Effects of the Life Story Questionnaire on Physical Therapy Participation in Patients With Dementia: A Randomized Control Trial
Phase: NA
Conditions: Dementia Alzheimers
Sponsor: Texas Tech University Health Sciences Center

 
 
 
 
 
 
 
Title: Effect of the Life Story Questionnaire on Physical 
Therapy Participation in Patients with Cognitive Impairment: 
A Randomized Control Trial  
  
 
Document date: 04/24/2023 
 
NCT05827276 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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RESEARCH PROPOSAL  
  
Title: Effect of the Life Story Questionnaire on Physical Therapy 
Participation in Patients with Cognitive Impairment: A Randomized Control 
Trial  
  
  
  
Principal Co-Investigators:  Jonathan Singer, PhD1  
Jean-Michel Brismée, PT, ScD2  
Additional Investigators:  
Megha Shah, PT, DPT2,3    
  
  
                                 Lisa Brite, OT, BS3  
  
1Department of Clinical Psychology, Texas Tech University, Lubbock, Texas, 
USA  
2Department of Rehabilitation Sciences, Center for Rehabilitation Research, 
Texas Tech University Health Sciences Center, Lubbock, Texas, USA  
3Peach Tree Place, Department of Rehabilitation, Weatherford, Texas, USA  
  
  
  
  

Dementia - Life Story Questionnaire – Physical Therapy  
  
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TABLE OF CONTENTS  
Abstract…………………………………………………………….……………………. v  
List of abbreviations……………………………………………………………………vii  
Background……………………………………………………...……………………… 1  
Purpose, Aim and Values………………………………………...…………………….6  
Research questions, Hypothesis and Variables………………...…………………...8  
Methods……………………………………………………...…………………………11  
Research design………………………………...…………………………….11  
Research setting/location………………………….……………………........11  
Sampling………………………………………………………………………. 11  
Sequence ………………………………………………………………...……12  
Data Analysis……………………………………………………………...…...16  
Descriptive statistics…………………………………………………….…….16  
Inferential statistics…………………………………………………………… 16  
References…………………………………………………………………………......17  
Research Project Timeline…………………………………………………………... 20  
Appendix A: Life story questionnaire……………………………………………...…21  
Appendix B: Pittsburgh Rehabilitation Participation Scale………………………...26  
Appendix C: Quality of Life Alzheimer’s disease……………………………...……27  
Appendix D: Cornell Scale for Depression in Dementia…………………………...30  
Appendix E: Mini-Mental State Examination……………………...........................33  
Appendix F: Pre-screening questionnaire…………………………………….…… 35  
Consent Form - Participants………………………………………………………….36  
Consent Form – Family …………………………………………..…………………. 38  
 
 
 
 
 

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SCIENTIFIC ABSTRACT 
Background: Dementia is characterized by a progressive decline in cognitive 
function. Dementia disease prevalence is substantially increased among people 
aged 65 years or older, with a progressive decline in memory, thinking, language 
and learning capacity. Although physical exercise benefits dementia patients, 
participation in activities is exceedingly difficult due to communication and 
cognitive impairments. Several studies demonstrated that life story books usage 
improved quality of life, depression symptoms, moods and participation in activity 
in people with dementia. However, these studies did not evaluate the effect of 
Life Story Questionnaire (LSQ) – a type of life story book - on physical therapy 
participation, depression symptoms, quality of life.  
  
Objectives: To evaluate the impact of LSQ on (1) participation in physical 
therapy using Pittsburg Rehabilitation Participation Scale; (2) quality of life using 
Quality of Life – Alzheimer’s Disease Scale (participant’s version); and (3) 
depression symptoms using Cornell Scale for Depression in Dementia (CSDD).  
  
Methods: A consecutive sample of convenience of up to 60 patients with mild to 
moderate cognitive impairment with 44 (22 per group) completing the study will 
be recruited from a nursing home facility. Patients will be randomly allocated in 
two groups: (1) Control group, which will receive standard physical therapy care 
without LSQ use; and (2) Experimental group, where physical therapists will use 
the LSQ. Each patient’s family member will receive a LSQ to complete prior to 
the start of the intervention. Patients’ participation, quality of life and depression 
symptoms will be measured on day 1 and again after 3 weeks (mid-term), and 6 
weeks of intervention. Quality of life and depression symptoms will also be 
measured 6 weeks following intervention.  A licensed occupational therapist 
blinded to the participants’ group allocation will measure all three dependent 
variables   
Statistical Analysis: Descriptive statistics including means, standard deviations, 
frequency counts, median, mode, variance and frequency counts will be used to 
assess sample demographics. The Rank Sum test will be used to assess 
differences in Pittsburg Rehabilitation Participation Scale between the 
intervention and control group. Spearman Rank correlations will be used to 
determine the strength of the correlation between Mini-Mental state examination, 
Pittsburg Rehabilitation Participation Scale and Quality of Life Alzheimer 
Disease.  
  
Key words: Dementia, Life story questionnaire, Physical therapy, Participation, 
exercise  
Financial Disclosure and Conflict of Interest: The investigators affirm that they 
have no financial affiliation (including research funding) or involvement with any 

Dementia - Life Story Questionnaire – Physical Therapy  
  
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commercial organization that has a direct financial interest in any matter included 
in this manuscript.    
 

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NON-SCIENTIFIC ABSTRACT  
Background: Dementia is a general term for difficulties remembering, thinking or 
making decisions. Dementia increases among people aged 65 years or older. 
Exercise benefits dementia patients, however participation in activities is very 
difficult due to difficulties communicating and understanding. Several studies 
demonstrated that life story books usage improved quality of life, depression 
symptoms, moods and participation in activity in people with dementia. However, 
these studies did not evaluate the effect of Life Story Questionnaire (LSQ)– a 
type of life story book - on physical therapy participation, depression symptoms, 
and quality of life.  
Objectives: To see the benefits of LSQ on (1) participation in physical therapy; 
(2) depression symptoms; and (3) quality of life.  
Methods: Up to 60 patients with mild to moderate cognitive impairment with 44 
(22 per group) completing the study will be recruited from a nursing home facility. 
Patients will be allocated in two groups: (1) Control group, which will receive 
standard physical therapy care without LSQ use; and (2) Experimental group, 
where physical therapists will use the LSQ. Each patient’s family member will 
receive a LSQ to complete prior to the start of the intervention. Patients’ 
participation, quality of life and depression symptoms will be measured on day 1 
and again after 3 weeks (mid-term), and 6 weeks of intervention. Quality of life 
and depression symptoms will also be measured 6 weeks following intervention.  
An occupational therapist will take the measurements.    
Statistical Analysis: Appropriate statistics will be used to analyze the data.  
  
