Early Identification, Assessment, and Treatment. Alzheimer s Disease. Dementia

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1 Tools Early Identication, ment, Treatment People Alzheimer s Disease Dementia A publication the Netwks Alzheimer s Disease itiative

2 Page 2 Tools Early Identication, ment, Treatment People Alzheimer s Disease Dementia Table Contents Netwks Alzheimer s Disease: About the Initiative... 3 Tools Early Identication Dementia... 4 Flowchart Tools Early Identication Dementia... 5 Early Identication Tool 1: Alzheimer s Association Ten Warng Signs... 6 Early Identication Tool 1: Patient Behavi Triggers Clical Staff... 7 Early Identication Tool 1: Sympms That May Indicate Dementia... 8 Early Identication Tool 2: Family Questionnaire... 9 Early Identication Tool 2: Use the Family Questionnaire Rationale the Removal the High-Risk Screeng Tool Initial Dementia ment Primary Care Providers: Three Levels Investigation Level 1: F All Patients Attachment 1: Mi-Mental State Examation (MMSE) Attachment 2: Geriatric Depression Scale (GDS) Sgle-Item Depression Indicar Attachment 3: Functional Activities Questionnaire (FAQ) Attachment 4: Activities Daily Livg (ADL) Attachment 5: MBR Caregiver Stra Instrument Attachment 6: Cognitive Incapacity & Problem Behavis ment Level 2: F Most Patients Level 3: F Some Patients Care Management Blueprts Alzheimer s Disease Doma 1: Patient Function Doma 2: Caregiver Suppt Doma 3: Medical Care Doma 4: Psychosocial Doma 5: Patient Nutrition Doma 6: Advance Directives Planng Livg Dementia: Caregiver Suppt Planng Tool Six-Phase Model Helpg Families Alzheimer s Disease Programs Materials People Alzheimer s Disease Related Disders: Prediagnostic Phase Diagnostic Phase Role-Change Phase givg Phase Transition Alternative Care Phase End--Le Phase... 40

3 Netwks Alzheimer s Disease: About the Initiative Between national local partnerships the Alzheimer s Association (NCCC) members demonstrated that netwks tegrated care, suppt, education can be developed cpate the range services needed by people dementia can function under risk-based managed care fancg traditional Medicare. Furtherme, these netwks result high levels satisfaction on the part participatg patients, family caregivers, primary healthcare providers, Alzheimer s Association chapter staff. (See latest evaluation repts at The national local partners are committed ongog dissemation user-friendly products, materials, ols, program descriptions, other novations developed through the demonstration. The materials that follow are current as the date at the botm this page. Changes can will be made these materials as the experience itiative implementation evaluation suggests improvements. Unless otherwise noted, the ols mation this publication were developed by the Care Management Advisy Group the Education Suppt Advisy Group the Netwks Alzheimer s Disease (CCN/AD) itiative. Duplication educational clical purposes is authized out pri written approval acknowledgment is given the the Alzheimer s Association as the source. Notication use suggestions improvement are appreciated. Contact the, th Avenue South, Suite 120, Bloomgn, MN Page 3 Netwks Alzheimer s Disease The latest version these ols along descriptive material about the conduct the itiative its research results can be found on the NCCC Web site at Care Management Advisy Group (1997 development period) Kathryn Bgenicht, M.D.; Kenneth Brummel-Smith, M.D.; Susan Denman, M.D.; Peter Engel, M.D.; Alan Lazarf, M.D.; Katie Maslow; Jon Mertz; Cheryl Phillips, M.D.; Elizabeth Pohlmann; John Selstad Education Suppt Advisy Group (1997 development period) Paule Bourgeois, D.S.W.; Wayne Caron, Ph.D.; Helen Ann Comsck; Elizabeth Edgerly, Ph.D.; Katie Maslow; Elizabeth McKney; Lda Mitchell; Kim Peloso; Theresa Polich, Ph.D.; John Selstad 1998 the Alzheimer s Association Revised June 2003

