==========================================================================================
Section CJ: DEMENTIA CHECKLIST & NEUROLOGICAL EXAM - FOLLOW-UP VISIT (Respondent)
==========================================================================================
HHID HRS HOUSEHOLD IDENTIFIER
Section: CJ Level: Respondent Type: Character Width: 6 Decimals: 0
This variable uniquely identifies an original HRS household across waves.
.................................................................................
315 010059-213467. Household Identification Number
==========================================================================================
PN HRS PERSON NUMBER IDENTIFIER
Section: CJ 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.
.................................................................................
195 010. Person Number
6 011. Person Number
78 020. Person Number
021. Person Number
17 030. Person Number
18 040. Person Number
1 041. Person Number
==========================================================================================
ADAMSSID ADAMS SUBJECT IDENTIFIER
Section: CJ Level: Respondent Type: Character Width: 5 Decimals: 0
This variable identifies an ADAMS subject in the ADAMS data files.
.................................................................................
315 00021-21271. ADAMS Subject Identification Number
==========================================================================================
CJNEURCOMP WHETHER NEUROLOGICAL EXAM COMPLETED
Section: CJ 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.
.................................................................................
295 1. YES
20 5. NO
==========================================================================================
CJRANGELAT NEUROLOGICAL EXAM - RANGE, EXTENT OF LATERAL GAZE
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NERANGELAT
RANGE/EXTENT OF LATERAL GAZE
.................................................................................
282 1. NORMAL -- complete gaze to left/right
6 2. ABNORMAL -- incomplete left or right gaze
2 3. ABNORMAL -- complete absence of left or right gaze
7. OTHER (SPECIFY)
2 8. CAN'T EXECUTE
3 9. MISSING
20 Blank. Inap
==========================================================================================
CJRANGEVER NEUROLOGICAL EXAM - RANGE,EXTENT OF VERTICAL GAZE
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NERANGEVER
RANGE/EXTENT OF VERTICAL GAZE
.................................................................................
284 1. NORMAL -- complete up & down gaze
4 2. ABNORMAL -- incomplete up & down gaze
3 3. ABNORMAL -- complete absence of up & down gaze
7. OTHER (SPECIFY)
2 8. CAN'T EXECUTE
2 9. MISSING
20 Blank. Inap
==========================================================================================
CJEYEBROWS NEUROLOGICAL EXAM - RAISE EYEBROWS
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NERAISE
FROWN WITH KNIT BROWS
.................................................................................
281 1. NORMAL -- no weakness noted
11 2. ABNORMAL -- inability to raise eyebrow
1 3. ABNORMAL -- inability to wrinkle forehead on left or
right(Specify left or right does not raised as high as other
side)
7. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
1 9. MISSING
20 Blank. Inap
==========================================================================================
CJWIDESMIL NEUROLOGICAL EXAM - WIDE SMILE, SHOW TEETH
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NESMILE
WIDE SMILE- SHOW TEETH
.................................................................................
289 1. NORMAL -- no weakness noted
2. ABNORMAL -- flattened nasolabial fold
3 3. ABNORMAL -- inability to raise corner of mouth on left or
right (Specify left or right not raised)
7. OTHER (SPECIFY)
2 8. CAN'T EXECUTE
1 9. MISSING
20 Blank. Inap
==========================================================================================
CJPHARYNGE NEUROLOGICAL EXAM - PHARYNGEAL MOVEMENTS
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEPHARYN
PHARYNGEAL MOVEMENTS (subject opens mouth, says 'ah')
.................................................................................
280 1. NORMAL -- SYMMETRIC PALATE ELEVATION
7 2. ABNORMAL -- ONE SIDE NOT ELEVATED AS HIGH (SPECIFY LEFT OR
RIGHT NOT ELEVATED AS HIGH)
7. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
7 9. MISSING
20 Blank. Inap
==========================================================================================
CJFACIAL NEUROLOGICAL EXAM - UPDRS FACIAL EXPRESSION
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUFACIAL
FACIAL EXPRESSION
.................................................................................
