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  2. Frontal Behavioral Inventory

Frontal Behavioral Inventory

Purpose

The FBI is a 24-item inventory designed to assess behavior and personality changes associated with the behavioral variant of frontotemporal dementia via caregiver report.

Link to Instrument

Instrument Details

Acronym FBI

Area of Assessment

Activities of Daily Living
Aphasia
Apraxia
Assertiveness
Attention & Working Memory
Behavior
Cognition
Communication
Coordination
Eating
Executive Functioning
Incontinence
Insight
Language
Life Participation
Mental Health
Motivation
Negative Affect
Occupational Performance
Personality
Reasoning/Problem Solving
Stress & Coping
Word Finding

Assessment Type

Proxy

Administration Mode

Paper & Pencil

Cost

Not Free

Actual Cost

$6.00

Cost Description

Purchase assessment at http://www.agedcaretests.com/Frontal_Behavioural_Inventory_(FBI)_Sample.pdf

Diagnosis/Conditions

  • Brain Injury Recovery
  • Parkinson's Disease & Movement Disorders

Populations

Alzheimer's Disease and Progressive Dementia

Key Descriptions

  • 24 items capture data regarding deficit and disinhibition behaviors
  • Item-level scores range from 0-3, determined by symptom severity and frequency (0 = never, 1 = mild or occasional, 2 = moderate, 3 = severe or very frequent)
  • Item scores are summed (Max = 72)
  • Administration instructions:
    A) Administrator first explains to the caregiver that they are looking for a change in behavior and personality.
    B) Administrator asks caregiver questions in the absence of the patient.
    C) Administrator is instructed to stick to provided script when describing each scoring item and to elaborate only when necessary.
    D) If the caregiver does not understand the question or talks about something unrelated to the question, the administrator is to redirect by repeating the question.
    E) At the end of each question, the administrator will ask about the extent frequency and severity of the behavioral change and assign a 0-3 score.
    F) Administrator should encourage caregiver to provide examples of abnormal behavior and record those on a separate sheet of paper attached to the inventory.
  • Any other important information from manuals or publications:
    A) In order to maintain objectivity, someone other than the clinician taking the history should administer the FBI (Kertesz, Davidson, & Fox, 2003).
    B) The administrator should ask the caregiver the questions in the absence of the patient (Kertesz et al., 2003).
    C) Scoring should be done preferably by the caregiver with guidance when needed from the administrator (Kertesz et al., 2003).
    D) Often, the score will be a consensus between the caregiver and the interviewer (Kertesz et al., 2003).
    Nonstandard administration should be followed up by a brief questioning of some of the answers (Kertesz et al., 2003).

Number of Items

24

Equipment Required

  • Scoring sheet
  • Additional sheet of paper for notes
  • Writing utensil

Time to Administer

10-30 minutes

Required Training

Reading an Article/Manual

Age Ranges

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by University of Illinois at Chicago Master of Science in Occupational Therapy students Stephen Buskirk, Azariah Huml, and Ricardo D. Ramirez.

ICF Domain

Activity
Body Function
Participation

Measurement Domain

Activities of Daily Living
Cognition
Emotion
Motor

Considerations

  • The FBI is intended to be used for a face-to-face interview with the caregiver. However, satisfactory administration has been found via telephone or the caregiver filling out and scoring the inventory at home to be mailed in (Kertesz et al., 2003).

  • Administration time depends on the extent and severity of symptoms and the caregiver’s verbal capacity (Kertesz et al., 2003).

  • Examination of the score may be required if the caregiver narrative is not representative of the produced score (Kertesz et al., 2003).

  • No certification is required for an administrator but basic interviewing skills and a basic knowledge of the behavioral variety of frontotemporal dementia is needed (Kertesz et al., 2003).

