DOI: 10.

1590/0004-282X20140177
ARTICLE

Validity of the Brazilian version of the

Neuropsychiatric Inventory Questionnaire
(NPI-Q)
Validação da versão brasileira do Questionário do Inventário Neuropsiquiátrico (Q-INP)
Ana Luiza Camozzato1,4, Claudia Godinho1,2, Renata Kochhann1, Graziela Massochini2,
Marcia Lorena Chaves1,2,3

ABSTRACT
The NPI-Q (Neuropsychiatry Inventory-Questionnaire) was developed to facilitate the evaluation of neuropsychiatric symptoms. This study
evaluated the internal consistency, the test-retest reliability of the Brazilian NPI-Q version and its convergent validity with the original NPI.
Method: The NPI-Q and the NPI were administered to 64 caregivers of dementia patients. Thirteen informants were asked to complete a
second NPI-Q form. Results: The internal consistency of the Brazilian NPI-Q version was 0.67 for the severity scale and 0.81 for the distress
scale. The test-retest reliability of the total NPI-Q severity and the distress scales were 0.97 and 0.92, respectively (p , 0.001). There were
significant correlations between the total NPI-Q severity score and the NPI (r = 0.75) and between the total NPI-Q distress score and the
total NPI standard distress (r = 0.74). Conclusion: The Brazilian NPI-Q version showed evidence of good psychometric properties and can
be used in general clinical practice.
Keywords: Brazilian NPI-Q version, validation study, neuropsychiatric symptoms, dementia.

RESUMO
O Q-INP (Questionário do Inventário Neuropsiquiátrico) foi desenvolvido para facilitar a avaliação dos sintomas neuropsiquiátricos. Este
estudo avaliou a consistência interna, confiabilidade teste-reteste e validade convergente da versão brasileira do Q-INP com o INP
(Inventário Neuropsiquiátrico). Método: Sessenta e quatro cuidadores de pacientes com demência responderam ambas as escalas. O
NPI-Q foi reaplicado em 13 informantes. Resultados: A consistência interna da versão brasileira do Q-INP foi 0,67 para a escala de
gravidade e 0,81 para escala de desgaste. A confiabilidade teste-reteste da escala de gravidade foi 0,97 e 0,92 para a escala de desgaste
(p , 0,001). Houve correlação significativa entre o escore de gravidade do Q-INP e INP (r = 0,75) e entre os escores de desgaste destas
escalas (r = 0,74). Conclusão: A versão brasileira do Q-INP mostrou evidências de boas propriedades psicométricas e pode ser usado na
prática clínica geral.
Palavras-chave: versão brasileira do Q-INP, estudo de validação, sintomas neuropsiquiátricos, demência.

The recognition of neuropsychiatric symptoms in (NPI-Q), was developed to facilitate the evaluation of neu-
dementia is relevant since they are frequent1, distressing ropsychiatric symptoms. The NPI-Q derives from NPI, asses-
for patients and for caregivers2, and characterize a frequent sing the same 12 NPI symptom domains and the caregiver’s
cause of institutionalization3. Among the scales used to distress produced by these domains. It is a self-administered
evaluate these symptoms, the Neuropsychiatric Inventory questionnaire, in opposition to the original NPI which is
(NPI), an informant-based interview4, is one of the most based on informant interview; and it assesses only symptom
widely used instruments in clinical research studies5. severity, instead of severity and frequency of the symptoms
However, it takes long time to be completed, making difficult as measured in the NPI. In addition, it is usually completed
its use in the general practice setting. In this scenario, a brief in 5 minutes or less. It showed adequate test-retest reliability
NPI version, the Neuropsychiatric Inventory Questionnaire (r = 0.80, p = 0.001) and convergent validity with the NPI

1
Departamento de Demência Clínica, Serviço de Neurologia, Hospital de Clínicas de Porto Alegre, Porto Alegre RS, Brazil;
2
Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre RS, Brazil;
3
Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre RS, Brazil;
4
Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre RS, Brazil.
Correspondence: Ana Luiza Camozzato; Rua Ramiro Barcelos, 2350 / sala 2040; 90035-091 Porto Alegre RS, Brasil; E-mail: anacamoz@gmail.com
Conflict of interest: There is no conflict of interest to declare.
Received 14 July 2014; Received 04 September 2014; Accepted 24 September 2014.