276 1. NORMAL
13 2. ABNORMAL -- Minimal hypomimia, could be normal "Poker Face"
3 3. ABNORMAL -- Slight but definitely abnormal diminution of
facial expression
4. ABNORMAL -- Moderate hypomimia: lips parted some of the time
1 5. ABNORMAL -- Masked or fixed facies with severe or complete
loss of facial expression; lips parted 1/4 inch or more
1 7. OTHER (SPECIFY)
8. CAN'T EXECUTE
1 9. Missing
20 Blank. Inap
==========================================================================================
CJSPEECH NEUROLOGICAL EXAM - UPDRS SPEECH
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUSPEECH
SPEECH
.................................................................................
275 1. NORMAL
10 2. ABNORMAL -- Slight loss of expression, diction and/or volume
4 3. ABNORMAL -- Monotone, slurred but understandable; moderately
impaired
3 4. ABNORMAL -- Marked impairment, difficult to understand
1 5. ABNORMAL -- Unintelligible
2 7. OTHER (SPECIFY)
8. CAN'T EXECUTE
9. Missing
20 Blank. Inap
==========================================================================================
CJF_NRIGHT NEUROLOGICAL EXAM - FINGER TO NOSE TOUCH, RIGHT REV
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NENOSETOUCHR
RIGHT FINGER-TO-NOSE TOUCHING
.................................................................................
231 1. NORMAL -- quickly, smooth and accurate
51 2. ABNORMAL -- slow but accurate
6 3. ABNORMAL -- dysmetria noted
7. OTHER (SPECIFY)
2 8. CAN'T EXECUTE
5 9. MISSING
20 Blank. Inap
==========================================================================================
CJF_NLEFT NEUROLOGICAL EXAM - FINGER TO NOSE TOUCH, LEFT REV
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NENOSETOUCHL
LEFT FINGER-TO-NOSE TOUCHING
.................................................................................
216 1. NORMAL -- quickly, smooth and accurate
64 2. ABNORMAL -- slow but accurate
6 3. ABNORMAL -- dysmetria noted
7. OTHER (SPECIFY)
3 8. CAN'T EXECUTE
6 9. MISSING
20 Blank. Inap
==========================================================================================
CJRF_TTAPP NEUROLOGICAL EXAM - UPDRS FINGER THUMB TAPPING, RIGHT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTHUMBTAPR
RIGHT FINGER-THUMB TAPPING
.................................................................................
199 1. NORMAL -- 4 taps/second
69 2. ABNORMAL -- Mild slowing and/or reduction in amplitude
13 3. ABNORMAL -- Moderately impaired. Definite and early
fatiguing. May have occasion arrests in movement.
6 4. ABNORMAL -- Severely impaired. Frequent hesitation in
initiating movements or arrests in ongoing movement.
1 5. ABNORMAL -- Can barely perform.
7. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
6 9. MISSING
20 Blank. Inap
==========================================================================================
CJLF_TTAPP NEUROLOGICAL EXAM - UPDRS FINGER THUMB TAPPING, LEFT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTHUMBTAPL
LEFT FINGER-THUMB TAPPING
.................................................................................
181 1. NORMAL -- 4 taps/second
80 2. ABNORMAL -- Mild slowing and/or reduction in amplitude
15 3. ABNORMAL -- Moderately impaired. Definite and early
fatiguing. May have occasion arrests in movement.
6 4. ABNORMAL -- Severely impaired. Frequent hesitation in
initiating movements or arrests in ongoing movement.
2 5. ABNORMAL -- Can barely perform.
7. OTHER (SPECIFY)
2 8. CAN'T EXECUTE
9 9. MISSING
20 Blank. Inap
==========================================================================================
CJHANDMOVER NEUROLOGICAL EXAM - UPDRS HAND MOVEMENTS, RIGHT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUHANDMOVER
RIGHT HAND MOVEMENTS
.................................................................................
217 1. NORMAL
64 2. ABNORMAL -- Mild slowing and/or reduction in amplitude
9 3. ABNORMAL -- Moderately impaired. Definite and early
fatiguing. May have occasional arrests in movement.
2 4. ABNORMAL -- Severely impaired. Frequent hesitation in
initiating movements or arrests in ongoing movement.