  

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LIST OF ABBREVIATIONS   
Cornell Scale for Depression in Dementia……………………………….…… CSDD  
Life story books………………………………………………………………...... LSBs  
Life Story Questionnaire…………………………………………………..………. LSQ  
Mini-Mental State Examination……………………………………...…………. MMSE  
Quality Of Life – Alzheimer’s Disease Scale…………………………..…… QOL-AD  
  

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 BACKGROUND  
Dementia is a devastating disease that places a significant physical, 
emotional and financial burden on patients, their caregivers and society1. In 2015, 
the number of people living with dementia worldwide was estimated at 46.8 
million. This number is expected to increase to 74.7 million in 2030 and 131.5 
million in 20502.In the US alone, dementia was responsible for a total expense of 
US$277billion in 2018, and is expected to reach approximately US$1.1trillion in  
20503.  
 Dementia is a medical condition in which there is a worsening in a 
person’s cognitive abilities compared with several months or years before. A 
person with dementia has difficulty with several types of cognitive abilities, most 
often with memory but also with language, attention, orientation, judgment, and 
planning4. Communication is a major concern for people with dementia5,6. 
Positive, person-centered communication is important to ensure good quality 
dementia care6,7,8. In 2016, the American Geriatrics Society Expert Panel 
developed a summarizing definition of person-centered care: “Person-centered 
care” means that individuals’ values and preferences are elicited and, once 
expressed, guide all aspects of their health care, supporting their realistic health 
and life goals. Person-centered care is achieved through a dynamic relationship 
among individuals, others who are important to them, and all relevant providers. 
This collaboration informs decision-making to the extent that the individual 
desires2,9. It can be enhanced by using reminiscence therapy10.  

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 Life story book (LSB) is a common approach in reminiscence therapy11. 
Life story books involve events and experience from the past, which can evoke 
memories, stimulate mental activity and improve well-being12.Several studies 
demonstrated that life story books usage improved quality of life, depression and 
participation in activity in people with dementia in nursing homes12-14. Life story 
books demonstrated positive effects on communication and interaction of 
persons with dementia immediately after the end of treatment, and also weeks to 
months later12. The majority of the life story books were tangible books, although 
some digital applications exist15. Qualitative findings demonstrated the value of 
life story books in triggering memories and in improving the relation with persons 
with dementia. Learning personal features and life events about dementia 
residents is beneficial to know actual facts as everything they state is not 
necessarily true14. Engaging in life story work, enabled staff to appreciate the 
person behind the dementia. Understanding (as opposed to knowing) the person 
with dementia's life story changed staff's thinking on what was important when 
delivering care to people with dementia2.  
  
The Crisis Prevention Institute developed a Life Story Questionnaire  
(LSQ) (Appendix A), which is a type of life story book for people with dementia. 
The information about LSQ can be gathered from multiple sources, especially 
family members. It includes information about preferences and lifestyle. 
Preferences include coffee vs tea, nickname vs full name, early riser vs night owl, 
small groups vs large groups, brands of personal care products. Lifestyle 
examples include culture, faith, family, relationships, job history, home, childhood 

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home and neighborhood, accomplishments, daily routine, and emotional needs. 
Understanding patient’s preferences, values, and motivation in life is the 
foundation of person-centered dementia care.   
  
The LSQ allows caregivers to start conversations about topics that are 
important to each patient, can help establish rapport between caregiver and 
patient. Clinicians’ LSQ knowledge for each patient gives dementia patients 
security because even when they do not remember life facts, clinicians can still 
provide relevance to patients, creating a sense of familiarity and personhood. 
Additionally, the LSQ helps reduce psycho-social behaviors such as anger, 
agitation and depression when caregivers thoroughly understand patients’ likes, 
dislikes, preferences, interests, and background. The LSQ can be used as a 
person’s identity keeper13.   
  
Older people have low levels of physical activity and even lower for people 
with dementia7. Physical activity is a potentially modifiable risk factor to reduce 
the risk of developing dementia as it can provide beneficial effects on brain health 
and cognition7. Regular exercise can positively impact dementia related 
symptoms including depression, anxiety, attention-deficit/hyperactivity disorder16. 
Additionally, it can relieve stress, improve memory, help sleep quality, and boost 
overall mood16. In older dementia adults living in residential care facilities, 
physical exercise helped patients improve their balance and maintain their 
independence17. However, participation in physical therapy for people with 
dementia is exceedingly difficult due to cognitive impairments. Physical therapists 
may need to develop other strategies to ensure that people with dementia  

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receive the input they need, such as improving caregivers’ involvement or 
incorporating exercises into more functional activities that can be undertaken with 
less supervision, while promoting self-efficacy18.  
  
Cognitive impairment is the clinical hallmark of dementia; however 
noncognitive neuropsychiatric symptoms are exceedingly common and dominate 
the presentation. Neuropsychiatric symptoms such as depression, psychosis, 
agitation, aggression, apathy, sleep disturbances, and disinhibition are common 
in people with dementia19. Non-pharmacologic techniques have substantial 
scientific evidence but are currently under-utilized in standard care. Kale et al. 
developed the Describe, Investigate, Create and Evaluate (DICE) approach, 
which is patient and caregiver centered and has demonstrated better outcome  
than pharmacological approach with less adverse effects19.   
  
Dementia and the related neuropsychiatric symptoms affect the quality of 
life of dementia individuals. Dementia causes a decrease in cognitive function, so 
quality of life has historically been reported by proxies such as family members or 
health-care providers21. Reminiscence activities/life story book can contribute to 
cognitive functioning, depression, and quality of life of persons with dementia2,12.  
  
 Elfrink et al. researched LSBs/LSQ interventions for people with dementia 
and confirmed the use of LSBs is promising to support reminiscence and 
personcentered care. The authors showed that creating and implementing 
LSBs/LSQ in dementia care seemed beneficial, although their effectiveness and 
long-term effects have not been investigated2.  

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Therefore, the purpose of this study will be to evaluate the impact of LSQ 
use on (1) cognitively impaired patients’ physical therapy activity participation; (2) 
quality of life; and (3) depression symptoms.   
  
  
 

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 PURPOSE, AIMS AND VALUES  
 Purpose: The purpose of this study is to evaluate in patients with cognitive 
impairment the impact of LSQ on (1) physical therapy participation; (2) quality of 
life; and (3) depression symptoms.   
 Aims: The study plans to evaluate the impact of LSQ use on participation in 
physical therapy, quality of life and depression symptoms in people with cognitive 
impairment. The intervention will include gathering LSQ information for selected 
subjects from family patient/family members and then using this information for 6 
weeks to evaluate the impact of LSQ on (1) participation in physical therapy 
using the Pittsburg Rehabilitation Participation Scale (Appendix B); (2) quality of 
life using the Quality of Life – Alzheimer’s Disease Scale (participant’s version)  
(Appendix C); and (3) depression symptoms  using the  Cornell Scale for 
Depression in Dementia (CSDD) (Appendix D).  
 Value: Previous studies demonstrated psychosocial life story book usage 
benefitted people with dementia in nursing homes, their relatives, and staff12-14. 
As per Woods et al. the life story book is beneficial to improve cognitive function, 
communication, quality of life and mood. However, randomized comparison trials 
are needed to evaluate the effect of life story book usage on physical therapy 
participation. People with dementia demonstrate challenges in physical therapy 
participation due to poor cognition ad communication. Physical therapists are 
challenged to develop plans of care for people with dementia due to poor 
cognition. The LSQ can help develop individualized and person-centered care. It 
is hypothesized that the LSQ will help increase physical therapy participation for 

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people with cognitive impairment and therefore improve their functional mobility, 
activities of daily living, depression symptoms and quality of life. If LSQ proposed 
benefits are substantiated, this study could be the first to highlight the importance 
of LSQ increasing physical therapy participation and improving depression 
symptoms and quality of life in patients with cognitive impairment.   
  