4 Tools Early Identication Dementia Dementia is very prevalent among the elderly but is ten overlooked even by skilled clicians. Clues the presence dementia may be subtle nonspecic. Unrecognized dementia may lead iatrogenic illness, unnecessary wkups driven by vague sympms, appropriate costly utilization hospital emergency room care, po outcomes. Improvg our ability recognize dementia is a key first step ward improvg this widespread situation. Page 4 Netwks Alzheimer s Disease The Netwks Alzheimer s Disease early identication process uses two ols identy people who may have dementia should receive a full assessment. The flowchart on the next page illustrates the early identication process. Tool 1: Education Awareness Materials Triggers The early identication process is based on recommendations from the Agency Health Care Policy Research (AHCPR) Clical Practice Guidele, Early Identication Alzheimer s Related Dementias.* This clical practice guidele recommends the use triggers identy people possible dementia. The CCN/AD itiative uses separate but somewhat overlappg sets triggers from three sources. These are: The Alzheimer s Association publication, Ten Warng Signs Alzheimer s Disease A list patient behavi triggers clical staff developed by the Care Management Advisy Group the CCN/AD The triggers recommended the AHCPR Clical Practice Guidele, Early Identication Alzheimer s Related Dementias* The triggers should be used creatively trag sessions crease awareness dementia among all care system staff, health plan enrollees, families. Useful will vary each health plan clic but may clude trag physicians other staff, sendg regular publications enrollees, displayg posters pamphlets clic waitg areas. Tool 2: Family Questionnaire Family members are likely be aware signs sympms possible dementia that are not readily apparent clical staff. People who are identied as possibly havg dementia by the triggers (Tool 1) / the Family Questionnaire should receive an Initial Dementia ment. Note: Until February 2001 CCN/AD used a third ol that has been removed from the CCN/AD model based on the rational on page 11. *Source: Costa, P. T., Jr., T. F. Williams, M. Somerfield, et al Early Identication Alzheimer s Disease Related Dementias. Clical Practice Guidele, Quick Reference Guide Clicians, No. 19. Rockville, Md.: U.S. Department Health Human Services. AHCPR Publication No Revised May the Alzheimer s Association

5 Flowchart Tools Early Identication Dementia Medical fice staff health plan enrollees their families recognize signs sympms possible dementia based on triggers from the Alzheimer s Association s Ten Warng Signs, the list patient behavis clical staff, the AHCPR guideles Family Questionnaire dicates possible dementia Page 5 Initial Dementia ment Negative wkup Uncerta results Monir by reassessg triggers admisterg MMSE every 6 months Delirium depression Treat reassess Diagnosis dementia Use care management ol family suppt ol 1998 the Alzheimer s Association Revised February 2001

6 Early Identication Tool 1 Alzheimer s Association Ten Warng Signs The Alzheimer s Association developed the followg checklist common sympms. (Some them also may apply other dementg illnesses.) Individuals several these sympms should see a physician a complete examation. Page 6 1. Memy loss. One the most common early signs dementia is gettg recently learned mation. While it s nmal get appotments, names, telephone numbers, those dementia will get such thgs me ten not remember them later. 2. Dficulty permg familiar tasks. People dementia ten fd it hard complete everyday tasks that are so familiar we usually do not thk about how do them. A person Alzheimer s may not know the steps preparg a meal, usg a household appliance, participatg a lelong hobby. 3. Problems language. Everyone has trouble fdg the right wd sometimes, but a person Alzheimer s disease ten gets simple wds substitutes unusual wds, makg his her speech writg hard underst. If a person Alzheimer s is unable fd his her othbrush, example, the dividual may ask that thg my mouth. 4. Disientation time place. It s nmal get the day the week where you re gog. But people Alzheimer s disease can become lost on their own street, get where they are how they got there, not know how get back home. 5. Po decreased judgment. No one has perfect judgment all the time. Those Alzheimer s may dress out regard the weather, wearg several shirts blouses on a warm day very little clothg cold weather. Individuals dementia ten show po judgment about money, givg away large amounts money telemarketers payg home repairs products they don t need. 6. Problems abstract thkg. Balancg a checkbook may be hard when the task is me complicated than usual. Someone Alzheimer s disease could get completely what the numbers are what needs be done them. 7. Misplacg thgs. Anyone can temparily misplace a wallet key. A person Alzheimer s disease may put thgs unusual places: an iron the freezer a wristwatch the sugar bowl. 8. Changes mood behavi. Everyone can become sad moody from time time. Someone Alzheimer s disease can show rapid mood swgs from calm tears anger no apparent reason. 9. Changes personality. People s personalities darily change somewhat age. But a person Alzheimer s disease can change a lot, becomg extremely confused, suspicious, fearful, dependent on a family member. 10. Loss itiative. It s nmal tire housewk, busess activities, social obligations at times. The person Alzheimer s disease may become very passive, sittg front the television hours, sleepg me than usual, not wantg do usual activities. Source: Alzheimer s Disease Related Disders Association, Inc Ten Warng Signs Alzheimer s Disease. This ol can be accessed at Revised May 2003