5. ABNORMAL -- Can barely perform the task.
7. OTHER (SPECIFY)
2 8. CAN'T EXECUTE
1 9. MISSING
20 Blank. Inap
==========================================================================================
CJHANDMOVEL NEUROLOGICAL EXAM - UPDRS HAND MOVEMENTS, LEFT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUHANDMOVEL
LEFT HAND MOVEMENTS
.................................................................................
202 1. NORMAL
68 2. ABNORMAL -- Mild slowing and/or reduction in amplitude
18 3. ABNORMAL -- Moderately impaired. Definite and early
fatiguing. May have occasional arrests in movement.
3 4. ABNORMAL -- Severely impaired. Frequent hesitation in
initiating movements or arrests in ongoing movement.
5. ABNORMAL -- Can barely perform the task.
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
4 9. MISSING
20 Blank. Inap
==========================================================================================
CJRAPIDHANDR NEUROL EXAM - UPDRS RAPID ALT HAND MOVE, RIGHT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEURAPIDHANDR
RIGHT RAPID ALTERNATING MOVEMENTS OF HANDS
.................................................................................
236 1. NORMAL--At least 3 pats/second and smooth
40 2. ABNORMAL -- Mild slowing and/or reduction in amplitude
10 3. ABNORMAL -- Moderately impaired. Definite and early
fatiguing. May have occasional arrests in movement.
2 4. ABNORMAL -- Severely impaired. Frequent hesitation in
initiating movements or arrests in ongoing movement.
1 5. ABNORMAL -- Can barely perform the task.
7. OTHER (SPECIFY)
2 8. CAN'T EXECUTE
4 9. MISSING
20 Blank. Inap
==========================================================================================
CJRAPIDHANDL NEUROL EXAM - UPDRS RAPID ALT HAND MOVE, LEFT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEURAPIDHANDL
LEFT RAPID ALTERNATING MOVEMENTS OF HANDS
.................................................................................
212 1. NORMAL--At least 3 pats/second and smooth
56 2. ABNORMAL -- Mild slowing and/or reduction in amplitude
13 3. ABNORMAL -- Moderately impaired. Definite and early
fatiguing. May have occasional arrests in movement.
5 4. ABNORMAL -- Severely impaired. Frequent hesitation in
initiating movements or arrests in ongoing movement.
5. ABNORMAL -- Can barely perform the task.
7. OTHER (SPECIFY)
2 8. CAN'T EXECUTE
7 9. MISSING
20 Blank. Inap
==========================================================================================
CJHAND_A NEUROLOGICAL EXAM -INTERLOCKING THUMBS
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEINTTHUMB
HAND PRAXIS TASKS: INTER-LOCKING THUMBS
A). Inter-locking thumbs
.................................................................................
242 1. NORMAL -- performs correctly
47 2. ABNORMAL -- performs incorrectly
7. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
5 9. MISSING
20 Blank. Inap
==========================================================================================
CJHAND_B NEUROLOGICAL EXAM - MIRRORED FINGERS
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEMIRRORFING
HAND PRAXIS TASKS: MIRRORED FINGERS
B). Mirrored fingers
.................................................................................
242 1. NORMAL -- performs correctly
47 2. ABNORMAL -- performs incorrectly
7. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
5 9. MISSING
20 Blank. Inap
==========================================================================================
CJTONUSNECK NEUROLOGICAL EXAM - UPDRS RIGIDITY MUSCLE TONUS (NECK)
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTONUSNEC
Rigidity MUSCLE TONUS (neck)
.................................................................................
221 1. NORMAL -- normal muscle tone, no rigidity
29 2. ABNORMAL -- Slight
8 3. ABNORMAL -- Mild to moderate
1 4. ABNORMAL -- Marked, but full range of motion easily achieved
6 5. ABNORMAL -- Severe, range of motion achieved with difficulty
1 7. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
28 9. MISSING
20 Blank. Inap
==========================================================================================
CJTONUSUPR NEUROL EXAM - UPDRS RIGIDITY MUSCLE TONUS (UPPER EX), RIGHT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTONUSUPR
RIGHT Rigidity MUSCLE TONUS (upper extremity)
.................................................................................
