==========================================================================================
Section BJ: DEMENTIA CHECKLIST & NEUROLOGICAL EXAM - FOLLOW-UP VISIT (Respondent)
==========================================================================================
HHID HRS HOUSEHOLD IDENTIFIER
Section: BJ Level: Respondent Type: Character Width: 6 Decimals: 0
This variable uniquely identifies an original HRS household across waves.
.................................................................................
252 010059-213468. Household Identification Number
==========================================================================================
PN HRS PERSON NUMBER
Section: BJ Level: Respondent Type: Character Width: 3 Decimals: 0
Each HRS respondent has a Person Number, PN, unique within an original
household. In combination, HHID and PN uniquely identify a respondent across
all waves of the study.
.................................................................................
160 010. Person Number
6 011. Person Number
56 020. Person Number
1 021. Person Number
11 030. Person Number
17 040. Person Number
1 041. Person Number
==========================================================================================
ADAMSSID ADAMS SUBJECT IDENTIFIER
Section: BJ Level: Respondent Type: Character Width: 5 Decimals: 0
This variable identifies an ADAMS subject in the ADAMS data files.
.................................................................................
252 00021-21311. ADAMS Subject Identification Number
==========================================================================================
BJNEURCOMP WHETHER NEUROLLOGICAL EXAM COMPLETED
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEURCOMP
NEUROLOGICAL EXAM COMPLETED?
The CRN conducts this standardized neurological examination with the subject.
For each question, Can't Execute and Missing will mean the following:
CAN'T EXECUTE: Subject will not/cannot attempt task secondary to dementia.
MISSING: Examiner omits task, subject refuses (not secondary to dementia), or
subject unable to do task secondary to physical reason.
.................................................................................
240 1. YES
12 2. NO
==========================================================================================
BJRANGELAT NEUROLOGICAL EXAM - RANGE, EXTENT OF LATERAL GAZE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: RANGELAT
RANGE/EXTENT OF LATERAL GAZE2
.................................................................................
219 1. NORMAL -- complete gaze to left/right
3 2. ABNORMAL -- incomplete left or right gaze
7 3. ABNORMAL -- complete absence of left or right gaze
2 4. OTHER (SPECIFY)
2 8. CAN'T EXECUTE
7 9. MISSING
12 Blank. Inap
==========================================================================================
BJRANGEVER NEUROLOGICAL EXAM - RANGE,EXTENT OF VERTICAL GAZE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: RANGEVER
RANGE/EXTENT OF VERTICAL GAZE
.................................................................................
219 1. NORMAL -- complete up & down gaze
9 2. ABNORMAL -- incomplete up & down gaze
2 3. ABNORMAL -- complete absence of up & down gaze
2 4. OTHER (SPECIFY)
2 8. CAN'T EXECUTE
6 9. MISSING
12 Blank. Inap
==========================================================================================
BJPUPILLAR NEUROLOGICAL EXAM - PUPILLARY REFLEX
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: PUPILLAR
PUPILLARY REFLEX
.................................................................................
193 1. NORMAL -- PERRLA
30 2. ABNORMAL -- re:pupil size, reaction time
12 3. OTHER (SPECIFY)
8. CAN'T EXECUTE
5 9. MISSING
12 Blank. Inap
==========================================================================================
BJOPENJAW NEUROLOGICAL EXAM - OPENING AND CLOSING JAW
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: OPENJAW
OPENING AND CLOSING JAW
.................................................................................
233 1. NORMAL -- No deviation of mandible
7 2. ABNORMAL (SPECIFY)
3. OTHER (SPECIFY)
8. CAN'T EXECUTE
9. MISSING
12 Blank. Inap
==========================================================================================
BJPHARYNGE NEUROLOGICAL EXAM - PHARYNGEAL MOVEMENTS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: PHARYNGE
PHARYNGEAL MOVEMENTS (subject opens mouth, says 'ah')
.................................................................................
220 1. NORMAL -- No deviation of uvula or tongue
8 2. ABNORMAL -- deviation to left or right
4 3. OTHER (SPECIFY)
8. CAN'T EXECUTE
8 9. MISSING
12 Blank. Inap
==========================================================================================
BJCLOSEYES NEUROLOGICAL EXAM - CLOSE EYES, RESIST OPENING
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CLOSEYES
CLOSE EYES, RESIST OPENING BY EXAMINER
.................................................................................
223 1. NORMAL -- no weakness of upper eyelid on either side
10 2. ABNORMAL -- unilateral or bilateral weakness
1 3. OTHER (SPECIFY)
8. CAN'T EXECUTE
6 9. MISSING
12 Blank. Inap
==========================================================================================
BJBLOWOUT NEUROLOGICAL EXAM - BLOW OUT CHEEKS WITH MOUTH CLOSED
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: BLOWOUT
BLOW OUT CHEEKS WITH MOUTH CLOSED
.................................................................................
208 1. NORMAL -- can perform evenly bilateral
14 2. ABNORMAL -- cannot perform evenly
8 3. ABNORMAL -- cannot perform with mouth closed
3 4. OTHER (SPECIFY)
2 8. CAN'T EXECUTE
5 9. MISSING
12 Blank. Inap
==========================================================================================
BJWIDESMIL NEUROLOGICAL EXAM - WIDE SMILE, SHOW TEETH
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: WIDESMIL
WIDE SMILE- SHOW TEETH
.................................................................................
220 1. NORMAL -- no weakness noted
2 2. ABNORMAL -- flattened nasolabial fold
15 3. ABNORMAL -- inability to raise corner of mouth on left or
right
3 4. OTHER (SPECIFY)
8. CAN'T EXECUTE
9. MISSING
12 Blank. Inap
==========================================================================================
BJEYEBROWS NEUROLOGICAL EXAM - RAISE EYEBROWS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: EYEBROWS
FROWN WITH KNIT BROWS
.................................................................................
234 1. NORMAL -- no weakness noted
1 2. ABNORMAL -- inability to raise eyebrow
2 3. ABNORMAL -- inability to wrinkle forehead on left or right
2 4. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
9. MISSING
12 Blank. Inap
==========================================================================================
BJWINK NEUROLOGICAL EXAM - WINK WITH OTHER EYE OPEN
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: WINK
WINK WITH OTHER EYE OPEN
.................................................................................
184 1. NORMAL -- can perform with either eye
36 2. ABNORMAL -- can perform with one eye only
18 3. ABNORMAL -- cannot perform
2 4. OTHER
8. CAN'T EXECUTE
9. MISSING
12 Blank. Inap
==========================================================================================
BJTONGUE NEUROLOGICAL EXAM - RAPID TONGUE MOVEMENT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: TONGUE
RAPID TONGUE MOVEMENT
.................................................................................
124 1. NORMAL -- 4 touches/second
111 2. ABNORMAL -- <4 touches/second or arrhythmic
3. OTHER (SPECIFY)
8. CAN'T EXECUTE
5 9. MISSING
12 Blank. Inap
==========================================================================================
BJMOTOR_A NEUROLOGICAL EXAM - EYE CLOSURE X20 SECS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: MOTOR_A
MOTOR IMPERSISTENCE: Eye Closure X 20 seconds
A. Eye closure x 20 seconds
.................................................................................
235 1. NORMAL -- maintains act for 20 seconds
4 2. ABNORMAL -- opens eyes before 20 seconds
3. OTHER (SPECIFY)
8. CAN'T EXECUTE
1 9. MISSING
12 Blank. Inap
==========================================================================================
BJMOTOR_B NEUROLOGICAL EXAM - TONGUE PROTRUSION X20 SECS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: MOTOR_B
MOTOR IMPERSISTENCE: Tongue protrusion x 20 seconds
B. Tongue protrusion x 20 seconds
.................................................................................
229 1. NORMAL -- maintains act for 20 seconds
9 2. ABNORMAL -- pulls tongue in before 20 seconds
1 3. OTHER (SPECIFY)
8. CAN'T EXECUTE
1 9. MISSING
12 Blank. Inap
==========================================================================================
BJRACOUSTA NEUROLOGICAL EXAM - RUBBING OF FINGERS, RIGHT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: RACOUSTA
RIGHT Acoustic nerve: Rubbing of fingers
.................................................................................
179 1. NORMAL -- able to hear
56 2. ABNORMAL -- unable to hear
3. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
4 9. MISSING
12 Blank. Inap
==========================================================================================
BJLACOUSTA NEUROLOGICAL EXAM - RUBBING OF FINGERS, LEFT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: LACOUSTA
LEFT Acoustic nerve: Rubbing of fingers
.................................................................................
176 1. NORMAL -- able to hear
59 2. ABNORMAL -- unable to hear
3. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
4 9. MISSING
12 Blank. Inap
==========================================================================================
BJRWHISPER NEUROLOGICAL EXAM - WHISPERING, RIGHT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: RWHISPER
RIGHT Acoustic nerve: whispering
.................................................................................
173 1. NORMAL -- able to hear
49 2. ABNORMAL -- unable to hear
14 3. OTHER (SPECIFY)
8. CAN'T EXECUTE
4 9. MISSING
12 Blank. Inap
==========================================================================================
BJLWHISPER NEUROLOGICAL EXAM - WHISPERING, LEFT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: LWHISPER
LEFT Acoustic nerve: whispering
.................................................................................
162 1. NORMAL -- able to hear
51 2. ABNORMAL -- unable to hear
23 3. OTHER (SPECIFY)
8. CAN'T EXECUTE
4 9. MISSING
12 Blank. Inap
==========================================================================================
BJCHIN NEUROLOGICAL EXAM - CHIN RESISTANCE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CHIN
CHIN RESISTANCE
.................................................................................
217 1. NORMAL -- no weakness noted on either side
8 2. ABNORMAL -- unilateral weakness
8 3. ABNORMAL -- bilateral weakness
4. OTHER (SPECIFY)
2 8. CAN'T EXECUTE
5 9. MISSING
12 Blank. Inap
==========================================================================================
BJSHOULDER NEUROLOGICAL EXAM - SHOULDER ELEVATION, SHRUG
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: SHOULDER
SHOULDER ELEVATION (shrug)
.................................................................................
225 1. NORMAL -- no weakness noted
2 2. ABNORMAL -- unilateral weakness
3 3. ABNORMAL -- bilateral weakness
1 4. OTHER (SPECIFY)
8. CAN'T EXECUTE
9 9. MISSING
12 Blank. Inap
==========================================================================================
BJMUTE NEUROLOGICAL EXAM - WHETHER SUBJECT IS MUTE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: MUTE
IS SUBJECT MUTE?
.................................................................................
1. YES
240 2. NO
12 Blank. Inap
==========================================================================================
BJREPEAT_A NEUROLOGICAL EXAM - REPEAT LA,LA,LA
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: REPEAT_A
REPEAT LA, LA, LA, LA, LA
A). 'La, La, La, La, La'
.................................................................................
205 1. NORMAL -- regular rate, rhythm and > 4 syllables/second,
each syllable clear
11 2. ABNORMAL -- arrhythmic
12 3. ABNORMAL -- < 4 syllables/second
10 4. ABNORMAL -- slurred words
5. OTHER (SPECIFY)
8. CAN'T EXECUTE
2 9. MISSING
12 Blank. Inap
==========================================================================================
BJREPEAT_B NEUROLOGICAL EXAM - REPEAT GO,GO,GO
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: REPEAT_B
REPEAT GO, GO, GO, GO, GO
B). 'Go, Go, Go, Go, Go'
.................................................................................
205 1. NORMAL -- regular rate, rhythm and > 4 syllables/second,
each syllable clear
9 2. ABNORMAL -- arrhythmic
16 3. ABNORMAL -- < 4 syllables/second
7 4. ABNORMAL -- slurred words
1 5. OTHER (SPECIFY)
8. CAN'T EXECUTE
2 9. MISSING
12 Blank. Inap
==========================================================================================
BJREPEAT_C NEUROLOGICAL EXAM - REPEAT KITTY,KITTY,KITTY
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: REPEAT_C
REPEAT KITTY, KITTY, KITTY, KITTY, KITTY
C). 'Kitty, Kitty, Kitty, Kitty, Kitty'
.................................................................................
213 1. NORMAL -- regular rate, rhythm and > 4 syllables/second,
each syllable clear
5 2. ABNORMAL -- arrhythmic
16 3. ABNORMAL -- < 4 syllables/second
2 4. ABNORMAL -- slurred words
2 5. OTHER (SPECIFY)
8. CAN'T EXECUTE
2 9. MISSING
12 Blank. Inap
==========================================================================================
BJRATECONV NEUROLOGICAL EXAM - RATE OF CONVERSATION
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: RATECONV
RATE OF CONVERSATION
.................................................................................
221 1. NORMAL -- normal speed
2 2. ABNORMAL -- too fast
13 3. ABNORMAL -- too slow
4 4. OTHER (SPECIFY)
8. CAN'T EXECUTE
9. MISSING
12 Blank. Inap
==========================================================================================
BJCLARCONV NEUROLOGICAL EXAM - CLARITY OF CONVERSATION
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CLARCONV
CLARITY OF CONVERSATION
.................................................................................