  
 

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 RESEARCH QUESTIONS, HYPOTHESES AND VARIABLES  
RESEARCH QUESTION(s) (RQs)-This project aims to answer the following 
research questions:   
1. RQ 1: What is the effect of LSQ usage on physical therapy participation in 
people with cognitive impairment at 3 weeks(mid-term) and six weeks as 
compared to a control group?    
2. RQ 2: What is the effect of LSQ usage on quality of life in people with 
cognitive impairment at 3 weeks(mid-term), six weeks and six weeks 
following intervention as compared to a control group?  
3. RQ 3: What is the effect of LSQ usage on depression in people with 
cognitive impairment at 3 weeks(mid-term), six weeks and six weeks 
following intervention as compared to a control group?  
4. RQ 4: What is the relationship between cognitive impairment severity and 
physical therapy participation improvement at the end of the intervention  
(6 weeks)?  
  
RESEARCH HYPOTHESES -This student has devised the following research 
experimental hypotheses   
1. Research Hypothesis 1: LSQ usage will increase physical therapy 
participation in people with cognitive impairment at 3 weeks(mid-term) and 
six weeks as compared to a control group.  

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2. Research Hypothesis 2: LSQ usage will improve symptoms of 
depression in people with cognitive impairment at 3 weeks(mid-term), six 
weeks and six weeks following intervention as compared to a control 
group  
3. Research Hypothesis 3:  LSQ usage will improve quality of life in people 
with cognitive impairment at 3 weeks(mid-term), six weeks and six weeks 
following intervention as compared to a control group.   
4. Research Hypothesis 4: Mild cognitive impairment will be positively 
associated with participation in physical therapy at six weeks following  
LSQ usage as compared to a control group.  
  
COMPARISON VARIABLES   
Independent Variable(s)-The student plans to use the following Independent  
Variable(s) (IV)   
1. IV1: physical therapist use of LSQ   
a. Level 1: LSQ usage  
b. Level 2: no LSQ usage  
Dependent Variable(s)-The Student plans to measure the following dependent 
variable(s) (DV)   
1. DV1: Pittsburg Rehabilitation Participation Scale25(Appendix B)  
2. DV2: Quality of Life (quality of life - Alzheimer's disease scale - 
participant's version)26(Appendix C)  

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3. DV3: Depression (Cornell Scale for Depression in Dementia  
(CSDD)27(Appendix D)  
  
Relationship Variable(s)- The investigator plans to use the following variables  
(RV) for RQ 4  
1. RV1: Pittsburg Rehabilitation Participation Scale25(Appendix B)   
2. RV2: Mini-mental state of examination (MMSE)22,23 = Measure of 
dementia severity3 (Appendix E)  
  
  
  
 

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 METHODS  
Research Design  
Prospective Randomized Control Trial. The trial will be registered on  
Clinicaltrials.gov.  
Research Setting/Location  
Peachtree Place (Dementia care facility), Weatherford, Texas. This study 
will be approved by Texas Tech University (TTU) Institutional Review Board  
(Lubbock Campus).  
Power Analysis  
Power calculations were performed to determine the sample size required 
for the study using the Pittsburgh participation in rehabilitation scale as the 
primary outcome measure and calculations using Mann-Whitney U test. The 
study was designed with α value set at 0.05 and Power set at 0.8 (β set at 0.2). 
The effect size was calculated using G*Power (version 3.1) using differences in 
the Pittsburgh participation in rehabilitation scale between the experimental 
versus the control group of 0.5 with a standard deviation of 0.5, based on pilot 
testing conducted at Peachtree Place, which resulted in effect size of 1 and a 
sample size of 44 (22 participants in each group) (http://www.gpower.hhu.de/).  
Sampling  
A consecutive sample of convenience of up to 60 patients (44 patients =  
22 per group completing the study) with MMSE scale score between 10-18 
(moderate cognitive impairment) and 19-23 (mild cognitive impairment), and 
residing at the Peachtree Place dementia care facility in Weatherford Texas will 

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be recruited. Patients (or their families) will be asked to participate after 
explanation of the study.  
Subjects  
Inclusion Criteria: (1) Patients residing in Peachtree Place in Weatherford, 
Texas; (2) Age 60-89 years; (2) Diagnosis of dementia disease, in mild to 
moderate stage using the MMSE (score between 10-23)22,23 and (3) attendance 
to physical therapy for 6 weeks.  
Exclusion Criteria: (1) Unable to speak English; (2) blindness; (3) 
deafness; (4) MMSE score >23 and (5) history of major psychiatric disorder such 
as schizophrenia and bipolar disorder that required hospital admission within the 
last year.  
Sequence  
Reliability Testing  
Investigator 2, who is a licensed occupational therapist with 15 years of 
clinical experience in geriatric population care, will be educated to collect the 
three dependent variables including the Pittsburg Rehabilitation Participation 
scale, the quality of life -Alzheimer's disease scale and the Cornell Scale of  
Depression in Dementia (CSDD) scale to establish intra-rater reliability. 
Investigator 1 who is the principal investigator and a licensed physical therapist 
with 10-year experience treating geriatric population and has experience in using 
the Pittsburg Rehabilitation Participation scale, the quality of life -Alzheimer's 
disease scale and the CSDD scale, will explain and educate Investigator 2 in 

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each scale usage. After demonstration, Investigator 2 will record the three 
dependent variables measurements on the same patients twice, with at least 
48hour interval between measurements. A minimum of five patients will be used. 
The intra-rater reliability of measurements on the two separate days will be 
calculated.   
Study Sequence  
Investigator 1 will conduct patients’ screening (Appendix F) before they 
enroll the study to determine their eligibility. Participants with mild cognitive 
impairment (MMSE 19-23) demonstrating understanding of the research and the 
consent decision and indicating a willingness to take part will be asked to sign a 
consent form. For participants with moderate cognitive impairment (MMSE 1018), 
both the potential participants and their legally authorized representatives will be 
asked to give consent to allow study participation.   
   
Patients will be randomly assigned using block randomization with a 1:1 
allocation ratio and randomly permuted block sizes of 2 to 6 based on severity of 
cognitive impairment. The randomization will be performed in R software (version 
4.1.2, R Core Team) using the randomize R package (version 2.0). Each subject 
will be randomized to one of two interventions: (1) Control group, which will 
receive standard physical therapy care without LSQ use; and (2) Experimental 
group, where physical therapists will use the LSQ. The randomization file will be 
generated by Investigator 1 (Physical therapist) not involved in the data collection 
process, with the results stored in a spreadsheet accessible only to the 
investigator responsible for the subjects’ group assignment. This investigator will 

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not participate in any data collection. Due to the nature of the study, participants 
will not be blinded to the group assignment and to the treatment they will receive. 
Investigator 2 measuring the dependent variables, however, will be blinded to the 
group assignment.  
Family members of each patient will receive an LSQ to complete prior to 
the start of the intervention (Appendix A). Investigator 1 will conduct all physical 
therapy sessions for the study patients. Investigator 2, will collect the following 
dependent variables on day 1 of week 1, and on day 1 of third and sixth 
weeks:(1) Pittsburg Rehabilitation Participation Scale, which measures patients’ 
participation in therapy; (2) Quality of Life - Alzheimer’s disease scale; and (3) 
depression symptoms (Cornell Scale for Depression in Dementia). Additionally, 
Investigator 2 will record quality of life and depression at six-week following the 
intervention.  Both investigators will enter their data using Texas Tech University 
Health Sciences Center password protected Qualtrics platform.  
Both control and intervention groups will receive individual exercises that 
include strengthening, balance, gait, aerobic, endurance, dual cognitive motor 
tasks and exercises to improve activities of daily living and functional mobility28. A 
pragmatic exercise program will be used for each participant needs based on 
physical therapy evaluation and goals.  Each session will last approximately 60 
minutes with five minutes warm up and five minutes cool down, three to five times 
per week for six weeks.   
All patients will be charged for physical therapy services provided, as 
these services are standard of care, but there will be no charge for the LSQ use.  

