Sample items are examples of actual questions or statements, intended to give a sense of the tone and focus of each instrument. Administration and scoring instructions Indicates where to find instructions on administering the instrument and scoring and interpreting the results. Permissions Indicates what permission is required to use the instrument, and if applicable, who to contact for permission.
Evaluation Instrument Details Instruments indicated with an asterisk (*) are available upon request from the Domain Instrument and citation links How many Sample questions Instructions, scoring Permissions ADL/ IADL Bristol Activities of Daily Living Scale () 20 Preparing food Selects and prepares food as required Able to prepare food if ingredients set out Can prepare food if prompted step by step Unable to prepare food even with prompting and supervision Not applicable Administration and scoring instructions are included on the instrument. Credit the developers by using the . No other permissions are required. (continued) Evaluation Instrument Details (continued) Instruments indicated with an asterisk (*) are available upon request from the National Alzheimer’s and Dementia Resource Center Domain Instrument and citation links How many items Sample questions Instructions, scoring Permissions
Domain Instrument and citation links How many Sample questions Instructions, scoring Permissions Anxiety Inventory (NPI) () 12 [In relation to 12 possible behavioral symptoms, is the symptom present? If yes: frequency, severity, and how much distress it causes.] Example: Agitation/aggression Does the patient have periods when he/she refuses to cooperate or won’t let people help him/her? Is he/she hard to handle? Does the patient or curse angrily? Does the patient slam doors, kick furniture, throw things? Attitudes Dementia Attitudes Scale (DAS) () 20 I feel uncomfortable being around people with ADRD. People with ADRD can feel when others are kind to them. Every person with ADRD has different needs. No instructions provided. Consult with an evaluator for appropriate use. No special permissions are required. If research using the DAS is published, please notify at University of Wisconsin-Osh Kosh. (continued) Evaluation Instrument Details (continued) Instruments indicated with an asterisk (*) are available upon request from the National Alzheimer’s and Dementia Resource Center Domain Instrument and citation links How many items Sample questions Instructions, scoring Permissions
Domain Instrument and citation links How many items Sample questions Instructions, scoring Permissions Burden Frustrations of Caregiving (REACH II) p. 65-66 () 8 How often in the past six months, have you: Blamed (care recipient) for having created difficulties? Used a harsh tone of voice with (care recipient)? Administration instructions are included on the instrument. Credit the developers by using the complete citation. No other permissions are required. Burden Zarit Burden - short Zarit Burden - long () 4 and versions Do you feel that because of your relative that you don’t have enough time for yourself? Do you feel stressed between caring for your relative and trying to meet other responsibilities (work, home)? Noncommercial may . Burden Caregiver Reaction Scale* () 54 To what extent have you lost a chance to do some of the things you planned? How much do you feel that, all in all, you’re a good caregiver? How much disagreement have you had with anyone in your family about the need to watch out for your relative’s safety? No instructions provided. Consult with an evaluator for appropriate use. No special permissions required. (continued) Evaluation Instrument Details (continued) Instruments indicated with an asterisk (*) are available upon request from the National Alzheimer’s and Dementia Resource Center Domain Instrument and citation links How many items Sample questions Instructions, scoring Permissions item
Cognitive function Ascertain Dementia (AD-8) () 8 [Changes in the last several years:] Problems with judgment (e.g., problems making decisions, bad financial decisions, problems with thinking). Less interest in hobbies/activities. Click the Administration and Scoring bookmark within the . Within the , select the Copyright & Permission bookmark. Cognitive Function Dementia Screening Indicator () 9 How old is your patient? Has your patient ever had a stroke? Administration and scoring instructions are included on the instrument. Credit the developers by using the complete citation. No other permissions are required. Cognitive function Functional Activities Questionnaire (FAQ) () 10 [Rate the patient’s ability] Writing checks, paying bills, balancing checkbook Preparing a balanced meal Administration and scoring instructions are included on the instrument Contact for permission. A nominal fee may be involved. Cognitive Function General Practitioner Assessment of Cognition (GPCOG) () 12 Time Orientation: “What is the date?” Information: “Can you tell me something that happened in the news recently?” Does the patient have more trouble remembering things that have happened recently than s/he used to? Administration and scoring instructions are included on the instrument. No special permissions required. (continued) Evaluation Instrument Details (continued) Instruments indicated with an asterisk (*) are available upon request from the National Alzheimer’s and Dementia Resource Center
