Understanding Dementia Alzheimer s Disease and Related Disorders

Transcription

1 CIAO Seminars Presents: Understanding Dementia Alzheimer s Disease and Related Disorders Jeanne Demory Post, MSW, LCSW 362 Gulf Breeze Pkwy #193 Gulf Breeze, FL business CIAO(2426) toll free fax web-

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3 Understanding Dementia Alzheimer s Disease and Related Disorders Course Description: An estimated 4.5 million Americans have Alzheimer s Disease. It is the leading cause of institutionalization of older Americans and is a growing challenge to health care providers. This learning experience provides an overview of Alzheimer s Disease and other irreversible and reversible causes of dementia. Participants will learn how to recognize warning signs and symptoms, and recognize the stages of Alzheimer s Disease. The course will outline dementia-related communication deficits and provide practical strategies for improving communication with the impaired client. Participants will gain understanding of behavioral symptoms and triggers and learn about interventions that may be effective in reducing behavioral symptoms.this course has been designed to have immediate practical application. The learning experience will provide insight into understanding and interacting with Alzheimer s and relateddementia clients. Additional Screening Techniques section included in course manual. Instructor: Jeanne Demory Post, MSW, LCSW has served as Clinical Coordinator and Clinical Social Worker for a state memory disorder clinic and as a State of Florida Alzheimer s Research Brain Bank Coordinator. She is a former committee member of the State of FloridaAlzheimer s Disease Initiative Nursing Home Committee for Behavior Management. Certified by the University of South Florida Training Academy on Aging, she taught the state-mandated Department of Elder Affairs Nursing Home Alzheimer s Disease Training and the ALF Level I and II Alzheimer s Disease Training. She has extensive experience as a training and group facilitator and has been a frequent guest lecturer at health care conferences, civic meetings, and public seminars on the subjects of dementia, Alzheimer s disease, caregiver burnout, and stress management. She is a Clinical Instructor at a College of Medicine and travels nationally and internationally in her work as a social work contractor for a government agency. Course Objectives Upon completion of this course, participants will be able to: 1. Discuss the distinction between dementia syndrome and Alzheimer's Disease 2. Identify reversible and irreversible causes of dementia 3. List communication deficits in dementia disorders 4. Discuss strategies for effective communication in each stage of dementia 5. Identify common triggers resulting in behavioral challenges 6. Describe primary, secondary, and peripheral psychiatric or behavioral symptoms of dementia 7. Discuss interventions that may be effective in reducing behavioral challenges

4 Agenda 10 minutes Introduction to Dementia 15 minutes Recognizing Dementia 15 minutes Causes of Dementia 10 minutes Medications 15 minutes Stages of Alzheimer s Disease 15 minutes Communication in Alzheimer s Disease 15 minutes Managing Behavioral Concerns in Alzheimer s Disease 10 minutes Person- Centered Care 15 minutes Q & A CEUs: 0.2 (2 Contact Hours) CIAO is an ASHA Approved CE Provider #AAWA (SLP/SLPAs) CIAO is an AOTA Approved Provider #4119 (OT/COTA s ) This course meets PDU requirements for NBCOT (2 PDUs) CIAO is an Illinois Approved Provider for PT/PTA Continuing Education CIAO is recognized as an Approved Provider for PT/PTAs by the NYSE Dept State Board for PT This activity is provided by the TBPTE Accredited Prov. #CIAO032010TPTA This activity meets the continuing competence requirements for PT/PTA license renewal in TX Approved for: Check website for specific state approvals ( This course is offered for 0.2 ASHA CEUs (Introductory level, Professional area). The assignment of AOTA CEUs does not imply endorsement of specific course content, products, or clinical procedures by AOTA. Meets PDU requirements for NBCOT.

5 Understanding Dementia Alzheimer s Disease and Related Disorders Dementia Dementia Syndrome Loss of cognitive function including thinking, remembering, and reasoning Resulting in the inability to perform activities of daily living A primary reason for nursing home placement What is Dementia? Development of multiple cognitive deficits manifested by Memory impairment and At least one of the following Aphasia Agnosia Apraxia Disturbance in executive functioning Impairment in occupational or social functioning representing a significant decline from a previously higher level of functioning American Psychiatric Association, DSM.IVR 1