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Upon completion of the trial, if LSQ results in outcomes improvements, the  
control group will receive six weeks of physical therapy using LSQ. All licensed 
therapists who participate in this research completed the Collaborative 
Institutional Training Initiative (CITI) training.   
Example of LSQ usage: Mr. Smith has been diagnosed with dementia and 
scores 15 (Mild Cognitive Impairment) on MMSE scale. His family has completed 
LSQ and submitted it to the facility. All Peach Tree Place employees have access 
to LSQ to facilitate patient care. Patient’s LSQ mentioned that patient loves 
coffee, enjoys playing cards and likes everything about cars. This patient is 
always excited to come to therapy when physical and occupational therapists 
(clinicians) mention drinking coffee together. Once patient arrives in therapy 
room, the clinician plays different card games with this patient in standing, to 
improve standing tolerance, also use balance board to challenge standing 
balance and to facilitate functional mobility. The clinician talks about cars, shows 
variety of car magazines while working on leg exercises. So, this clinician used 
various information from LSQ for this patient to motivate and improve therapy 
participation.   
Outcome Assessment:  
1. Pittsburgh rehabilitation participation scale (Appendix B) – to measure 
participant’s participation in physical therapy  
2. Quality of life in Alzheimer’s disease – participant’s version (Appendix C) – 
to access quality of life in dementia participants   

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3. Cornell scale for depression in dementia (Appendix D) – to access 
depression symptoms in dementia participants   
  
Data Analysis  
Descriptive statistics (means, medians, modes, standard deviations, frequency 
counts, minimum and maximum values) will be calculated using Excel version  
2017 and SPSS version 20 (IBM Corp. Released 2011. IBM SPSS Statistics for 
Windows, Version 20.0. Armonk, NY: IBM Corp.) for the subjects’ characteristics 
including age, gender, marital status, education, severity of cognitive impairment 
(MMSE) and living with family prior to admission to the dementia facility and the 
dependent and relationship variables.  
Inferential statistics: the following statistics will be calculated using Jamovi 
version 1.6.  
Research Questions 1-3: Because the data are ordinal (Pittsburg Rehabilitation  
Participation Scale, Quality of Life Alzheimer Disease, CSDD), the Mann-Whitney 
U test will be used to assess differences between the intervention and control 
group.   
Research Question 4: Because the data are ordinal (MMSE, Pittsburg 
Rehabilitation Participation Scale) Spearman Rank correlations will be used to 
determine the strength of the correlation between MMSE and Pittsburg  
Rehabilitation Participation Scale.  
Alpha level will be set at α=.05 for all analyses.  
All statistical analyses will follow the intention-to-treat principle.  
  
  

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20. Kitching D. Depression in dementia. Australian Prescriber. 
2015;38(6):209211. Accessed August 26, 2022.  
21. Burks HB, des Bordes JKA, Chadha R, Holmes HM, Rianon NJ. Quality of  
Life Assessment in Older Adults with Dementia: A Systematic  
Review. Dementia and geriatric cognitive disorders. 2021;50(2):103-110.  
22. Creavin ST, Wisniewski S, Noel-Storr AH, et al. Mini-Mental State 
Examination (MMSE) for the detection of dementia in clinically unevaluated 
people aged 65 and over in community and primary care populations. 
Cochrane database of systematic reviews. 2016;(1).  
23. Folstein MF, Folstein SE, McHugh PR. Mini-Mental State”. A Practical method 
for grading cognitive state of patients for the clinician. Journal of Psychiatric 
research. 1975;12(3):189-198.  
24. https://www.crisisprevention.com/Blog/Use-This-Life-Story-Questionnaire-
forMore-Person.  Accessed August 28, 2015.  
25. Lenze EJ, Mnin MC, Quear T, et al. The Pittsburgh rehabilitation participation 
scale:reliability and validity of a clinician-rated measure of participation in 
acute rehabilitation. Archives of physical medicine and rehabilitation. 
2004;85(3):380-384.  
26. Weyer G, Erzigkeit H, Kanowski S, Ihl R, Hadler D. Alzheimer's Disease 
Assessment Scale: Reliability and Validity in a Multicenter Clinical Trial. 
International psychogeriatrics. 1997;9(2):123-138.  
27. Kørner A, Lauritzen L, Abelskov K, et al. The Geriatric Depression Scale and 
the Cornell Scale for Depression in Dementia. A validity study. Nordic journal 
of psychiatry. 2006;60(5):360-364.  

Dementia - Life Story Questionnaire – Physical Therapy  
 19  
  
  
28. Gbiri CAO, Amusa BF. Progressive task-oriented circuit training for cognition, 
physical functioning and societal participation in individuals with dementia. 
Physiotherapy research international.2020:25(4).  
29. AsanoT, Wang C-W, Tsugaruva M, Ishikawa T. Effectiveness of 
highfrequency individual reminiscence interventions using life story books on 
person with dementia. British Journal of Occupational therapy. 
2021:84(5):317-326.  
30. Folstein MF, Folstein SE, McHugh PR. Mini-Mental State”. A Practical method 
for grading cognitive state of patients for the clinician. Journal of Psychiatric 
research. 1975;12(3):189-198.  
31.  http://www.gpower.hhu.de/, accessed XXXXXX  
32. The jamovi project (2021). Jamovi (version 1.6) (computer software). 
Retrieved from https://www.jamovi.org  
  
 

Dementia - Life Story Questionnaire – Physical Therapy  
 20  
  
  
RESEARCH PROJECT TIMELINE  
  
Submission to Texas Tech University  
IRB  
January 2023  
IRB Approval  
March 2023  
Prospective Trial Registration  
March 2023  
Trial Registration approved  
May 2023  
Data collection  
May 2023 – September 2024  
Data Analysis   
October - November 2024  
Writing  
December 2024  
Submit for publication  
Spring 2025  
  
  
  
 
 

Dementia - Life Story Questionnaire – Physical Therapy  
 21  
  
  
APPENDIX A: Life Story Questionnaire   
  
Professional Care Partners: Use this questionnaire to learn about the clients 
you work with. Complete one questionnaire with each client and/ or the client’s 
loved ones. This great resource will provide you with helpful information as you 
get to know your clients and encourage their interests and abilities.   
  
Family Care Partners: Use this questionnaire to help others learn about your 
loved one. Complete this questionnaire with your family member or on her behalf. 
With this valuable tool in hand, everyone who cares for your loved one will have 
the information they need to engage her likes and interests.   
  
