Today's date:                 Time:

Patient's Initials:                    Patient Number:  

Study Number:                       Rater's Initials:

Psychometric Tests:

1. Word learning: (Record # of correct responses. If pt. is completely right on trials one and two, trial three may be omitted. The patient's error score is the number of items missed or recalled incorrectly.)

            "hand"           "watch"           "shoe"             

            "hand"           "watch"           "shoe"

            "hand"           "watch"           "shoe"                    score (0-9):

2. Remote memory                             (correct)                                     (wrong)

   year you were born?                           0               1                 2

   who was first President?                      0               1                 2

    two presidents you remember?           0               1                 2

    what letter comes after a,b,c,?            0               1                 2

                                                                                                    score (0-8)

3.Orientation:                                      (correct)             (wrong)

    your name? (first/last)                                             

    how old are you? (within 1 yr)                                 

    what is the year?                                                      

    what is the month?                                                  

    what country are we in?                                          

    name of this place?                                                  

                                                                                                   score (0-6)

4. Naming: If no answer after "What is this called?", give cue listed after the object. Six errors are possible.

                correct                                                                  incorrect

   flower;               (cue)  grows in a garden                                      

    bed;                  (cue) used for sleeping                          

    whistle;             (cue)  it makes a sound when blown      

    pencil;               (cue)  used for writing                           

    house;               (cue)  a kind of building                         

    cup;                  (cue)  you drink from it                         

                                                                                                    score (0-6)

5. Commands: An error on each counts one point. Instructions are: "I want you to do some simple things for me."  Each command can be repeated twice if necessary.

                                                                            can do                  can not

    Make a fist.                                                                             

    Point to the floor.                                                                     

    Put your hand together, then pull them apart.                            

                                                                                                    score (0-3)

6. Expressive language: Assessed by asking pt. to generate a sentence. Instructions are: "I want you to say something for me that begins with ' I wish...'. Instructions can be repeated if necessary. Response is scored as follows:

   3 = no response

   2 = response does not begin with "I wish"                

   1 = response begins with "I wish", but, is not a sentence

   0 = correct response

Total score for part one     (0 - 35)

7. Memory: Rates the extent to which the clinician believes that the pt's. difficulties in completing the exam are a result of memory failures.

    4 =  pt. completes none of the tasks due to poor memory. Can not remember any of the instructions.

    3 = has difficulty remembering task instructions over 50% of time, & only completes 1-2 tasks.         

    2 = has difficulty remembering task instructions at least 25% of time, & fails to complete some tasks. 

   1 = has difficulty remembering task instructions and fails to complete at least one task.                        

   0 = may have some difficulty in remembering instructions, but completes all tasks.                                                          

8. Speech : Rates pt.'s speech during the testing session, both in terms of quantity and in terms of information conveyed.  

    4 =  does not speak even when spoken to.                                                    

    3 = speech is limited to one or two word utterances.                                      

    2 = Over 50% of the responses are not understandable and vocabulary is significantly reduced      

    1 = usually has difficulty responding appropriately and some responses are not understandable.       

    0 = fluent speech but understandability may sometimes be lost due to memory problems.                                                  

9. Comprehension: Rates pt.'s ability to comprehend speech which can be inferred from either verbal or other responses during testing session.

    4 = gives neither verbal nor nonverbal indications of response.                                                        

    3 = responds to voices by orienting, but can follow no commands.                                                  

    2 = occasionally responds appropriately, usually to yes or no questions.                                          

    1= usually respond appropriately, but often requires repetition or rephrasing.                                   

    0 = normal comprehension, or only a few instances where repetition or rephrasing are required.      

10. Movement control: Rates the extent to which pt. can perform common movements at will. Score item based on observation                      

   4 = has almost no movement control. (e.g. bedridden due to dementia)                                            

   3 = ambulatory, but most movements appear to be pointless and repetitious (e.g. pacing, rocking, grimacing)   

   2 = initiates purposeful activities, but also spends a significant amount of time in purposeless activity.                  

   1 = has some difficulty performing common but complex activities such as dressing.                                           

   0 = no obvious difficulty in controlling movements except on specialized tests such as drawing.                           

11. Affect-Depression: rated on basis of information from caregivers and from direct examination of the pt. Usual time period for this item is the week prior to the examination.

    4 = is continuously depressed. Expresses depressed feelings (e.g."I wish I were dead.") with evidence of reduced activity due to depressed mood.                                                                                                                                   

   3 = pervasive depressed mood, but with some evidence of reactivity.                                                                

   2 = more than one instance of depressed mood (e.g. crying, depressive thoughts, lack of reactivity not appropriate to the  situation.                                                                                                                                                     

   1 = at least one instance of depressed mood not appropriate to the situation.                                                      

   0 = normal or appropriate mood.                                                                                                                       

12. Pathological Thinking/Perceptions: rates evidence of either delusions or hallucinations based primarily on evidence provided by a caregiver. The time period is one week prior to the exam.                