6 10 Warning Signs of Dementia Memory loss Difficulty performing familiar tasks Problems with language Disorientation to time and place Poor or decreased judgment 10 Warning Signs of Dementia (continued) Problems with abstract thinking Misplacing things Changes in mood or behavior Changes in personality Loss of initiative Reversible Conditions Sometimes Mimic Dementia High fever Dehydration Vitamin deficiency Poor nutrition Medication reactions Substance use/abuse Thyroid problems Minor head trauma Depression (pseudo-dementia) dementia) Excessive stress Shock/bereavement 2

7 Mild Cognitive Impairment (MCI) Not a specific medical condition or disease No/minimal problems in daily living Impaired memory Subjective report Standard neuropsychological testing Often without Confusion Attention problems Difficulty with language Delirium Sudden, fluctuating cognitive disorder characterized by Disorientation Decline in level of consciousness Inability to pay attention Inability to think clearly Perceptual disturbance Delirium in Older Persons Sometimes attributed to dementia possibly delaying needed treatment Significantly increased vulnerability to Less severe conditions Relatively minor illness 3

8 Suspected Delirium Dehydration Infection (UTI) Retention of urine or feces Bowel obstruction Medication reaction Head trauma Sensory deprivation Delirium versus Dementia Delirium Sudden onset Days to weeks May fluctuate from lethargy to agitation Variable/unpredictable mental function May be unintelligible Dementia Slow onset Months to years Normal until late stages Memory loss but fairly consistent mental function Word-finding Irreversible Dementia Static (unchanging) Such as single, major trauma to the brain Step-like decline Vascular Dementia (VaD) Gradual onset/progressive decline Alzheimer s Disease (AD) 4

9 Most Common Forms of Dementia Degenerative Alzheimer s Lewy Bodies Vascular (multi-infarct infarct dementia) Alcohol-induced Korsakoff s syndrome Irreversible Causes of Dementia Alzheimer s Disease (AD) Frontotemporal Lobe Dementia (FLD) Dementia of the Lewy Body type (DLB) Vascular Dementia (VaD) Parkinson s Disease Dementia (PD) Huntington s Disease (HD) Creutzfeldt-Jakob Disease (CJD) Progressive Supranuclear Palsy (PSP) AIDS-related Dementia Some Statistics about AD Most common form of dementia An estimated 4.5 million Americans have AD Onset usually occurs after age 60 Risk increases with age About 5 percent of men and women ages 65 to 74 have AD Nearly half of those age 85 and older may have the disease AD is not a normal part of aging 5

10 Forms of AD Late-onset The number of people with the disease doubles every five years beyond age 65 Early-onset Diagnosed before age 65 Early-onset familial A rare form of AD that usually occurs between the ages of 30 and 60 is inherited Medications Used to Treat AD Donepezil (Aricept ) Rivastigmine (Exelon ) Galantamine (Razadyne, formerly known as Reminyl ) Memantine (Namenda ) Other Medications Medications may be used to control behavioral symptoms of AD Sleeplessness Agitation Wandering Anxiety Depression 6

11 Stages of Alzheimer s Disease Early (Mild) Middle (Moderate) Late (Severe) End-Stage (Terminal) Early (Mild) Stage of AD Difficulty concentrating Difficulty recalling recently stored info Anomia (the loss of the ability to recall words including names) Misplacing/losing belongings Problems planning and organizing Personality changes Decline in grooming Difficulty initiating activity Middle (Moderate) Stage of AD More pronounced memory loss and language difficulties Disorientation o to person, place, and time Social withdrawal Changes in eating habits Increased spontaneity Decreased inhibitions 7

12 Middle (Moderate) Stage of AD Restlessness, fidgeting, pacing Agitation Changes in sleep patterns Sun-downing Wandering, eloping, and getting lost even in familiar places Hallucinations or delusions Increased risk to self and others due to forgetfulness Middle (Moderate) Stage of AD Requires significant support in order to maintain activities of daily living (ADLs) Frequent reminders about bathing, dressing, eating, and toileting Caregiver supported routines Late (Severe) Stage of AD Increased care needs - eventually totally dependent Little or no memory Incapable of recognizing g close friends/family Minimal or lost language skills Increased agitation, aggression, wandering likely Increased physical frailty Shuffling, unsteady gate Increasing difficulty with coordinated movements - eventually wheelchair or bed- bound 8

