Evaluation Instrument Details Domain Instrument and citation How many items Sample item(s) 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) Domain Instrument and citation links How many items Sample item(s) Instructions, scoring Permissions ADL/ IADL Care Needs Assessment Tool () 23 disturbances (waking you or other family members up at night) Resists bathing or showering Insists on driving Administration and scoring instructions are included on the instrument. Use this citation.1 No other permissions required. ADL/ IADL Instrumental Activities of Daily Living Scale (IADL) 8 Shopping: Takes care of all shopping needs independently independently for small purchases In each category, score according to the highest level of functioning. Permission is granted to use or reproduce this scale provided that proper attribution is
Checklist (RMBPC) () Trouble remembering significant past events Forgetting what day it is Behavioral symptoms () 23 Sleep disturbances (waking you or other family members up at night). Resists bathing or showering. Insists on driving. Administration and scoring instructions are included on the instrument. Use this citation.1 No other permissions required. (continued) Evaluation Instrument Details (continued) Domain Instrument and citation links How many items Sample item(s) Instructions, scoring Permissions Behavioral symptoms () 12 [In relation to each behavioral symptom, 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 shout or curse angrily? Does the patient slam doors, kick furniture, throw things? Burden Burden Scale for Family Caregivers (BSFC-s) (Graessel et al.) 10 I often feel physically exhausted. My health is affected by the care situation. I feel torn between the demands of my environment (such as family) and the demands of the care. Point values for each item are included on the scale. Scores of 0-4 = low burden; 5-14 = moderate burden; 15-30 = high burden. The BSFC-s is free of charge for commercial
Burden Caregiver Burden Inventory () 24 I have to watch him/her constantly. My social life has suffered. I feel ashamed over his/her behavior. Scoring instructions are included on the instrument. Contact for permission. (continued) Evaluation Instrument Details (continued) Domain Instrument and citation links How many items Sample item(s) Instructions, scoring Permissions Burden Caregiver Burden Scale (Macera et al.) 15 For each activity, caregiver indicates whether patient needed assistance during the past month, if they provided assistance, if doing so added to their stress level, and why. Examples of activities include: transportation, bathing, and financial record keeping. Administration and scoring instructions are included on the instrument. Credit the developers by using the complete citation. No other permissions are required. Burden () 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 the need to watch out for your relative’s safety? No instructions provided. Consult with an evaluator for appropriate use. No special permissions required. Burden Caregiver Strain Instrument () 19 During the past four weeks, because of helping the patient: I was unsure whether he or she was getting proper care. Scoring and interpretation instructions are Contact for permission.
I felt that I should be doing more for him/her. I felt my physical health was than before. included on the instrument. (continued) Evaluation Instrument Details (continued) Domain Instrument and citation links How many items Sample item(s) Instructions, scoring Permissions Burden Caregiver Vigilance Scale () 4 In the case of a family emergency, are you able to (name person) home alone, that is, with no one else there? If yes: How long can you leave (name person) alone? Scoring instructions available from the Resource Center. Contact for a copy of the scale and permission. 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 the complete citation. No other permissions are required. Burden Zarit Burden - short Zarit Burden - long (Bédard et al.) 4 and 12-item 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 users may . Cognitive functioning Ascertain Dementia (AD-8) () 8 Changes in the last several 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. (continued)
Evaluation Instrument Details (continued) Domain Instrument and citation links How many items Sample item(s) Instructions, scoring Permissions Cognitive functioning 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 functioning Functional Activities (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 functioning General Practitioner Assessment of Cognition (GPCOG) (Brodaty et al.) 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) Domain Instrument and citation How many items Sample item(s) Instructions, scoring Permissions
Cognitive functioning Global Deterioration Scale (GDS) () 7 Caregiver observes the individual’s behavioral characteristics and compares them to the GDS levels. Example: Level 2, Very mild cognitive decline - Subjective complaints of memory deficit, most frequently in following areas: (a) forgetting where one has placed familiar objects; (b) forgetting names one formerly knew well. No objective evidence of memory deficit on clinical interview. No objective deficits in employment or social situations. Appropriate concern with respect to symptomatology. 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) Domain Instrument and citation links How many items Sample item(s) Instructions, scoring Permissions Cognitive functioning Making & Executing Decisions for Safe and Independent Living (MED-SAIL) () 12-18 (6 per scenario) Interviewer selects 2-3 appropriate scenarios 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? Administration and scoring instructions are included on the instrument. No special permissions required.