   4 = fixed delusions or frequent hallucinations. May be paranoid or other delusions, but  must not be simply a result of poor memory or confabulation.

   3 = delusions or hallucinations that are frequent and affect the pt.'s behavior (e.g. wants to run away because he feels the people around him are possessed.)

   2 = any delusions or hallucinations that occur repeatedly or any single delusion or hallucination that affects the pt.'s  behavior.

   1 = any less severe delusion or hallucination.                                                                                                         

   0 = no evidence of delusions or hallucinations.                                                                                                       

     Total score for part two = 0 - 24  _________

13.  Memory & learning : Rates the extent to which the pt. shows evidence of memory impairment outside the testing session.
       Examiner asks caregiver about pt.'s usual activities, and, if possible, determines how pt. responds to changes in surroundings or routines.                     

   4 = profound memory loss with no evidence of ability to adapt to any change in surroundings;
                  has little or no memory of remote events. (i.e. those prior to  disease onset).                                                                                        

   3 = severe memory loss; learns almost no new information, but, may be able to remember people, events, objects from the past.

   2 = serious memory loss with some learning ability preserved; may be manifested by ability to adapt
               to rearranged furniture, ability to recognize new pt's.,  staff etc.

   1 = moderate memory impairment, but, several clear instances where pt. was able to follow and retain verbal instructions.

   0 = usually remembers verbal instructions, but may require reminders.                                                                        

14. Speech : Rates speech outside the testing situation both in terms of quantity and understandability.   

    4 = never speaks or only makes sounds that are not words.                                                                                

    3 = speech is limited to a few words or phrases.                                                                                                 

    2 = speech is not understandable at least 50% of the time.                                                                                   

    1 = has difficulty communicating; but, is understandable more than 50% of the time.                                              

    0 = fluent speech with occasional lack of understandability due to memory problems.                                            

15.Spontaneous movement : Rates the extent to which pt's. ability to initiate and control purposeful movements is impaired.
          To assess ask caregiver whether pt. is able to walk, reach, pick up objects, & use utensils appropriately.            

    4 = does not perform any purposeful movements. (e.g. bedridden, chairbound)                                                               

    3 = initiates only occasional purposeful movements. (e.g. while eating & most movements are repetitious or stereotyped) 

    2 = gross movements (e.g. walking, reaching) performed at will; but, pt. has obvious difficulty with more complex actions.

   1 = at least one or more instances of difficulty in spontaneous movement, even if only trying to dress or use utensils or  appliances.                                                                                                                                               

    0 = no difficulty in movement control.                                                                                                                     

16. Social awareness: Rates the extent to which the pt. can recognize and respond appropriately to people around him.              

    4 = does not recognize even close relatives.                                                                                                    

    3 = usually recognizes immediate family members, but frequently misidentifies others. Instances of socially inappropriate
                      behavior often present. ( Takes off clothes in front of others; does not respond when spoken to).                

     2 = more than two instances where the pt. misidentifies others, or more than two instances of inappropriate behavior.   

    1 = at least one instance of misidentification or socially inappropriate behavior.                                                                

    0 = recognizes other familiar people and is socially appropriate.                                                                                    

Total score for part three:   0 - 16 _________

Items rated on basis of best available information, either from caregiver, pt's. chart, or direct observation. Time frame of one week.

17. Toileting  

    4 = doubly incontinent                                                                                                                            

    3 = occasionally uses toilet, but, soils and wets self frequently while awake.                                              

    2 = frequent soiling and wetting while asleep,but no more than one instance per week while awake.         

    1 = soiling or wetting while asleep no more than twice per week.                                                              

    0 = no incontinence or only a rare accident. (less than 2 per week).                                                                                                                                                                                                                                                

18. Feeding                                         

      4 = can offer no assistance in feeding, or actively resists eating.                                                                    

    3 = requires extensive assistance in feeding; must be attended at every meal.                                                                  

   2 = tries to eat on his own, but, is untidy, and needs assistance.                                                                

    1 = often eats without assistance, but, is messy at least 25% of the time.                                                   

   0 = eats without assistance.                                                                                                                     

19. Dressing

    4 = can offer no assistance in dressing, or actively resists dressing.                                                           

    3 = requires extensive assistance in dressing, but, moves limbs to assist in getting dressed.                        

    2 = attempts to dress on his own, but, requires assistance each time.                                                        

    1 = can put clothes on with few errors when they are selected by someone else.                                       

    0 = usually dresses appropriately unaided, but, may need some assistance in selecting clothes.                                                                                 

20. Physical Ambulation  

    4 = bedridden, can not sit without support.                                                                                               

    3 = sits without support, but, can not move a wheelchair without assistance.                                              

    2 = can move with a walker or a wheelchair.                                                                                             

    1 = can walk with a cane or a handrail.                                                                                                     

    0 = walks without aid, although distance may be reduced.                                                                                          

Total score for part four :  0 - 16 _____________

Total score for entire scale : 0 - 81 ______________