Background:  
  
Full name_______________________________________________________  
  
Does your name have a special significance?  
________________________________________________________________  
  
Do you have a nickname?  
________________________________________________________________  
  
Where did your nickname come from?  
________________________________________________________________ 
Where were you born?  
_______________________________________________________________ 
What was your father’s name?  
________________________________________________________________  
Please describe your father.  
________________________________________________________________  
________________________________________________________________ 
What was your mother’s name?  
________________________________________________________________ 
Please describe your mother.  
________________________________________________________________  
________________________________________________________________ 
Do you have brothers and/or sisters?  
________________________________________________________________  
If yes, please describe your siblings.  
________________________________________________________________  
________________________________________________________________ 
Did you know your grandparents?  
________________________________________________________________  
If yes, please describe your grandparents.  

Dementia - Life Story Questionnaire – Physical Therapy  
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________________________________________________________________ 
________________________________________________________________ 
Where did you grow up?  
________________________________________________________________ 
Please describe the house you lived in.  
________________________________________________________________  
________________________________________________________________ 
What was your neighborhood like?  
________________________________________________________________  
________________________________________________________________ 
Who were your neighbors?  
________________________________________________________________  
________________________________________________________________ 
What games did you play?  
________________________________________________________________ 
________________________________________________________________ 
Are/were you married?  
________________________________________________________________ 
________________________________________________________________  
If yes, please describe your spouse.  
________________________________________________________________ 
________________________________________________________________ 
you have children and grandchildren?  
________________________________________________________________ 
________________________________________________________________  
If yes, please describe your children and grandchildren.  
________________________________________________________________ 
________________________________________________________________  
  
Daily Routine   
  
What time do you like to get up in the morning?  
________________________________________________________________  
Do you prefer to stay in your pajamas for a while?  
________________________________________________________________  
Describe your routine after waking (e.g., brushing your teeth, doing your hair, 
dressing).  
________________________________________________________________ 
________________________________________________________________  
Do you prefer showers or baths?  
________________________________________________________________ 
At what time of day do you take a shower/bath?  
________________________________________________________________ 
Do you eat breakfast?  

Dementia - Life Story Questionnaire – Physical Therapy  
 23  
  
  
________________________________________________________________  
If yes, what do you like to eat for breakfast?  
________________________________________________________________  
________________________________________________________________ 
What’s your typical lunch and afternoon routine?  
________________________________________________________________ 
________________________________________________________________  
Do you like to take naps?  
________________________________________________________________ 
Do you like a big meal at noon or in the evening?  
_______________________________________________________________  
Please describe your typical evening routine.  
________________________________________________________________  
________________________________________________________________  
 What time do you like to go to bed?  
________________________________________________________________ 
What hygiene products do you prefer?  
________________________________________________________________ 
Education Where did you go to school?  
________________________________________________________________ 
How did you get there?  
________________________________________________________________ 
What did you like about school?  
________________________________________________________________ 
________________________________________________________________  
Also ask questions about high school and college, if appropriate.   
  
Work   
  
What was your first paid job?  
________________________________________________________________ 
What kind of job was it?  
________________________________________________________________ 
________________________________________________________________  
What were your duties/responsibilities?  
________________________________________________________________ 
________________________________________________________________ 
What were your accomplishments?  
________________________________________________________________ 
________________________________________________________________  
  
Leisure  
  
What are your hobbies/interests?  

Dementia - Life Story Questionnaire – Physical Therapy  
 24  
  
  
________________________________________________________________ 
________________________________________________________________ 
What are your favorite movies/books?  
________________________________________________________________ 
________________________________________________________________ 
Do you enjoy music? If yes, what kind? 
________________________________________________________________ 
________________________________________________________________ 
Did you have pets? If so, what kind, and what were their names?  
________________________________________________________________ 
________________________________________________________________ 
Are you afraid of or allergic to any pets?  
________________________________________________________________ 
________________________________________________________________ 
Did you travel, and if so, where did you go?  
________________________________________________________________ 
________________________________________________________________ 
What have been some special events in your life?  
________________________________________________________________ 
________________________________________________________________ 
What’s your favorite time of year?  
________________________________________________________________ 
________________________________________________________________ 
Do you prefer solitary activities, small groups, or large groups?  
________________________________________________________________ 
________________________________________________________________  
  
Religion/Faith   
  
Did you attend a place of worship?  
________________________________________________________________ 
________________________________________________________________ 
Did you have a role in the services? If so, please describe.  
________________________________________________________________ 
________________________________________________________________ 
How did you spend your day of worship?  
________________________________________________________________ 
________________________________________________________________ 
Do you have a prayer book?  
________________________________________________________________ 
________________________________________________________________ 
Emotional Needs What makes you feel happy?  

Dementia - Life Story Questionnaire – Physical Therapy  
 25  
  
  
________________________________________________________________ 
________________________________________________________________ 
What makes you feel safe?  
________________________________________________________________ 
________________________________________________________________ 
What makes you feel sad?  
________________________________________________________________ 
________________________________________________________________  
Is there anything that helps you alleviate this feeling?  
________________________________________________________________ 
________________________________________________________________ 
What makes you feel anxious, angry, or frustrated?  
________________________________________________________________ 
________________________________________________________________  
Is there anything that helps you alleviate these feelings?  
________________________________________________________________ 
________________________________________________________________ 
Please describe your bedroom at home.  
________________________________________________________________ 
________________________________________________________________ 
Please describe the room in your home where you relaxed.  
________________________________________________________________ 
________________________________________________________________   
  
Additional Information   
  
Please note other important likes and interests.  
_________________________________________________________________ 
________________________________________________________________________ 
________________________________________________________________________ 
________________________________________________________________________ 
________________________________________________________________________  
  
  
 

Dementia - Life Story Questionnaire – Physical Therapy  
 26  
  
  
 APPENDIX B: PITTSBURGH REHABILITATION PARTICIPATION SCALE   
Patient name: _______________________________   
Date: _____________________________  
 Instructions to therapist: for each therapy session, please circle one of each of 
the following to assess the patient’s participation (effort and motivation as 
perceived by you) in the therapy session.  
 Please rate as follows:   
None: patient refused entire session, or did not participate in any exercises in 
session. (see Note below)   
Poor: patient refused or did not participate in at least half of session.  Fair: 
patient participated in most or all of exercises*, but did not show maximal 
effort or finish most exercises*, or required much encouragement to finish 
exercises*.   
Good: patient participated in all exercises* with good effort and finished most but 
not all exercises* and passively followed directions (rather than actively taking 
interest in exercises* and future therapy).   
Very good: patient participated in all exercises* with maximal effort and finished 
all exercises, but passively followed directions (rather than actively taking interest 
in exercises* and future therapy).   
Excellent: patient participated in all exercises* with maximal effort, finished all 
exercises*, and actively took interest in exercises* and/or future therapy 
sessions.  
 Note: if patient was unable to attend therapy because of medical test, bed rest 
order, illness, or scheduling conflict, do not mark any score. Note: in cases of  
doubt, choose the lower rating, eg, “good” rather than “very good.”  
Participation:  
Session Number Date  Therapist  
Initials  
1 – prior to 
intervention  
  