Domain Instrument and citation links How many Sample questions Instructions, scoring Permissions Cognitive function Global Deterioration Scale () 7 [Caregiver observes the individual’s behavioral characteristics and compares them to the GDS levels.] Example: Level 3, Mild cognitive decline: Earliest clear-cut deficits. Manifestations in more than one of the following areas: (a) patient may have gotten lost when traveling to an unfamiliar location; (b) co-workers become aware of patient’s relatively poor performance; (c) word and name finding deficit becomes evident to intimates. [includes 4 more symptoms of mild cognitive decline] Administration instructions are included on the instrument. Permission has been obtained for ADSSP, ADI-SSS and ADPI grantees. Users must provide the citation, the copyright information “Copyright © 1983 Barry Reisberg, M.D.” and indicate “Reproduced with permission.” Other users contact Dr. Barry Reisberg at NYU Langone, 212-263-8550. (continued) Evaluation Instrument Details (continued) Instruments indicated with an asterisk (*) are available upon request from the National Alzheimer’s and Dementia Resource Center Domain Instrument and citation links How many items Sample questions Instructions, scoring Permissions
Cognitive function Making & Executing Decisions for Safe and Independent Living () 12-18 (6 per scenario) [Select 2-3 scenarios that are appropriate out of 7 possibilities] Example: The door to your home is locked and you do not have a key What you do if the door to your home was locked and you didn’t have a key? What would you do if [this response] didn’t work? What could you do to prevent yourself from getting locked out of your home? Administration and scoring instructions are included on the instrument. No special permissions required. Cognitive Function Memory Impairment Screen (MIS) () 4 Patient is given 4 words and asked which category each belongs to. This is followed by free and cued recall activity with same words. Administration and scoring instructions are included on the instrument. Credit the developers by using the complete citation. No other permissions are required. (continued) Evaluation Instrument Details (continued) Instruments indicated with an asterisk (*) are available upon request from the National Alzheimer’s and Dementia Resource Center Domain Instrument and citation links How many items Sample questions Instructions, scoring Permissions
Domain Instrument and citation links How many items Sample questions Instructions, scoring Permissions Cognitive function St. Louis University Mental Status Exam (SLUMS) () 11 What day of the week is it? Please name as many animals as you can in one minute You have $100 and you go to the and buy a dozen apples for $3 and a tricycle for $20. How much did you spend? How much do you have left? Scoring instructions are included on the instrument. According to Dementia Friendly America, this tool is in the public domain. Cognitive function - IDD Dementia Screening Questionnaire for Individuals with Intellectual Disabilities (DSQIID) () 56 [Is the symptom there, has it always been there, is it new, has it gotten worse] Cannot wash and/or bathe without help. Withdraws from social activities. Needs help eating. No instructions provided. Consult with an evaluator for appropriate use. Contact for permission. (continued) Evaluation Instrument Details (continued) Instruments indicated with an asterisk (*) are available upon request from the National Alzheimer’s and Dementia Resource Center Domain Instrument and citation links How many Sample questions Instructions, scoring Permissions
Cognitive function - IDD National Task Group on Intellectual Disabilities and Dementia - Early Detection Screen for Dementia (NTG-EDSD) (NTG) 32 Needs help with dressing. Does not follow simple instructions. Check all significant life events in the past year from a list. No special permissions are required. Cognitive Function - IDD Test for Severe Impairment (TSI)* () 24 Performance: ”Show me how you would use this comb.” Language-Comprehension: “Point to your ear.” “Close your eyes.” Conceptualization: “Which of these is different?” [of two paper clips and one pen] Administration and scoring instructions are included on the instrument. No special permissions required. Coping Brief COPE () 28 I’ve been turning to work or other activities to take my mind off things. I’ve been concentrating my efforts on doing something about the situation I’m in. I’ve been using alcohol or other drugs to make myself feel better. No special permissions are required. (continued)