7 Early Identication Tool 1 Patient Behavi Triggers Clical Staff Individuals undiagnosed dementia may exhibit behavis sympms that fer a clue the presence dementia can be observed by physicians, nurses, other clical fice staff. Educational sessions discussions all fice staff can create an awareness on everyone s part that general decle change the nature listed below on the part a patient is wthy note a clician further attention. Some examples: The patient Is a po hisrian seems odd Is attentive appearance, appropriately dressed the weather, dirty Fails appear scheduled appotments comes at the wrong time on the wrong day Repeatedly apparently untentionally fails follow structions (e.g., changg medications) Page 7 Has unexplaed weight loss, failure thrive, vague sympms (e.g., weakness dizzess) Seems unable adapt experiences functional dficulties under stress (e.g., the hospitalization, death, illness a spouse) Defers a caregiver a family member answers questions directed the patient In addition failure arrive at the right time appotments, the clician can look dficulty discussg current events an area terest changes behavi dress. It also may be helpful follow up on areas concern by askg the patient family members relevant questions. All the above needs be modied an fice s own patient panel can be strengthened case examples. This idea physician fice staff trag was developed by the Care Management Advisy Group the Netwks Alzheimer s Disease itiative is the jot property the the Alzheimer s Association. The primary auth is Alan Lazarf, M.D. Duplication educational clical purposes is authized out pri written approval acknowledgment is given the the Alzheimer s Association as the source. Notication use suggestions improvement are appreciated. Contact the, th Avenue South, Suite 120, Bloomgn, MN the Alzheimer s Association Revised May 2003

8 Early Identication Tool 1 Sympms That May Indicate Dementia Many older adults suffer from dementia. Positive answers the followg questions can help identy possible dementia. Does the person have creased dficulty any the activities listed below? If the answer is yes, he she should receive a dementia assessment from a docr. Learng retag new mation. Is me repetitive; has trouble rememberg recent conversations, events, appotments; frequently misplaces objects. Page 8 Hlg complex tasks. Has trouble followg a complex tra thought permg tasks that require many steps, such as balancg a checkbook cookg a meal. Reasong ability. Is unable respond a reasonable plan problems at wk home, such as knowg what do the bathroom is flooded; shows uncharacteristic disregard rules social conduct. Sense direction. Has trouble drivg, ganizg objects around the house, fdg his her way around familiar places. Language. Has creasg dficulty fdg the wds express what he she wants say followg conversations. Behavi. Appears me passive less responsive, is me irritable than usual, is me suspicious than usual, misterprets visual audiry stimuli. Experience from the CCN/AD Initiative Sites Even though sites found signicant overlap between this AHCPR (now AHRQ) list the Alzheimer s Association s Ten Warng Signs, they found both be useful dferent applications. The authity medical source the AHCPR sympms list seemed especially imptant physician trag sessions. Other fice staff, patients, family members seemed respond better the Ten Warng Signs. ) Source: Costa, P. T., Jr., T. F. Williams, M. Somerfield, et al Early Identication Alzheimer s Disease Related Dementias. Clical Practice Guidele, Quick Reference Guide Clicians, No. 19. Rockville, Md.: U.S. Department Health Human Services. AHCPR Publication No Revised May 2003