221 1. NORMAL -- normally understandable
14 2. ABNORMAL -- examiner must listen carefully
2 3. ABNORMAL -- subject must repeat to be understood
1 4. ABNORMAL -- almost incomprehensible
2 5. OTHER (SPECIFY)
8. CAN'T EXECUTE
9. MISSING
12 Blank. Inap
==========================================================================================
BJF_NRIGHT NEUROLOGICAL EXAM - FINGER TO NOSE TOUCH, RIGHT REV
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: F_NRIGHT
RIGHT FINGER -TO-NOSE TOUCHING
.................................................................................
148 1. NORMAL -- quickly, smooth and accurate
72 2. ABNORMAL -- slow but accurate
4 3. ABNORMAL -- dysmetria noted
4 4. OTHER (SPECIFY)
8. CAN'T EXECUTE
12 9. MISSING
12 Blank. Inap
==========================================================================================
BJF_NLEFT NEUROLOGICAL EXAM - FINGER TO NOSE TOUCH, LEFT REV
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: F_NLEFT
LEFT FINGER -TO-NOSE TOUCHING
.................................................................................
142 1. NORMAL -- quickly, smooth and accurate
74 2. ABNORMAL -- slow but accurate
8 3. ABNORMAL -- dysmetria noted
2 4. OTHER (SPECIFY)
8. CAN'T EXECUTE
14 9. MISSING
12 Blank. Inap
==========================================================================================
BJRF_TTAPP NEUROLOGICAL EXAM - FINGER THUMB TAPPING, RIGHT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: RF_TTAPP
RIGHT: FINGER-THUMB TAPPING
.................................................................................
196 1. NORMAL -- 4 taps/second
29 2. ABNORMAL -- 3 taps/second or faster but arrhythmic
4 3. ABNORMAL -- < 3 taps/second
4 4. OTHER (SPECIFY)
8. CAN'T EXECUTE
7 9. MISSING
12 Blank. Inap
==========================================================================================
BJLF_TTAPP NEUROLOGICAL EXAM - FINGER THUMB TAPPING, LEFT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: LF_TTAPP
LEFT: FINGER-THUMB TAPPING
.................................................................................
191 1. NORMAL -- 4 taps/second
31 2. ABNORMAL -- 3 taps/second or faster but arrhythmic
6 3. ABNORMAL -- < 3 taps/second
4 4. OTHER (SPECIFY)
8. CAN'T EXECUTE
8 9. MISSING
12 Blank. Inap
==========================================================================================
BJRDIADOCH NEUROLOGICAL EXAM - DIADOCHOKINESIS, RIGHT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: RDIADOCH
RIGHT: DIADOCHOKINESIS
.................................................................................
192 1. NORMAL -- at least 3 pats/second and smooth
29 2. ABNORMAL -- 2 pats/second or faster but arrhythmic
3. ABNORMAL -- < 2 pats/second
8 4. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
10 9. MISSING
12 Blank. Inap
==========================================================================================
BJRDIADCOD NEUROLOGICAL EXAM - DIADOCHOKINESIS ABNORM CODE RIGHT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: RDIADCOD
RIGHT: Type of Abnormality
.................................................................................
8 1. <3 pats/second
6 2. Arrhythmic =2
15 3. Both
223 Blank. Inap
==========================================================================================
BJLDIADOCH NEUROLOGICAL EXAM - DIADOCHOKINESIS, LEFT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: LDIADOCH
LEFT: DIADOCHOKINESIS
.................................................................................
175 1. NORMAL -- at least 3 pats/second and smooth
44 2. ABNORMAL -- 2 pats/second or faster but arrhythmic
3. ABNORMAL -- < 2 pats/second
10 4. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
10 9. MISSING
12 Blank. Inap
==========================================================================================
BJLDIADCOD NEUROLOGICAL EXAM - DIADOCHOKINESIS ABNORM CODE LEFT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: LDIADCOD
LEFT : Type of Abnormality
.................................................................................
10 1. <3 pats/second
15 2. Arrhythmic =2
19 3. Both
208 Blank. Inap
==========================================================================================
BJHAND_A NEUROLOGICAL EXAM - INTERLOCKING THUMBS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: HAND_A
HAND PRAXIS TASKS: INTER-LOCKING FINGERS
A). Inter-locking fingers
.................................................................................
198 1. NORMAL -- performs correctly
29 2. ABNORMAL -- performs incorrectly
1 3. OTHER (SPECIFY)
8. CAN'T EXECUTE
12 9. MISSING
12 Blank. Inap
==========================================================================================
BJHAND_B NEUROLOGICAL EXAM - MIRRORED FINGERS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: HAND_B
HAND PRAXIS TASKS: MIRRORED FINGERS
B). Mirrored fingers
.................................................................................
203 1. NORMAL -- performs correctly
25 2. ABNORMAL -- performs incorrectly
1 3. OTHER (SPECIFY)
8. CAN'T EXECUTE
11 9. MISSING
12 Blank. Inap
==========================================================================================
BJRGRASP NEUROLOGICAL EXAM - GRASP, RIGHT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: RGRASP
RIGHT GRASP
.................................................................................
235 1. NORMAL -- absent
1 2. ABNORMAL -- subject grasps examiner's hand on stimulation
1 3. ABNORMAL -- grasps after verbal request not to do so
4. OTHER (SPECIFY)
8. CAN'T EXECUTE
3 9. MISSING
12 Blank. Inap
==========================================================================================
BJLGRASP NEUROLOGICAL EXAM - GRASP, LEFT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: LGRASP
LEFT GRASP
.................................................................................
234 1. NORMAL -- absent
2. ABNORMAL -- subject grasps examiner's hand on stimulation
1 3. ABNORMAL -- grasps after verbal request not to do so
4. OTHER (SPECIFY)
8. CAN'T EXECUTE
5 9. MISSING
12 Blank. Inap
==========================================================================================
BJRMUSCLE NEUROLOGICAL EXAM - MUSCLE TONUS, ELBOW,WRIST, RIGHT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: RMUSCLE
RIGHT MUSCLE TONUS (passive flexion/extension at elbow and wrist)
.................................................................................
228 1. NORMAL -- normal muscle tone, no rigidity
10 2. ABNORMAL -- rigidity or stiffness present
3. OTHER (SPECIFY)
8. CAN'T EXECUTE
2 9. MISSING
12 Blank. Inap
==========================================================================================
BJLMUSCLE NEUROLOGICAL EXAM - MUSCLE TONUS, ELBOW,WRIST, LEFT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: LMUSCLE
LEFT MUSCLE TONUS (passive flexion/extension at elbow and wrist)
.................................................................................
228 1. NORMAL -- normal muscle tone, no rigidity
9 2. ABNORMAL -- rigidity or stiffness present
3. OTHER (SPECIFY)
8. CAN'T EXECUTE
3 9. MISSING
12 Blank. Inap
==========================================================================================
BJRCOGWHL NEUROLOGICAL EXAM - COGWHEEL PHENOMENON, RIGHT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: RCOGWHL
RIGHT COGWHEEL PHENOMENON
.................................................................................
229 1. NORMAL -- no cogwheeling noted
7 2. ABNORMAL -- slight or noticeable rhythmicity throughout
3. OTHER (SPECIFY)
8. CAN'T EXECUTE
4 9. MISSING
12 Blank. Inap
==========================================================================================
BJLCOGWHL NEUROLOGICAL EXAM - COGWHEEL PHENOMENON, LEFT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: LCOGWHL
LEFT COGWHEEL PHENOMENON
.................................................................................
224 1. NORMAL -- no cogwheeling noted
11 2. ABNORMAL -- slight or noticeable rhythmicity throughout
3. OTHER (SPECIFY)
8. CAN'T EXECUTE
5 9. MISSING
12 Blank. Inap
==========================================================================================
BJRANKLE NEUROLOGICAL EXAM - ANKLE CLONUS, RIGHT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: RANKLE
RIGHT ANKLE CLONUS
Right
.................................................................................
214 1. NORMAL -- absent
2 2. ABNORMAL -- present
1 3. OTHER (SPECIFY)
8. CAN'T EXECUTE
23 9. MISSING
12 Blank. Inap
==========================================================================================
BJLANKLE NEUROLOGICAL EXAM - ANKLE CLONUS, LEFT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: LANKLE
LEFT ANKLE CLONUS
Left
.................................................................................
213 1. NORMAL -- absent
3 2. ABNORMAL -- present
1 3. OTHER (SPECIFY)
8. CAN'T EXECUTE
23 9. MISSING
12 Blank. Inap
==========================================================================================
BJRPROPRIC NEUROLOGICAL EXAM - PROPRIOCEPTION, RIGHT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: RPROPRIC
RIGHT KINESTHESIS
.................................................................................
150 1. PRESENT
33 2. ABSENT
1 8. CAN'T EXECUTE
56 9. MISSING
12 Blank. Inap
==========================================================================================
BJLPROPRIC NEUROLOGICAL EXAM - PROPRIOCEPTION, LEFT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: LPROPRIC
LEFT KINESTHESIS
.................................................................................
149 1. PRESENT
33 2. ABSENT
2 8. CAN'T EXECUTE
56 9. MISSING
12 Blank. Inap
==========================================================================================
BJRVIBRAT NEUROLOGICAL EXAM - VIBRATING SENSATION, RIGHT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: RVIBRAT
RIGHT VIBRATING SENSATION
.................................................................................
160 1. PRESENT
58 2. ABSENT
8. CAN'T EXECUTE
22 9. MISSING
12 Blank. Inap
==========================================================================================
BJLVIBRAT NEUROLOGICAL EXAM - VIBRATING SENSATION, LEFT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: LVIBRAT
LEFT VIBRATING SENSATION
.................................................................................
154 1. PRESENT
64 2. ABSENT
8. CAN'T EXECUTE
22 9. MISSING
12 Blank. Inap
==========================================================================================
BJRPLANTAR NEUROLOGICAL EXAM - PLANTAR RESPONSE, RIGHT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: RPLANTAR
RIGHT PLANTAR RESPONSE
.................................................................................
112 1. NORMAL -- plantar flexion of great toe
15 2. ABNORMAL -- extension of great toe
55 3. ABNORMAL -- no reflex present
4 4. OTHER (SPECIFY)
8. CAN'T EXECUTE
54 9. MISSING
12 Blank. Inap
==========================================================================================
BJLPLANTAR NEUROLOGICAL EXAM - PLANTAR RESPONSE, LEFT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: LPLANTAR
LEFT PLANTAR RESPONSE
.................................................................................
116 1. NORMAL -- plantar flexion of great toe
11 2. ABNORMAL -- extension of great toe
56 3. ABNORMAL -- no reflex present
3 4. OTHER (SPECIFY)
8. CAN'T EXECUTE
54 9. MISSING
12 Blank. Inap
==========================================================================================
BJRHEEL NEUROLOGICAL EXAM - HEEL TO KNEE TEST, RIGHT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: RHEEL
RIGHT HEEL - TO - KNEE TEST
.................................................................................
145 1. NORMAL -- moving foot is dorsi flexed and motion down shin
is smooth, slow and accurate
19 2. ABNORMAL -- path of heel is shaky, jerky, wavering
7 3. ABNORMAL -- knee is overshot
4. ABNORMAL -- slide down skin accompanied by action tremor
10 5. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
58 9. MISSING
12 Blank. Inap
==========================================================================================
BJLHEEL NEUROLOGICAL EXAM - HEEL TO KNEE TEST, LEFT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: LHEEL
LEFT HEEL - TO - KNEE TEST
.................................................................................
150 1. NORMAL -- moving foot is dorsiflexed and motion down shin is
smooth, slow and accurate
16 2. ABNORMAL -- path of heel is shaky, jerky, wavering
6 3. ABNORMAL -- knee is overshot
4. ABNORMAL -- slide down skin accompanied by action tremor
10 5. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
57 9. MISSING
12 Blank. Inap
==========================================================================================
BJROMBERG NEUROLOGICAL EXAM - ROMBERGS SIGN
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: ROMBERG
ROMBERG'S SIGN (stand with feet together for 10-15 seconds)
.................................................................................
177 1. NORMAL -- normally still or slight weaving
1 2. ABNORMAL -- falls to one side with eyes closed
3. ABNORMAL -- falls to one side with eyes open
13 4. ABNORMAL -- needs widened base to stay in one place
5. OTHER (SPECIFY)
8. CAN'T EXECUTE
49 9. MISSING
12 Blank. Inap
==========================================================================================
BJGAIT_A NEUROLOGICAL EXAM - WALK HALL 10 PACES
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: GAIT_A
GAIT ACTIVITIES: WALKING DOWN HALL AT LEAST 10 PACES
A). Walking down a hall at least 10 paces
.................................................................................