41
 regarding total and individual symptom domain scores and appetite/eating disturbances). Each domain is assessed by
caregiver distress ratings (r = 0.92, p = 0.001). The correlation a written screening question that assesses presence and
between NPI and NPI-Q total symptom scores was signific- severity of the core symptom manifestations over the past
ant (p = 0.001) for any dementia severity (r = 0.91), being month. All screening questions are in the ‘yes/no’ format
greater in subjects with more severe dementia (r = 0.95). and severity is rated as ‘mild’ = 1, ‘moderate’ = 2 and
Both NPI and NPI-Q total scores showed weak, but signific- ‘severe’ = 3. The total NPI-Q severity score ranges from 0
ant, correlations with Mini Mental State Examination to 36. In addition, the NPI-Q assesses the primary caregiver
(MMSE) scores in the lower MMSE group (r = 0.44), while distress as in the NPI. The distress scale is rated with 6-
these associations were not observed in the higher point level questions, ranging from “not emotionally stress-
MMSE group6. ful” to “extremely stressful”, and the total NPI-Q distress
The NPI-Q has been already validated for Spanish, score ranges from 0 to 60.
Japanese and Dutch languages7,8,9. The NPI-Q Spanish ver- The original English version of the NPI-Q was translated
sion showed strong test-retest reliability for total symptom by the authors to Brazilian Portuguese. Further, the Brazilian
scale and for distress scale, besides convergent validity version was independently back translated into English.
with NPI total symptom (r = 0.879) and with NPI distress Final adaptations were performed to warrant cultural and
(r = 0.92)7. The NPI-Q Japanese version also showed strong educational comprehension.
correlation with NPI for both total NPI-Q severity score This Brazilian NPI-Q version was administered to non-
(r = 0.77, p , 0.01) and distress score (r = 0.80, p , 0.01). professional caregivers who were fully aware of the patient’s
It also showed high and significant test-retest reliability for behavior since they spent at least three hours with the
severity and distress score8. The depressive symptoms meas- patient in a daily basis. The Brazilian version of the standard
ured by the NPI-Q Dutch version showed a moderate cor- NPI17 was applied to measure the NPI-Q concurrent validity.
relation with the Geriatric Depression Scale (GDS)9. In order to avoid biased responses in the NPI-Q by the pre-
The aim of this study was to evaluate the internal con- vious application of NPI interview, the Brazilian version of
sistency, the test-retest reliability of the Brazilian NPI-Q ver- the NPI-Q was first applied. The clinician who carried out
sion and its convergent validity with the NPI. The effect of the NPI interview was blinded to the results of the NPI-Q.
demographic and clinical data – severity of dementia – on This clinician was a member of the research team previously
NPI-Q, as well as the impact of sex, age and educational level trained to apply the NPI. Thirteen informants (25% of the
of caregivers on this scale was also evaluated. Our hypothesis sample) were asked to complete a further NPI-Q form
was that the NPI-Q Brazilian version presents psychometric upon arriving home in the same day. A member from the
properties similar to those observed in other languages. research team called them in the next morning to check
the answers. This procedure was made to evaluate the
test-retest reliability.
METHOD
Statistical analysis
A cross-sectional investigation was carried out in a sam- Descriptive analyses were previously performed. The nor-
ple of 64 caregivers of patients with dementia due mality of data was assessed by the Kolmogorov-Smirnov test
Alzheimer’s disease (AD) and vascular dementia (VD) conse- and parametric or non-parametric statistics were carried out
cutively selected from the Dementia Clinic of Hospital de according to the variables distribution. The Cronbach’s
Clínicas de Porto Alegre, Brazil. The AD dementia diagnosis alpha test was used to verify the NPI-Q internal consistency.
was ascertained by the DSM-V10 and the Alzheimer The Pearson correlation test was used to evaluate the
Association criteria11. Vascular dementia was diagnosed with test-retest NPI-Q reliability and to assess the bivariate corre-
the DSM-V criteria for Major Vascular Neurocognitive lations between NPI-Q and NPI standard (total and single
Disorder10. The Mini Mental State Examination (MMSE)12,13 item scores), as well to evaluate the correlations between
and the Clinical Dementia Rating scale (CDR) were NPI-Q and NPI standard stratified by dementia severity.
applied14,15,16 to evaluate the severity of dementia. The Pearson correlation test was used to evaluate cor-
Demographic data from the outpatients and from caregiver relation between CDR, MMSE, age and education with the
informants were collected. NPI-Q. The association of sex with the NPI-Q was evaluated
The NPI-Q6 is a self-administered scale derived from by Chi-square association test.
the NPI standard that evaluates the same 12-symptom The absolute and the relative difference in individual
domains (delusions, hallucinations, agitation/aggression, symptom frequency across NPI-Q and NPI were described.
dysphoria/depression, anxiety, euphoria/elation, apathy/ The study was approved by the Ethics Committee
indifference, disinhibition, irritability/lability, aberrant for Medical Research at Hospital de Clínicas de Porto Alegre.
motor behaviors, nighttime behavioral disturbances, and All participants and their proxies signed an informed consent.