13 End (Terminal) Stage of AD Incontinence - bladder and bowel Speech less than six words Difficulty remembering how to eat/swallow Loss of interest in food/drink Weight loss of more than 10% over a six month period Medical complications Late-Stage Complications Common complications that may hasten death Pneumonia UTI sepsis Decubiti Fractured hips Language Difficulties Difficulty following conversation Slowness in responding Poor turn-taking taking Failure to initiate conversation Unfocused, empty, repetitious content Difficulty understanding written material Difficulty writing 9

14 Communication Early Stage Word-finding difficulty and use of vague terms Usually more alert and oriented in the morning than later in the day Speak to residents about important matters early in the day, encourage family members to do so Focus on a singe topic using visual cues Large written signs Messages Reminder cards Communication Middle Stage Speak slowly and use short explanations Break down tasks in steps, give one step at a time If resident communicates only in single words, use as few words as possible to direct or respond To reinforce verbal messages use Sensory stimulation Gestures Tactile (touching) cues Communication Late Stage A resident may understand few, if any, words Staff can connect with nonverbal residents by Continuing to speak warmly and soothingly Making eye contact Smiling Patting or gently stroking 10

15 Behavior As Communication Negative behavior is communication of an unmet need Resident is NOT the problem Negative labels Stigmatize Categorize Reduce interaction and care of resident Behavioral Challenges in AD May be physically healthier/stronger Appearance of wellness Ability to maintain social presence Caregivers may have unrealistic expectations Loss of self-soothing soothing skills Escalating Negative Behavior Fear, Confusion, Frustration, Pain, Anxiety Agitation Aggression, Violent Behavior 11

16 Agitation Agitation occurs at some time in about half of all patients with dementia Associated behaviors Aggression Combativeness Disinhibition Hyperactivity Catastrophic response Behavioral Triggers/Precipitants Systemic causes Changes in medication Frustration over loss of control Forced activities i i Invasion of personal space Pain or physical discomfort Excessive stimulation Sleep deprivation Frustrating interactions Factors Contributing to Anxiety Loss of roles and objects Increased confusion Misperception of environment and events Perceived threats to physical and emotional integrity Pain Paradoxical medication effects 12

17 Interventions Exude calm speak low, go slow Don t argue Distract, divert, and redirect Treat the resident with dignity i Allow the resident to have some sense of control Break tasks into simple steps give one step at a time Use resident s name Smile Person-Centered Care Problem-solving Meaning of the behavior Why here? Why now? Who owns the problem? Focus is on ability rather than disability What person can do Strengths Interests Skills 13

18 References Understanding Dementia Course Alzheimer s Disease and related dementias fact sheet. Alzheimer s Disease and Related Disorders Association, Inc. National Office Web site Available at: Accessed October 14, Alzheimer s Disease fact sheet. Alzheimer s Disease Education and Referral Center Web site. September Available at: Accessed October 14, Alzheimer s Society information sheet. Alzheimer s Society Web site. October Available at: Accessed October 15, American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4 th ed., text rev. Washington, D.C.: American Psychiatric Association; Desai A, Grossberg, GT. Diagnosis and treatment of Alzheimer s disease. Neruology 2005:64:S34-S39. Donohue M. Dementia diagnosis often missed in primary care. Family Practice News [serial online]. January 15, Available at: Accessed October 16, Glickstein JK. Therapeutic interventions in Alzheimer s DIsease: a program of functional skills for activities of daily living and communication. 2 nd ed. Gaithersburg, Md: Aspen Publishers; Hebert LE, Scherr PA, Bienias JL, Bennett DA, Evans DA. Alzheimer Disease in the U.S. population: prevalence estimates using the 2000 census. Archives of Neurology August 2003;60;8: Livingston G, Johnston K, Katona C, Paton J, Lyketsos CG. Systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia. American Journal of Psychiatry Novermber 2005;162: Small GW, Rabins PV, Barry PB, Buckholtz PP, DeKosky NS, Ferris ST, Finkel SI, et al. Diagnosis and treatment of Alzheimer disease and related disorders: consensus statement of the American Association for Geriatric Psychiatry, the Alzheimer s Association, and the American Geriatrics Society. The Journal of the American Medical Association. October 22, 1997;278:16: Specific strategies to manage sundowner s syndrome. Regional Dementia Management Strategy Web site: Management/Strategies.html#Sundowner. Accessed October 22, 2005.