  
2 – 3-week  
  
  
3 – 6-week  
  
  
4 – 6-week 
following end 
intervention  
  
  
 
None  Poor  Fair  Good  Very 
good  
Excellent  
1  
2  
3  
4  
5  
6  
1  
2  
3  
4  
5  
6  
1  
2  
3  
4  
5  
6  
1  
2  
3  
4  
5  
6  
 
 
* This version is specifically for physical therapists. For the occupational therapy form, 
“exercises” should be replaced by “activities”.   
Source: https://www.sralab.org/sites/default/files/2017-
06/PITTSBURGH%20REHABILITATION%20PARTICIPATION%20SCALE.pdf   

Dementia - Life Story Questionnaire – Physical Therapy  
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APPENDIX C: Quality of Life in Alzheimer’s Disease Instruction for 
interviewers  
The Quality of Life in Alzheimer’s Disease (QOL-AD) is administered in 
interview format to individuals with dementia, following the instructions below. 
The interview is carried out with the subject and/or an informant. The subject 
should be interviewed alone. Hand the form to the participant, so that he or she 
may look at it as you give the following instructions (instructions should closely 
follow the wording given in bold type): I want to ask you some questions about 
your quality of life and have you rate different aspects of your life using one 
of four words: poor, fair, good, or excellent. Point to each word (poor, fair, 
good, and excellent) on the form as you say it. When you think about your life, 
there are different aspects, like your physical health, energy, family, money, and 
others. I’m going to ask you to rate each of these areas. We want to find out how 
you feel about your current situation in each area. If you’re not sure about what a 
question means, you can ask me about it. If you have difficulty rating any item, 
just give it your best guess. It is usually apparent whether an individual 
understands the questions, and most individuals who are able to communicate 
and respond to simple questions can understand the measure. If the participant 
answers all questions the same, or says something that indicates a lack of 
understanding, the interviewer is encouraged to clarify the question. However, 
under no circumstances should the interviewer suggest a specific response. Each 
of the four possible responses should be presented, and the participant should 
pick one of the four. If a participant is unable to choose a response to a particular 
item or items, this should be noted in the comments. If the participant is unable to 
comprehend and/or respond to two or more items, the testing may be 
discontinued, and this should be noted in the comments. As you read the items 
listed below, ask the participant to circle her/his response. If the participant has 
difficulty circling the word, you may ask her/him to point to the word or say the 
word, and you may circle it for him or her. You should let the participant hold his 
or her own copy of the measure, and follow along as you read each item.   
1. First of all, how do you feel about your physical health? Would you say 
it’s poor, fair, good, or excellent? Circle whichever word you think best 
describes your physical health right now.   
2. How do you feel about your energy level? Do you think it is poor, fair, 
good, or excellent? If the participant says that some days are better than 
others, ask him or her to rate how she/he has been feeling most of the time 
lately.   
3. How has your mood been lately? Have your spirits been good, or have you 
been feeling down? Would you rate your mood as poor, fair, good, or 
excellent?   
4. How about your living situation? How do you feel about the place you live 
now? Would you say it’s poor, fair, good, or excellent?  
5. How about your memory? Would you say it is poor, fair, good, or excellent?   

Dementia - Life Story Questionnaire – Physical Therapy  
 28  
  
  
6. How about your family and your relationship with family members? 
Would you describe it as poor, fair, good, or excellent? If the respondent says 
they have no family, ask about brothers, sisters, children, nieces, nephews.   
7. How do you feel about your marriage? How is your relationship with 
(spouse’s name). Do you feel it’s poor, fair, good, or excellent? Some 
participants will be single, widowed, or divorced. When this is the case, ask 
how they feel about the person with whom they have the closest relationship, 
whether it’s a family member or friend. If there is a family caregiver, ask about 
their relationship with this person. It there is no one appropriate, or the 
participant is unsure, score the item as missing.   
8. How would you describe your current relationship with your friends? 
Would you say it’s poor, fair, good, or excellent? If the respondent answers 
that they have no friends, or all their friends have died, probe further. Do you 
have anyone you enjoy being with besides your family? Would you call that 
person a friend? If the respondent still says they have no friends, ask how do 
you feel about having no friends—poor, fair, good, or excellent?   
9. How do you feel about yourself? —when you think of your whole self, and 
all the different things about you, would you say it’s poor, fair, good, or 
excellent?  
10. How do you feel about your ability to do things like chores around the 
house or other things you need to do? Would you say it’s poor, fair, good, 
or excellent?   
11. How about your ability to do things for fun, that you enjoy? Would you 
say it’s poor, fair, good, or excellent?   
12. How do you feel about your current situation with money, your financial 
situation? Do you feel it’s poor, fair, good, or excellent? If the respondent 
hesitates, explain that you don’t want to know what their situation is (as in 
amount of money), just how they feel about it.   
13. How would you describe your life as a whole? When you think about your 
life as a whole, everything together, how do you feel about your life? Would 
you say it’s poor, fair, good, or excellent?   
   
  
Scoring instructions for QOL-AD:   
Points are assigned to each item as follows: poor = 1, fair = 2, good = 3, excellent 
= 4. The total score is the sum of all 13 items.  
  
Participant Last Name:______________ First Name:____________   
  
Date:__/__/202_   
QOL: Alzheimer Disease (Participant’s version)  
Instruction:  
  
  
  
  
Score  
1. Physical 
health  
Poor  
Fair  
Good  
Excellent  
  

Dementia - Life Story Questionnaire – Physical Therapy  
 29  
  
  
2. Energy  
Poor  
Fair  
Good  
Excellent  
  
3. Mood  
Poor  
Fair  
Good  
Excellent  
  
4. Living 
situation  
Poor  
Fair  
Good  
Excellent  
  
5. Memory  
Poor  
Fair  
Good  
Excellent  
  
6. Family  
Poor  
Fair  
Good  
Excellent  
  
7. Marriage  
Poor  
Fair  
Good  
Excellent  
  
8. Friends  
Poor  
Fair  
Good  
Excellent  
  
9. Self as a 
whole  
Poor  
Fair  
Good  
Excellent  
  
10. Ability to 
do chores 
around the 
house  
Poor  
Fair  
Good  
Excellent  
  
11. Ability to 
do things 
for fun  
Poor  
Fair  
Good  
Excellent  
  
12. Money  
Poor  
Fair  
Good  
Excellent  
  
13. Life as a 
whole  
Poor  
Fair  
Good  
Excellent  
  
Comments:  
  
  
  
  
  
  
  
Source: https://www.cogsclub.org.uk/professionals/files/QOL-AD.pdf    
 
 

Dementia - Life Story Questionnaire – Physical Therapy  
 30  
  
  
APPENDIXE D: Cornell Scale for Depression in Dementia  
The scale is designed as a screening tool and is not diagnostic.  
  