42 Arq Neuropsiquiatr 2015;73(1):41-45

 Table 1. Correlations coefficients among NPI-Q, NPI, and dementia severity.
Variable All subjects* (N = 64) Mild dementia* (N = 31) Moderate to severe dementia* (N = 33)
NPI-Q severity to NPI severity 0.755 0.741 0.724
NPI-Q severity to NPI total (FXS) 0.705 0.675 0.692
NPI-Q distress to NPI distress 0.739 0.723 0.713
NPI-Q severity to NPI-Q distress 0.913 0.905 0.906
*Pearson correlation coefficient (r) with p , 0.001. NPI: Neuropsychiatric inventory; NPI-Q: NPI Questionnaire; F x S: Frequency versus severity.

RESULTS The majority of the correlations between each item of

NPI-Q and NPI were statistically significant (either mild or
Sixty-four non-professional caregivers of AD or VD moderate), with the exception of the severity of motor aber-
patients answered the research protocol. The sample was rant behavior and appetite/eating disturbances domains
composed of 57 (89%) women. Of the 64 participants, 25 (Table 2).
were spouses, 27 were children, and 12 had other familial The total MMSE score did not show significant correla-
relationship with the patient. Forty-eight (67%) informants tion with NPI-Q severity score (r = -0.151, p = 0.235). The
lived with the patient. The mean age of caregivers was NPI-Q severity score did not differ among CDR categories
52.5 (standard devistion (SD) = 14.31) and education varied (F = 1,720, p = 0.173, one-way ANOVA). Patients age and edu-
from 1 to 19 years of study (10.41 ± 4.22, mean ± SD). cation did not correlate with NPI-Q severity (r = -0.145,
The mean age of patients was 75.9 (SD = 9.6), and 40 p = 0.331 and r = -0.057, p = 0.671, respectively). Men showed
(62%) were female. Education varied from illiteracy (zero significantly higher scores on NPI-Q (p = 0.024, Student t-test).
years) to fifteen years of schooling (4.5 ± 3.5, mean ± SD). Among sex, age and education of caregivers, only edu-
Thirty-one patients were classified as mild dementia cation was significantly inversely correlated with total
(CDR = 1) and 33 as moderate to severe dementia (CDR = 2 NPI-Q severity (r = -0.340, p = 0.007) and with NPI-Q distress
and CDR = 3). The mean (± SD) MMSE score was 14.84 (± 5.46). score (r = -0.320, p = 0.012).
The internal consistency of the severity scale of the Table 3 shows the absolute and the relative values of indi-
Brazilian NPI-Q version was 0.67 and it was 0.81 for the dis- vidual NPI-Q and NPI frequency of symptoms and the differ-
tress scale. The reliability (test-retest correlation) of the total ence between scales of the number of symptoms reported
NPI-Q severity and the distress scales were 0.97 and 0.92, for a given domain. The frequency of all domains was higher
respectively (p , 0.001 for both). when assessed with the NPI-Q and the average difference
The correlations between the total NPI-Q severity score between scales of the number of reported symptoms was
and the NPI standard (total severity and total score-sum 15% (mean absolute difference).
of frequency x severity ratings for all domains) were signific-
ant and moderate, as well the correlation between the total
NPI-Q distress score and the total NPI standard distress DISCUSSION
score. These correlations coefficients were also significant
and moderate when the sample was stratified by dementia The present study aimed to evaluate the psychometric
severity. A stronger correlation was observed between total properties of the Brazilian NPI-Q version. This scale fulfils
NPI-Q severity and total NPI-Q distress score (Table 1). a gap in the evaluation of neuropsychiatric symptoms of

Table 2. Item correlation coefficients among NPI-Q and NPI scale.

Subscale NPI-Q severity to NPI-Severity NPI-Q severity to NPI-Total (F x S) NPI-Q Distress to NPI Distress
Delusions 0.697* 0.663* 0.592*
Hallucinations 0.662* 0.564* 0.627*
Agitation/Aggression 0.366** 0.437** 0.537*
Dysphoria/Depression 0.538* 0.567* 0.549*
Anxiety 0.375* 0.403* 0.304**
Euphoria/Elation 0.386** 0.337** 0.426**
Apathy/Indifference 0.685* 0.592* 0.680*
Disinhibition 0.400* 0.287** 0.419*
Irritability/Lability 0.447* 0.445* 0.500*
Aberrant Motor 0.203 (NS) 0.179 (NS) 0.536*
Nighttime Disturbances 0.478* 0.441* 0.435*
Appetite/Eating disturbances 0.103 (NS) 0.134 (NS) 0.211 (NS)
*Pearson correlation coefficient (r) with p , 0.001; **Pearson correlation coefficient (r) with p , 0.05. NS: Non significant; NPI: Neuropsychiatric inventory;
NPI-Q: NPI Questionnaire; F x S: Frequency versus severity.