274 1. NORMAL -- normal muscle tone, no rigidity
14 2. ABNORMAL -- Slight or detectable only when activated by
mirror or other movements
4 3. ABNORMAL -- Mild to moderate
4. ABNORMAL -- Marked, but full range of motion easily achieved
5. ABNORMAL -- Severe, range of motion achieved with difficulty
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
3 9. MISSING
20 Blank. Inap
==========================================================================================
CJTONUSUPL NEUROL EXAM - UPDRS RIGIDITY MUSCLE TONUS (UPPER EX), LEFT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTONUSUPL
LEFT Rigidity MUSCLE TONUS (upper extremity)
.................................................................................
274 1. NORMAL -- normal muscle tone, no rigidity
12 2. ABNORMAL -- Slight or detectable only when activated by
mirror or other movements
2 3. ABNORMAL -- Mild to moderate
1 4. ABNORMAL -- Marked, but full range of motion easily achieved
1 5. ABNORMAL -- Severe, range of motion achieved with difficulty
1 7. OTHER (SPECIFY)
8. CAN'T EXECUTE
4 9. MISSING
20 Blank. Inap
==========================================================================================
CJTONUSLOWR NEUROL EXAM - UPDRS RIGIDITY MUSCLE TONUS (LOWER EX), RIGHT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTONUSLOWR
RIGHT Rigidity MUSCLE TONUS (lower extremity)
.................................................................................
244 1. NORMAL -- normal muscle tone, no rigidity
17 2. ABNORMAL -- Slight or detectable only when activated by
mirror or other movements
10 3. ABNORMAL -- Mild to moderate
2 4. ABNORMAL -- Marked, but full range of motion easily achieved
5 5. ABNORMAL -- Severe, range of motion achieved with difficulty
7. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
16 9. MISSING
20 Blank. Inap
==========================================================================================
CJTONUSLOWL NEUROL EXAM - UPDRS RIGIDITY MUSCLE TONUS (LOWER EX), LEFT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTONUSLOWL
LEFT Rigidity MUSCLE TONUS (lower extremity)
.................................................................................
242 1. NORMAL -- normal muscle tone, no rigidity
20 2. ABNORMAL -- Slight or detectable only when activated by
mirror or other movements
13 3. ABNORMAL -- Mild to moderate
2 4. ABNORMAL -- Marked, but full range of motion easily achieved
3 5. ABNORMAL -- Severe, range of motion achieved with difficulty
1 7. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
13 9. MISSING
20 Blank. Inap
==========================================================================================
CJRCOGWHL NEUROLOGICAL EXAM - COGWHEEL PHENOMENON, RIGHT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NECOGWHEELR
RIGHT COGWHEEL PHENOMENON
.................................................................................
288 1. NORMAL -- no cogwheeling noted
5 2. ABNORMAL -- slight or noticeable rhythmicity throughout
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
2 9. MISSING
20 Blank. Inap
==========================================================================================
CJLCOGWHL NEUROLOGICAL EXAM - COGWHEEL PHENOMENON, LEFT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NECOGWHEELL
LEFT COGWHEEL PHENOMENON
.................................................................................
289 1. NORMAL -- no cogwheeling noted
3 2. ABNORMAL -- slight or noticeable rhythmicity throughout
3. OTHER (SPECIFY)
8. CAN'T EXECUTE
3 9. MISSING
20 Blank. Inap
==========================================================================================
CJUPPERMSA NEUROLOGICAL EXAM - UPPER EX MOTOR STRENGTH
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUPPERMSA
UPPER EXTREMITY MOTOR STRENGTH
.................................................................................
203 1. WRIST EXTENSION
84 2. TRICEPS PULL
28 Blank. Inap
==========================================================================================
CJUPPERMS NEUROLOGICAL EXAM - UPPER EXTREMITY MOTOR STRENGTH
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUPPERMS
UPPER EXTREMITY MOTOR STRENGTH
.................................................................................
275 1. NORMAL -- No strength difference between R and L trials
12 2. ABNORMAL -- SPECIFY WEAKNESS(L OR R)
7. OTHER
8. CAN'T EXECUTE
8 9. MISSING
20 Blank. Inap
==========================================================================================
CJTREMFACE NEUROLOGICAL EXAM - UPDRS TREMOR AT REST (FACE, LIP, CHIN)
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTREMFACE
TREMOR AT REST (face, lip, chin)
.................................................................................