166 1. NORMAL -- normal gait, narrow base
7 2. ABNORMAL -- deviation from straight line
23 3. OTHER (SPECIFY)
8. CAN'T EXECUTE
44 9. MISSING
12 Blank. Inap
==========================================================================================
BJGAIT_B NEUROLOGICAL EXAM - PIVOT WHILE TURNING
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: GAIT_B
GAIT ACTIVITIES: PIVOT WHILE TURNING
B). Pivot while turning
.................................................................................
130 1. NORMAL -- pivots on narrow base
36 2. ABNORMAL -- hesitates
11 3. ABNORMAL -- widens base or moves feet
17 4. ABNORMAL -- turns slowly or awkwardly
1 5. OTHER (SPECIFY)
8. CAN' T EXECUTE
45 9. MISSING
12 Blank. Inap
==========================================================================================
BJGAIT_C NEUROLOGICAL EXAM - STOPPING ON UNEXPECTED COMMAND
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: GAIT_C
GAIT ACTIVITIES: STOPPING ON UNEXPECTED COMMAND
C). Stopping on unexpected command
.................................................................................
166 1. NORMAL -- stops on command or takes one small step
3 2. ABNORMAL -- stops but body lurches forward
7 3. ABNORMAL -- takes > 1 step before stopping
1 4. OTHER (SPECIFY)
8. CAN'T EXECUTE
63 9. MISSING
12 Blank. Inap
==========================================================================================
BJGAIT_D NEUROLOGICAL EXAM - FESTINATION
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: GAIT_D
GAIT ACTIVITIES: FESTINATION
D). Festination
.................................................................................
136 1. NORMAL -- none
51 2. ABNORMAL -- slow start
8 3. ABNORMAL -- shuffling gait
2 4. OTHER (SPECIFY)
8. CAN'T EXECUTE
43 9. MISSING
12 Blank. Inap
==========================================================================================
BJGAIT_E NEUROLOGICAL EXAM - ACCESSORY MOVEMENTS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: GAIT_E
GAIT ACTIVITIES: ACCESSORY MOVEMENTS
E). Accessory movements
.................................................................................
107 1. NORMAL -- normal
78 2. ABNORMAL -- decrease of arm swings
5 3. ABNORMAL -- trunk/neck rigid and flexed
4. ABNORMAL -- width of gait gets smaller
4 5. OTHER (SPECIFY)
8. CAN'T EXECUTE
46 9. MISSING
12 Blank. Inap
==========================================================================================
BJTREMOR NEUROLOGICAL EXAM - TREMOR AT REST
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: TREMOR
TREMOR AT REST
.................................................................................
208 1. NORMAL -- none
25 2. ABNORMAL -- slight/occasional
7 3. ABNORMAL -- moderate to severe
4. OTHER (SPECIFY)
8. CAN'T EXECUTE
9. MISSING
12 Blank. Inap
==========================================================================================
BJTREM_ARM NEUROLOGICAL EXAM - TREMOR ARMS OUTSTRETCHED
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: TREM_ARM
TREMOR WITH ARMS OUTSTRETCHED
.................................................................................
172 1. NORMAL -- none
53 2. ABNORMAL -- slight/ occasional
10 3. ABNORMAL -- moderate to severe
4. OTHER (SPECIFY)
8. CAN'T EXECUTE
5 9. MISSING
12 Blank. Inap
==========================================================================================
BJPRONAT NEUROLOGICAL EXAM - PRONATOR DRIFT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: PRONAT
PRONATOR DRIFT (arms out-stretched, palms up, eyes closed)
.................................................................................
218 1. NORMAL -- absence of drift
9 2. ABNORMAL -- spontaneous drift of either /both hands
3. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
12 9. MISSING
12 Blank. Inap
==========================================================================================
BJSTRENGTH NEUROLOGICAL EXAM - STRENGTH DIFFERENCE, DOWN PRESSURE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: STRENGTH
STRENGTH DIFFERENCE WITH DOWNWARD PRESSURE AND THEN SUDDEN RELEASE BY EXAMINER
(arms outstretched, resists examiner's pressure)
.................................................................................
179 1. NORMAL -- no strength difference, equal rebound
33 2. ABNORMAL -- unequal rebound
3 3. OTHER (SPECIFY)
2 8. CAN' T EXECUTE
23 9. MISSING
12 Blank. Inap
==========================================================================================
BJGRIP_BIC NEUROLOGICAL EXAM - UPPER EXTREMITY, WHICH TEST
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: GRIP_BIC
UPPER EXTREMITY MOTOR STRENGTH. GRIP STRENGTH, OR BICEPS PULL. STRENGTH
DIFFERENCE BETWEEN L AND R FINGER GRASP OR BICEPS PULL. SUBJECT GRASPS
EXAMINER'S EXTENDED FINGERS (2 digits) WITH R AND L TRIALS.
WHICH TEST DID THE SUBJECT PERFORM?
.................................................................................
174 1. GRIP STRENGTH TEST
66 2. BICEPS PULL
12 Blank. Inap
==========================================================================================
BJUPPEREXT NEUROLOGICAL EXAM - UPPER EXTREMITY MOTOR STRENGTH
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: UPPEREXT
UPPER EXTREMITY MOTOR STRENGTH. GRIP STRENGTH OR BICEPS PULL. STRENGTH
DIFFERENCE BETWEEN L AND R FINGER GRASP OR BICEPS PULL. SUBJECT GRASPS
EXAMINER'S EXTENDED FINGERS (2 digits) WITH R AND L TRIALS.
.................................................................................
196 1. NORMAL -- No strength difference between R and L trials
41 2. ABNORMAL -- Specify weakness (L or R)
3. OTHER
1 8. CAN' T EXECUTE
2 9. MISSING
12 Blank. Inap
==========================================================================================
BJBRADYKIN NEUROLOGICAL EXAM - BRADYKENESIA
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: BRADYKIN
BRADYKINESIA
.................................................................................
209 1. NORMAL -- voluntary movements are NORMAL
30 2. ABNORMAL -- mild or marked slowness
3. OTHER (SPECIFY)
8. CAN' T EXECUTE
1 9. MISSING
12 Blank. Inap
==========================================================================================
BJMYOCLONU NEUROLOGICAL EXAM - MYOCLONUS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: MYOCLONU
MYOCLONUS
.................................................................................
238 1. NORMAL -- absent
2. ABNORMAL -- mild myoclonus
1 3. ABNORMAL -- occasional myoclonus
4. ABNORMAL -- frequent myoclonus
5. ABNORMAL -- severe myoclonus
6. OTHER (SPECIFY)
8. CAN'T EXECUTE
1 9. MISSING
12 Blank. Inap
==========================================================================================
BJPOSTURE NEUROLOGICAL EXAM - POSTURE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: POSTURE
POSTURE
.................................................................................
93 1. NORMAL -- normal, erect
121 2. ABNORMAL -- slightly stooped
19 3. ABNORMAL -- very stooped
3 4. ABNORMAL -- leans to one side
1 5. OTHER (SPECIFY)
8. CAN'T EXECUTE
3 9. MISSING
12 Blank. Inap
==========================================================================================
BJCOMB NEUROLOGICAL EXAM - PRAXIS, COMB YOUR HAIR
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: COMB
PRAXIS TASKS (PRETEND TO COMB YOUR HAIR)
.................................................................................
187 1. NORMAL, PERFORMS CORRECTLY
44 2. ABNORMAL (SPECIFY)
3. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
8 9. MISSING
12 Blank. Inap
==========================================================================================
BJHAMMER NEUROLOGICAL EXAM - PRAXIS, HAMMER A NAIL
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: HAMMER
PRAXIS TASKS (PRETEND TO HAMMER A NAIL)
.................................................................................
173 1. NORMAL, PERFORMS CORRECTLY
59 2. ABNORMAL (SPECIFY)
3. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
7 9. MISSING
12 Blank. Inap
==========================================================================================
BJBRUSH NEUROLOGICAL EXAM - PRAXIS, BRUSH YOUR TEETH
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: BRUSH
PRAXIS TASKS (PRETEND TO BRUSH YOUR TEETH)
.................................................................................
177 1. NORMAL, PERFORMS CORRECTLY
54 2. ABNORMAL (SPECIFY)
1 3. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
7 9. MISSING
12 Blank. Inap
==========================================================================================
BJCHKDONE WHETHER DEMENTIA CHECKLIST COMPLETED
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CHKDONE
DEMENTIA CHECKLIST COMPLETED
.................................................................................
250 1. YES
2 2. NO
==========================================================================================
BJA1 DEMENTIA, DSM IV, MEM IMPAIRMENT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA1
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
1. Memory Impairment 'short or long term)
.................................................................................
204 1. YES
45 2. NO
3 8. DK
==========================================================================================
BJA2 DEMENTIA, DSM IV, APHASIA
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA2
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
2. Aphasia
.................................................................................
46 1. YES
203 2. NO
3 8. DK
==========================================================================================
BJA3 DEMENTIA, DSM IV, APRAXIA
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA3
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
3. Apraxia
.................................................................................
41 1. YES
198 2. NO
13 8. DK
==========================================================================================
BJA4 DEMENTIA, DSM IV, AGNOSIA
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA4
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
4. Agnosia
.................................................................................
17 1. YES
230 2. NO
5 8. DK
==========================================================================================
BJA5 DEMENTIA, DSM IV, EXEC FUNCTION DISTURBANCE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA5
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
5. Disturbance in executive functioning
.................................................................................
108 1. YES
139 2. NO
5 8. DK
==========================================================================================
BJA6 DEMENTIA, DSM IV, SOCIAL OR OCCUP IMPAIRMENT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA6
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
6. 1 - 5 cause significant impairment in social or occupational functioning
.................................................................................
81 1. YES
52 2. NO
8. DK
119 Blank. Inap
==========================================================================================
BJA7 DEMENTIA, DSM IV, SIGNIFICANT DECLINE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA7
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
7. 1 - 5 Represent significant decline from previous level of functioning
.................................................................................
132 1. YES
2. NO
8. DK
120 Blank. Inap
==========================================================================================
BJA8 DEMENTIA, DSM IV, COG DEFICITS DURING DELIRIUM
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA8
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
8. Cognitive deficits occur exclusively during delirium
.................................................................................
1. YES
132 2. NO
8. DK
120 Blank. Inap
==========================================================================================
BJA1MET DEMENTIA - CRITERIA FOR CKA1
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA1MET
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
CHECKLIST IS MET IF CKA1=YES
.................................................................................
48 0. NO
204 1. YES
==========================================================================================
BJA2MET DEMENTIA - CRITERIA FOR CKA2 - CKA5
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA2MET
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
CHECKLIST IS MET IF AT LEAST ONE OF CKA2-CKA5=YES
.................................................................................
110 0. NO
142 1. YES
==========================================================================================
BJA3MET DEMENTIA - CRITERIA FOR CKA6 AND CKA7
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA3MET
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
CHECKLIST IS MET IF BOTH CKA6 AND CKA7=YES
.................................................................................
171 0. NO
81 1. YES
==========================================================================================
BJA4MET DEMENTIA - CRITERIA FOR CKA8
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA4MET
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
CHECKLIST IS MET IF CKA8=YES
.................................................................................
120 0. NO
132 1. YES
==========================================================================================
BJAMET DEMENTIA - WHETHER OVERALL DSM IV CRITERIA MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKAMET
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
OVERALL CHECKLIST ONE CRITERIA MET=YES IF CKA1MET, CKA2MET, CKA3MET AND
CKA4MET=YES
.................................................................................
171 0. NO
81 1. YES
==========================================================================================
BJB1 DEMENTIA, DSM III R, SHORT TERM MEMORY
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB1
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
1. Short Term Memory
.................................................................................
199 1. YES
50 2. NO
3 8. DK
==========================================================================================
BJB2 DEMENTIA, DSM III R, LONG TERM MEMORY
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB2
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
2. Long Term Memory
.................................................................................
107 1. YES
142 2. NO
3 8. DK
==========================================================================================
BJB3 DEMENTIA, DSM III R, ABSTRACT THINKING
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB3
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
3. Abstract thinking
.................................................................................
91 1. YES
156 2. NO
5 8. DK
==========================================================================================
BJB4 DEMENTIA, DSM III R, JUDGEMENT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB4
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
4. Judgement
.................................................................................
95 1. YES
154 2. NO
3 8. DK
==========================================================================================
BJB5 DEMENTIA, DSM III R, OTHER HIGHER CORTICAL FUNCTIONING
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB5
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
5. Other Higher Cortical Functioning
.................................................................................
113 1. YES
134 2. NO
5 8. DK
==========================================================================================
BJB6 DEMENTIA, DSM III R, PERSONALITY CHANGE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB6
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
6. Personality Change
.................................................................................
46 1. YES
201 2. NO
4 8. DK
1 Blank. Inap
==========================================================================================
BJB7 DEMENTIA, DSM III R, SOCIAL OR OCCUP IMPAIRMENT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB7
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
7. 1 - 6 cause significant impairment in social or occupational functioning
.................................................................................
69 1. YES
20 2. NO
8. DK
163 Blank. Inap
==========================================================================================
BJB8 DEMENTIA, DSM III R, SIGNIFICANT DECLINE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB8
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
8. 1 - 6 Represent significant decline from previous level of functioning
.................................................................................