9 Early Identication Tool 2 Family Questionnaire We are tryg improve the care older adults. Some older adults develop problems memy the ability thk clearly. When this occurs, it may not come the attention the physician. Family members friends an older person may be aware problems that should prompt further evaluation by the physician. Please answer the followg questions. This mation will help us provide better care your family member. In your opion does Please circle the answer. 1. Repeatg askg the same thg over over? 2. Rememberg appotments, family occasions, holidays? 3. Writg checks, payg bills, balancg the checkbook? 4. Shoppg dependently (e.g., clothg groceries)? 5. Takg medications accdg structions? 6. Gettg lost while walkg drivg familiar places? have problems any the followg? Not at all Sometimes Frequently Does not apply Not at all Sometimes Frequently Does not apply Not at all Sometimes Frequently Does not apply Not at all Sometimes Frequently Does not apply Not at all Sometimes Frequently Does not apply Not at all Sometimes Frequently Does not apply Page 9 Relationship patient (spouse, son, daughter, brother, sister, grchild, friend, etc.) This mation will be given the patient s primary care provider. If any additional testg is appropriate, he she will let you know. Thank you your help the Alzheimer s Association Revised May 2003

10 Early Identication Tool 2 Use the Family Questionnaire The Family Questionnaire is designed help us identy patients memy problems that might otherwise go unnoticed. It consists five simple questions. A family member friend the patient can complete the questionnaire less than a mute. Page 10 When Use the Family Questionnaire If the patient has no pri diagnosis dementia If the patient is aged 65 older If the patient comes the clic the company a family member friend If the questionnaire has not been completed the past year We encourage the use the Family Questionnaire all patients who meet all these criteria. How Use the Family Questionnaire First, fd out a family member friend has come the patient. When you are checkg vital signs collectg other screeng mation, tell the patient you have a brief questionnaire his her family member friend that will help us fd out the patient has trouble rememberg thkg clearly. Expla that these sympms may not come our attention unless we ask about them that the mation will help us take better care the patient. Show the questionnaire the patient he she asks see it. Be sure the patient consents, then present the questionnaire the family member friend. Use the mation on the questionnaire itself when you expla it the family member. Ask the family member return it you once it is complete; sce the questionnaire, attach it the patient s chart. Scg: Not at all = 0 Sometimes = 1 Frequently = 2 Total Sce: Sce Interpretation: A sce 3 me should prompt the consideration a me detailed evaluation. Experience from the CCN/AD Initiative Sites Although some staff at CCN/AD sites were concerned that patients might become upset when their family members friends were asked complete the Family Questionnaire, this problem did not occur at any our sites. This ol was developed by the Care Management Advisy Group the Netwks Alzheimer s Disease itiative is the jot property the the Alzheimer s Association. The primary auths are Alan Lazarf, M.D., Judith Dollf, L.C.S.W. Duplication educational clical purposes is authized out pri written approval acknowledgment is given the the Alzheimer s Association as the source. Notication use suggestions improvement are appreciated. Contact the Chronic Care, th Avenue South, Suite 120, Bloomgn, MN Revised June the Alzheimer s Association

