Cognitive Assessment Form (65+)

Clinical Dementia Rating Worksheet

This is a semi-structured interview. Please ask all of these questions. Ask any additional questions necessary to determine the subject’s Clinical Dementia Rating (CDR). Please note information from the additional questions.

Memory Questions for the person close to the subject:

1. Does he/she have a problem with his/her memory or thinking?

Yes No

1a. If yes, is this a consistent problem (as opposed to inconsistent)?

Yes No

2. Can he/she recall recent events?

Usually Sometimes Rarely

3. Can he/she remember a short list of items (shopping)?

Usually Sometimes Rarely

4. Has there been some decline in memory during the past year?

Yes No

5. Is his/her memory impaired to such a degree that it would have interfered with his/her activities of daily life a few years ago (or pre-retirement activities)? (in the opinion of family and friends)

Yes No

6. Does he/she completely forget a major event (e.g., trip, social function, family wedding) within a few weeks of the event?

Usually Sometimes Rarely

7. Does he/she forget pertinent details of the major event?

Usually Sometimes Rarely

8. Does he/she completely forget important information of the distant past (e.g., birthdate, wedding date, place of employment)?

Usually Sometimes Rarely

9. Tell me about some recent event in his/her life that he/she should remember. (For later comparison with the subject’s responses, obtain details such as location of the event, time of day, participants, how long the event was, when it ended and how the subject or other participants got there).

Within 1 week:

Within 1 month:

10. When was he/she born?

11. Where was he/she born?

12. What was the last school he/she attended?

Name

Town/City

Highest level achieved

13. What was his/her main occupation/job (or spouse’s job if subject was not employed)?

14. What was his/her last major job (or spouse’s job if subject was not employed)?

15. When did he/she (or spouse) retire and why?

Orientation Questions for the person close to the subject

How often does he/she know of the exact:

1. Date of the Month?

Usually Sometimes Rarely Don’t Know

2. Month?

Usually Sometimes Rarely Don’t Know

3. Year?

Usually Sometimes Rarely Don’t Know

4. Day of the Week?

Usually Sometimes Rarely Don’t Know

5. Does he/she have difficulty with time relationships (when events happened in relation to each other)?

Usually Sometimes Rarely Don’t Know

6. Can he/she find his/her way about familiar streets?

Usually Sometimes Rarely Don’t Know

7. How often does he/she know how to get from one place to another outside his/her neighbourhood?

Usually Sometimes Rarely Don’t Know

8. How often can he/she find his/her way about indoors?

Usually Sometimes Rarely Don’t Know

Judgment and Problem Solving Questions for the person close to the subject:

1. In general, if you had to rate his/her abilities to solve problems at the present time, would you consider them:

As good as they have ever been Good, but not as good as before Fair Poor No ability at all

2. Rate his/her ability to cope with small sums of money (e.g., give change, calculate the cost of groceries sold by weight):

No loss Some loss Severe loss

3. Rate his/her ability to handle complicated financial or business transactions (e.g., balance check-book, pay bills):

No loss Some loss Severe loss

4. Can he/she handle a household emergency (e.g., plumbing leak, small fire)?

As well as before Worse than before because of trouble thinking Worse than before, another reason (why)

5. Can he/she understand situations or explanations?

Usually Sometimes Rarely Don’t Know

6. Does he/she behave* appropriately [i.e., in his/her usual (premorbid) manner] in social situations and interactions with other people?

Usually Sometimes Rarely Don’t Know

*This item rates behaviour, not appearance.

Community Participation Questions for the person close to the subject:

Occupational

1. Is the subject still working?

Yes No N/A

If not applicable, proceed to item 4

If yes, proceed to item 3

If no, proceed to item 2

2. Did memory or thinking problems contribute to the subject’s decision to retire? (Question 4 is next)

Yes No D/K

3. Does the subject have significant difficulty in his/her job because of problems with memory or thinking?

Rarely or Never Sometimes Usually Don’t Know

Social life

4. Did he/she ever drive a car?

Yes No

Does the subject drive a car now?

Yes No

If no, is this because of memory or thinking problems?

Yes No

5. If he/she is still driving, are there problems or risks because of poor thinking?

Yes No

6. Is he/she able to independently shop for needs?

Rarely or Never

(Needs to be accompanied on any shopping trip)

Sometimes

(Shops for limited number of items; buys duplicate items or forgets needed items)

Usually Don’t Know

7. Is he/she able to independently carry out activities outside the home?

Rarely or Never

(Generally unable to perform activities without help)

Sometimes

(Limited and/or routine, e.g., superficial participation in church or meetings; going to the haidresser’s)

Usually

(Meaningful participation in activities, e.g., voting)

Don’t Know

8. Is he/she taken to social functions outside a family home?

Yes No

If no, why not?