Depression Patient Health (PHQ-4) () Patient Health Questionnaire (PHQ-9) () 4 or versions Over the last 2 weeks, how often have you been bothered by any of the following problems? Feeling nervous, anxious, or on edge. Not being able to stop or control worrying. No special permissions required. Exemplary Caregiving Exemplary Caregiving (REACH II) p. 66-67 () 18 I show special amounts of physical affection to (care recipient). I actively treating (care recipient) like a child. I make sure that where (care recipient) lives is bright and cheery. Administration instructions are included on the instrument. Credit the developers by the complete citation. No other permissions are required. (continued) Evaluation Instrument Details (continued) Instruments indicated with an asterisk (*) are available upon request from the National Alzheimer’s and Dementia Resource Center Domain Instrument and citation links How many items Sample questions Instructions, scoring Permissions
Formal supports Formal Care and Services Use II) p. 43-48 () 22 In the past did you or (care recipient): Have a homemaker who helped with shopping, cleaning, laundry, preparing meals, etc.? Go to a center for low cost meals or have cooked meals delivered to you at home? Attend a senior day care or senior day health program? Administration instructions are included on the instrument. Credit the developers by using the complete citation. No other permissions are required. Health Caregiver Questionnaire () 18 During the past week or so, I have been edgy or irritable. During the past week or so, I have felt lonely. Please rate your current health compared to what it was this time last year. Scoring and interpretation instructions are included on the instrument. Contact for permission. Health Duke Health Profile (DUKE-8) () 8 During the past week, how much trouble have you had with feeling depressed or sad? During the past week, how did you socialize with other people? Administration and scoring instructions are included on the instrument. Contact for permission. (continued) Evaluation Instrument Details (continued) Instruments indicated with an asterisk (*) are available upon request from the National Alzheimer’s and Dementia Resource Center
Domain Instrument and citation links How many items Sample questions Instructions, scoring Permissions Intent to place in nursing home Desire to Institutionalize Scale (DIS)* () 6 Have you ever considered or thought a nursing home for your family member now or for the future? Have you ever felt that someday they might be better off in a nursing home? Total score is calculated by summing responses across questions, unweighted. Scores range from 0-6 with higher scores indicating greater desire to institutionalize. Credit the developers by using the complete citation. No other permissions are required. Knowledge Alzheimer’s Disease Knowledge Scale (ADKS) () 30 People with Alzheimer’s disease are particularly prone to depression. It has been scientifically proven that mental exercise can prevent a person from getting Alzheimer’s disease. When people with Alzheimer’s disease begin to have difficulty taking care of themselves, caregivers should take over right away. An answer key is included on the instrument. Permission has been obtained for ADSSP, ADI-SSS and ADPI grantees. Other users contact for permission. Knowledge Dementia Knowledge Assessment Tool V2 (DKAT v2) () 21 Dementia occurs because of changes in the brain. Brain changes causing dementia are often progressive. It is impossible to tell if a person who is in the later stages of dementia is in pain. Administration instructions are included on the instrument. Credit the developers by using the complete citation. No other permissions are required. (continued)
Evaluation Instrument Details (continued) Instruments indicated with an asterisk (*) are available upon request from the National Alzheimer’s and Dementia Resource Center Domain Instrument and citation How many items Sample questions Instructions, scoring Permissions Knowledge IDD and Dementia Knowledge Scale* () 20 Aging affects older persons with intellectual disabilities harder than it does other people. Aging in place means growing older where you are. As people age, some changes in physical and mental abilities are expected. An answer key is included on the instrument. No special permissions required. Pain Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) () 60 [An observer indicates which symptoms of pain are present] Grimacing Verbal Aggression Pale Face Administration and scoring instructions are included on the instrument. Contact for permission. (continued) Evaluation Instrument Details (continued) Instruments indicated with an asterisk (*) are available upon request from the National Alzheimer’s and Dementia Resource Center Domain Instrument and citation links How many items Sample questions Instructions, scoring Permissions
