalade,
butter and... Honey, Cheese
4 John went to the barber and Moon, table... Washed, lengthened, Cut
got his hair... singed...
5 She dived into the swimming... Garden, Pond, bath, rock... Pool
swing...
6 They all went to the local café Jump, Do, play, buy... Eat, drink.
for something to... dance...

Social Cognition – Part A

Administration: The first page contains six boxes each with four pictures in each corner.
Say: “You are going to see some pictures, one in each corner of a box. You have to choose which picture you like
best. Either point to or say which picture you like best. Please respond as quickly as possible.”
Score: Answers are recorded but not scored; responses are used as information to support scoring in the next section.

Social Cognition – Part B: Score 0-12

Administration: Say: “You are going to see some pictures, one in each corner of a box. You have to choose which
picture does the face like best. Either point to or say which the face likes best. Please respond as quickly as possible.’
Progress through all questions even when incorrect answers are provided. If the participant does not understand the
instructions do not elaborate, but repeat the instructions.

© Copyright, The University Court of the University of Edinburgh, 2009 - 2013. All Rights Reserved. The authors being S. Abrahams & T. H. Bak
Score: Two points for each correct response. Of the items not correctly identified, score 1 point if answer was NOT the
item that participant picked as their own favourite in the previous section, score 0 points if the item WAS picked as their
own favourite.

Memory – Delayed recall: Score 0-10

Administration: Say: “At the beginning of this interview, I read you a story. Tell me as much as you can remember from
that story.” Time for recall is unlimited, until participants say that they can remember no more. Self-corrections are
allowed; only the final answer is taken for marking.
Mark: 1 point for each (either entire or part of) underlined section recalled. The percentage of memory retained is now
calculated. Take the total recall for Delayed Memory and divide it by the Immediate Memory score, before
multiplying this number by 100. For example:
With a Delayed Memory recall of 8 sections, and an Immediate Memory Score of 9/10
The percentage of retained memory is 89%.
Some patients may recall more at delay than immediate and the percentage will be displayed as being over 100%. Use
the conversion table provided in ECAS to derive scoring.

Memory – Delayed recognition: Score 0-4

Administration: This test should only be done if the person failed to recall one or more items. If all the items were recalled,
skip the test and score 4.
Otherwise, say: “Lets see if you can remember anything more about that story. I will ask you some questions, please
tell me if they are true or false”.
Score: Score 1 point for each correct answer; correct answers are marked in bold in this section. If the person gives a
“don’t know” answer ask them to make a guess on True or False and score accordingly. Use the conversion table
provided in ECAS to derive final scoring for recognition section.

SCORES
Language Naming, Comprehension, Spelling /28
Verbal Fluency Fluency Letter S, Fluency Letter T /24
Executive Reverse Digit Span, Alternation, Sentence Completion, Social
Cognition /48
ALS-SPECIFIC: /100

Memory Immediate recall, Delayed recall score, /24

Delayed recognition
Visuospatial Dot Counting, Cube Counting, Number Location /12
ALS NON-SPECIFIC: /36
ECAS TOTAL SCORE /136
K CUT OFF SCORES FOR ABNORMALITY (Abrahams et al. 2013)
ECAS TOTAL SCORE 105
ALS-SPECIFIC 77
ALS NON-SPECIFIC 24
Language 26
Verbal Fluency 14
Executive 33
Memory 13
Visuospatial 10

© Copyright, The University Court of the University of Edinburgh, 2009 - 2013. All Rights Reserved. The authors being S. Abrahams & T. H. Bak
 ALS Carer Behaviour Screen
Guidance and Administration
English Version

Guidance.
Please ask the carer or relative to complete this screen in private from the patient, ideally in a separate room. There are
five components to this screen.
Some people may have noticed a change in all areas, some in a few and others may note there are no changes with
the patient. Please ask the carer or relative to give any examples if possible.

Administration – Score 0-10

Please ask the carer about the listed possible behaviours. Symptoms should have occurred repeatedly and not just on
one instance, and may have occurred prior to the development of any motor signs. Tick ‘Yes’, ‘No’ or ‘Don’t Know’. If
‘Yes’, please provide a brief written description. Give one mark for every ‘Yes’ response (maximum = 10).

ALS – Psychosis Screen

Guidance and Administration
English Version

Guidance
Please ask the carer or relative to complete this section away from the patient, ideally in another room. Please remind
the carer or relative that the questions asked are only relevant since the onset of ALS.

Administration- score 0-3

Please ask the carer about the following possible symptoms. Tick ‘Yes’, ‘No’ or ‘Don’t Know’. If ‘Yes’, please provide a
brief written description. Give one mark for every ‘Yes’ response (maximum = 3).

Guidance
Please ask the carer or relative the listed questions. If the answer is Yes to any question please note any relevant
examples or comments.

© Copyright, The University Court of the University of Edinburgh, 2009 - 2013. All Rights Reserved. The authors being S. Abrahams & T. H. Bak
 REFERENCE
Abrahams, S., Newton, J., Niven, E.H., Foley, J. & Bak, T.H.B. Screening for cognitive and behavioural changes
in ALS (2013). Amyotrophic Lateral Sclerosis and Frontotemporal Degenerations. Posted online June 13, 2013.
doi:10.3109/21678421.2013.805784

Acknowledgement: The development f the ECAS was funded by an award from the Motor Neurone Disease
Association, UK.

© Copyright, The University Court of the University of Edinburgh, 2009 - 2013. All Rights Reserved. The authors being S. Abrahams & T. H. Bak