Alzheimer's Disease and Progressive Dementia

back to Populations

Standard Error of Measurement (SEM)

Frontotemporal dementia: (Kertesz et al., 2000; n = 26; mean age = 58.2 (9.0) years; mean duration of illness = 28.8 (22.0) months)

  • SEM for entire group (n = 26): 3.02

Minimal Detectable Change (MDC)

Frontotemporal dementia:(Kertesz et al., 2000)

  • MDC for entire group (n = 26): 8.37 points

Cut-Off Scores

Frontotemporal lobar degeneration (FTDL): (Alberici et al., 2007; n = 159; Italian sample)

  • Score of < 28.6 indicates there is 83.6% diagnostic accuracy that individuals have FTDL rather than other dementias.

Behavioral variant of Frontotemporal lobar dementia (FLTD-bv): (Blair et al., 2007; n = 177; Canadian sample)

  • Using a cut-off score of 27, the sensitivity of the FTLD-bv group was 70.8% with a specificity of 85.7%.

  • The cut-off score of 27 correctly categorized 94.12% of ‘cognitively impaired not demented’ patients, 84.21% of patients with possible Alzheimer’s disease, and 73.58% of patients with other types of dementia.

Frontal Lobe Dementia (FLD): (Kertesz, Davidson, & Fox, 1997; n = 39)

  • A sensitive cut-off score of 27 for diagnosis of FLD showed one false positive. A more conservative cut-off score of 30 was selected to eliminate false positives and increase specificity. This cut-off score was found to be effective in differentiating between FLD, Alzheimer’s disease, and depressive dementia patients.

Frontotemporal lobar degeneration (FTLD): (Konstantinopoulou, Aretouli, Ioannidis, Karacostas, & Kosmidis, 2013); n = 117; mean age = 67.72 (9.40); mean duration of illness = 2.57 years (1.63 years); Northern Greek sample)

  • Using a cut-off score of 17 resulted in 83% sensitivity and 98% specificity.

Frontal variant frontotemporal dementia (fv-FTD): (Milan et al., 2007; n = 72; Italian sample)

  • Using the recommended cut-off score of 27, the FBI was able to detect 88.57% of patients with fv-FTD and attribute a false positive to 4.55% of patients with Alzheimer’s and 6.67% of patients with vascular dementia.

Test/Retest Reliability

Frontal Lobe Dementia: (Milan et al., 2008; n = 72)

  • Excellent test-retest reliability (k = 0.90, p < 0.0001)

Frontotemporal lobar degeneration (FTDL): (Alberici et al., 2007)

  • Excellent test-retest reliability for both negative (ICC = 0.86) and positive (ICC = 0.97) subscales.

  • Excellent test-retest reliability for the overall FBI (ICC = 0.92).

Interrater/Intrarater Reliability

Frontotemporal dementia: (Kertesz et al., 2000; n = 108; FLD = 26, AD = 38, PPA = 11, VaD =16, DD = 17)

  • Excellent interrater reliability: (coefficient alpha = .89)

Frontotemporal lobar degeneration: (Alberici et al., 2007)

  • Excellent interrater reliability for both negative (ICC = 0.92) and positive (ICC = 0.91) subscales.

  • Excellent interrater reliability for the overall FBI (ICC = 0.92).

Internal Consistency

Frontotemporal dementia: (Kertesz et al., 2000)

  • Excellent internal consistency (Cronbach’s alpha = 0.89)

Frontal variant frontotemporal dementia (fv-FTD): (Milan et al., 2008)

  • Excellent internal consistency (Cronbach’s alpha = 0.93)

Frontotemporal lobar degeneration (FTDL): (Alberici et al., 2007)

  • Excellent internal consistency (Cronbach’s alpha = 0.97)

Criterion Validity (Predictive/Concurrent)

Predictive validity:

Behavioral variant of Frontotemporal lobar dementia (FLTD-bv): (Blair et al., 2007)

  • Adequate predictive validity of the FBI at predicting classification of FLTD-bv and Alzheimer’s disease patients.

Frontotemporal lobar degeneration (FTLD): (Konstantinopoulou et al., 2013)

  • Excellent predictor of Alzheimer’s disease-FTLD membership (standardized canonical coefficient = 0.926, Wilk’s λ = 0.633, p < 0.001).