The Cornell Scale for Depression in Dementia (CSDD) was specifically 
developed to assess signs and symptoms of major depression in demented 
patients. Because some of these patients may give unreliable reports, the CSDD 
uses a comprehensive interviewing approach that derives information from the 
patient and the informant. Information is elicited through two semi-structured 
interviews; an interview of an informant and an interview of the patient. The 
interviewer should assign preliminary scores to each item of the scale on the 
basis of the informant’s report in the “Informant” column. The next step is for the 
rater to interview the patient using the Cornell scale items as a guide. The 
interviews focus on depressive symptoms and signs occurring during the week 
preceding the interview. Many of the items during the patient interview can be 
filled after direct observation of the patient. If there are discrepancies in ratings 
from the informant and the patient interviews, the rater should re-interview both 
the informant and the patient with the goal to resolve the discrepancies. The final 
ratings of the CSDD items represent the rater's clinical impression rather that the 
responses of the informant or the patient. The CSDD takes approximately 20 
minutes to administer.  
   
  
 

Dementia - Life Story Questionnaire – Physical Therapy  
 31  
  
  
Cornell Scale for Depression in Dementia  
  
Participant Last Name:______________ First Name:____________   
  
Date:__/__/202_  
  
Scoring System:  
a = unable to evaluate  0 
= absent  
1= mild or intermittent   
2 = severe  
  
Ratings should be based on symptoms and signs occurring during the week prior 
to interview. No score should be given if symptoms result from physical disability 
or illness.   
A. Mood-Related Signs   
1. Anxiety     
  
  
  
  
  
 a  
0  
1  
2 
anxious expression, ruminations, worrying   
2. Sadness                                                                      a  
0  
1  
2 sad 
expression, sad voice, tearfulness   
3. Lack of reactivity to pleasant events                           a  
0  
1  
2 4. 
Irritability                                                                      a  
0  
1  
2 
easily annoyed, short-tempered   
B. Behavioral Disturbance   
1. Agitation                                                                       a  
0  
1  
2 
restlessness, handwringing, hairpulling   
2. Retardation                                                                  a  
0  
1  
2     
slow movements, slow speech, slow reactions   
3. Multiple physical complaints                                        a  
0  
1  
2  
4. Loss of interest                                                            a  
0  
1  
2 less 
involved in usual activities (score only if change   
occurred acutely, i.e.in less than 1 month)  
 C. Physical Signs   
1. Appetite loss                                                                a  
0  
1  
2     
eating less than usual   
2. Weight loss                                                                  a   
0  
1  
2     
score 2 if greater than 5 lb. in one month   
3. Lack of energy                                                             a  
0  
1  
2 
fatigues easily, unable to sustain activities (score only if change occurred         
acutely, i.e., in less than 1 month) continued on reverse   
D. Cyclic Functions   
1. Diurnal variation of mood                                             a  
0  
1  
2     
symptoms worse in the morning   

Dementia - Life Story Questionnaire – Physical Therapy  
 32  
  
  
2. Difficulty falling asleep                                                 a  
0  
1  
2     
later than usual for this individual   
3. Multiple awakenings during sleep                                a  
0  
1  
2  
4. Early-morning awakening                                            a  
0  
1  
2      
earlier than usual for this individual   
E. Ideational Disturbance   
1. Suicide                                                                         a  
0  
1  
2     
feels life is not worth living, has suicidal wishes or makes suicide attempt  2. 
Poor self-esteem                                                         a  
0  
1  
2     
self-blame, self-depreciation, feelings of failure   
3. 
Pessimism                                                                   a  
0  
1 
 
2     anticipation of the worst   
4. 
Mood-congruent delusions                                          a  
0  
1 
 
2     delusions of poverty, illness or loss   
  
Scoring: A score >10 probably major depressive episode   
A score >18 definite major depressive episode  
  
  
Source:  
Alexopoulos GA, Abrams RC, Young RC & Shamoian CA: Cornell scale for 
depression in dementia. Biol Psych, 1988, 23:271-284.   
https://dementiaresearch.org.au/wp-content/uploads/2016/06/CSDD.pdf   
  

Dementia - Life Story Questionnaire – Physical Therapy  
33  
  
APPENDIX E: Mini-Mental State Examination   
  
Patient’s Name: __________________________  
  
Date: __/__/202_  
Instruction: Ask the questions in the order listed. Score one point for each correct 
response within each question or activity.   
  
Maximum 
score  
Patient’s Score  Questions  
5  
  
“What is the year? Season? Date? Day of the week? Month?”  
5  
  
“Where are now: state? Country? Town/city? Hospital? Floor?”  
3  
  
The examiner names three unrelated objects clearly and slowly, 
then asks the patient to name all three of them. The patient’s 
response is used for scoring. The examiner repeats then until 
patient learns all of them, if possible. Number of trials:  
5  
  
“I would like you to count backward from 10- by sevens.” 
(93,86,79,72, 65...) stop after five answers.  
Alternative: “spell WORLD backwards.” (D-L-R-O-W)  
3  
  
“Earlier I told you the names of three things. Can you tell me 
what those were?”  
2  
  
Show the patient two simple objects, such as a wristwatch and a 
pencil, and ask the patient to name them.   
1  
  
“Repeat the phrase: No ifs, ands, or buts.”  
3  
  
Take the paper in your right hand, fold it in half, and put it on the 
floor.” (the examiner gives the patient a piece of blank paper.)  
1  
  
“Please read this and do what it says.” (This sentence must 
contain a noun and a verb.)  
1  
  
“Please copy this picture.” (The examiner gives the patient a 
blank piece of paper and asks him/her to draw the symbol 
below. All 10 angles must be present and two must intersect.)  
 
30  
  
Total  
  
   
  
 
 

Dementia - Life Story Questionnaire – Physical Therapy  
34  
Interpretation of MMSE Scores:  
  
Score  
Degree of 
Impairment  
Formal Psychometric Assessment  
Day-to-Day Functioning  
24-30  
Questionably 
significant  
If clinical signs of cognitive impairment 
are present, formal assessment of 
cognition may be valuable.  
May have clinically significant but 
mild deficits. Likely to affect only 
most demanding activities of daily 
living  
19-23  
Mild  
Formal assessment may be helpful to 
better determine pattern and extent of 
deficits.  
Significant effect. May require some 
supervision, support and assistance.  
10-18  
Moderate  
Formal assessment may be helpful if 
there are specific clinical indications.  
Clear impairment. May require 
24hour supervision.  
0-9  
Severe  
Patient not likely to be testable  
Marked impairment. Likely to require 
24-hour supervision and assistance 
with ADL.  
  
Source:   
Adapted from Folstein MF, Folstein SE, McHugh PR: “Mini-mental state: A practical 
method for grading the cognitive state of patients for the clinician.” J  
Psychiatr Res 1975;12:189-198  
  
  
  
 
 

Dementia - Life Story Questionnaire – Physical Therapy  
35  
APPENDIX F  
  
PRE-SCREENING QUESTIONNAIRE   
  
Patient:  Last name:  _________________     First name: ________________     
Phone #: ___________________      Subject #:  ________________  
  
1. For Family Member: Do you prefer to be contacted in regard to research study?     
morning    afternoon    evening     no preference  
  
2. For patient or Family member to answer depending on severity of cognitive 
impairment: Are you interested to participate in a research project related to 
cognitive impairment disease and their participation in therapy in which patients 
will receive physical therapy service 5 days a week with or without use of Life 
story questionnaire? You will be selected for this study if you score >10 on 
MMSE which is a scale to measure cognitive impairments.  There is no extra 
charge for this service.     Yes /  
No  
  
3. Are you between the ages of 60 and 89 years old?  
a. Yes  
b. No  
  
4. Can you speak English?  
a. Yes  
b. No  
  
5. Are you deaf or blind?  
a. Yes  
b. No  
  
  
FRONT OFFICE USE ONLY  
History of Psychiatric disorder:                  Yes       No  
Diagnosis of Dementia:                             Yes       No Patient’s 
MMSE score between 10-23:     Yes       No  
Patient referral for Physical Therapy:        Yes       No  
   
  
 
 

Dementia - Life Story Questionnaire – Physical Therapy  
36  
CONSENT FORM  
  
PATIENT CONSENT FORM  
Effect of the Life Story Questionnaire on Physical Therapy Participation in Patients with 
Dementia: A Randomized Control Trial  
  
What is this research studying?   
This study will help us to investigate the effect of Life Story Questionnaire in physical therapy 
participation in people with milder forms of dementia. Communication, problem solving, impaired 
understanding and memory are common problems in people with dementia. This can affect quality of 
life, participation in activities and can eventually lead towards depression.   
The study is being done to see if using your Life Story Questionnaire during physical therapy will improve 
your participation and social life.  
  