(Nasreddine et al.) Name as many words as possible in one minute that start with the letter F. Cognitive functioning Short Information Questionnaire on Cognitive Decline in the Elderly (Short IQCODE) (Jorm) 16 Compared with 10 years ago, how is this person at: Remembering things about family and friends e.g. occupations, birthdays, addresses? Recalling conversations a few days later Remembering where things are usually kept Administration instructions are included on the instrument. Notify of use. No other permissions required. (continued) Evaluation Instrument Details (continued) Domain Instrument and citation links How many items Sample item(s) Instructions, scoring Permissions Cognitive functioning 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 functioning- IDD Dementia Screening for Individuals with Intellectual Disabilities (DSQIID) 56 Is the symptom 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) Domain Instrument and citation How many items Sample item(s) Instructions, scoring Permissions Cognitive IDD Early Detection Screen for Dementia (NTG-EDSD) (National Task Group on Intellectual Disabilities and Dementia) 32 Needs help with dressing. Does not follow simple instructions. all significant life events in the past year from a list. No special permissions are required. Cognitive IDD Test for Severe Impairment (TSI) () 24 Motor 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 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)
Evaluation Instrument Details (continued) Domain Instrument and citation How many items Sample item(s) Instructions, scoring Permissions Depression Center for Studies Depression Scale - Revised (CESD-R) () 20 In the past week or so: My appetite was poor. I could not shake off the blues. I had trouble keeping my mind on what I was doing. No special permissions required. Depression Geriatric Depression Scale (Yesavage et al.) 15 and 30-item versions Have you dropped many of your activities and interests? Are you in good spirits most of the time? Do you think that most people are better off than you are? No special permissions required. (continued) Evaluation Instrument Details (continued) Domain Instrument and citation links How many Sample item(s) Instructions, scoring Permissions Depression Patient Health () Patient Health 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 II) p. 66-67 () 18 I show special amounts of physical affection to (care recipient). I actively avoid 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 using the complete citation. No other permissions are required. (continued) Evaluation Instrument Details (continued) Domain Instrument and citation links How many items Sample item(s) Instructions, scoring Permissions Formal supports Formal Care and Services Use (REACH II) p. 43-48 () 22 In the past month, 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.
Outcome Measurement Information System (PROMIS) () In general, would you say your quality of life is: [Excellent, Very good, Good, Fair, Poor] included on the instrument. individual research, clinical practice, educational assessment, or application. Commercial users must seek permission to use, reproduce, or distribute measures. Integration into proprietary technology also requires written permission. Intent to place in nursing home Desire to Scale (DIS) (REACH II) p. 45 () 6 Have you ever considered or thought about 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. (continued) Evaluation Instrument Details (continued) Domain Instrument and citation links How many Sample item(s) Instructions, scoring Permissions 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 An answer key is included on the instrument. Permission has been obtained for ADSSP, ADI-SSS and ADPI grantees.
themselves, caregivers should take over right away. Other users contact for permission. Knowledge Dementia Knowledge Assessment Tool V2 (DKAT v2) () 21 Dementia occurs because of changes in the 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. Knowledge IDD and Dementia Knowledge () 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. (continued) Evaluation Instrument Details (continued) Domain Instrument and citation links How many items Sample item(s) Instructions, scoring Permissions Pain Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) () 60 An observer indicates which symptoms of pain are present Examples: Grimacing Verbal Aggression Pale Face Administration and scoring instructions are included on the instrument. Contact for permission. Pain Pain Assessment in Advanced Dementia 5 Health care provider observes for 5 minutes and rates behaviors such as breathing, facial expression, and consolability based on observation. Administration and scoring instructions are included on the instrument. Instructions No special permissions required.
Scale (PAINAD) () Example: Breathing 0 = normal 1 = Occasional labored breathing; short period of hyperventilation 2 = Noisy labored breathing; long period of hyperventilation; respirations include definitions for the terms included in the ratings. (continued) Evaluation Instrument Details (continued) Domain Instrument and citation links How many Sample item(s) Instructions, scoring Permissions Positives of caregiving 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. Positives of caregiving Positive Aspects of Caregiving (REACH II) p. 49 (Tarlow et al.) 11 Providing help to (care recipient) has: Made me feel more useful. Made me feel needed. Enabled me to learn new skills. Administration instructions are included on the instrument. Credit the developers by using the complete citation. No other permissions are required. 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 interest in events, places or habits from his/her past such as old Administration instructions are included on the instrument. Nonfunded academic users and individual medical practices may obtain the instrument at no cost.
