G. FUNCTIONAL MEMORY AND COGNITION ASSESSMENT 100

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1 G. FUNCTIONAL MEMORY AND COGNITION ASSESSMENT Check if any of the following exist: 1000 Learning disability 105 Communication, sensory or motor disabilities 110 Diagnosed Traumatic Brain Injury prior to the person turning 22 years of age 115 Diagnosed Traumatic Brain Injury since turning Memory Loss 125 a. Is there a diagnosis on record that explains the functional memory and cognitive issues? Yes, specify: No, make referral for full cognitive assessment Does the person have a problem with cognitive functioning due to mental retardation or a related condition, which manifested itself during the developmental period (birth through age 21), by report or by review of psychological testing results? 1005 Yes enter psychological testing results: No testing information available Is the person demonstrating problems with cognitive functioning in the home, school, or work environment, which requires the person to receive a habilitative support program, including the need for active treatment? 1010 Yes describe: 105 Cognitive Impairment Severity 1000 Level of Support Required 1005 Attention/Concentration 200 Learning 205 Perception 210 Mild 100 Moderate 105 Task Completion 215 Severe 110 Very Severe 115 Awareness 220 Not Present Communication 225 Judgement 230 Memory 235 Planning 240 Problem Solving No Support Required 100 Occasional Support 105 Frequent Support 110 Availability of 24-hour Support or Monitoring 115 Unsure 110 Functional Memory and Cognition - Page 1

2 4. Mental Status Evaluation 103 (Ask person only. Score 1 for each incorrect response. In scoring, a No Response is treated as incorrect. A correct response is 0. For the memory phrase, have the person repeat the phrase twice before continuing.) Now, I m going to read you a list of questions. These are questions that are often asked in interviews like this and we are asking them the same way to everyone. Some may be easy and some may be difficult. Let s start with today s date. Orientation-Memory-Concentration Test (Katzman et al., 1983) Items Maximum Errors 100 Score 105 Weight 110 Weighted Score 115 a. What year is it now? X 4 = b. What month is it now? X 3 = Repeat this phrase after me: Memory phrase: John Brown, 42 Market Street, Chicago c. About what time is it? (Within 1 hour) X 3 = d. Count backwards 20 to X 2 = e. Say the months in reverse order X 2 = f. Repeat the memory phrase (Once) X 2 = Total Weighted Score 1027 Chose not to answer 1030, 100 Maximum weighted error score = 28. INTERPRETATION: A score of 10 or more is consistent with the presence of dementia, excluding REFUSED: Score 29, NA: Score 30 If the individual scores 10 or higher and a responsible party is not present, stop assessment If score 10 or higher, complete the following: b. What type of support does the person need in the home for assistance with activities that require remembering, decision-making or judgment? 1020 Someone else needs to be with the person always, to observe or provide supervision. 100 Someone else needs to be around always, but they only need to check on the person now and then. 105 Sometimes the person can be left alone for an hour or two. 110 Sometimes the person can be left alone for most of the day. 115 The person can be left alone all day and all night, but someone needs to check in on the person every day. 120 The person can be left alone without anyone checking in. 125 Chose not to answer 130 c. What type of support does the person need to help with remembering, decision-making, or judgment when away from home? 1025 The person cannot leave home, even with someone else, because of behavioral difficulties (becomes very confused or agitated during outings, engages in inappropriate behavior, becomes aggressive, etc.). 100 Someone always needs to be with the person to help with remembering, decision making or judgment when away from the home. 105 The person can go places alone as long as they are familiar places. 110 The person does not need help going anywhere. 115 Chose not to answer 120 Functional Memory and Cognition - Page 2

3 HELPS BRAIN INJURY SCREENING TOOL Have you Hit your head or been Hit on the head? 1000 If yes, answer the following: 2. Were you ever seen in the Emergency room, hospital, or by a doctor or because of an injury to your head? Did you ever Lose consciousness or experience a period of being dazed and confused because of an injury to your head? Do you experience any of these Problems in your daily life since you hit your head? headaches difficulty reading, writing, calculating dizziness poor problem solving anxiety difficulty performing your job/school work depression poor judgment (being fired from job, arrests, fights) difficulty concentrating difficulty remembering 145 chose not to answer Any other significant Sickness? (The person experienced any other significant sickness or symptom due to an injury to the head. Consider an acquired brain injury or oxygen deprivation following a life-threatening emergency) Score: 1022/100 Algorithms for program: Scoring Instructions: Score one point if yes is answered for questions 1, 2, or 5. Score one point if yes is answered for questions 2 or 3. Score one point if 2 or more problems are identified in question 4. A score of 3 is considered positive for a possible TBI. A note from the developer: Consider positive responses within the context of Functional Memory and Cognition - Page 3

4 the person s self-report and documentation of altered behavioral and/or cognitive functioning. Original instrument created by M. Pricard, D. Scarisbrick, R. Paluck (International Center for the Disabled, TBI-NET, U.S. Department of Education, Rehabilitation Services Administration, Grant #H128A00022). This version was found at: Modified Rancho Los Amigos Level of Cognitive Functioning 108 Level I Person is completely unresponsive to stimuli 100 II Peson reacts inconsistently and non-purposefully to stimuli 105 III Person responds specifically but inconsistently to stimuli and may follow simple commands 110 IV Person is in a heightened state of activity with severely decreased ability to process information. Behavior is non-purposeful relative to the immediate environment 115 V Person appears alert and responds to simple commands fairly consistently. Agitation, which is out of proportion (but directly related to stimuli), may be evident 120 VI Person shows goal directed behavior but depends on external input for direction 125 VII Person goes through daily routine automatically, has absent to minimal confusion but lacks insight. 130 VIII Person is alert and oriented. Independence in the home and community has returned. Social, emotional and cognitive abilities may be decreased. 135 Comments: Referrals Needed Select One 1000 Cognitive functioning assessment by a licensed professional 100 Neuropsychological assessment 103 Vocational Rehabilitation 105 Physical Therapist 110 Occupational Therapist 115 Speech Language Pathologist 120 Assistive technology specialist 130 Functional Memory and Cognition - Page 4

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