11 Rationale the Removal the High-Risk Screeng Tool When the CCN/AD model was designed, we believed that use the triggers the Family Questionnaire would identy many dividuals possible dementia that healthcare ganizations would want reduce the tal number dividuals who went on receive a full diagnostic assessment. Theree, we created what we believed would be a very dficult brief mental status test by takg the most dficult items from the Mi Mental State Examation (MMSE) addg the Clock Drawg. 1 The test we created, the High-Risk Screeng Tool, was tended be used after dividuals were identied on the basis the triggers / the Family Questionnaire, it was tended rule out dividuals who were very unlikely have dementia. We set a very high sce dividuals would have sce perfectly on the test be ruled out. We reasoned that dividuals dementia would be very unlikely sce perfectly on this dficult mental status test. After the CCN/AD sites began implementg the model, we heard about three kds problems the use the High-Risk Screeng Tool: Staff at some sites said they were not usg it due resistance physicians other clical staff. Page 11 Staff at some sites were completg the High-Risk Screeng Tool as a required activity, but they were completg it after they had already decided proceed the Initial Dementia ment. That was not the tended use the High-Risk Screeng Tool. Meover, sce the MMSE is part the Initial Dementia ment sce the MMSE the High-Risk Screeng Tool clude two identical items (name remember three objects spell wld backwards), usg both results duplication eft clicians dividuals possible dementia. Staff clicians at some sites used were thkg about usg the High-Risk Screeng Tool screen possible dementia dividuals who had not been previously identied on the basis the triggers the Family Questionnaire. That was not the tended use the High-Risk Screeng Tool, it is probably a very po ol that purpose. As noted above, we created the High-Risk Screeng Tool be used after someone has dicated concern about the dividual on the basis the triggers the Family Questionnaire, we created what we thought would be a very dficult test that would identy only those dividuals who are very unlikely have dementia even though someone had identied them on the basis the triggers the Family Questionnaire. All screeng tests have the same two potential problems: false positives (that is, situations where the test dicates the person has the condition, but he she really doesn t) false negatives (that is, situations where the test dicates the person does not have the condition, but he she really does). We believe that the High-Risk Screeng Tool used as a screeng test dividuals who have not been previously identied on the basis the triggers the Family Questionnaire will produce many false positives. False positives result 1 Two comprehensive literature reviews show that the items we selected from the MMSE are the most dficult items on the MMSE [Tombaugh, McIntyre, Journal the American Geriatrics Society 40(9): ] that one the items we selected from the MMSE the clock drawg are two the four most dficult items on any the widely used brief mental status tests. [Siu, A. L Screeng Dementia Investigatg Its Causes. Ann. Intern. Med. 115: ] 1998 the Alzheimer s Association Revised May 2003

12 Rationale the Removal the High-Risk Screeng Tool (cont.) unnecessary wk staff. Me imptantly, false positives create unnecessary fear time-consumg tests dividuals their families. (False negatives are probably less a problem the High-Risk Screeng Tool because the test is so dficult, but we have no data suppt that idea.) Page 12 Other brief mental status tests ( example, the MMSE the 7-Mute Screen) are probably less likely than our High-Risk Screeng Tool produce large numbers false positives when used screeng purposes a general population because they clude some less dficult questions, they do not require perfect sces as our High-Risk Screeng Tool did. On the other h, research suggests that all brief mental status tests are likely result false positives. 2 In addition, as many our sites found, dividuals who sce above the usual cuff sce on the MMSE ( example, 24 29) may nevertheless have dementia. F these reasons a committee Alzheimer s experts med by the Agency Health Care Policy Research recommended agast screeng dementia general populations elderly people. 3 An ternational consensus group Alzheimer s experts also recommended agast screeng dementia general populations elderly people, concludg that cognitive testg should occur older patients when there is a reason suspect dementia. Testg may occur an dividual considered be at risk because an mant hisry cognitive functional decle, clical observation,, sometimes, very old age. 4 In November 2000 the Medical Scientic Advisy Council the Alzheimer s Association reaffirmed its recommendation agast screeng dementia general populations elderly people. 2 In the federal government sponsed a large-scale survey, the Epidemiologic Catchment Areas (ECA) study five sites the United States. In all sites, a probability sample adults was terviewed usg the MMSE other tests. Thus, the MMSE was used the general population not just people who are suspected some reason have dementia. In the East Baltime site subjects whose sces on any the tests dicated that they might have a cognitive psychiatric disder were then terviewed by a psychiatrist who used stardized clical methods make a clical diagnosis based on DSM III criteria. Of those aged 65 over who sced below 24 on the MMSE (the usual cuff sce the MMSE), only 26.4 percent had dementia; 5 percent had delirium; others had other psychiatric disders, 33.1 percent had no diagnosable cognitive psychiatric disder. Thus, the use the MMSE this general population generated a very high rate false positives. [Folste, et al Journal the American Geriatrics Society 33(4): ] 3 Costa, P. T., Jr., T. F. Williams, M. Somerfield, et al Early Identication Alzheimer s Disease Related Dementias. Clical Practice Guidele, Quick Reference Guide Clicians, No. 19. Rockville, Md.: U.S. Department Health Human Services Health Human Services. AHCPR Publication No Brodaty, et al Alzheimer s Disease Associated Disders 12(1):1 13. Revised May the Alzheimer s Association