9. Would a casual observer of the subject’s behaviour think the subject was ill?

Yes No

10. If in nursing home, does he/she participate appropriately in social functions (thinking)?

Yes No

IMPORTANT:

Is there enough information available to rate the subject’s level of impairment in community participation? If not, please probe further.

Community Participation: Such as going to church, visiting with friends or family, political activities, professional organisations such as associations of lawyers, other professional groups, social clubs, service organisations, educational programmes.

*Please add notes if needed to clarify subject’s level of functioning in this area.

Questions on Housework and Hobbies for the person close to the subject:

1a. What changes have occurred in his/her abilities to perform household tasks?

1b. What can he/she still do well?

2a. What changes have occurred in his/her abilities to perform hobbies?

2b. What can he/she still do well?

3. If in nursing home, what can he/she no longer do well (Housework and Hobbies)?

Everyday Activities (the Dementia Scale of Blessed):

4. Ability to perform household tasks

0 - No Loss 0.5 1 - Severe Loss

Please describe:

5. Is he/she able to perform household tasks at the level of: (Pick one. The person close to the subject does not need to be asked directly).

No meaningful function.

(Performs simple activities, such as making a bed, only with much supervision)

Functions in limited activities only.

(With some supervision, washes dishes with acceptable cleanliness; sets table)

Functions independently in some activities.

(Operates appliances, such as a vacuum cleaner; prepares simple meals)

Functions in usual activities but not at usual level. Normal function in usual activities.

IMPORTANT:

Is there enough information available to rate the subject’s level of impairment in HOME & HOBBIES? If not, please probe further.

Household Tasks: Such as cooking, laundry, cleaning, grocery shopping, taking out the rubbish, gardening, and basic home care.

Hobbies: Sewing, painting, handcrafts, reading, entertaining, photography, gardening, going to theatre or symphony, woodworking, participation in sports.

Personal Care Questions for the person close to the subject:

*What is your estimate of his/her mental ability in the following areas:

A. Dressing (the Dementia Scale of Blessed)

0 - Unaided 1 - Occasionally misplaced buttons, etc. 2 - Wrong sequence, commonly forgotten items 3 - Unable to dress

B. Washing, grooming

0 - Unaided 1 - Needs prompting 2 - Sometimes needs help 3 - Always or nearly always needs help

C. Eating habits

0 - Cleanly; proper utensils 1 - Messily; spoon 2 - Simple solids 3 - Has to be fed completely

D. Control of bladder and bowel (the Dementia Scale of Blessed)

0 - Normal complete control 1 - Occasionally wets bed 2 - Frequently wets bed 3 - Doubly incontinent

* A box-score of 1 can be considered if the subject’s personal care is improved compared with before, even if they do not receive prompting.

Memory Questions for Subject:

1. Do you have problems with memory or thinking?

Yes No

2. A few moments ago your (spouse, etc.) told me a few recent experiences you had. Will you tell me something about those? (Prompt for details, if needed such as location of the event, time of day, participants, how long the event was, when it ended and how the subject or other participants got there).

Within 1 week

1.0 – Largely correct

0.5

0.0 – Largely incorrect

Within 1 month

1.0 – Largely correct

0.5

0.0 – Largely incorrect

3. I will give you a name and address to remember for a few minutes. Repeat this name and address after me: (Repeat until the phrase is correctly repeated or to a maximum of three trials).

(Select elements repeated correctly in each trial).

4. When were you born?

5. Where were you born?

6. What was the last school you attended?

Name

Town/City

Highest level achieved

7. What was your main occupation/job (or spouse if not employed)?

8. What was your last major job (or spouse if not employed)?

9. When did you (or spouse) retire and why?

10. Repeat the name and address I asked you to remember:

1 - John

2 - Brown

3 - 42

4 - Queen Street,

5 - Auckland

(Select elements repeated correctly).

Orientation Questions for Subject:

Record the subject’s answer verbatim for each question

1. What is the date today?

2. What day of the week is it?

3. What is the month?

4. What is the year?

5. What is the name of this place?

6. What town or city are we in?

7. What time is it?

8. Does the subject know who the person close to the subject is (in your judgment)?

Judgment and Problem Solving Questions for Subject:

Instructions: If initial response by subject does not merit a grade 0, press the matter to identify the subject’s best understanding of the problem. Select nearest response.

Similarities:

Example: “How are a pencil and pen alike? (writing instruments)

How are these things alike?” Subject’s Response

1. carrot……cauliflower

(0 = vegetables)

(1 = edible foods, living things, can be cooked, etc.)

(2 = answers not pertinent; differences; buy them)

2. desk……bookcase

(0 = furniture, office furniture; both hold books)

(1 = wooden, legs)

(2 = not pertinent, differences)

Differences:

Example: “What is the difference between sugar and vinegar? (sweet vs. sour)

What is the difference between these things?”