Evaluation Instrument Details (continued) Instruments indicated with an asterisk (*) are available upon request from the National Alzheimer’s and Dementia Resource Center Domain Instrument and citation links How many items Sample questions Instructions, scoring Permissions Quality of life Alzheimer’s Quality of Life (ADRQL) () 40 He/she smiles or laughs when around other people. He/she reacts with pleasure to pets or small children. He/she shows interest in events, places or habits from his/her past such as old friends, former residences, church or prayer. Administration instructions are included on the instrument. Nonfunded academic users and individual medical practices may obtain the instrument at no cost. Quality of life Dementia Quality of Life (DEMQOL) () 28 In the last week: Have you felt cheerful? How worried have you been forgetting who people are? How worried have you been about your health overall? Administration instructions are included on the instrument. Credit the developers by the complete citation. No other permissions are required. Quality of life Perceived Change Index* () 13 [Caregiver indicates whether each has become stayed the same, or improved in the past month] Feeling rested Ability to have time for yourself Feelings of being upset Scoring instructions available from the Resource Center. Notify of use. No other permissions are required. (continued) Evaluation Instrument Details (continued) Instruments indicated with an asterisk (*) are available upon request from the National Alzheimer’s and Dementia Resource Center
Domain Instrument and citation How many items Sample questions Instructions, scoring Permissions Quality of life Quality of Life in Alzheimer’s Disease (QoL - AD) () 13 Caregivers or PWD rates items such as physical health, mood, and ability to do things for fun. Administration and scoring instructions are included on the instrument. Not funded academic users and individual medical practice may obtain the instrument at no cost. Quality of life Quality of Life in Dementia Scale (QUALID) () 11 [Informant selects the best descriptor in several areas such as Smiles, Is Irritable or aggressive, and Enjoys eating] Example: Enjoys eating At most meals and snacks Twice a day At least once a day Less than once a day Rarely or never Administration and scoring instructions are included on the instrument. Contact for permission. (continued) Evaluation Instrument Details (continued) Instruments indicated with an asterisk (*) are available upon request from the National Alzheimer’s and Dementia Resource Center Domain Instrument and citation links How many items Sample questions Instructions, scoring Permissions
Domain Instrument and citation links How many items Sample questions Instructions, scoring Permissions Risk/ Safety Caregiver Risk Appraisal Questionnaire (REACH II) p. 68-73 () 53 Do you or a family member have durable power of attorney or guardianship for [care recipient]? Do you ever leave [care recipient] alone or unsupervised in the home? Does [care recipient] drive? Administration instructions are included on the instrument. Credit the developers by using the complete citation. No other permissions are required. Risk/ Safety Dementia Crisis to Thriving Scale* () 13 Respondent rates the person’s level of risk on several domains such as food security, in-home care, and falls risk. Example - Falls Risk: Falls 2 or more times in past month, with injury, home is unsafe. Home unsafe. Fall without injury, or no fall in past 3 months. Home is safe. Fall within three to five months, no injury. Fall risk factors exist. No falls in past 6 months, home is safe, no fall risk factors. No falls in past 12 months, gait stable, active, safe home. No instructions provided. Consult with an evaluator for appropriate use. No special permissions required. (continued) Evaluation Instrument Details (continued) Instruments indicated with an asterisk (*) are available upon request from the National Alzheimer’s and Dementia Resource Center
Domain Instrument and citation links How many items Sample questions Instructions, scoring Permissions Risk/ Safety p. 65-66 () 8 How often in the past six months, have you: Blamed (care recipient) for having created difficulties? Used a harsh tone of voice with (care recipient)? Administration instructions are included on the instrument. Credit the developers by using the complete citation. No other permissions are required. Risk/ Safety Live Alone Assessment () 29 Observed or reported conditions during a home visit: Wandering outside the home. Inability to take medications correctly. Dirty/infested household. Scoring instructions are included on the instrument. Permission has been obtained for ADSSP, ADI-SSS and ADPI grantees. Other users contact the . Risk/ Safety Living Environment - Positive Aspects and Hazards (REACH II) p. 64-65 () 14 Do you keep materials present to occupy CR or that provide comfort or meaning (e.g. games, sorting tasks, magazines, photos, stuffed animals)? Observe: Objects on floor or pathways in main areas used by (care recipient) Do you have a grab bar in the bathroom primarily used by (care recipient)? Administration instructions are included on the instrument. Credit the developers by using the complete citation. No other permissions are required. (continued) Evaluation Instrument Details (continued) Instruments indicated with an asterisk (*) are available upon request from the National Alzheimer’s and Dementia Resource Center