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. Example: Enjoys eating At most 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. Risk assessment/ Safety Care Needs Assessment Tool () 23 Sleep disturbances (waking you or other family members up at night). Resists bathing or showering. Insists on driving. Administration and scoring instructions are included on the instrument. Use this citation.1 No other permissions required. (continued) Evaluation Instrument Details (continued) Domain Instrument and citation links How many items Sample item(s) Instructions, scoring Permissions Risk assessment/ Safety Caregiver Risk Appraisal II) p. 68-73 () 53 Do you or a family member have durable 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 assessment/ Safety Dementia Crisis to 13 Respondent rates the person’s level of risk on several domains such as food security, in-home care, and falls risk. No instructions provided. Consult with No special permissions required.
Thriving Scale () 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 in past 6 months, home is safe, no fall risk factors. No falls in past 12 months, gait stable, active, safe home. an evaluator for appropriate use. (continued) Evaluation Instrument Details (continued) Domain Instrument and citation links How many Sample item(s) Instructions, scoring Permissions Risk assessment/ Safety p. 65-66 () 8 How in the past six months, have you: Blamed (care recipient) for having created difficulties? Used a 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 assessment/ 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 assessment/ Safety Living - Positive Aspects and 14 Do you keep materials present to occupy CR or that provide comfort or meaning (e.g. games, sorting tasks, magazines, photos, stuffed animals)? Administration instructions are included on the instrument. Credit the developers by using the complete citation. No other permissions are required.
Evaluation Instrument Details (continued) Domain Instrument and citation links How many Sample item(s) Instructions, scoring Permissions Social functioning Social Functioning in Dementia Scale (Sommerlad et al.) 20 Thinking about the past month, how often have you: Seen friends or family in your own home Had an argument or shouted at other people Contacted friends or family by phone or computer SF-DEM is freely available for use by other researchers under a Creative Commons 4.0 International License. Social support Scale of Perceived Social Support () 12 There is a special person who is around when I am in need. There is a special person with whom I can share joys and sorrows. My family really to help me. Scoring instructions are included on the instrument. Credit the developers by using the complete citation. No other permissions are required. Social support Lubben Social Network Scale (Lubben) 6 or versions How many relatives do you feel close to such that you could call on them for help? How many of your friends do you see or hear from at least once a month? Scoring instructions are included on the instrument. Complete the . (continued) Evaluation Instrument Details (continued) Domain Instrument and citation links How many items Sample item(s) Instructions, scoring Permissions Social support Perceived Support Scale p. 57-59 () 16 Overall, how satisfied have you been in the past month with the help you have received from family members, friends, or neighbors? No instructions provided. Consult with an evaluator for appropriate use. No special permissions required.
How many relatives, friends, neighbors, other than (care recipient) do you see or hear from at least once a month? How many relatives, friends, neighbors, other than (care recipient) do you feel you can call on for help with chores, transportation, etc.? Stigma Affiliate Stigma Scale () 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 out with my family member with dementia. Scoring instructions are included on the instrument. Credit the developers by using the complete citation. Contact for a copy of the instrument and for permission. (continued) Evaluation Instrument Details (continued) Domain Instrument and citation How many items Sample item(s) Instructions, scoring Permissions Stigma Measures of Stigma and the Social Impact of Disease () 24 I feel others avoid me because of my illness. Some family members have rejected me because of my illness. I encounter embarrassing situations as a result of my illness. No instructions provided. Consult with an evaluator for appropriate use. Individuals may use this information for research or educational purposes only and may not use this information for purposes. Users must credit the developers; complete citation information is in the References section. When presenting results using any
Evaluation Instrument Details (continued) Domain Instrument and citation How many items Sample item(s) Instructions, scoring Permissions Traumatic experience Primary Care PTSD Screen (PC-PTSD-5) (Prins et al.) 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) Domain Instrument and citation links How many items Sample item(s) Instructions, scoring Permissions Needs Care Needs Assessment Tool () 23 disturbances (waking you or other family members up at night). Resists bathing or showering. Insists on driving. Administration and scoring instructions are included on the instrument. Use this citation.1 No other permissions required.