3. lie……mistake

(0 = one deliberate, one unintentional)

(1 = one bad the other good – oxplar eins only one)

(2 = anything else, similarities)

4. river……canal (lake……dam)

(0 = natural - artificial)

(2 = anything else)

Calculations:

5. How many 5 cent pieces in a dollar?

6. How many 20 cent pieces in $5.40?

7. Subtract 3 from 20 and keep subtracting 3 from each new number all the way down.

Judgment:

8. Upon arriving in a strange city, how would you locate a friend that you wished to see?

(0 = try the telephone book, go to the city council for a directory; call a mutual friend)

(1 = call the police, call directory service (usually will not give address)

(2 = no clear response)

9. Subject’s assessment of disability and social position and understanding of why he/she is present at the examination (perhaps already mentioned, but make your own judgment here)

Good Insight

Partial Insight

Little Insight

CLINICAL DEMENTIA RATING (CDR): 0 | 0.5 | 1 | 2 | 3

Score only as decline from previous usual level due to cognitive loss, not impairment due to other factors.

Epworth Sleepiness Scale

How likely are you to nod off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times.

Even if you haven’t done some of these things recently, try to work out how they would have affected you. It is important that you answer each question as best you can.

Use the following scale to choose the most appropriate number for each situation.

Sitting and reading

0 - Would never nod off 1 - Slight chance of nodding off 2 - Moderate chance of nodding off 3 - High chance of nodding off

Watching TV

0 - Would never nod off 1 - Slight chance of nodding off 2 - Moderate chance of nodding off 3 - High chance of nodding off

Sitting, inactive, in a public place (e.g., in a meeting, theater, or dinner event)

0 - Would never nod off 1 - Slight chance of nodding off 2 - Moderate chance of nodding off 3 - High chance of nodding off

As a passenger in a car for an hour or more without stopping for a break

0 - Would never nod off 1 - Slight chance of nodding off 2 - Moderate chance of nodding off 3 - High chance of nodding off

Lying down to rest when circumstances permit

0 - Would never nod off 1 - Slight chance of nodding off 2 - Moderate chance of nodding off 3 - High chance of nodding off

Sitting and talking to someone

0 - Would never nod off 1 - Slight chance of nodding off 2 - Moderate chance of nodding off 3 - High chance of nodding off

Sitting quietly after a meal without alcohol

0 - Would never nod off 1 - Slight chance of nodding off 2 - Moderate chance of nodding off 3 - High chance of nodding off

In a car, while stopped for a few minutes in traffic or at a light

0 - Would never nod off 1 - Slight chance of nodding off 2 - Moderate chance of nodding off 3 - High chance of nodding off

Add up your points to get your total score. A score of 10 or greater raises concern: you may need to get more sleep, improve your sleep practices, or seek medical attention to determine why you are sleepy.

GAD-7 Anxiety

Over the last two weeks, how often have you been bothered by the following problems?

1. Feeling nervous, anxious, or on edge

0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day

2. Not being able to stop or control worrying

0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day

3. Worrying too much about different things

0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day

4. Trouble relaxing

0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day

5. Being so restless that it is hard to sit still

0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day

6. Becoming easily annoyed or irritable

0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day

7. Feeling afraid, as if something awful might happen

0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day

Column totals

Total Score

If you select any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all Somewhat difficult Very difficult Extremely difficult

Source: Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD-PHQ). The PHQ was developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues. For research information, contact Dr. Spitzer at ris8@columbia.edu. PRIME-MD® is a trademark of Pfizer Inc. Copyright© 1999 Pfizer Inc. All rights reserved. Reproduced with permission

Scoring GAD-7 Anxiety Severity

This is calculated by assigning scores of 0, 1, 2, and 3 to the response categories, respectively, of “not at all,” “several days,” “more than half the days,” and “nearly every day.” GAD-7 total score for the seven items ranges from 0 to 21.

0–4: minimal anxiety | 5–9: mild anxiety | 10–14: moderate anxiety | 15–21: severe anxiety

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

ID #:

Date

Over the last 2 weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things

0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day

2. Feeling down, depressed, or hopeless

0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day

3. Trouble falling or staying asleep, or sleeping too much

0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day

4. Feeling tired or having little energy

0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day

5. Poor appetite or overeating

0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day

6 . Feeling bad about yourself or that you are a failure or have let yourself or your family down

0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day

7. Trouble concentrating on things, such as reading the newspaper or watching television

0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day

8. Moving or speaking so slowly that other people could have noticed. Or the opposite being so figety or restless that you have been moving around a lot more than usual

0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day

9. Thoughts that you would be better off dead, or of hurting yourself

0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day

add columns

TOTAL:

(Healthcare professional: For interpretation of TOTAL, TOTAL: please refer to accompanying scoring card).

If you select any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all Somewhat difficult Very difficult Extremely difficult

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