Concurrent validity:

Frontal variant frontotemporal dementia (fv-FTD): (Milan et al., 2007)

  • Adequate concurrent validity of FBI with Frontal Assessment Battery (FAB) scores (r = -0.308).

  • Adequate concurrent validity of FBI with ‘frontal’ items of the Neuropsychiatric Inventory (NPI-P) (r = 0.447).

Construct Validity

Convergent validity:

Behavioral variant of Frontotemporal lobar dementia (FLTD-bv): (Blair et al., 2007)

  • Excellent convergent validity of FBI total scores with neuropsychiatric inventory (NPI) total scores (r = 0.72).

Frontotemporal lobar degeneration (FTDL): (Alberici et al., 2007)

  • Adequate convergent validity of FBI scores with neuropsychiatric inventory (NPI) scores (r = 0.449).

Discriminant validity:

Frontotemporal lobar degeneration (FTDL): (Alberici et al., 2007)

  • The FBI correctly categorized 86.8% of participants with FTDL from Alzheimer’s disease.

Behavioral variant of Frontotemporal lobar dementia (FLTD-bv): (Blair et al., 2007)

  • Significantly higher scores with FLTD behavioral variant patients than all other groups.

  • The FBI was better than the neuropsychiatric inventory (NPI) at discriminating patients with FLTD-bv from all other patient groups.

  • When excluding patients with behavioral syndromes at onset and those with FLTD-bv with a behavioral change as a secondary diagnosis, the FBI correctly categorized 78.9% of FLTD-bv patients and 80% of patients with Alzheimer’s disease [Wilks’ λ = 0.6, χ2(1) = 25.1, p < 0.001].

  • The FLTD-bv group had significantly higher mean scores than all other patient groups in indifference, inflexibility, concreteness, personal neglect, and hyperorality, p < 0.05. The FLTD-bv group scores significantly higher than the Alzheimer’s group in apathy, asponeity, disorganization, loss of insight, perseveration, excessive jocularity, poor judgement, inappropriateness, impulsivity, restlessness, and aggression, p < 0.05.

Frontotemporal lobar degeneration (FTLD): (Konstantinopoulou et al., 2013)

  • Significant difference between patients with FTLD and patients with Alzheimer’s disease overall [F (1, 113) = 61.837, p = < 0.001, eta-squared = 0.354].

  • The FBI correctly categorized 88% of behavioral variant FTLD patients and 84% of primary progressive aphasia (PPA) patients.

Frontal variant frontotemporal dementia (fv-FTD): (Milan et al., 2007)

Population

n

Mean

SD

Range

fv-FTD

35

39.06

8.58

22-54

Alzheimer’s disease (AD)

22

12.32

6.71

3-29

Vascular dementia (VaD)

15

11.40

6.75

2-28

  • Significant difference between patients with fv-FTD and patients with other forms of dementia [F (2,69) = 111.68; p < 0.0001].

  • Significantly higher scores in patients with fv-FTD than those in AD (p < 0.0001) and VaD (p < 0.0001) as reported by Scheffé post hoc comparisons.

  • FBI scores did not correlate with the Mini Mental State Examination (MMSE).

Frontal Lobe Dementia (FLD) or Frontotemporal Degeneration (FTD): (Kertesz et al., 2000)

Discriminant Analysis Cross-Validation of the FBI:

Comparison

Percent Classified Correctly

Chi-square test

Percent False Negatives

Percent False Positives

FLD vs. NON-FLD

92.7

(χ2 = 126.0, p < .001)

11.5

6.1

FLD vs. VAD

85.7

(χ2 = 49.9, p < .001)

11.5

18.8

FLD vs. AD

100

(χ2 = 119.8, p < .001)

0

0

FLD vs. PPA

100

(χ2 = 82.1, p < .001)

0

0

FLD vs. DD

90.7

(χ2 = 67.0, p < .001)

7.7

11.8

  • High diagnostic specificity of 89.5%

  • High diagnostic sensitivity of 93.9%

Differences Between Groups:

Group

FBI Score

Mean

Standard Deviation

Range

Frontotemporal Dementia (FLD)

39.5

9.1

27-61

Vascular Dementia (VaD)

24.6

11.0

7-47

Alzheimer’s Disease (AD)

12.0

7.6

0-26

Primary Progressive Aphasia (PPA)

11.5

5.9

4-20

Depressive Disorder (DD)

9.2

8.7

0-28

  • Significant difference in group scores [F (4,103) = 52.8, p < 0.001].