Domain Instrument and citation How many items Sample questions Instructions, scoring Permissions Risk/ Safety Making & Executing Decisions for Safe and Independent Living () 12-18 (6 per scenario) [Select 2-3 scenarios that are appropriate out of 7 possibilities] Example: The door to your home is locked and you do not have a key What would you do if the door to your home was locked and you didn’t have a key? What would you do if [this response] didn’t work? What could you do to prevent yourself from getting locked out of your home? Administration and scoring instructions are included on the instrument. No special permissions required. Fortinsky Caregiver () 10 “How certain are you right now that you can…” Handle any problems your relative has, like memory loss, wandering, or behavior problems? Do something to keep your relative as independent as possible? No instructions provided. Consult with an evaluator for appropriate use. Notify of use. No other permissions are required. Preparedness for Caregiving Scale () 8 How well prepared do you you are to take care of your family member’s physical needs? How well prepared do you think you are to find out about and set up services for him or her? Scoring instructions are included on the instrument. Credit the developers by using the complete citation. No other permissions are required. (continued) Evaluation Instrument Details (continued) Instruments indicated with an asterisk (*) are available upon request from the National Alzheimer’s and Dementia Resource Center
Stigma Affiliate Stigma () 22 Others will discriminate against me if I am with my family member with dementia. The behavior of my family member with dementia embarrasses me. I have cut down on going out with my family member with dementia. Scoring instructions are included on the instrument. Credit the developers by using the complete citation. No other permissions are required. If the scale needs to be modified or translated, contact . (continued) Evaluation Instrument Details (continued) Instruments indicated with an asterisk (*) are available upon request from the National Alzheimer’s and Dementia Resource Center Domain Instrument and citation links How many items Sample questions Instructions, scoring Permissions
Stress Perceived Stress Scale () 4 or versions In the last month, how often have you: Been upset because of something that happened unexpectedly? Felt that you were unable to control the important things in your life? This scale may be used for nonprofit academic research or nonprofit educational purposes. For other uses, please contact . Traumatic experience Life Events Checklist (LEC-5) () 17 or versions [For events experienced over entire lifetime, indicates: Happened to me; Witnessed it; Learned about it; Part of my job; Not sure; Doesn’t apply] Natural disaster (for example, flood, hurricane, tornado, earthquake) Physical assault (for example, being attacked, hit, slapped, kicked, beaten up) Life-threatening illness or injury No special permissions required. (continued) Evaluation Instrument Details (continued) Instruments indicated with an asterisk (*) are available upon request from the National Alzheimer’s and Dementia Resource Center Domain Instrument and citation links How many items Sample questions Instructions, scoring Permissions
Traumatic experience Primary Care PTSD Screen (PC-PTSD-5) () 5 [Respondents are given several examples of possible traumatic events and asked if they have experienced this kind of event.] If yes, in the past month, have you: Had nightmares about the event(s) or thought about the event(s) when you did not want to? Been constantly on guard, watchful, or easily startled? No special permissions required. Traumatic experience PTSD Checklist for DSM-5 () 20 In the past month, how much were you bothered by: Repeated, disturbing, and unwanted memories of the stressful experience? Repeated, disturbing dreams of the stressful experience? Avoiding memories, thoughts, or feelings related to the stressful experience? No special permissions required. (continued) Evaluation Instrument Details (continued) Instruments indicated with an asterisk (*) are available upon request from the National Alzheimer’s and Dementia Resource Center Domain Instrument and citation links How many items Sample questions Instructions, scoring Permissions