89 1. YES
2. NO
8. DK
163 Blank. Inap
==========================================================================================
BJB9 DEMENTIA, DSM III R, COG DEFICITS DURING DELIRIUM
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB9
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
9. Cognitive deficits occur exclusively during delirium
.................................................................................
1. YES
89 2. NO
8. DK
163 Blank. Inap
==========================================================================================
BJB1MET DEMENTIA, DSM III R - CRITERIA FOR CKB1 AND CKB2
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB1MET
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
CHECKLIST MET IF CKB1 AND CKB2=YES
.................................................................................
150 0. NO
102 1. YES
==========================================================================================
BJB2MET DEMENTIA, DSM III R - CRITERIA FOR CKB3 - CKB6
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB2MET
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
CHECKLIST MET IF AT LEAST ONE OF CKB3-CKB6=YES
.................................................................................
100 0. NO
152 1. YES
==========================================================================================
BJB3MET DEMENTIA, DSM III R - CRITERIA FOR CKB7 AND CKB8
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB3MET
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
CHECKLIST MET IF CKB7 AND CKB8=YES
.................................................................................
183 0. NO
69 1. YES
==========================================================================================
BJB4MET DEMENTIA, DSM III R - CRITERIA FOR CKB9
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB4MET
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
CHECKLIST MET IF CKB9=NO
.................................................................................
163 0. NO
89 1. YES
==========================================================================================
BJBMET DEMENTIA, DSM III R - WHETHER OVERALL DSM III R CRITERIA MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKBMET
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
OVERALL CHECKLIST TWO CRITERIA MET=YES IF CKB1MET, CKB2MET, CKB3MET AND
CKB4MET=YES
.................................................................................
184 0. NO
68 1. YES
==========================================================================================
BJC1 PROB AD, DEMENTIA, ESTABLISHED BY CKAMET OR CKBMET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKC1
CHECKLIST THREE
Checklist for Probable Alzheimer's Disease
1. Dementia established by DSM-III-R or DSM-IV criteria (based on clinical and
neuropsychological assessment information
.................................................................................
1 1. YES
2. NO
8. DK
251 Blank. Inap
==========================================================================================
BJC2 PROB AD, PROGRESSION OF COGNITIVE SYMPTOMS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKC2
CHECKLIST THREE
Checklist for Probable Alzheimer's Disease
2. Progression of cognitive symptoms over time.
.................................................................................
1 1. YES
2. NO
8. DK
251 Blank. Inap
==========================================================================================
BJC3 PROB AD, ABSENCE OF OTHER CONDITIONS SUFFICIENT TO CAUSE DEM
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKC3
CHECKLIST THREE
Checklist for Probable Alzheimer's Disease
3. Absence of other conditions or other brain diseases that may alone be
sufficient to cause dementia
.................................................................................
1 1. YES
2. NO
8. DK
251 Blank. Inap
==========================================================================================
BJC4 PROB AD, RPT OF MED EVAL TO RULE OUT OTHER CAUSES OF DEMENTIA
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKC4
CHECKLIST THREE
Checklist for Probable Alzheimer's Disease
4. Report that a medical evaluation has been done to rule out other causes for
the dementia
.................................................................................
1 1. YES
2. NO
8. DK
251 Blank. Inap
==========================================================================================
BJC5 PROB AD, ONSET AFTER AGE 40
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKC5
CHECKLIST THREE
Checklist for Probable Alzheimer's Disease
5. Onset after age 40
.................................................................................
1 1. YES
2. NO
8. DK
251 Blank. Inap
==========================================================================================
BJC1MET PROB AD - CRITERIA FOR CKC1 - CKC5
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKC1MET
CHECKLIST THREE
Checklist for Probable Alzheimer's Disease
CHECKLIST IS MET IF CKC1-CKC5=YES
.................................................................................
0. NO
1 1. YES
251 Blank. Inap
==========================================================================================
BJCMET PROB AD - CRITERIA FOR CKC1MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKCMET
CHECKLIST THREE
Checklist for Probable Alzheimer's Disease
OVERALL CHECKLIST THREE CRITERIA MET=YES IF CKC1MET=YES
.................................................................................
0. NO
1 1. YES
251 Blank. Inap
==========================================================================================
BJD1 POSS AD - CRITERIA FOR CKAMET OR CKBMET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKD1
CHECKLIST FOUR
Checklist for Possible Alzheimer's Disease
1. Dementia established by DSM-III-R or DSM-IV criteria (based on clinical and
neuropsychological assessment information)
.................................................................................
32 1. YES
4 2. NO
8. DK
216 Blank. Inap
==========================================================================================
BJD2 POSS AD, PROGRESSION OF COGNITIVE SYMPTOMS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKD2
CHECKLIST FOUR
Checklist for Possible Alzheimer's Disease
2. Progression of symptoms over time
.................................................................................
35 1. YES
1 2. NO
8. DK
216 Blank. Inap
==========================================================================================
BJD3 POSS AD, ONSET AFTER AGE 40
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKD3
CHECKLIST FOUR
Checklist for Possible Alzheimer's Disease
3. Onset after age 40
.................................................................................
35 1. YES
1 2. NO
8. DK
216 Blank. Inap
==========================================================================================
BJD4 POSS AD, ATYPICAL ONSET, PRESENTATION OR PROGRESSION
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKD4
CHECKLIST FOUR
Checklist for Possible Alzheimer's Disease
4. Atypical onset, presentation or progression of cognitive/personality symptoms
.................................................................................
5 1. YES
31 2. NO
8. DK
216 Blank. Inap
==========================================================================================
BJD5 POSS AD, PRESENCE OF SYSTEMIC OR BRAIN DISORDER, NOT SOLE CA
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKD5
CHECKLIST FOUR
Checklist for Possible Alzheimer's Disease
5. Presence of another systemic or brain disorder sufficient to cause dementia,
but which is not thought to be the sole cause of the dementia
.................................................................................
10 1. YES
26 2. NO
8. DK
216 Blank. Inap
==========================================================================================
BJD6 POSS AD, NO RPT OF MED EVAL TO RULE OUT OTHER DEM
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKD6
CHECKLIST FOUR
Checklist for Possible Alzheimer's Disease
6. No report that a medical evaluation has been done to rule out other causes
for the dementia
.................................................................................
30 1. YES
6 2. NO
8. DK
216 Blank. Inap
==========================================================================================
BJD1MET POSS AD - CRITERIA FOR CKD1 - CKD3
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKD1MET
CHECKLIST FOUR
Checklist for Possible Alzheimer's Disease
CHECKLIST MET IF CKD1-CKD3=YES
.................................................................................
4 0. NO
32 1. YES
216 Blank. Inap
==========================================================================================
BJD2MET POSS AD - CRITERIA FOR CKD4 - CKD6
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKD2MET
CHECKLIST FOUR
Checklist for Possible Alzheimer's Disease
CHECKLIST MET IF CKD4-CKD6=YES
.................................................................................
0. NO
36 1. YES
216 Blank. Inap
==========================================================================================
BJDMET POSS AD - CRITERIA FOR CKD1MET AND CKD2MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKDMET
CHECKLIST FOUR
Checklist for Possible Alzheimer's Disease
OVERALL CHECKLIST FOUR CRITERIA MET=YES IF CKD1MET AND CKD2MET=YES
.................................................................................
4 0. NO
32 1. YES
216 Blank. Inap
==========================================================================================
BJE1 PROB VASC DEM - CRITERIA FOR CKAMET OR CKBMET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKE1
CHECKLIST FIVE
Checklist for Probable Vascular Dementia
1. Dementia based on DSM-III-R or DSM- IV criteria
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJE2 PROB VASC DEM, IMPAIRMENT IN MEM AND 2 OTHER COG DOMAINS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKE2
CHECKLIST FIVE
Checklist for Probable Vascular Dementia
2. Impairment in memory and two other cognitive domains.
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJE3 PROB VASC DEM, SOCIAL OR OCCUP IMPAIRMENT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKE3
CHECKLIST FIVE
Checklist for Probable Vascular Dementia
3. Impairment in occupational and social functioning and in daily activities is
not due solely to physical effects of stroke.
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJE4 PROB VASC DEM, CVD BASED ON HIST OR EXAM
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKE4
CHECKLIST FIVE
Checklist for Probable Vascular Dementia
4. Cerebrovascular disease (CVD) based history or examination. This may include
focal signs on neurologic examination that are consistent with stroke (with or
without history of stroke).
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJE5 PROB VASC DEM, EVIDENCE OF RELEVANT CVD NOTED ON BRAIN IMAGI
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKE5
CHECKLIST FIVE
Checklist for Probable Vascular Dementia
5. Evidence of relevant CVD noted on report of brain imaging.
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJE6 PROB VASC DEM, ONSET OF DEM WITHIN 3 MOS OF STROKE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKE6
CHECKLIST FIVE
Checklist for Probable Vascular Dementia
6. Temporal relationship between stroke and dementia (onset of dementia
generally within three months of stroke).
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJE7 PROB VASC DEM, DETERIORATION IN FUNCTION
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKE7
CHECKLIST FIVE
Checklist for Probable Vascular Dementia
7. Abrupt or stepwise deterioration in mental function or fluctuating course.
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJE8 PROB VASC DEM, SPECIFIC BRAIN IMAGING INDICATE DAMAGE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKE8
CHECKLIST FIVE
Checklist for Probable Vascular Dementia
8. Specific brain imaging findings, indicating damage to regions important for
higher cerebral function
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJE1MET PROB VASC DEM - CRITERIA FOR CKE1 - CKE5
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKE1MET
CHECKLIST FIVE
Checklist for Probable Vascular Dementia
CHECKLIST MET IF CKE1-CKE5=YES
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJE2MET PROB VASC DEM - CRITERIA FOR CKE6, CKE7, OR CKE8
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKE2MET
CHECKLIST FIVE
Checklist for Probable Vascular Dementia
CHECKLIST MET IF AT LEAST ONE OF CKE6-CKE8=YES
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJEMET PROB VASC DEM - CRITERIA FOR CKE1MET AND CKE2MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKEMET
CHECKLIST FIVE
Checklist for Probable Vascular Dementia
OVERALL CHECKLIST FIVE CRITERIA MET=YES IF CKE1MET AND CKE2MET=YES
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJF1 POSS VASC DEM, EST BY CKAMET OR CKBMET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKF1
CHECKLIST SIX
Checklist for Possible Vascular Dementia
1. Dementia based on DSM-III-R or DSM- IV criteria.
.................................................................................
3 1. YES
2. NO
8. DON'T KNOW
249 Blank. Inap
==========================================================================================
BJF2 POSS VASC DEM, IMPAIRMENT IN MEM AND 2 OTHER COG DOMAINS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKF2
CHECKLIST SIX
Checklist for Possible Vascular Dementia
2. Impairment in memory and two other cognitive domains
.................................................................................
3 1. YES
2. NO
8. DON'T KNOW
249 Blank. Inap
==========================================================================================
BJF3 POSS VASC DEM, SOCIAL OR OCCUP IMPAIRMENT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKF3
CHECKLIST SIX
Checklist for Possible Vascular Dementia
3. Impairment in occupational and social functioning and in daily activities is
not due solely to physical effects of stroke
.................................................................................
3 1. YES
2. NO
8. DON'T KNOW
249 Blank. Inap
==========================================================================================
BJF4 POSS VASC DEM, CVD BASED ON HIST OR EXAM
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKF4
CHECKLIST SIX
Checklist for Possible Vascular Dementia
4. Cerebrovascular disease (CVD) based history or examination. This may include
focal signs on neurologic examination that are consistent with stroke (with or
without history of stroke).
.................................................................................
3 1. YES
2. NO
8. DON'T KNOW
249 Blank. Inap
==========================================================================================
BJF5 POSS VASC DEM, BRAIN IMAGING HAS NOT BEEN DONE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKF5
CHECKLIST SIX
Checklist for Possible Vascular Dementia
5. Brain imaging has not been done.
.................................................................................
1. YES
1 2. NO
2 8. DON'T KNOW
249 Blank. Inap
==========================================================================================
BJF6 POSS VASC DEM, UNCLEAR REL BET STROKE AND DEMENTIA
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKF6
CHECKLIST SIX
Checklist for Possible Vascular Dementia
6. There is an absence of a clear temporal relationship between stroke and
dementia
.................................................................................
3 1. YES
2. NO
8. DON'T KNOW
249 Blank. Inap
==========================================================================================
BJF7 POSS VASC DEM, SUBTLE ONSET AND VARIABLE COURSE OF COG DEFICITS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKF7
CHECKLIST SIX
Checklist for Possible Vascular Dementia
7. There was a subtle onset and variable course (plateau or improvement) of
cognitive deficits.
.................................................................................