19 Strategies to manage behaviors. Regional Dementia Management Strategy Web site: Accessed October 22, Volicer, L, Bloom-Charette, L. Assessment of quality of life in advanced dementia. In: Volicer L, Bloom-Charette, L., eds. Enhancing quality of life in advanced dementia. Philadelphia, Pa: Brunner/Mazel; 1999:3-20. Walker MP, Are GA, Perry EK, Wesnes K, McKeith IG, Tovee M, Edwardson JA, Ballard CG. Quantification and characterization of fluctuating cognition in dementia with Lewy Bodies and Alzheimer's Disease. Dementia and Geriatric Cognitive Disorders. 2000;11:

20 Improving Treatment Outcomes: Screening Geriatric Clients Maintaining each client s maximal functional independence is an important goal of rehabilitation. When treating a geriatric client, consider screening for hearing, vision, malnutrition, depression, and dementia. Hearing Screening Test hearing acuity by o Asking patient to identify presence of fingers rubbed together by the ear o Use the whisper test stand six inches behind the patient and whisper 10 words repetition of less than five words may indicate a hearing loss Ask patients and caregivers about changes in hearing Inquire about difficulty understanding o Women and children (higher frequencies) o Telephone conversations o Voices when more than one person is speaking o Avoidance of family functions, movies or religious services due to changes in hearing If hearing loss is suspected, make formal referral to audiologist Vision Screening By age 75: o presbyopia (gradual loss of ability to focus on near objects) is present in 92% of individuals o cataract formation (lens opacity) is present to some degree in 95% of people aged 65+: age-related macular degeneration (ARMD) and diabetic retinopathy may also be present Test for near-vision (with aid of glasses if worn) using Rosenbaum card at reading distance of 14 inches or Lighthouse card at reading distance of 16 inches Test for far-vision using Snellen wall chart at a distance of 20 feet If vision deficit is noted, refer to ophthalmologist for evaluation Malnutrition Inquire of client and caregiver about involuntary weight loss in client and weigh client at each visit (weight loss >15 lb over 6 mo, >12 lb in 3 mo, or > 9 lb in 1 mo is indicative of malnutrition) Skipped meals and dietary intake below 75% can be indicators of malnutrition Signs of malnutrition include thinning of teeth enamel, thinning of hair, spoon nails, bleeding gums, and edema Dementia and peripheral neuropathy may also be indicators of nutritional deficiency Formal referral to physician/dietician as appropriate if malnutrition is indicated

21 Depression Depression is not a normal part of aging diagnosis and treatment of depression can significantly improve function and quality of life Per the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) major depression is indicated if five or more of the following symptoms are present o depressed mood o diminished interest or pleasure o weight loss or gain o insomnia or hypersomnia o psychomotor agitation or retardation o fatigue or loss of energy o feelings of worthlessness or guilt o diminished energy to concentrate o suicidal ideation. The risk of suicide in older white men is five times higher than any other population Somatic complaints (masked depression) are common in geriatric clients The Geriatric Depression Scale (GDS) (see appendix) may be used to screen for depression and repeated as desired to assess improvement Depression should be reported to treating physician or appropriate referral made to geriatric psychiatrist Delirium and Dementia Screening Delirium is an acute disorder of attention and global cognition (memory and perception) and is treatable Essential features of delirium o acute onset (hours/days) and a fluctuating course o inattention or distraction o Disorganized thinking or altered level of consciousness Diagnosis of delirium is missed in more than 50% of cases Risk factors for delirium include o age o pre-existing brain disease o medications anticholinergics sedative-hypnotics narcotics histamine-receptor blockers agents used to treat Parkinson disease tricyclic antidepressants lithium neuroleptics gastrointestinal and cardiac medications. The Confusion Assessment Method (CAM) can be used to screen for delirium (see appendix) The Folstein Mini-Mental Status Examination (MMSE) may be used to screen for delirium as well as dementia Other dementia screening tools include the Mini-Cog (see appendix) and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) which can be found at When used in combination, the Mini-Cog and IQCODE can be effective screening tools

22 The Brief Community Screening Instrument for Dementia published in 2010 in the International Journal of Geriatric Psychiatry by the 10/66 Dementia Group is represented in the literature as having culture-fair screening properties and is a promising brief screening tool (see appendix)