13 Initial Dementia ment Primary Care Providers: Three Levels Investigation Attached is the approach dementia assessment developed by the Care Management Advisy Group the Netwks Alzheimer s Disease itiative. These recommendations are based upon the Advisy Group s evaluation currently available practice guideles regardg dementia assessment wk by Siu. The guideles were developed implementation primary care-driven, managed care settgs. In such settgs where there may be me opptunities practicg population-based care usg non-physician personnel, the detection wkup dementia is likely be dferent than fee--service settgs. In developg the recommended assessment, the Advisy Group considered both comprehensiveness cost effectiveness. The approach dementia assessment recommended by the Advisy Group assumes that people possible dementia have been identied usg case fdg methods such as provider education about signs sympms possible dementia, use a family questionnaire, other health risk assessments. It is not expected that all parts the assessment will necessarily be implemented one visit, rather two three visits could be required. The results the Initial Dementia ment (IDA) suppt both the physician s diagnosis the development a care plan management care over time. The Advisy Group recommends a three-step approach assessment. The examations tests listed Level 1 should be done all clients. We estimate that 65 percent clients will need no me than this level assessment. Level 2 examations tests should be done all clients unless there is relative certaty about the diagnosis based upon the Level 1 mation, the results a Level 2 test would not change the care plan. We estimate that virtually all remag clients will be this categy. Level 3 terventions are rarely needed the route assessment management dementia primary care settgs. However, onset is early (age < 65), course is atypical, diagnostic uncertaty is high, they may be helpful. Page 13 Netwks Alzheimer s Disease Sources: Costa, P. T., Jr., T. F. Williams, M. Somerfield, et al Early Identication Alzheimer s Disease Related Dementias. Clical Practice Guidele, Quick Reference Guide Clicians, No. 19. Rockville, Md.: U.S. Department Health Human Services. AHCPR Publication No Siu, A. L Screeng Dementia Investigatg Its Causes. Ann. Intern. Med. 115: Veterans Health Admistration Dementia Identication ment: Guideles Primary Care Practitioner. U.S. Dept. Veterans Affairs. Wk Group on Alzheimer s Disease Related Dementias Practice Guideles the Treatment Patients Alzheimer s Disease Related Dementias Late Le. American Journal Psychiatry 154 (Supplement):1-39. This ol was developed by the Care Management Advisy Group the Netwks Alzheimer s Disease itiative is the jot property the the Alzheimer s Association. The primary auth is Kenneth Brummel-Smith, M.D. Duplication educational clical purposes is authized out pri written approval acknowledgment is given the the Alzheimer s Association as the source. Notication use suggestions improvement are appreciated. Contact the, th Avenue South, Suite 120, Bloomgn, MN the Alzheimer s Association Revised May 2003

14 Initial Dementia ment Level 1 F All Patients Note: This wkup assumes that the patient has met early identication criteria dicatg the need assessment that the patient caregiver has requested an -depth assessment. Page 14 Interview (should be crobated family caregiver) Focused hisry Patterns losses, behavial issues, current functiong, safety concerns, onset memy other cognitive problems Past medical hisry Risk facrs, head trauma, neurological conditions Geriatric review systems Contence, drivg, falls, constipation, vision hearg, dental, depression, neurologic sympms Social family hisry Review medications Prescriptions, OTC Review preventive terventions Immunizations, appropriate cancer screeng Advance healthcare directive status Expressed wishes, chosen surrogate Family Interview (out patient present) Caregiver stra Repts by caregivers negative consequences caregivg their: health, relationship care receivers, non-caregivg social activities, perceived ability function effectively the caregiver role. MBRC Caregiver Stra Instrument (Attachment 5) Caregiver perceptions patient s cognitive behavial sympms Caregiver repts common sympms dementia. Cognitive Incapacity & Problem Behavis ment (Attachment 6) Examation Physical exam Hearg vision screens, thostatic blood pressure Neurologic exam Cranial nerves, muscle strength ne, trem, localized fdgs, deep tendon pathologic reflexes Functional status Functional Activities Questionnaire (FAQ) Activities Daily Livg (ADL) (Attachments 3 4) Mental status assessment Mi-Mental State Examation (MMSE)* (Attachment 1) Depression assessment Geriatric Depression Scale Sgle-Item Depression Indicar (Attachment 2) Labary Tests (pri labary studies should be sufficient done a relatively recent time frame) CBC Serum electrolytes TSH Glucose BUN/create Drug levels (e.g., digox) Therapeutic Diagnostic Tests Remove possible fendg medications Treat depression *Use the MMSE is required the Netwks Alzheimer s Disease sites. Other struments mentioned this section are highly recommended. Revised June the Alzheimer s Association