2 1. YES
1 2. NO
8. DON'T KNOW
249 Blank. Inap
==========================================================================================
BJF1MET PROB VASC DEM - CRITERIA FOR CKF1 - CKF4
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKF1MET
CHECKLIST SIX
Checklist for Possible Vascular Dementia
CHECKLIST MET IF CKF1-CKF4=YES
.................................................................................
0. NO
3 1. YES
249 Blank. Inap
==========================================================================================
BJF2MET PROB VASC DEM - CRITERIA FOR CKF5 - CKF7
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKF2MET
CHECKLIST SIX
Checklist for Possible Vascular Dementia
CHECKLIST MET IF CKF5-CKF7=YES
.................................................................................
0. NO
3 1. YES
249 Blank. Inap
==========================================================================================
BJFMET PROB VASC DEM - CRITERIA FOR CKF1MET AND CKF2MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKFMET
CHECKLIST SIX
Checklist for Possible Vascular Dementia
OVERALL CHECKLIST SIX CRITERIA MET=YES IF CKF1MET AND CKF2MET=YES
.................................................................................
0. NO
3 1. YES
249 Blank. Inap
==========================================================================================
BJG1 CIND, SHORT TERM OR LONG TERM MEMORY IMPAIRMENT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKG1
CHECKLIST SEVEN
Checklist for Cognitive Impairment, Not Demented
1. Short-term and/or long-term impairment based on performance >1.5 standard
deviations below appropriate mean on any of the memory measures
.................................................................................
149 1. YES
6 2. NO
3 8. DK
94 Blank. Inap
==========================================================================================
BJG2 CIND, EXECUTIVE FUNCTION
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKG2
CHECKLIST SEVEN
Checklist for Cognitive Impairment, Not Demented
2. Executive function (>1.5 s.d. below mean)
.................................................................................
116 1. YES
33 2. NO
9 8. DK
94 Blank. Inap
==========================================================================================
BJG3 CIND, LANGUAGE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKG3
CHECKLIST SEVEN
Checklist for Cognitive Impairment, Not Demented
3. Language (>1.5 s.d. below mean)
.................................................................................
111 1. YES
42 2. NO
5 8. DK
94 Blank. Inap
==========================================================================================
BJG4 CIND, PRAXIS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKG4
CHECKLIST SEVEN
Checklist for Cognitive Impairment, Not Demented
4. Praxis (>1.5 s.d. below mean)
.................................................................................
27 1. YES
119 2. NO
12 8. DK
94 Blank. Inap
==========================================================================================
BJG5 CIND, ORIENTATION
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKG5
CHECKLIST SEVEN
Checklist for Cognitive Impairment, Not Demented
5. Orientation (>1.5 s.d. below mean)
.................................................................................
32 1. YES
126 2. NO
8. DK
94 Blank. Inap
==========================================================================================
BJG6 CIND, BASED ON DSRS SCORE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKG6
CHECKLIST SEVEN
Checklist for Cognitive Impairment, Not Demented
6. Dementia Severity Rating Scale score >5, but generally < 12
.................................................................................
58 1. YES
91 2. NO
9 8. DK
94 Blank. Inap
==========================================================================================
BJG7 CIND, DOES NOT MEET CRITERIA FOR CKAMET OR CKBMET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKG7
CHECKLIST SEVEN
Checklist for Cognitive Impairment, Not Demented
7. Does not meet DSM-III-R or DSM-IV criteria for dementia
.................................................................................
119 1. YES
39 2. NO
8. DK
94 Blank. Inap
==========================================================================================
BJG1MET CIND - CRITERIA FOR CKG1 - CKG6
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKG1MET
CHECKLIST SEVEN
Checklist for Cognitive Impairment, Not Demented
CHECKLIST MET IF AT LEAST ONE OF CKG1-CKG6=YES
.................................................................................
1 0. NO
157 1. YES
94 Blank. Inap
==========================================================================================
BJG2MET CIND - CRITERIA FOR CKG7
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKG2MET
CHECKLIST SEVEN
Checklist for Cognitive Impairment, Not Demented
CHECKLIST MET IF CKG7=YES
.................................................................................
39 0. NO
119 1. YES
94 Blank. Inap
==========================================================================================
BJGMET CIND - CRITERIA FOR CKG1MET AND CKG2MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKGMET
CHECKLIST SEVEN
Checklist for Cognitive Impairment, Not Demented
OVERALL CHECKLIST SEVEN CRITERIA MET=YES IF CKG1MET AND CKG2MET=YES
.................................................................................
40 0. NO
118 1. YES
94 Blank. Inap
==========================================================================================
BJH1 MCI, MEMORY COMPLAINT BY INFORMANT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKH1
CHECKLIST EIGHT
Checklist for Mild Cognitive Impairment (MCI)
1. Memory complaint verified by informant (determined by Memory score on
Dementia Severity Rating Scale >2)
.................................................................................
1 1. YES
2. NO
8. DK
251 Blank. Inap
==========================================================================================
BJH2 MCI, MEMORY IMPAIRMENT BY MEASUREMENT ON MEMORY TASKS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKH2
CHECKLIST EIGHT
Checklist for Mild Cognitive Impairment (MCI)
2. Memory impairment based on objective measurement (>1.5 standard deviation
below appropriate mean on either Wechsler Memory Scale Revised Logical Memory II
or Delayed Recall on CERAD Word List or the Delayed Recall)
.................................................................................
1 1. YES
2. NO
8. DK
251 Blank. Inap
==========================================================================================
BJH3 MCI, BASED ON MMSE SCORE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKH3
CHECKLIST EIGHT
Checklist for Mild Cognitive Impairment (MCI)
3. MMSE > 24
.................................................................................
1 1. YES
2. NO
8. DK
251 Blank. Inap
==========================================================================================
BJH4 MCI, BASED ON CDR MEMORY SCORE AND OVERALL CDR
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKH4
CHECKLIST EIGHT
Checklist for Mild Cognitive Impairment (MCI)
4. Memory score on CDR = 0.5 and overall CDR < 1.0
.................................................................................
1 1. YES
2. NO
8. DK
251 Blank. Inap
==========================================================================================
BJH5 MCI, NOT DUE TO MCKOR DEPRESSION
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKH5
CHECKLIST EIGHT
Checklist for Mild Cognitive Impairment (MCI)
5. Major depression as determined by NPI and clinical history can not explain
impairment
.................................................................................
1 1. YES
2. NO
8. DK
251 Blank. Inap
==========================================================================================
BJH6 MCI, MEETS CRITERIA FOR CIND
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKH6
CHECKLIST EIGHT
Checklist for Mild Cognitive Impairment (MCI)
6. Meets criteria for Cognitive Impairment, No Dementia
.................................................................................
1 1. YES
2. NO
8. DK
251 Blank. Inap
==========================================================================================
BJH1MET MCI - CRITERIA FOR CKH1 - CKH6
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKH1MET
CHECKLIST EIGHT
Checklist for Mild Cognitive Impairment (MCI)
CHECKLIST MET IF CKH1-CKH6=YES
.................................................................................
0. NO
1 1. YES
251 Blank. Inap
==========================================================================================
BJHMET MCI - CRITERIA FOR CKH1MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKHMET
CHECKLIST EIGHT
Checklist for Mild Cognitive Impairment (MCI)
OVERALL CHECKLIST EIGHT CRITERIA MET=YES IF CKH1MET=YES
.................................................................................
0. NO
1 1. YES
251 Blank. Inap
==========================================================================================
BJI1 MAJOR DEPRESSION BASED ON NPI, CIDI, OR CLINICAL OR MEDICAL HISTORY
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKI1
CHECKLIST NINE
Checklist for Depression
1. Presence of Major Depression based on the NPI, CIDI or clinical/medical
history
.................................................................................
4 1. YES
1 2. NO
8. DK
247 Blank. Inap
==========================================================================================
BJI2 DEPRESSION, IMPAIRMENT NOT EXPLAINED BY OTHER ETIOLOGY
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKI2
CHECKLIST NINE
Checklist for Depression
2. Impairment can not be better explained by another etiology listed under
Cognitive Impairment, Not Demented.
.................................................................................
5 1. YES
2. NO
8. DK
247 Blank. Inap
==========================================================================================
BJI3 DEPRESSION, MEETS CRITERIA FOR CIND
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKI3
CHECKLIST NINE
Checklist for Depression
3. Meets criteria for Cognitive Impairment
.................................................................................
2 1. YES
3 2. NO
8. DK
247 Blank. Inap
==========================================================================================
BJI1MET DEPRESSION - CRITERIA FOR CKI1, CKI2, AND CKI3
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKI1MET
CHECKLIST NINE
Checklist for Depression
CHECKLIST MET IF CKI1-CKI3=YES
.................................................................................
4 0. NO
1 1. YES
247 Blank. Inap
==========================================================================================
BJIMET DEPRESSION - CRITERIA FOR CKI1MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKIMET
CHECKLIST NINE
Checklist for Depression
OVERALL CHECKLIST NINE CRITERIA MET=YES IF CKI1MET=YES
.................................................................................
4 0. NO
1 1. YES
247 Blank. Inap
==========================================================================================
BJJ1 NEUROPSYCHIATRIC DISORDER - CLINICAL OR MEDICAL HISTORY
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKJ1
CHECKLIST TEN
Checklist for Psychiatric Disorder
1. Presence of a neuropsychiatric disorder (includes bipolar disorder,
schizophrenia, personality disorder) based on clinical and medical history
.................................................................................
4 1. YES
2. NO
8. DK
248 Blank. Inap
==========================================================================================
BJJ2 NEUROPSYCHIATRIC DISORDER, NOT OTHERWISE EXPLAINED
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKJ2
CHECKLIST TEN
Checklist for Psychiatric Disorder
2. Impairment can not be better explained by another etiology listed under
Cognitive Impairment, Not Demented
.................................................................................
4 1. YES
2. NO
8. DK
248 Blank. Inap
==========================================================================================
BJJ3 NEUROPSYCHIATRIC DISORDER, MEETS CRITERIA FOR CIND
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKJ3
CHECKLIST TEN
Checklist for Psychiatric Disorder
3. Meets criteria for Cognitive Impairment, No Dementia
.................................................................................
4 1. YES
2. NO
8. DK
248 Blank. Inap
==========================================================================================
BJJ1MET NEUROPSYCHIATRIC DISORDER, CRITERIA FOR CKJ1 - CKJ3
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKJ1MET
CHECKLIST TEN
Checklist for Psychiatric Disorder
CHECKLIST MET IF CKJ1-CKJ3=YES
.................................................................................
0. NO
4 1. YES
248 Blank. Inap
==========================================================================================
BJJMET NEUROPSYCHIATRIC DISORDER, CRITERIA FOR CKJ1MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKJMET
CHECKLIST TEN
Checklist for Psychiatric Disorder
OVERALL CHECKLIST TEN CRITERIA MET=YES IF CKJ1MET=YES
.................................................................................
0. NO
4 1. YES
248 Blank. Inap
==========================================================================================
BJK1 LIFELONG HISTORY OF MENT RET, LD, LOW BASELINE INTELLECT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKK1
CHECKLIST ELEVEN
Checklist for Mental Retardation/ Learning Disorder/Low Baseline Intellect
1. Lifelong history of mental retardation of marked learning disorder based
clinical, educational, social, and medical history. Performance on the Shipley
Vocabulary Test may be used to support this.
.................................................................................
6 1. YES
2. NO
8. DK
246 Blank. Inap
==========================================================================================
BJK2 MENT RET, LD, LOW BASELINE INTELLECT NOT EXPLAINED BY OTHER ETIOLOGY
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKK2
CHECKLIST ELEVEN
Checklist for Mental Retardation/ Learning Disorder/Low Baseline Intellect
2. Impairment can not be explained by another etiology listed under Cognitive
Impairment, Not Demented
.................................................................................
6 1. YES
2. NO
8. DK
246 Blank. Inap
==========================================================================================
BJK3 MENT RET, LD, LOW BASELINE INTELLECT, MEETS CRITERIA FOR CIND
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKK3
CHECKLIST ELEVEN
Checklist for Mental Retardation/ Learning Disorder/Low Baseline Intellect
3 Meets criteria for Cognitive Impairment, No Dementia
.................................................................................
6 1. YES
2. NO
8. DK
246 Blank. Inap
==========================================================================================
BJK1MET MENT RET, LD, LOW BASELINE INTELLECT - CRITERIA FOR CKK1 - CKK3
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKK1MET
CHECKLIST ELEVEN
Checklist for Mental Retardation/ Learning Disorder/Low Baseline Intellect
CHECKLIST MET IF CKK1-CKK3=YES
.................................................................................
0. NO
6 1. YES
246 Blank. Inap
==========================================================================================
BJKMET MENT RET, LD, LOW BASELINE INTELLECT - CRITERIA FOR AKJMET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKKMET
CHECKLIST ELEVEN
Checklist for Mental Retardation/ Learning Disorder/Low Baseline Intellect
OVERALL CHECKLIST ELEVEN CRITERIA MET=YES IF CKK1MET=YES
.................................................................................