  • Significantly higher scores in FLD group than all other groups (p < 0.05).

Frontal Lobe Dementia (FLD): (Kertesz et al., 1997)

  • Significantly higher scores on the FBI in the FLD group compared to the Alzheimer’s disease group and the depressive dementia group F = 59.8, p < .001.

Content Validity

Content validity was not formally assessed by subject matter experts, but the assessment was operationalized using the consensus statement from the Lund and Manchester groups regarding the main features of frontal lobe dementia (Kertesz et al., 1997). The assessment was then updated to reflect guidelines based on Neary et al. criteria (Kertesz et al., 2003). The authors also based the content of the instrument based off of their experience with 12 patients with frontal lobe dementia (Kertesz et al., 1997).

Face Validity

The authors of the FBI created items by selecting the most frequent symptoms of frontal lobe dementia from the Lund/Manchester criteria, but subject matter experts did not formally assess face validity (Kertesz et al., 1997).

Bibliography

Alberici, A., Geroldi, C., Cotelli, M., Adorni, A., Calabria, M., Rossi, G., … Kertesz, A. (2007). The Frontal Behavioural Inventory (Italian version) differentiates frontotemporal lobar degeneration variants from Alzheimer’s disease. Neurological Sciences, 28(2), 80–86.

Blair, M., Kertesz, A., Davis-Faroque, N., Hsiung, G.-Y. R., Black, S. E., Bouchard, R. W., … Feldman, H. (2007). Behavioural measures in frontotemporal lobar dementia and other dementias: The utility of the Frontal Behavioural Inventory and the Neuropsychiatric Inventory in a national cohort study. Dementia and Geriatric Cognitive Disorders, 23(6), 406–415.

Kertesz, A., Davidson, W., & Fox, H. (1997). Frontal Behavioral Inventory: Diagnostic criteria for frontal lobe dementia. Canadian Journal of Neurological Sciences/Journal Canadien Des Sciences Neurologiques, 24(1), 29-36.

Kertesz, A., Davidson, W., & Fox, H. (2003). Frontal Behavioral Inventory [Measurement instrument]. Retrieved from

Kertesz, A., Davidson, W., Mccabe, P., & Munoz, D. (2003). Behavioral quantitation is more sensitive than cognitive testing in frontotemporal dementia. Alzheimer Disease & Associated Disorders,17(4), 223-229.

Kertesz, A., Nadkarni, N., Davidson, W., & Thomas, A. (2000). The Frontal Behavioral Inventory in the differential diagnosis of frontotemporal dementia. Journal of the International Neuropsychological Society, 6(4), 460-468.

Konstantinopoulou, E., Aretouli, E., Ioannidis, P., Karacostas, D., & Kosmidis, M. H. (2013). Behavioral disturbances differentiate frontotemporal lobar degeneration subtypes and Alzheimer’s disease: Evidence from the Frontal Behavioral Inventory. International Journal of Geriatric Psychiatry, 28(9), 939–946.

Malloy, P., & Grace, P. (2005). A review of rating scales for measuring behavior change due to frontal systems damage. Cognitive and Behavioral Neurology, 18(1), 18–27.

Milan, G., Iavarone, A., Lorè, E., Vitaliano, S., Lamenza, F., Sorrentino, P., & Postiglione, A. (2007). When behavioral assessment detects frontotemporal dementia and cognitive testing does not: Data from the Frontal Behavioral Inventory. International Journal of Geriatric Psychiatry, 22, 266-267.

Milan, G., Lamenza, F., Iavarone, A., Galeone, F., Lorè, E., De Falco, C., Sorrentino, P., & Postiglione, A. (2008). Frontal Behavioural Inventory in the differential diagnosis of dementia. Acta Neurologica Scandinavica, 117: 260-265.

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