DEMENTIA FUNCTIONAL ASSESSMENT TOOL

1 DEMENTIA FUNCTIONAL ASSESSMENT tool . I NAME: LEVEL CLINICAL CHARACTERISTICS DATE DATE DATE DATE. 1 2 3 4. 1 .. EarlyStage No demonstrated memorydeficits No Cognitive NOsubiective cases of memolYdeficits Decline FunctionsindeoendentIY. 2 - Early Stage Very Mild Subjective cases of memorydeficits(placement of familiarobjects, names he/she knows well). Cognitive Decline No problems completingtasks or at social functions (FOrgetfulness). - 3 Middle Stage Mild Cognitive Memorvdeficitevident on intensive interview Attemots to conceal deficits Decline Exoresses concem reaardina deficits (mildlmoderateanxietY). (EarlyConfusional) Problems oerforminain demancfU1Q situations {workor socian 4 -Middle Stage Moderate Decreased knowledae of current and recent events Memorvdeficitsreaardina oelSOnalhistorY.}

2 Cognitive Decline Decreased abllilvto concentrate on serial subtractions (LateConfusional) Difficulty with eomDIex tasks Denial of deficits 5 - Late Stage Moderately Withdrawsfrom DIsorientationtocheSituations time da day ofweelt. season, ele.}or Dlace Immediate memory relativelvintact Severe CognItive Needs assistance choosina dothing Decline Wears cIothina a . {hear/na carriesourse}. (Early DEMENTIA ) Feeds self (mav need meal set-up). Sleep disturbances Wanders,bmooarorawavom Iwander/na}. Tearfulness Catastrophic reactbns Some resistance to care aiving - Needs verbal cues ror ADL's followssimPle instructions .. 6 -Late Stage Severe Cognitive Unable to recall most recent events Reoetltiveness Decline Removeslwon't wear cbthina apPIO lasses. hearina aid). (MIddleDementia) Refuses to chanae dothina Bathina results In challenaina behavior Feeds selfwith set-uo; cues; assist SleeP disturbances CatastroDhlc reactions Great resistance to care aivina Purooseless wander/na (Wander/no witham an aaenda).

3 Cannot comDiete a e command Late Stage FreauentIY no soeech at all- runtina Very Severe Cannot feed self Cognitive Decline Cannot complete even simple meaninGful tasks (Late DEMENTIA ) Unable to sit UP indeoendentlv Loss of basic DSvchomotor skills (unable to walk wlo assistance). Unable to hold head uo Hvoer oral (mav Dm evervthina in mouth). Lona term memorY severelv affected LEVEL. DATE SIGNATURE OF PERSON(S) COMPLETING ASSESSMENT PER REVIEW.