0. NO
6 1. YES
246 Blank. Inap
==========================================================================================
BJL1 HISTORY OF PAST ALCOHOL ABUSE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKL1
CHECKLIST TWELVE
Checklist for Alcohol Abuse (past)
1. History of past abuse of alcohol based on clinical and medical history.
History of DUI's, missing work, alcohol-abuse related treatment, alcohol-related
medical conditions or neurological signs, and negative effects of alcohol use on
personal relationships support this.
.................................................................................
1 1. YES
2. NO
8. DK
251 Blank. Inap
==========================================================================================
BJL2 ALCOHOL ABUSE PAST, DISCONTINUED AT LEAST SIX MONTHS PRIOR TO EVAL
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKL2
CHECKLIST TWELVE
Checklist for Alcohol Abuse (past)
2. Discontinued alcohol abuse > 6 months prior.
.................................................................................
1 1. YES
2. NO
8. DK
251 Blank. Inap
==========================================================================================
BJL3 PAST ALCOHOL ABUSE, NOT EXPLAINED BY OTHER ETIOLOGY
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKL3
CHECKLIST TWELVE
Checklist for Alcohol Abuse (past)
3. Impairment can not be better explained by another etiology listed under
Cognitive Impairment, Not Demented.
.................................................................................
1 1. YES
2. NO
8. DK
251 Blank. Inap
==========================================================================================
BJL4 PAST ALCOHOL ABUSE, MEETS CRITERIA FOR CIND
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKL4
CHECKLIST TWELVE
Checklist for Alcohol Abuse (past)
4. Meets criteria for Cognitive Impairment, Not Dementia
.................................................................................
1 1. YES
2. NO
8. DK
251 Blank. Inap
==========================================================================================
BJL1MET PAST ALCOHOL ABUSE - CRITERIA FOR CKL1 - CKL4
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKL1MET
CHECKLIST TWELVE
Checklist for Alcohol Abuse (past)
CHECKLIST MET IF CKL1-CKL4=YES
.................................................................................
0. NO
1 1. YES
251 Blank. Inap
==========================================================================================
BJLMET PAST ALCOHOL ABUSE - CRITERIA FOR CKL1MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKLMET
CHECKLIST TWELVE
Checklist for Alcohol Abuse (past)
OVERALL CHECKLIST TWELVE CRITERIA MET=YES IF CKL1MET=YES
.................................................................................
0. NO
1 1. YES
251 Blank. Inap
==========================================================================================
BJM1 HISTORY OF PAST AND CURRENT ALCOHOL ABUSE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKM1
CHECKLIST THIRTEEN
Checklist for Alcohol Abuse (current)
1. Report of past and current abuse of alcohol based on clinical and medical
history. History of DUI's, missing work, alcohol-abuse related treatment,
alcohol-related medical conditions or neurological signs, and negative effects
of alcohol use on personal relationships support this.
.................................................................................
4 1. YES
2. NO
8. DK
248 Blank. Inap
==========================================================================================
BJM2 HAS ABUSED ALCOHOL IN THE PAST SIX MONTHS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKM2
CHECKLIST THIRTEEN
Checklist for Alcohol Abuse (current)
2. Has abused alcohol in the past 6 months.
.................................................................................
4 1. YES
2. NO
8. DK
248 Blank. Inap
==========================================================================================
BJM3 CURRENT ALCOHOL ABUSE, NOT EXPLAINED BY OTHER ETIOLOGY
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKM3
CHECKLIST THIRTEEN
Checklist for Alcohol Abuse (current)
3. Impairment can not be better explained by another etiology listed under
Cognitive Impairment, Not Demented.
.................................................................................
4 1. YES
2. NO
8. DK
248 Blank. Inap
==========================================================================================
BJM4 CURRENT ALCOHOL ABUSE, MEETS CRITERIA FOR CIND
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKM4
CHECKLIST THIRTEEN
Checklist for Alcohol Abuse (current)
4. Meets criteria for Cognitive Impairment, Not Dementia
.................................................................................
2 1. YES
2 2. NO
8. DK
248 Blank. Inap
==========================================================================================
BJM1MET CURRENT ALCOHOL ABUSE - CRITERIA FOR CKM1 - CKM4
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKM1MET
CHECKLIST THIRTEEN
Checklist for Alcohol Abuse (current)
CHECKLIST MET IF CKM1-CKM4=YES
.................................................................................
2 0. NO
2 1. YES
248 Blank. Inap
==========================================================================================
BJMMET CURRENT ALCOHOL ABUSE - CRITERIA FOR CKM1MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKMMET
CHECKLIST THIRTEEN
Checklist for Alcohol Abuse (current)
OVERALL CHECKLIST THIRTEEN CRITERIA MET=YES IF CKM1MET=YES
.................................................................................
2 0. NO
2 1. YES
248 Blank. Inap
==========================================================================================
BJN1 STROKE HIST BASED ON CLINICAL, MED HISTORY, OR NEUROLOGICAL EXAM
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKN1
CHECKLIST FOURTEEN
Checklist for Stroke
1. History of stroke based on clinical or medical history or neurological exam.
.................................................................................
21 1. YES
2. NO
8. DK
231 Blank. Inap
==========================================================================================
BJN2 STROKE SYMPTOM ONSET WITHIN THREE MONTHS AFTER REPORTED STROKE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKN2
CHECKLIST FOURTEEN
Checklist for Stroke
2. Onset of symptoms within three months after reported stroke
.................................................................................
10 1. YES
8 2. NO
3 8. DK
231 Blank. Inap
==========================================================================================
BJN3 STROKE, IMPAIRMENT NOT EXPLAINED BY OTHER ETIOLOGY
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKN3
CHECKLIST FOURTEEN
Checklist for Stroke
3. Impairment can not be explained by another etiology listed under Cognitive
Impairment, No Dementia
.................................................................................
21 1. YES
2. NO
8. DK
231 Blank. Inap
==========================================================================================
BJN4 STROKE, MEETS CRITERIA FOR CIND
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKN4
CHECKLIST FOURTEEN
Checklist for Stroke
4. Meets criteria for Cognitive Impairment, No Dementia
.................................................................................
15 1. YES
6 2. NO
8. DK
231 Blank. Inap
==========================================================================================
BJN1MET STROKE - CRITERIA FOR CKN1 - CKN4
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKN1MET
CHECKLIST FOURTEEN
Checklist for Stroke
CHECKLIST MET IF CKN1-CKN4=YES
.................................................................................
14 0. NO
7 1. YES
231 Blank. Inap
==========================================================================================
BJNMET STROKE - CRITERIA FOR CKN1MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKNMET
CHECKLIST FOURTEEN
Checklist for Stroke
OVERALL CHECKLIST FOURTEEN CRITERIA MET=YES IF CKN1MET=YES
.................................................................................
14 0. NO
7 1. YES
231 Blank. Inap
==========================================================================================
BJO1 OTHER NEUROL COND, PRESENCE OF NEUROLOGICAL CONDITION
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKO1
CHECKLIST FIFTEEN
Checklist for Other Neurological Condition
1. Presence of a neurological condition sufficient to cause cognitive
impairment. Based on clinical history, medical history or neurological exam. May
include: Parkinson's disease, history of head injury, normal pressure
hydrocephalus w/out dementia, multiple sclerosis, Parkinsonism, hypoxic episode
.................................................................................
8 1. YES
1 2. NO
8. DK
243 Blank. Inap
==========================================================================================
BJO2 OTHER NEUROL COND, NOT EXPLAINED BY OTHER ETIOLOGY
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKO2
CHECKLIST FIFTEEN
Checklist for Other Neurological Condition
2. Impairment can not be explained by another etiology listed under Cognitive
Impairment, No Dementia
.................................................................................
9 1. YES
2. NO
8. DK
243 Blank. Inap
==========================================================================================
BJO3 OTHER NEUROL COND, MEETS CRITERIA FOR CIND
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKO3
CHECKLIST FIFTEEN
Checklist for Other Neurological Condition
3. Meets criteria for Cognitive Impairment, No Dementia
.................................................................................
7 1. YES
1 2. NO
1 8. DK
243 Blank. Inap
==========================================================================================
BJO1MET OTHER NEUROL COND - CRITERIA FOR CKO1 - CKO3
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKO1MET
CHECKLIST FIFTEEN
Checklist for Other Neurological Condition
CHECKLIST MET IF CKO1-CK03=YES
.................................................................................
3 0. NO
6 1. YES
243 Blank. Inap
==========================================================================================
BJOMET OTHER NEUROL COND - CRITERIA FOR CKO1MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKOMET
CHECKLIST FIFTEEN
Checklist for Other Neurological Condition
OVERALL CHECKLIST FIFTEEN CRITERIA MET=YES IF CKO1MET=YES
.................................................................................
3 0. NO
6 1. YES
243 Blank. Inap
==========================================================================================
BJP1 OTHER MEDICAL COND, PRESENCE OF MEDICAL CONDITION
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKP1
CHECKLIST SIXTEEN
Checklist for Other Medical Condition
1. Presence of a medical condition sufficient enough to cause cognitive
impairment. Based on clinical history, medical history May include: medication
effects, COPD, delirium, toxic effects of chemotherapy or other chemicals,
congestive heart failure, chronic pain, and many other chronic conditions.
.................................................................................
34 1. YES
2. NO
8. DK
218 Blank. Inap
==========================================================================================
BJP2 OTHER MEDICAL COND, NOT EXPLAINED BY OTHER ETIOLOGY
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKP2
CHECKLIST SIXTEEN
Checklist for Other Medical Condition
2. Impairment can not be explained by another etiology listed under Cognitive
Impairment, No Dementia
.................................................................................
34 1. YES
2. NO
8. DK
218 Blank. Inap
==========================================================================================
BJP3 OTHER MEDICAL COND, MEETS CRITERIA FOR CIND
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKP3
CHECKLIST SIXTEEN
Checklist for Other Medical Condition
3. Meets criteria for Cognitive Impairment, No Dementia
.................................................................................
27 1. YES
7 2. NO
8. DK
218 Blank. Inap
==========================================================================================
BJP1MET OTHER MEDICAL COND - CRITERIA FOR CKP1 - CKP3
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKP1MET
CHECKLIST SIXTEEN
Checklist for Other Medical Condition
CHECKLIST MET IF CKP1-CKP3=YES
.................................................................................
7 0. NO
27 1. YES
218 Blank. Inap
==========================================================================================
BJPMET OTHER MEDICAL COND - CRITERIA FOR CKP1MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKPMET
CHECKLIST SIXTEEN
Checklist for Other Medical Condition
OVERALL CHECKLIST SIXTEEN CRITERIA MET=YES IF CKP1MET=YES
.................................................................................
7 0. NO
27 1. YES
218 Blank. Inap
==========================================================================================
BJQ1 PRESENCE OF CEREBROVASCULAR OR CARDIOVASCULAR CONDITIONS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKQ1
CHECKLIST SEVENTEEN
Checklist for Cognitive Impairment Secondary to Vascular Disease
1. Presence of a cerebrovascular/cardiovascular conditions thought sufficient to
cause cerebrovascular changes. May include: atrial fibrillation, history of
possible TIA's history of coronary bypass, diabetes mellitus, and coronary
artery disease
.................................................................................
18 1. YES
2. NO
8. DK
234 Blank. Inap
==========================================================================================
BJQ2 IMPAIRMENT NOT LINKED TO ONE FOCAL VASCULAR LESION
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKQ2
CHECKLIST SEVENTEEN
Checklist for Cognitive Impairment Secondary to Vascular Disease
2. Impairment was not linked in time to one focal vascular lesion and can not be
explained by one focal lesion.
.................................................................................
18 1. YES
2. NO
8. DK
234 Blank. Inap
==========================================================================================
BJQ3 GRADUAL ONSET OF CEREBROVASCULAR OR CARDIOVASCULAR SYMPTOMS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKQ3
CHECKLIST SEVENTEEN
Checklist for Cognitive Impairment Secondary to Vascular Disease
3. Gradual onset of symptoms and history suggests progression of symptoms
.................................................................................
13 1. YES
5 2. NO
8. DK
234 Blank. Inap
==========================================================================================
BJQ4 CIND SECONDARY TO VASCULAR DISEASE, NOT EXPLAINED BY OTHER ETIOLOGY
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKQ4
CHECKLIST SEVENTEEN
Checklist for Cognitive Impairment Secondary to Vascular Disease
4. Impairment can not be better explained by another etiology listed under
Cognitive Impairment, No Dementia
.................................................................................
18 1. YES
2. NO
8. DK
234 Blank. Inap
==========================================================================================
BJQ5 CIND SECONDARY TO VASCULAR DISEASE, MEETS CIND CRITERIA
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKQ5
CHECKLIST SEVENTEEN
Checklist for Cognitive Impairment Secondary to Vascular Disease
5. Meets criteria for Cognitive Impairment, No Dementia
.................................................................................