Ana Luiza Camozzato et al. Validity of the NPI-Q Brazilian version 43

 Table 3. Comparison of individual symptoms between NPI and NPI-Q (n = 47).
Number (percentage) of subjects with symptom
NPI NPI-Q Difference NPI-Q to NPI
Delusions 20 (41) 26 (55) +6 (6.0)
Hallucinations 14 (28) 21 (45) +7 (17.0)
Agitation/Aggression 27 (56) 31 (66) +4 (10.0)
Dysphoria/Depression 27 (56) 31 (66) +4 (10.0)
Anxiety 24 (51) 34 (72) +10 (21.0)
Euphoria/Elation 13 (26) 14 (30) +1 (4.0)
Apathy/Indifference 28 (49) 34 (72) +6 (14.0)
Disinhibition 13 (26) 23 (49) +10 (23.0)
Irritability/Lability 24 (51) 34 (72) +10 (21.0)
Aberrant motor 16 (33) 24 (51) +8 (18.0)
Nighttime disturbances 16 (33) 30 (64) +14 (31.0)
Appetite/Eating disturbances 20 (41) 26 (55) +6 (14.0)
Mean # (%) absolute differencea 7.1 (15.1)
a
Mean absolute difference reflects the average difference between scales of the number of reported symptoms for each domain. NPI: Neuropsychiatric
inventory; NPI-Q: NPI questionnaire.

dementia, because it is a brief and feasible screening tool, of “Does the patient awaken you during the night, rise too early
easy application in clinical settings, and allows the recog- in the morning, or take excessive naps during the day?”,
nition and management of these frequent and distressing while the screening question in the NPI is “Does the patient
symptoms. It measures the severity of NP symptoms and have difficulty sleeping (do not count as present if the
the caregiver distress related to them. The Brazilian NPI-Q patient simply gets up once or twice per night only to go
version showed adequate internal consistency and test-ret- to the bathroom and falls back asleep immediately)? Is
est reliability. The scores of symptoms domain and the care- he/she up at night? Does he/she wander at night, get
giver distress ratings were equivalent to those assessed by dressed, or disturb your sleep?” Other possible explanations
the NPI, demonstrating good convergent valid. The internal for this result could be cultural characteristics, i.e. infor-
consistency was moderate for severity scale and strong for mants with more "permissiveness" to be complaining; and
distress scale. Its test-retest was strong and significant; socio-economic reasons, such as higher caregiver burden
ensuring its stability over the time. Although the correlation due to the scarce support sources in developing countries.
with NPI was statistically significant and moderate for both However the study design did not allow for testing these
scales and across all dementia severity stages, these correla- hypotheses.
tion coefficients were slightly smaller than those observed in Since the NPI-Q is an informant-based instrument, we
the other NPI-Q versions6,7,8. It is possible that the wide think it was important to examine the association of this
range of caregiver’s educational attainment (ranging from 1 scale with age, education and sex of caregivers. Among these
to 19 years), might have influenced our results. Informants variables, only education was inversely correlated with the
with lower education could have some difficulty to under- NPI-Q severity and NPI-Q distress scores. Although this cor-
stand and to answer the questionnaire. relation can only be a random finding, we can hypothesize
The neuropsychiatric symptom frequency was higher in that the lower caregiver’s education could impair the com-
the Brazilian version of the NPI-Q than in the NPI. Kaufer prehension of the scale leading to higher rates of false-
and colleagues found similar result, however the difference positive answers. This issue was not the focus of the present
between prevalence assessed by the two scales was greater study, but further studies with properly design should
in our study (15% overall). This result could be partially address this relevant question. Other caregiver’s characteris-
explained by the expected higher sensitivity and lower spe- tics such as affiliation degree with the patient, years as care-
cificity of the screening questions. In fact, a rate of 5% of giver and to receive payment could impact the perception of
false positive in the NPI screening questions had already the patient and its behavior and also should be investigated.
been showed4. Furthermore, some screening questions of Finally, the Brazilian NPI-Q version demonstrated evid-
NPI-Q are more open question then those from NPI, i.e., ence of good psychometric properties. Therefore, the
are less detailed and give a few number of examples. This NPI-Q can be used in the clinical practice or research set-
difference could have produced NPI-Q false-positive tings as a comprehensive, practical, reliable and brief instru-
answers. For example, the nighttime behavior showed the ment to measure neuropsychiatric symptoms in subjects
highest difference of frequency between NPI-Q and NPI, with with dementia and to assess the related emotional stress
higher NPI-Q score. The screening question in the NPI-Q is of primary caregivers.

44 Arq Neuropsiquiatr 2015;73(1):41-45

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Ana Luiza Camozzato et al. Validity of the NPI-Q Brazilian version 45