286 1. NORMAL - ABSENT
2 2. ABNORMAL - SLIGHT AND INFREQUENTLY PRESENT
5 3. ABNORMAL - MILD IN AMPLITUDE AND PERSISTENT. OR MODERATE IN
AMPLITUDE, BUT ONLY INTERMITTENTLY PRESENT.
1 4. ABNORMAL - MODERATE IN AMPLITUDE AND PRESENT MOST OF THE
TIME.
5. ABNORMAL - MARKED IN AMPLITUDE AND PRESENT MOST OF THE TIME.
1 7. OTHER (SPECIFY)
8. CAN'T EXECUTE
9. MISSING
20 Blank. Inap
==========================================================================================
CJTREMHANDSR NEUROLOGICAL EXAM - UPDRS TREMOR AT REST (HANDS), RIGHT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTREMHANDSR
RIGHT TREMOR AT REST (hands)
.................................................................................
253 1. NORMAL - ABSENT
32 2. ABNORMAL - SLIGHT AND INFREQUENTLY PRESENT
6 3. ABNORMAL - MILD IN AMPLITUDE AND PERSISTENT. OR MODERATE IN
AMPLITUDE, BUT ONLY INTERMITTENTLY PRESENT.
3 4. ABNORMAL - MODERATE IN AMPLITUDE AND PRESENT MOST OF THE
TIME.
1 5. ABNORMAL - MARKED IN AMPLITUDE AND PRESENT MOST OF THE TIME.
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
9. MISSING
20 Blank. Inap
==========================================================================================
CJTREMHANDSL NEUROLOGICAL EXAM - UPDRS TREMOR AT REST (HANDS), LEFT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTREMHNDSL
LEFT TREMOR AT REST (hands)
.................................................................................
248 1. NORMAL - ABSENT
32 2. ABNORMAL - SLIGHT AND INFREQUENTLY PRESENT
12 3. ABNORMAL - MILD IN AMPLITUDE AND PERSISTENT. OR MODERATE IN
AMPLITUDE, BUT ONLY INTERMITTENTLY PRESENT.
2 4. ABNORMAL - MODERATE IN AMPLITUDE AND PRESENT MOST OF THE
TIME.
1 5. ABNORMAL - MARKED IN AMPLITUDE AND PRESENT MOST OF THE TIME.
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
9. MISSING
20 Blank. Inap
==========================================================================================
CJTREMFEETR NEUROLOGICAL EXAM - UPDRS TREMOR AT REST (FEET), RIGHT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTREMFEETR
RIGHT TREMOR AT REST (feet)
.................................................................................
289 1. NORMAL - ABSENT
1 2. ABNORMAL - SLIGHT AND INFREQUENTLY PRESENT
3. ABNORMAL - MILD IN AMPLITUDE AND PERSISTENT. OR MODERATE IN
AMPLITUDE, BUT ONLY INTERMITTENTLY PRESENT.
1 4. ABNORMAL - MODERATE IN AMPLITUDE AND PRESENT MOST OF THE
TIME.
5. ABNORMAL - MARKED IN AMPLITUDE AND PRESENT MOST OF THE TIME.
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
4 9. MISSING
20 Blank. Inap
==========================================================================================
CJTREMFEETL NEUROLOGICAL EXAM - UPDRS TREMOR AT REST (FEET), LEFT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTREMFEETL
LEFT TREMOR AT REST (feet)
.................................................................................
291 1. NORMAL - ABSENT
2 2. ABNORMAL - SLIGHT AND INFREQUENTLY PRESENT
3. ABNORMAL - MILD IN AMPLITUDE AND PERSISTENT. OR MODERATE IN
AMPLITUDE, BUT ONLY INTERMITTENTLY PRESENT.
4. ABNORMAL - MODERATE IN AMPLITUDE AND PRESENT MOST OF THE
TIME.
5. ABNORMAL - MARKED IN AMPLITUDE AND PRESENT MOST OF THE TIME.
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
2 9. MISSING
20 Blank. Inap
==========================================================================================
CJPRONAT NEUROLOGICAL EXAM - PRONATOR DRIFT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEPRONATOR
PRONATOR DRIFT (arms out-stretched, palms up, eyes closed)
.................................................................................