14 1. YES
4 2. NO
8. DK
234 Blank. Inap
==========================================================================================
BJQ1MET CIND SECONDARY TO VASCULAR DISEASE, CRITERIA FOR CKQ1 - CKQ5
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKQ1MET
CHECKLIST SEVENTEEN
Checklist for Cognitive Impairment Secondary to Vascular Disease
CHECKLIST MET IF CKQ1-CKQ5=YES
.................................................................................
8 0. NO
10 1. YES
234 Blank. Inap
==========================================================================================
BJQMET CIND SECONDARY TO VASC DISEASE - CRITERIA FOR CKQ1MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKQMET
CHECKLIST SEVENTEEN
Checklist for Cognitive Impairment Secondary to Vascular Disease
OVERALL CHECKLIST SEVENTEEN CRITERIA MET=YES IF CKQ1MET=YES
.................................................................................
8 0. NO
10 1. YES
234 Blank. Inap
==========================================================================================
BJR1 MILD AMBIGUOUS, IMPAIRMENT NOT EXPLAINED BY ETIOLOGY IN CIND
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKR1
CHECKLIST EIGHTEEN
Checklist for Mild Ambiguous
1. Impairment can not be better explained by another etiology listed under
Cognitive Impairment, No Dementia. Typically is primarily memory impairment, but
memory is not always the only impairment
.................................................................................
55 1. YES
2. NO
8. DK
197 Blank. Inap
==========================================================================================
BJR2 MILD AMBIGUOUS, GRADUAL ONSET AND PROGRESSION OF SYMPTOMS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKR2
CHECKLIST EIGHTEEN
Checklist for Mild Ambiguous
2. Gradual onset of symptoms and history suggests progression of symptoms
.................................................................................
51 1. YES
4 2. NO
8. DK
197 Blank. Inap
==========================================================================================
BJR3 MILD AMBIGUOUS, MEETS CRITERIA FOR CIND
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKR3
CHECKLIST EIGHTEEN
Checklist for Mild Ambiguous
3. Meets criteria for Cognitive Impairment, No Dementia
.................................................................................
39 1. YES
16 2. NO
8. DK
197 Blank. Inap
==========================================================================================
BJR1MET MILD AMBIGUOUS - CRITERIA FOR CKR1 - CKR3
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKR1MET
CHECKLIST EIGHTEEN
Checklist for Mild Ambiguous
CHECKLIST MET IF CKR1-CKR3=YES
.................................................................................
21 0. NO
34 1. YES
197 Blank. Inap
==========================================================================================
BJRMET MILD AMBIGUOUS - CRITERIA FOR CKR1MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKRMET
CHECKLIST EIGHTEEN
Checklist for Mild Ambiguous
OVERALL CHECKLIST EIGHTEEN CRITERIA MET=YES IF CKR1MET=YES
.................................................................................
21 0. NO
34 1. YES
197 Blank. Inap
==========================================================================================
BJS1 DEM UNDETERMINED ETIOLOGY, EST BY DSM III OR DSM IV CRITERIA
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKS1
CHECKLIST NINETEEN
Checklist for Dementia Undetermined Etiology
1. Dementia established by DSM-III-R or DSM-IV criteria (based on clinical and
neuropsychological assessment information
.................................................................................
7 1. YES
1 2. NO
8. DK
244 Blank. Inap
==========================================================================================
BJS2 DEMENTIA UNDETERMINED ETIOLOGY PROGRESSION OF SYMPTOMS OVER TIME
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKS2
CHECKLIST NINETEEN
Checklist for Dementia Undetermined Etiology
2. Progression of symptoms over time
.................................................................................
8 1. YES
2. NO
8. DK
244 Blank. Inap
==========================================================================================
BJS3 DEMENTIA UNDETERMINED ETIOLOGY, ATYPICAL FEATURES
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKS3
CHECKLIST NINETEEN
Checklist for Dementia Undetermined Etiology
3. Atypical features that exceed those usually seen in Possible AD, but they do
not clearly meet the criteria for any other type of dementia
.................................................................................
8 1. YES
2. NO
8. DK
244 Blank. Inap
==========================================================================================
BJS1MET DEMENTIA UNDETERMINED ETIOLOGY - CRITERIA FOR CKS1 - CKS3
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKS1MET
CHECKLIST NINETEEN
Checklist for Dementia Undetermined Etiology
CHECKLIST MET IF CKS1-CKS3=YES
.................................................................................
1 0. NO
7 1. YES
244 Blank. Inap
==========================================================================================
BJSMET DEMENTIA UNDETERMINED ETIOLOGY - CRITERIA FOR CKS1MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKSMET
CHECKLIST NINETEEN
Checklist for Dementia Undetermined Etiology
OVERALL CHECKLIST NINETEEN CRITERIA MET=YES IF CKS1MET=YES
.................................................................................
1 0. NO
7 1. YES
244 Blank. Inap
==========================================================================================
BJT1 PD, DEM ESTABLISHED BY DSM III OR DSM IV CRITERIA
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKT1
CHECKLIST TWENTY
Checklist for Parkinson's Dementia
1. Dementia established by DSM-III-R or DSM-IV criteria (based on clinical and
neuropsychological assessment information
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJT2 PD, DIAGNOSIS OF PD
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKT2
CHECKLIST TWENTY
Checklist for Parkinson's Dementia
2. Diagnosis of Parkinson's disease
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJT3 PD, COG SYMPTOMS PRIMARILY SUBCORTICAL
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKT3
CHECKLIST TWENTY
Checklist for Parkinson's Dementia
3. Cognitive symptoms primarily subcortical in nature
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJT4 PD, ONSET OF COG SYMPTOMS AT LEAST 1 YR PAST MOTOR SYMPTOMS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKT4
CHECKLIST TWENTY
Checklist for Parkinson's Dementia
4. Onset of cognitive symptoms at least one year after onset of motor symptoms
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJT1MET PD - CRITERIA FOR CKT1 - CKT4
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKT1MET
CHECKLIST TWENTY
Checklist for Parkinson's Dementia
CHECKLIST MET IF CKT1-CKT4=YES
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJTMET PD - CRITERIA FOR CKT1MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKTMET
CHECKLIST TWENTY
Checklist for Parkinson's Dementia
OVERALL CHECKLIST TWENTY CRITERIA MET=YES IF CKT1MET=YES
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJU1 PROB LEWY BODY DEMENTIA EST BY DSM III OR DSM IV CRITERIA
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKU1
CHECKLIST TWENTY ONE
Checklist for Probable Lewy Body Dementia
1. Dementia established by DSM-III-R or DSM-IV criteria (based on clinical and
neuropsychological assessment information)
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJU2 PROB LEWY BODY DEMENTIA, FLUCTUATING COGNITION
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKU2
CHECKLIST TWENTY ONE
Checklist for Probable Lewy Body Dementia
2. Fluctuating cognition with pronounced variation in attention and alertness
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJU3 PROB LEWY BODY DEMENTIA, RECURRENT VISUAL HALLUCINATIONS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKU3
CHECKLIST TWENTY ONE
Checklist for Probable Lewy Body Dementia
3. Recurrent visual hallucinations that are typically well formed and detailed
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJU4 PROB LEWY BODY DEMENTIA, MOTOR FEATURES OF PARKINSONISM
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKU4
CHECKLIST TWENTY ONE
Checklist for Probable Lewy Body Dementia
4. Spontaneous motor features of parkinsonism
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJU5 PROB LEWY BODY DEMENTIA, REPEATED FALLS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKU5
CHECKLIST TWENTY ONE
Checklist for Probable Lewy Body Dementia
5. Repeated falls
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJU6 PROB LEWY BODY DEMENTIA, SYNCOPE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKU6
CHECKLIST TWENTY ONE
Checklist for Probable Lewy Body Dementia
6. Syncope
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJU7 PROB LEWY BODY DEMENTIA, LOSS OF CONSCIOUSNESS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKU7
CHECKLIST TWENTY ONE
Checklist for Probable Lewy Body Dementia
7. Transient loss of consciousness
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJU8 PROB LEWY BODY DEMENTIA, NEUROLEPTIC SENSITIVITY
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKU8
CHECKLIST TWENTY ONE
Checklist for Probable Lewy Body Dementia
8. Neuroleptic sensitivity
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJU9 PROB LEWY BODY DEMENTIA, SYSTEMATIZED DELUSIONS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKU9
CHECKLIST TWENTY ONE
Checklist for Probable Lewy Body Dementia
9. Systematized delusions
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJU10 PROB LEWY BODY DEMENTIA, OTHER MODAL HALLUCINATIONS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKU10
CHECKLIST TWENTY ONE
Checklist for Probable Lewy Body Dementia
10. Hallucinations in other modalities
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJU11 PROB LEWY BODY DEMENTIA, REM SLEEP DISORDER
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKU11
CHECKLIST TWENTY ONE
Checklist for Probable Lewy Body Dementia
11. REM sleep behavior disorder
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJU12 PROB LEWY BODY DEMENTIA, DEPRESSIVE SYMPTOMS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKU12
CHECKLIST TWENTY ONE
Checklist for Probable Lewy Body Dementia
12. Depressive symptoms
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJU1MET PROB LEWY BODY DEMENTIA - CRITERIA FOR CKU1
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKU1MET
CHECKLIST TWENTY ONE
Checklist for Probable Lewy Body Dementia
CHECKLIST MET IF CKU1=YES
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJU2MET PROB LEWY BODY DEMENTIA - CRITERIA FOR CKU2 - CKU4
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKU2MET
CHECKLIST TWENTY ONE
Checklist for Probable Lewy Body Dementia
CHECKLIST MET IF AT LEAST TWO OF CKU2-CKU4=YES
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJUMET PROB LEWY BODY DEM - CRITERIA FOR CKU1MET AND CKU2MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKUMET
CHECKLIST TWENTY ONE
Checklist for Probable Lewy Body Dementia
OVERALL CHECKLIST TWENTY-ONE CRITERIA MET=YES IF CKU1MET AND CKU2MET=YES
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJV1 PSP, DEMENTIA EST BY DSM III OR DSM IV CRITERIA
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKV1
CHECKLIST TWENTY TWO
Checklist for Progressive Supranuclear Palsy Dementia
1. Dementia established by DSM-III-R or DSM-IV criteria (based on clinical and
neuropsychological assessment information)
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJV2 PSP, IMPAIRMENT OF VOLUNTARY DOWNWARD GAZE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKV2
CHECKLIST TWENTY TWO
Checklist for Progressive Supranuclear Palsy Dementia
2. Impairment of voluntary downward gaze
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJV3 PSP, IMPAIRMENT NOT EXPLAINED BY ANOTHER DEMENTIA TYPE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKV3
CHECKLIST TWENTY TWO
Checklist for Progressive Supranuclear Palsy Dementia
3. Impairment can not be better explained by another type of dementia
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJV1MET PSP, CRITERIA FOR CKV1 - CKV3
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKV1MET
CHECKLIST TWENTY TWO
Checklist for Progressive Supranuclear Palsy Dementia
CHECKLIST MET IF CKV1-CKV3=YES
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJVMET PSP, CRITERIA FOR CKV1MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKVMET
CHECKLIST TWENTY TWO
Checklist for Progressive Supranuclear Palsy Dementia
OVERALL CHECKLIST TWENTY-TWO CRITERIA MET=YES IF CKV1MET =YES
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJW1 NORMAL PRESSURE HYDROCEPHALUS, EST BY DSM III OR DSM IV CRITERIA
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKW1
CHECKLIST TWENTY THREE
Checklist for Dementia due to Normal Pressure Hydrocephalus
1. Dementia established by DSM-III-R or DSM-IV criteria (based on clinical and
neuropsychological assessment information
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJW2 NORMAL PRESSURE HYDROCEPHALUS, REPORT FROM NEUROIMAGING
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKW2
CHECKLIST TWENTY THREE
Checklist for Dementia due to Normal Pressure Hydrocephalus
2. Report of NPH based on neuroimaging
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJW3 NORMAL PRESSURE HYDROCEPHALUS, NOT EXPLAINED BY OTHER DEMENTIA TYPE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKW3
CHECKLIST TWENTY THREE
Checklist for Dementia due to Normal Pressure Hydrocephalus
3. Impairment can not be better explained by another type of dementia
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJW1MET NORMAL PRESSURE HYDROCEPHALUS, CRITERIA FOR CKW1 - CKW3
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKW1MET
CHECKLIST TWENTY THREE
Checklist for Dementia due to Normal Pressure Hydrocephalus
CHECKLIST MET IF CKW1-CKW3 = YES
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJWMET NORMAL PRESSURE HYDROCEPHALUS - CRITERIA FOR CKW1MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKWMET
CHECKLIST TWENTY THREE
Checklist for Dementia due to Normal Pressure Hydrocephalus
OVERALL CHECKLIST TWENTY-THREE CRITERIA MET=YES IF CKW1MET =YES
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJX1 HUNTINGTONS DEMENTIA, EST BY DSM III OR DSM IV CRITERIA
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKX1
CHECKLIST TWENTY FOUR
Checklist for Huntington's Dementia
1. Dementia established by DSM-III-R or DSM-IV criteria (based on clinical and
neuropsychological assessment information)
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJX2 HUNTINGTONS, DIAGNOSIS OF HUNTINGTONS DISEASE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKX2
CHECKLIST TWENTY FOUR
Checklist for Huntington's Dementia
2. Diagnosis of Huntington's disease
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJX1MET HUNTINGTONS DEMENTIA, CRITERIA FOR CKX1 AND CKX2
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKX1MET
CHECKLIST TWENTY FOUR
Checklist for Huntington's Dementia
CHECKLIST MET IF CKX1 AND CKX2=YES
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJXMET HUNTINGTONS DEMENTIA, CRITERIA FOR CKX1MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKXMET
CHECKLIST TWENTY FOUR
Checklist for Huntington's Dementia
OVERALL CHECKLIST TWENTY-FOUR CRITERIA MET=YES IF CKX1MET =YES
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJY1 FRONTAL LOBE, INSIDIOUS ONSET AND SLOWLY PROGRESSIVE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKY1
CHECKLIST TWENTY FIVE
Checklist for Frontal Lobe Dementia
1. Behavioral disorder which is insidious in onset, slowly progressive, and
characterized by any of the following early features:
a) Loss of personal awareness (neglect of personal hygiene or grooming)
b) Loss of social awareness (e.g. loss of social tact, misdemeanors, etc)
c) Decreased insight of pathologic changes in their own behavior or mental state
d) Disinhibition early in course (e.g. unrestrained sexuality)
e) Mental inflexibility
f) Hyperorality
g) Sterotyped and perseverative behaviors
h) Utilization behavior (unrestrained exploration of objects in the environment)
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJY2 FRONTAL LOBE, PROFOUND FAILURE ON FRONTAL LOBE TESTS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKY2