What would I do if I participate?   
In this study, you will be asked to answer questions about your life experiences, cognitive ability, 
daily routine, religion/faith, leisure preferences, and quality of life. You will be randomly 
assigned to either receive the intervention during your physical therapy sessions (experimental 
group), or not receive the intervention during these sessions (control group). Both groups will 
receive individual exercises and tasks to improve activities of daily living and mobility, but only 
the experimental group will be given the Life Story Questionnaire (LSQ) which is a type of life 
story book that gathers information on preferences and lifestyle (e.g., coffee vs. tea, early bird 
vs. night owl). Family members of participants in both groups will be asked to complete this 
questionnaire prior to the start of participation. Upon completion of the intervention, if the LSQ 
results in improved outcomes, the control group will receive the LSQ for their next 6 weeks of 
physical therapy.   
  
Can I quit if I become uncomfortable?   
Yes, absolutely. Dr. Jonathan Singer and Texas Tech University’s Institutional Review Board have 
reviewed this research project and think you can participate comfortably. However, you can skip 
parts of the research you are not comfortable with and stop at any time. You will keep all the 
benefits of participating even if you stop. Participating is your choice.  
  
How long will participation take?  
We are asking for 6 weeks of your time. You will attend 60-minute physical therapy sessions 2-5 times a 
week for the duration of this study.   
  
How are you protecting privacy?  
Your name will not be linked to any material in reports, publications or presentations.  No one 
other than the researchers associated with this project will have access to the raw data.  All 
related documentation will be stored in the researcher’s locked office and on a password 
protected computer.  
  

Dementia - Life Story Questionnaire – Physical Therapy  
37  
What will happen to my data?   
Your information collected as part of the research, even if identifiers are removed, will not be 
used or distributed for future research studies.  
  
What are the benefits and risks of participating in this research?  
There are no known risks other than soreness during or after physical therapy treatment. There are no 
direct benefits for participating in this research.  We appreciate your time and effort with this research 
study.    
  
I have some questions about this study. Who can I ask?  
The study is being run by Dr. Jonathan Singer from the Department of Psychological Sciences at 
Texas Tech University and Megha Shah from Peach Tree Place. If you have questions, you can 
call them at 770-241-4526.   
  
Texas Tech University also has an Institutional Review Board that protects the rights of people 
who participate in research. You can contact them at 806-742-2064 or hrpp@ttu.edu.  
  
  
____________________________________________    
  
          ______________  
Signature of Participant   
  
  
  
  
  
  
          Date  
  
  
____________________________________________________   
  
           
Printed Name of Participant  
  
  
  
  
  
  
  
  
  
 
 

Dementia - Life Story Questionnaire – Physical Therapy  
38  
FAMILY CONSENT FORM  
Effect of the Life Story Questionnaire on Physical Therapy Participation in Patients with 
Dementia: A Randomized Control Trial  
  
What is this research studying?   
This study will help us to investigate the effect of Life Story Questionnaire in physical therapy 
participation in people with milder forms of dementia. Communication, problem solving, impaired 
understanding and memory are common problems in people with dementia. This can affect quality of 
life, participation in activities and can eventually lead towards depression.   
The study is being done to see if using your Life Story Questionnaire during physical therapy will improve 
your participation and social life.  
  
What would I do if I participate?   
In this study, your family member will be asked to answer questions about their life experiences, 
cognitive ability, daily routine, religion/faith, leisure preferences, and quality of life. They will be 
randomly assigned to either receive the intervention during their physical therapy sessions 
(experimental group), or not receive the intervention during these sessions (control group). Both 
groups will receive individual exercises and tasks to improve activities of daily living and 
mobility, but only the experimental group will be given the Life Story Questionnaire (LSQ) which 
is a type of life story book that gathers information on preferences and lifestyle (e.g., coffee vs. 
tea, early bird vs. night owl). You, a family member of a participant in either the experimental or 
control group, will be asked to complete the LSQ about your loved one prior to the start of their 
participation. Upon completion of the intervention, if the LSQ results in improved outcomes, the 
control group will receive the LSQ for their next 6 weeks of physical therapy.   
  
Can I quit if I become uncomfortable?   
Yes, absolutely. Dr. Jonathan Singer and Texas Tech University’s Institutional Review Board have 
reviewed this research project and think you can participate comfortably. However, you can skip 
parts of the research you are not comfortable with and stop at any time. You will keep all the 
benefits of participating even if you stop. Participating is your choice.  
  
How long will participation take?  
We are asking for about an hour of your time. This may vary depending on how in-depth you want to go 
with the LSQ. Your family member will be in the study for about 6 weeks and will attend 60-minute physical 
therapy sessions 2-5 times a week.   
  
How are you protecting privacy?  
Your name will not be linked to any material in reports, publications or presentations.  No one 
other than the researchers associated with this project will have access to the raw data.  All 
related documentation will be stored in the researcher’s locked office and on a password 
protected computer.  
  
What will happen to my data?   

Dementia - Life Story Questionnaire – Physical Therapy  
39  
Your information collected as part of the research, even if identifiers are removed, will not be 
used or distributed for future research studies.  
  
What are the benefits and risks of participating in this research?  
There are no known risks other than soreness during or after physical therapy treatment. There are no 
direct benefits for participating in this research.  We appreciate your time and effort with this research 
study.     
  
I have some questions about this study. Who can I ask?  
The study is being run by Dr. Jonathan Singer from the Department of Psychological Sciences at 
Texas Tech University and Megha Shah from Peach Tree Place. If you have questions, you can 
call them at 770-241-4526  
   
Texas Tech University also has an Institutional Review Board that protects the rights of people 
who participate in research. You can contact them at 806-742-2064 or hrpp@ttu.edu.  
   
   
_____________________________________________   
  
          _________  
Signature of Family Member Participant   
  
  
  
  
    Date  
   
   
____________________________________________________   
  
           
Printed Name of Family Member Participant  
   
   
   
   
Please check this box and sign below if acting as the Legally Authorized Representative of the 
participant  
  
   
_____________________________________________   
  
          __________  
Signature of Family Member on behalf of Physical Therapy Participant    
      Date  
   
   
____________________________________________________   
  
Printed Name of Physical Therapy Participant