23 Geriatric Depression Scale (GDS) The GDS short-form scale consists of the 15 questions below. Patients are asked to reply "Yes" or "No," and the answers in parentheses are counted as 1 point. Are you basically satisfied with your life? (No) Have you dropped many of your activities and interests? (Yes) Do you feel that your life is empty? (Yes) Do you often get bored? (Yes) Are you in good spirits most of the time? (No) Are you afraid that something bad is going to happen to you? (Yes) Do you feel happy most of the time? (No) Do you often feel helpless? (Yes) Do you prefer to stay at home, rather than going out and doing new things? (Yes) Do you feel you have more problems with memory than most? (Yes) Do you think it is wonderful to be alive now? (No) Do you feel worthless the way you are now? (Yes) Do you feel full of energy? (No) Do you feel that your situation is helpless? (Yes) Do you think that most people are better off than you are? (Yes) A score of 0-5 points is normal, 6-10 indicates mild depression, and indicates severe depression. This screening tool can be helpful as a guide to rehabilitation management in the inpatient and outpatient settings.

24 The Confusion Assessment Method Instrument 1. [Acute Onset] Is there evidence of an acute change in mental status from the patient's baseline? 2A. [Inattention] Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said? 2B. (If present or abnormal) Did this behavior fluctuate during the interview, that is, tend to come and go or increase and decrease in severity? 3. [Disorganized thinking] Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? 4. [Altered level of consciousness] Overall, how would you rate this patient's level of consciousness? (Alert [normal]; Vigilant [hyperalert, overly sensitive to environmental stimuli, startled very easily], Lethargic [drowsy, easily aroused]; Stupor [difficult to arouse]; Coma; [unarousable]; Uncertain) 5. [Disorientation] Was the patient disoriented at any time during the interview, such as thinking that he or she was somewhere other than the hospital, using the wrong bed, or misjudging the time of day? 6. [Memory impairment] Did the patient demonstrate any memory problems during the interview, such as inability to remember events in the hospital or difficulty remembering instructions? 7. [Perceptual disturbances] Did the patient have any evidence of perceptual disturbances, for example, hallucinations, illusions or misinterpretations (such as thinking something was moving when it was not)? 8A. [Psychomotor agitation] At any time during the interview did the patient have an unusually increased level of motor activity such as restlessness, picking at bedclothes, tapping fingers or making frequent sudden changes of position? 8B. [Psychomotor retardation]. At any time during the interview did the patient have an unusually decreased level of motor activity such as sluggishness, staring into space, staying in one position for a long time or moving very slowly? 9. [Altered sleep-wake cycle]. Did the patient have evidence of disturbance of the sleep-wake cycle, such as excessive daytime sleepiness with insomnia at night? The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1: Acute Onset and Fluctuating Course This feature is usually obtained from a family member or nurse and is shown by positive responses to the following questions: Is there evidence of an acute change in mental status from the patient's baseline? Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go, or increase and decrease in severity? Feature 2: Inattention This feature is shown by a positive response to the following question: Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said? Feature 3: Disorganized thinking This feature is shown by a positive response to the following question: Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? Feature 4: Altered Level of consciousness This feature is shown by any answer other than "alert" to the following question:: Overall, how would you rate this patient's level of consciousness? (alert [normal]), vigilant [hyperalert], lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [unarousable]) The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4.

25 Folstein Mini Mental Status Examination Task Instructions Scoring Date Orientation Place Orientation Register 3 Objects Serial Sevens Recall 3 Objects Naming Repeating a Phrase Verbal Commands Written Commands Writing Drawing "Tell me the date?" Ask for omitted items "Where are you?" Ask for omitted items. Name three objects slowly and clearly. Ask the patient to repeat them. Ask the patient to count backwards from 100 by 7. Stop after five answers. (Or ask them to spell "world" backwards.) Ask the patient to recall the objects mentioned above. Point to your watch and ask the patient "what is this?" Repeat with a pencil. Ask the patient to say "no ifs, ands, or buts." Give the patient a plain piece of paper and say "Take this paper in your right hand, fold it in half, and put it on the floor." Show the patient a piece of paper with "CLOSE YOUR EYES" printed on it. Ask the patient to write a sentence. piece of paper. Ask the patient to copy a pair of intersecting pentagons onto a One point each for year, season, date, day of week, and month One point each for state, county, town, building, and floor or room One point for each item correctly repeated 3 One point for each correct answer (or letter) 5 One point for each item correctly remembered 3 One point for each correct answer 2 One point if successful on first try 1 One point for each correct action 3 One point if the patient's eyes close 1 One point if sentence has a subject, a verb, and makes sense One point if the figure has ten corners and two intersecting lines Scoring A score of 24 or above is considered normal