CHECKLIST TWENTY FIVE
Checklist for Frontal Lobe Dementia
2. Neuropsychological findings of profound failure on frontal lobe tests.
Absence of severe memory impairments, aphasic disorder, or perceptual spatial
disturbance
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJY3 FRONTAL LOBE, PERCEPTUAL SPATIAL DISORDERS ARE ABSENT
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKY3
CHECKLIST TWENTY FIVE
Checklist for Frontal Lobe Dementia
3. Perceptual spatial disorders are absent. Intact abilities to negotiate the
environment
.................................................................................
1. YES
2. NO
8. DK
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==========================================================================================
BJY4 FRONTAL LOBE, UNIQUE SPEECH DISTURBANCES
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKY4
CHECKLIST TWENTY FIVE
Checklist for Frontal Lobe Dementia
4.Speech disturbances characteristic of the disorder uniquely identify it form
other common dementias. Symptoms include:
a. Progressive reduction of speech (aspontaneity, economy of utterance)
b. Sterotyped speech (limited repertoire of words or themes)
c. Echolalia or perseveration
d. Late mutism
.................................................................................
1. YES
2. NO
8. DK
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==========================================================================================
BJY5 FRONTAL LOBE, COMMON AFFECTIVE SYMPTOMS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKY5
CHECKLIST TWENTY FIVE
Checklist for Frontal Lobe Dementia
5. Affective symptoms are common and include any of the following:
a. Depression, anxiety, sentimentality, suicidal and fixed ideation of delusions
early in the disorder
b. Hypochondriasis or bizarre somatic preoccupations early in the illness
c. Emotional indifference or lack of empathy, sympathy, apathy
Amimia (inertia, aspontaneity)
.................................................................................
1. YES
2. NO
8. DK
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==========================================================================================
BJY6 FRONTAL LOBE SIGNS AND OTHER PHYSICAL SIGNS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKY6
CHECKLIST TWENTY FIVE
Checklist for Frontal Lobe Dementia
6. Frontal lobe signs and other physical signs
a. Early primitive reflexes
b. Early incontinence
c. Late akinesia, rigidity, tremor
Low and labile blood pressure
.................................................................................
1. YES
2. NO
8. DK
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==========================================================================================
BJY7 FRONTAL LOBE, NORMAL EEG
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKY7
CHECKLIST TWENTY FIVE
Checklist for Frontal Lobe Dementia
7. Normal EEG despite clinically evident dementia
.................................................................................
1. YES
2. NO
8. DK
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==========================================================================================
BJY8 FRONTAL LOBE, BRAIN IMAGING
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKY8
CHECKLIST TWENTY FIVE
Checklist for Frontal Lobe Dementia
8. Brain imaging 'structural or functional or both) that show predominantly
frontal or anterior temporal lobe abnormalities
.................................................................................
1. YES
2. NO
8. DK
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==========================================================================================
BJY9 FRONTAL LOBE, OTHER SUPPORTIVE DIAGNOSTIC FEATURES
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKY9
CHECKLIST TWENTY FIVE
Checklist for Frontal Lobe Dementia
9. Supportive Diagnostic Features
a) Onset before age 65
b) Positive family history of similar disorder in first degree relative (parent,
sibling)
c) Bulbar palsy, muscular weakness, wasting, fasciculations (motor neuron
disease)
.................................................................................
1. YES
2. NO
8. DK
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==========================================================================================
BJY10 FRONTAL LOBE, EXCLUSIONARY FEATURES (LIST)
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKY10
CHECKLIST TWENTY FIVE
Checklist for Frontal Lobe Dementia
10. Exclusionary Features
Abrupt onset with ictal events
Head trauma related to the onset
Early severe amnesia
Early spatial disorientation or other signs of agnosia
Early severe apraxia
Logoclonic speech with rapid
Loss of train of thought
Myoclonus
Corticobulbar and spinal deficits
Cerebellar ataxia
Coreo-athetosis
Early, severe pathological EEG
Laboratory tests indicating brain inflammatory process
Brain imaging with either:
predominant post-central structural or functional defect
or multi-focal cerebral lesions on CT or MRI.
.................................................................................
1. YES
2. NO
8. DK
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==========================================================================================
BJY1MET FRONTAL LOBE, CRITERIA FOR CKY1
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKY1MET
CHECKLIST TWENTY FIVE
Checklist for Frontal Lobe Dementia
CHECKLIST MET IF CKY1=YES
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJY2MET FRONTAL LOBE, CRITERIA FOR CKY2
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKY2MET
CHECKLIST TWENTY FIVE
Checklist for Frontal Lobe Dementia
CHECKLIST MET IF CHY2=YES
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJY3MET FRONTAL LOBE, CRITERIA FOR CKY3
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKY3MET
CHECKLIST TWENTY FIVE
Checklist for Frontal Lobe Dementia
CHECKLIST MET IF CKY3=YES
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJY4MET FRONTAL LOBE, CRITERIA FOR CKY4
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKY4MET
CHECKLIST TWENTY FIVE
Checklist for Frontal Lobe Dementia
CHECKLIST MET IF CKY4=YES
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJY5MET FRONTAL LOBE, CRITERIA FOR CKY10
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKY5MET
CHECKLIST TWENTY FIVE
Checklist for Frontal Lobe Dementia
CHECKLIST MET IF CKY10=NO
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJYMET FRONTAL LOBE - CRITERIA FOR CKY1MET - CKY5MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKYMET
CHECKLIST TWENTY FIVE
Checklist for Frontal Lobe Dementia
OVERALL CHECKLIST TWENTY-FIVE CRITERIA MET=YES IF CKY1MET-CKY5MET =YES
.................................................................................
0. NO
1. YES
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==========================================================================================
BJZ1 POSS LEWY BODY DEMENTIA EST BY DSM III OR DSM IV CRITERIA
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKZ1
CHECKLIST TWENTY SIX
Checklist for Possible Lewy Body Dementia
1. Dementia established by DSM-III-R or DSM-IV criteria (based on clinical and
neuropsychological assessment information)
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJZ2 POSS LEWY BODY DEMENTIA, FLUCTUATING COGNITION
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKZ2
CHECKLIST TWENTY SIX
Checklist for Possible Lewy Body Dementia
2. Fluctuating cognition with pronounced variation in attention and alertness
.................................................................................
1. YES
2. NO
8. DK
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==========================================================================================
BJZ3 POSS LEWY BODY DEMENTIA, RECURRENT VISUAL HALLUCINATIONS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKZ3
CHECKLIST TWENTY SIX
Checklist for Possible Lewy Body Dementia
3. Recurrent visual hallucinations that are typically well formed and detailed
.................................................................................
1. YES
2. NO
8. DK
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==========================================================================================
BJZ4 POSS LEWY BODY DEMENTIA, MOTOR FEATURES OF PARKINSONISM
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKZ4
CHECKLIST TWENTY SIX
Checklist for Possible Lewy Body Dementia
4. Spontaneous motor features of parkinsonism
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJZ5 POSS LEWY BODY DEMENTIA, REPEATED FALLS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKZ5
CHECKLIST TWENTY SIX
Checklist for Possible Lewy Body Dementia
5. Repeated falls
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJZ6 POSS LEWY BODY DEMENTIA, SYNCOPE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKZ6
CHECKLIST TWENTY SIX
Checklist for Possible Lewy Body Dementia
6. Syncope
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJZ7 POSS LEWY BODY DEMENTIA, LOSS OF CONSCIOUSNESS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKZ7
CHECKLIST TWENTY SIX
Checklist for Possible Lewy Body Dementia
7. Transient loss of consciousness
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJZ8 POSS LEWY BODY DEMENTIA, NEUROLEPTIC SENSITIVITY
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKZ8
CHECKLIST TWENTY SIX
Checklist for Possible Lewy Body Dementia
8. Neuroleptic sensitivity
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJZ9 POSS LEWY BODY DEMENTIA, SYSTEMATIZED DELUSIONS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKZ9
CHECKLIST TWENTY SIX
Checklist for Possible Lewy Body Dementia
9. Systematized delusions
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJZ10 POSS LEWY BODY DEMENTIA, OTHER MODAL HALLUCINATIONS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKZ10
CHECKLIST TWENTY SIX
Checklist for Possible Lewy Body Dementia
10. Hallucinations in other modalities
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJZ11 POSS LEWY BODY DEMENTIA, REM SLEEP DISORDER
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKZ11
CHECKLIST TWENTY SIX
Checklist for Possible Lewy Body Dementia
11. REM sleep behavior disorder
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJZ12 POSS LEWY BODY DEMENTIA, DEPRESSIVE SYMPTOMS
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKZ12
CHECKLIST TWENTY SIX
Checklist for Possible Lewy Body Dementia
12. Depressive symptoms
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJZ1MET POSS LEWY BODY DEMENTIA - CRITERIA FOR CKZ1
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKZ1MET
CHECKLIST TWENTY SIX
Checklist for Possible Lewy Body Dementia
CHECKLIST MET IF CKZ1=YES
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJZ2MET POSS LEWY BODY DEMENTIA - CRITERIA FOR CKZ2 - CKZ4
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKZ2MET
CHECKLIST TWENTY SIX
Checklist for Possible Lewy Body Dementia
CHECKLIST MET IF AT LEAST ONE OF CKZ2-CKZ4=YES
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJZMET POSS LEWY BODY DEMENTIA - CRITERIA FOR CKZ1MET AND CKZ2MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKZMET
CHECKLIST TWENTY SIX
Checklist for Possible Lewy Body Dementia
OVERALL CHECKLIST TWENTY-SIX CRITERIA MET=YES IF CKZ1MET AND CKZ2MET =YES
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJAA1 SEVERE HEAD TRAUMA, DEM ESTABLISHED BY CKAMET OR CKBMET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKAA1
CHECKLIST TWENTY SEVEN
Checklist for Dementia due to Severe Head Trauma
1. Dementia established by DSM-III-R or DSM-IV criteria (based on clinical and
neuropsychological assessment information
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJAA2 SEVERE HEAD TRAUMA, SEVERE COGNITIVE SEQUELAE
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKAA2
CHECKLIST TWENTY SEVEN
Checklist for Dementia due to Severe Head Trauma
2. Report of head trauma resulting in severe cognitive sequelae that begins
immediately after trauma and does not resolve over time
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJAA3 SEVERE HEAD TRAUMA, IMPAIRMENT NOT OTHERWISE EXPLAINED
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKAA3
CHECKLIST TWENTY SEVEN
Checklist for Dementia due to Severe Head Trauma
3. Impairment can not be better explained by another type of dementia
.................................................................................
1. YES
2. NO
8. DK
252 Blank. Inap
==========================================================================================
BJAA1MET SEVERE HEAD TRAUMA - CRITERIA FOR CKAA1 - CKAA3
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKAA1MET
CHECKLIST TWENTY SEVEN
Checklist for Dementia due to Severe Head Trauma
CHECKLIST MET IF CKAA1-CKAA3 =YES
.................................................................................
0. NO
1. YES
252 Blank. Inap
==========================================================================================
BJAAMET SEVERE HEAD TRAUMA - CRITERIA FOR CKAA1MET
Section: BJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKAAMET
CHECKLIST TWENTY SEVEN
Checklist for Dementia due to Severe Head Trauma
.................................................................................
0. NO
1. YES
252 Blank. Inap
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