281 1. NORMAL -- absence of drift
9 2. ABNORMAL -- spontaneous drift of either/both hands
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
5 9. MISSING
20 Blank. Inap
==========================================================================================
CJSTRENGTH NEUROLOGICAL EXAM - STRENGTH DIFFERENCE, DOWN PRESSURE
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NESTRENGTH
STRENGTH DIFFERENCE WITH DOWNWARD PRESSURE AND THEN SUDDEN RELEASE BY EXAMINER
(arms outstretched, resists examiner's pressure)
.................................................................................
232 1. NORMAL -- no strength difference, equal rebound
50 2. ABNORMAL -- unequal rebound
7. OTHER (SPECIFY)
8. CAN' T EXECUTE
13 9. MISSING
20 Blank. Inap
==========================================================================================
CJACTIONHNDSR NEUROL EXAM - UPDRS ACTION OR POSTURAL HAND TREMOR, RIGHT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUACTIONHNDSR
RIGHT ACTION OR POSTURAL TREMOR OF HANDS
.................................................................................
246 1. NORMAL - Absent
42 2. ABNORMAL - Slight; present with action
3 3. ABNORMAL - Moderate in amplitude, present with action
2 4. ABNORMAL - Moderate in amplitude with posture holding as
well as action
1 5. ABNORMAL - Marked in amplitude; interferes with feeding
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
1 9. MISSING
20 Blank. Inap
==========================================================================================
CJACTIONHNDSL NEUROL EXAM - UPDRS ACTION OR POSTURAL HAND TREMOR, LEFT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUACTIONHNDSL
LEFT ACTION OR POSTURAL TREMOR OF HANDS
.................................................................................
249 1. NORMAL - Absent
41 2. ABNORMAL - Slight; present with action
2 3. ABNORMAL - Moderate in amplitude, present with action
1 4. ABNORMAL - Moderate in amplitude with posture holding as
well as action
1 5. ABNORMAL - Marked in amplitude; interferes with feeding
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
1 9. MISSING
20 Blank. Inap
==========================================================================================
CJRANKLE NEUROLOGICAL EXAM - ANKLE CLONUS, RIGHT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEANKLECLONR
RIGHT ANKLE CLONUS
Right
.................................................................................
272 1. NORMAL -- absent
2. ABNORMAL -- present
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
23 9. MISSING
20 Blank. Inap
==========================================================================================
CJLANKLE NEUROLOGICAL EXAM - ANKLE CLONUS, LEFT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEANKLECLONL
LEFT ANKLE CLONUS
Left
.................................................................................
272 1. NORMAL -- absent
2. ABNORMAL -- present
1 7. OTHER (SPECIFY)
8. CAN'T EXECUTE
22 9. MISSING
20 Blank. Inap
==========================================================================================
CJLEGAGILR NEUROLOGICAL EXAM - UPDRS LEG AGILITY, RIGHT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEULEGAGILR
RIGHT LEG AGILITY
.................................................................................
214 1. Absent
53 2. Mild Slowing and/or reduction in amplitude
4 3. ABNORMAL - Moderately impaired. Definite and early
fatiguing. May have occasional arrests in movement.
2 4. ABNORMAL -- Severly impaired. Frequent hesitation in
initiating movements or arrests in ongoing movement.
5. ABNORMAL -- Can barely perform the task.
7. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
21 9. MISSING
20 Blank. Inap
==========================================================================================
CJLEGAGILL NEUROLOGICAL EXAM - UPDRS LEG AGILITY, LEFT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEULEGAGILL
LEFT LEG AGILITY
.................................................................................
202 1. Absent
61 2. Mild Slowing and/or reduction in amplitude
7 3. ABNORMAL - Moderately impaired. Definite and early
fatiguing. May have occasional arrests in movement.
1 4. ABNORMAL -- Severly impaired. Frequent hesitation in
initiating movements or arrests in ongoing movement.
1 5. ABNORMAL -- Can barely perform the task.
7. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
22 9. MISSING
20 Blank. Inap
==========================================================================================
CJRPROPRIC NEUROLOGICAL EXAM - PROPRIOCEPTION, RIGHT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEPROPRIOCEPR
RIGHT KINESTHESIS
.................................................................................
188 1. PRESENT
65 2. ABSENT
1 8. CAN'T EXECUTE
41 9. MISSING
20 Blank. Inap
==========================================================================================
CJLPROPRIC NEUROLOGICAL EXAM - PROPRIOCEPTION, LEFT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEPROPRIOCEPL
LEFT KINESTHESIS
.................................................................................
179 1. PRESENT
75 2. ABSENT
1 8. CAN'T EXECUTE
40 9. MISSING
20 Blank. Inap
==========================================================================================
CJRVIBRAT NEUROLOGICAL EXAM - VIBRATING SENSATION, RIGHT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEVIBRATINGR
RIGHT VIBRATING SENSATION
.................................................................................
192 1. PRESENT
84 2. ABSENT
1 8. CAN'T EXECUTE
18 9. MISSING
20 Blank. Inap
==========================================================================================
CJLVIBRAT NEUROLOGICAL EXAM - VIBRATING SENSATION, LEFT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEVIBRATINGL
LEFT VIBRATING SENSATION
.................................................................................
192 1. PRESENT
85 2. ABSENT
1 8. CAN'T EXECUTE
17 9. MISSING
20 Blank. Inap
==========================================================================================
CJRPLANTAR NEUROLOGICAL EXAM - PLANTAR RESPONSE, RIGHT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEPLANTARR
RIGHT PLANTAR RESPONSE
.................................................................................
113 1. NORMAL -- plantar flexion of great toe
8 2. ABNORMAL -- extension of great toe
127 3. ABNORMAL -- no reflex present
6 7. OTHER (SPECIFY)
8. CAN'T EXECUTE
41 9. MISSING
20 Blank. Inap
==========================================================================================
CJLPLANTAR NEUROLOGICAL EXAM - PLANTAR RESPONSE, LEFT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEPLANTARL
LEFT PLANTAR RESPONSE
.................................................................................
105 1. NORMAL -- plantar flexion of great toe
16 2. ABNORMAL -- extension of great toe
128 3. ABNORMAL -- no reflex present
6 7. OTHER (SPECIFY)
8. CAN'T EXECUTE
40 9. MISSING
20 Blank. Inap
==========================================================================================
CJARISECH NEUROLOGICAL EXAM - UPDRS ARISING FROM CHAIR
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUARISING
ARISING FROM CHAIR
.................................................................................
188 1. NORMAL
20 2. Slow; or may need more than one attempt
45 3. Pushes self up from arms of seat
10 4. Tend to fall back and may have to try more than one time,
but can get up without help.
13 5. Unable to arise without help
1 7. Other (Specify)
8. CAN'T EXECUTE
18 9. MISSING
20 Blank. Inap
==========================================================================================
CJROMBERG NEUROLOGICAL EXAM - ROMBERGS SIGN
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEROMBERGS
ROMBERG'S SIGN (stand with feet together for 10-15 seconds)
.................................................................................
238 1. NORMAL -- normally still or slight weaving
20 2. ABNORMAL -- falls to one side with eyes closed
3. ABNORMAL -- falls to one side with eyes open
3 4. ABNORMAL -- needs widened base to stay in one place
2 7. OTHER (SPECIFY)
8. CAN'T EXECUTE
32 9. MISSING
20 Blank. Inap
==========================================================================================
CJPOSTSTABIL NEUROLOGICAL EXAM - POSTURAL STABILITY
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUPOSTSTABIL
POSTURAL STABILITY
.................................................................................
184 1. NORMAL
39 2. Retropulsion, but recovers unaided.
26 3. Absence of postural response; would fall if not caught by
examiner
5 4. Very unstable, tends to lose balance spontaneously
3 5. Unable to stand without help
7. Other (Specify)
1 8. CAN'T EXECUTE
37 9. MISSING
20 Blank. Inap
==========================================================================================
CJGAIT NEUROLOGICAL EXAM - UPDRS GAIT: WALK 10 PACES
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUGAIT
GAIT - and also time gait task
A). Walking down a hall at least 10 paces
.................................................................................