26 Instructions for the Mini-Cog Test Administration The Mini-Cog test is a 3-minute instrument to screen for cognitive impairment in older adults in the primary care setting. The Mini-Cog uses a three-item recall test for memory and a simply scored clockdrawing test (CDT). The latter serves as an informative distractor, helping to clarify scores when the memory recall score is intermediate. In comparative tests, the Mini-Cog was at least twice as fast as the Mini-Mental State Examination. The Mini-Cog is less affected by subject ethnicity, language, and education, and can detect a variety of different dementias. Moreover, the Mini-Cog detects many people with mild cognitive impairment (cognitive impairment too mild to meet diagnostic criteria for dementia). Scoring (see figure 1) 1 point for each recalled word Score clock drawing as Normal (the patient places the correct time and the clock appears grossly normal) or Abnormal Score 0 Positive for cognitive impairment 1-2 Abnormal CDT then positive for cognitive impairment 1-2 Normal CDT then negative for cognitive impairment 3 Negative screen for dementia (no need to score CDT)

27 Pt. Name: DOB: Date: The MINI-COG 1. Instruct the patient to listen carefully and repeat the following: APPLE WATCH PENNY 2. Administer the Clock Drawing Test (shown below) 3. Ask the patient to repeat the three words given previously Scoring Number of correct items recalled [if 3 then negative screen. STOP] If answer is 1-2 Is CDT Abnormal? No Yes If No, then negative screen If Yes, then screen positive for cognitive impairment Clock Drawing Test This is a simple test that can be used as a part of a neurological test or as a screening tool for Alzheimer's and other types of dementia. The person undergoing testing is asked to: Draw a clock Put in all the numbers Set the hands at ten past eleven Scoring system for Clock Drawing test (CDT) There are a number of scoring systems for this test. The Alzheimer's disease cooperative scoring system is based on a score of five points. 1 point for the clock circle 1 point for all the numbers being in the correct order 1 point for the numbers being in the proper special order 1 point for the two hands of the clock 1 point for the correct time. A normal score is four or five points. Test results Test can provide significant information about general cognitive and adaptive functioning such as memory, how people are able to process information and vision. A normal clock drawing almost always predicts that a person's cognitive abilities are within normal limits.

28 Brief Community Screening Instrument for Dementia Name of person being assessed Age in years Sex Male Female Highest completed level of education None Minimal Completed primary Completed secondary Completed tertiary Now I am going to tell you three words and I would like you to repeat them after me Boat House Fish Repeat the three words, up to a maximum of six times or until the person has remembered them all correctly. Then say: Very good, now try to remember these words because I will be asking you later Question Incorrect (score 0) Correct (score 1) (Interviewer points to their elbow) What do we call this? What do you do with a hammer? Acceptable answer To drive a nail into something Where is the local market/local store? What day of the week is it? What is the season? Please point first to the window and then to the door Do you remember the three words I told you a few minutes ago? Boat House Fish TOTAL SCORE (MAXIMUM 9) Probable dementia 0 4 Possible dementia (check informant score) 5 6 Normal 7 9

29 Improving Treatment Outcomes: Screening Geriatric Clients References Borson S. (2000) The mini-cog: a cognitive vitals signs measure for dementia screening in multi-lingual elderly, International Journal of Geriatric Psychiatry, 15(11):1021. Burton, J. (2004) Dementia and delirium, Med, 140 (501). Retrieved 03/13/11 Folstein s Mini Mental Exam. Retrieved 03/13/11 Kennard, C. (updated April 19, 2006) The clock drawing test, About.com Guide. Retrieved 03/13/11 Muche, J.A. and McCarty, S. (updated October 13, 2009) Geriatric rehabilitation, emedicine. Retrieved 03/13/11 Prince, M., Acosta, D., Ferri, C. P., Guerra, M., Huang, Y., Jacob, K. S., Llibre Rodriguez, J. J., Salas, A., Sosa, A. L., Williams, J. D., Hall, K. S. and the 10/66 Dementia Group, A brief dementia screener suitable for use by non-specialists in resource poor settings the cross-cultural derivation and validation of the brief Community Screening Instrument for Dementia. International Journal of Geriatric Psychiatry, n/a. doi: /gps.2622 Shua-Haim et al. (1996) A simple scoring system for clock-drawing in patients with Alzheimer's disease, Journal of the American Geriatric Society, 44:335. Waszynski C.M. (2004) Confusion Assessment Method (CAM), Dermatology Nursing. 16(3). Retrieved 03/13/11