15 Initial Dementia ment Attachment 1 Mi-Mental State Examation (MMSE)* The MMSE was a required part the Initial Dementia ment the CCN/AD itiative was previously cluded the Tools Early Identication, ment, Treatment People Alzheimer s Disease Dementia document. Due copyright restrictions that ok effect after the CCN/AD ols document was developed, we can no longer reproduce the MMSE. MMSE sources are listed at the botm this page. Copyright purchasg mation is listed below. * 1975, 1998, 2001 by MiMental, LLC. All rights reserved. Published 2001 by Psychological ment Resources, Inc. May not be reproduced whole part any m by any means out written permission Psychological ment Resources, Inc., Nth Flida Avenue, Lutz, FL The complete MMSE can be purchased from PAR, Inc., by callg (800) (813) , visit Page 15 Sources: Crum, R. M., J. C. Anthony, S. S. Bassett, M. F. Folste Population-Based Nms the Mi- Mental State Examation by Age Educational Level. J. Am. Med. Assoc. 269: Folste, M. F., S. E. Folste, P. R. McHugh Mi-Mental State: A Practical Method Gradg the Cognitive State Patients the Clician. J. Psych. Res. 12: Revised May 2003

16 Initial Dementia ment Attachment 2 Geriatric Depression Scale (GDS) Sgle-Item Depression Indicar Geriatric Depression Scale 1. Are you basically satisfied your le?...yes No 2. Have you dropped many your activities terests?...yes No 3. Do you feel that your le is empty?...yes No 4. Do you ten get bed?...yes No Page 16 Scg: Depressed answers are: No on numbers 1, 5, 7, 11, 13 Yes on numbers 2, 3, 4, 6, 8, 9, 10, 12, 14, No cause concern 5 9 Strong probability depression 10+ Indicative depression 5. Are you good spirits most the time?...yes No 6. Are you afraid that somethg bad is gog happen you?...yes No 7. Do you feel happy most the time?...yes No 8. Do you ten feel helpless?...yes No 9. Do you prefer stay at home, rather than gog out dog new thgs?...yes 10. Do you feel you have me problems memy than most?...yes No 11. Do you thk it is wonderful be alive now?...yes No 12. Do you feel pretty wthless the way you are now?...yes No 13. Do you feel full energy?...yes No 14. Do you feel that your situation is hopeless?...yes No 15. Do you thk that most people are better f than you are?...yes No Sce: (number depressed answers) Five me depressed responses warrants further evaluation. No The followg question could be used stead the GDS (see Mahoney, et al., 1994) addition the GDS. If usg both, consider askg the Sgle-Item question not direct sequence the GDS. Sgle-Item Depression Indicar 1. Do you ten feel sad depressed? Yes No Sources: Lachs, M. S., et al A Simple Procedure General Screeng Functional Disability Elderly Patients. Ann. Intern. Med. 112(9): Mahoney, J., et al Screeng Depression: Sgle Question versus GDS. JAGS 42(9): Sheikh, J. I., J. A. Yesavage Geriatric Depression Scale (GDS): Recent Evidence Development a Shter Version. In Clical Geronlogy: A Guide ment Intervention, edited by T. L. Brk, New Yk: Hawth Press. Revised Ocber 2000

