II. Indications

  1. Dementia Screening

III. Questions: Part 1

  1. Remember Name and Address (first name, last name, street number, street name, city)
    1. Say the info and allow patient to repeat it up to 4 times to commit to memory
  2. Give the exact date (month, day, year) (1 point)
  3. Clock Drawing Test (place 3,6,9, and 12 on clock face) (1 point)
  4. Draw clock with two hands showing 11:10 (1 point)
  5. Tell me something that happened in the news in the last week (1 point)
  6. Recall all 5 components of the name and address (5 points total - 1 point each)

IV. Interpretation: Part 1

  1. Score <5: Dementia
  2. Score 5-8: Intermediate (Distinguish with Part 2 Questions below)
  3. Score 9-10: Normal

V. Questions: Part 2 (Indicated for intermediate result in Part 1)

  1. Protocol
    1. Questions asked of a person who has known the patient for at least 5 years
    2. Questions are asked with the perspective of "compared with a few years ago"
    3. Answers for each question are: Yes, No, Don't Know, N/A
  2. Questions
    1. Patient have more trouble remembering things that have happened recently?
    2. Patient have more trouble remembering conversations a few days later?
    3. Patient have more difficulty finding the right word or using the wrong word when speaking?
    4. Patient less able to pay bills, budget, manage money and other financial affairs?
    5. Patient less able to manage medications independently?
    6. Patient need more assistance with transportation?

VI. Interpretation: Part 2

  1. Score one point for each "No" answered in Part 2
  2. Add score from Part 2 to Part 1 result (maximum: 15 points)
  3. Score of 10 or less indicates further evaluation needed for Dementia

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