17 Initial Dementia ment Attachment 3 Functional Activities Questionnaire (FAQ) The FAQ is an mant-based measure functional abilities. Inmants provide permance ratgs the target person on ten complex higher-der activities. Individual Items the FAQ 1. Writg checks, payg bills, balancg checkbook 2. Assemblg tax recds, busess affairs, papers 3. Shoppg alone clothes, household necessities, groceries 4. Playg a game skill, wkg on a hobby 5. Heatg water, makg a cup cfee, turng f sve 6. Preparg a balanced meal Page Keepg track current events 8. Payg attention, understg, discussg a TV show, book, magaze 9. Rememberg appotments, family occasions, holidays, medications 10. Travelg out neighbhood, drivg, arrangg take buses Total The levels permance assigned range from dependence dependence are rated as follows. Dependent = 3 Requires assistance = 2 Has dficulty, but does by self = 1 Nmal = 0 Two other response options can also be sced. Never did (the activity), but could do now = 0 Never did, would have dficulty now = 1 A tal sce the FAQ is computed by simply summg the sces across the 10 items. Sces range from A cutpot 9 (dependent 3 me activities) is recommended. Source: Pfeffer, R., T. Kurosaki, C. Harrah, J. Chance, S. Filos Measurement Functional Activities Older Adults the Community. Journal Geronlogy 37 (May): Reprted permission The Geronlogical Society America, th Street NW, Suite 250, Washgn, DC Reproduced by permission the publisher via Copyright Clearance Center, Inc. Revised April 1999

18 Initial Dementia ment Attachment 4 Activities Daily Livg (ADL) Please circle the response that you feel best represents the person s ability do each the followg activities daily livg. Needs no Needs some Totally assistance assistance dependent/ Activity: supervision supervision cannot do at all Page 18 Eatg Toiletg Bathg (sponge, shower, tub) Dressg Groomg (combg, shampoog hair; shavg; trimmg nails) Transferrg Total Sce Source: Katz, S., A. B. Fd, R. W. Moskowitz, B. A. Jackson, M. W. Jaffe Studies Illness the Aged. The Index ADL: A Stardized Measure Biological Psychosocial Function. Journal the American Medical Association 185: Revised June 2000

19 Initial Dementia ment Attachment 5 MBRC Caregiver Stra Instrument A primary caregiver is the family member friend who gives the most help someone a health problem. The followg items refer how a caregiver feels behaves as a result providg care. Please use the followg scale answer questions There are no right wrong answers. Strongly agree = 3 Agree = 2 Disagree = 1 Strongly disagree = 0 Durg the past four weeks, because helpg the patient, I felt: 1. unsure whether he/she was gettg proper care. 2. uncerta about how best care him/her. Page that I should be dog me him/her. 4. that I could do a better job carg him/her. 5. that he/she tried manipulate me. 6. that my relationship him/her was straed. 7. that he/she made requests over above what he/she needed. 8. resentful ward him/her. 9. angry ward him/her. 10. my physical health was wse than bee. 11. downhearted, blue, sad me ten. 12. me nervous bothered by nerves than bee. 13. I had less pep energy. 14. bothered me by aches pas. Caregiver Mastery Sce (Sum items 1 4) Relationship Stra Sce (Sum items 5 9) Health Stra Sce (Sum items 10 14) Contued on page 20. Revised June 2000

20 Initial Dementia ment Attachment 5 MBRC Caregiver Stra Instrument (cont.) Please use the followg scale answer questions There are no right wrong answers. Less ten = 2 The same = 1 Strongly disagree = 0 Durg the past four weeks, because helpg the patient, I: Page participated church religious activities. 16. visited friends family. 17. participated group ganized activities. 18. engaged volunteer activities. 19. went out dner, the theater, a show. Activity Restriction Sce (Sum items 15 19) No exact cuttg pots heightened caregiver risk have been determed this ol. Answers can help caregivers describe dficulties they are experiencg, repeated admistrations, it can be used assess change the care situation over time. However, sces greater than 8 mastery, greater than 10 relationship stra health stra, greater than 5 activity restriction may dicate heightened risk may warrant further clical vestigation. Sources: Bass, D. M., L. S. Noelker, L. R. Rechl The Moderatg Influence Service Use on Negative Caregivg Consequences. Journals Geronlogy 51B:S Used by permission the Margaret Blenkner Research Center at The Benjam Rose Institute. Bass, D. M., M. J. McClendon, G. T. Deimlg, S. Mukherjee The Influence Diagnosed Mental Impairment on Family Caregiver Stra. Journals Geronlogy 49:S Used by permission the Margaret Blenkner Research Center at The Benjam Rose Institute. Revised June 2000

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