131 1. NORMAL -- normal gait
83 2. ABNORMAL -- Walks slowly, may shuffle with short steps, but
no festination (hastening steps) or propulsion
37 3. ABNORMAL -- Walks with difficulty, but requires little or no
assistance; may have some festination, short steps, or
propulsion
12 4. ABNORMAL -- Severe disturbance of gait, requiring assistance
1 5. ABNORMAL -- Cannot walk at all, even with assistance
2 7. OTHER (SPECIFY)
8. CAN'T EXECUTE
29 9. MISSING
20 Blank. Inap
==========================================================================================
CJPIVOT NEUROLOGICAL EXAM - GAIT: PIVOT WHILE TURNING
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUPIVOT
GAIT - and also time gait task
B). Pivot while turning
.................................................................................
165 1. NORMAL -- pivots on narrow base
46 2. ABNORMAL -- Hesitates
24 3. ABNORMAL -- Widens base or moves feet
25 4. ABNORMAL -- Turns slowly or awkwardly
1 7. OTHER (SPECIFY)
8. CAN' T EXECUTE
34 9. MISSING
20 Blank. Inap
==========================================================================================
CJTIMED1_COMP NEUROLOGICAL EXAM - TIMED GAIT TR 1 COMPLETED
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTIMED1_COMP
GAIT - and also time gait task
C). Timed gait task
Trial 1 Completed
.................................................................................
243 1. Completed
8. CAN'T EXECUTE
52 9. MISSING
20 Blank. Inap
==========================================================================================
CJTIMED1 NEUROLOGICAL EXAM - TIMED GAIT TR 1 TIME (SEC)
Section: CJ Level: Respondent Type: Numeric Width: 2 Decimals: 0
Ref: NEUTIMED1
GAIT - and also time gait task
C). Timed gait task
Trial 1 Time (sec)
.................................................................................
243 2-19.87. Seconds
72 Blank. Inap
==========================================================================================
CJTIMED2_COMP NEUROLOGICAL EXAM - TIMED GAIT TR 2 COMPLETED
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTIMED2_COMP
GAIT - and also time gait task
C). Timed gait task
Trial 2 Completed
.................................................................................
243 1. Completed
8. CAN'T EXECUTE
52 9. MISSING
20 Blank. Inap
==========================================================================================
CJTIMED2 NEUROLOGICAL EXAM - TIMED GAIT TR 2 TIME (SEC)
Section: CJ Level: Respondent Type: Numeric Width: 2 Decimals: 0
Ref: NEUTIMED2
GAIT - and also time gait task
C). Timed gait task
Trial 2 Time (sec)
.................................................................................
243 1.68-20.99. Seconds
72 Blank. Inap
==========================================================================================
CJTIMEDFL NEUROLOGICAL EXAM - TYPE OF FLOOR SURFACE
Section: CJ Level: Respondent Type: Numeric Width: 2 Decimals: 0
Ref: NEUTIMEDFL
TYPE OF FLOOR SURFACE
.................................................................................
109 1. Linoleum/tile/wood
126 2. Low-pile carpet
10 3. High-pile carpet
1 4. Concrete
7. Other(specify)
98. DON'T KNOW
69 Blank. Inap
==========================================================================================
CJTIMEDAID NEUROLOGICAL EXAM - TYPE OF AID USED
Section: CJ Level: Respondent Type: Numeric Width: 2 Decimals: 0
Ref: NEUTIMEDAID
TYPE OF AID USED
.................................................................................
228 1. None
10 2. Walking stick or cane
3. Crutches
8 4. Walking frame
7. Other (specify)
98. DON'T KNOW
69 Blank. Inap
==========================================================================================
CJHYPOKINES NEUROLOGICAL EXAM - UPDRS BODY BRADYKINESIA AND HYPOKINESIA
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUHYPOKINES
UPDRS - BODY BRADYKINESIA AND HYPOKINESIA (Combining slowness, hesitancy,
decreased arm swing, small amplitude, and poverty of movement in general).
.................................................................................
206 1. NORMAL -- None
60 2. ABNORMAL -- Minimal slowness, giving movement a deliberate
character; could be normal for some persons, Possibly
reduced amplitude.
15 3. ABNORMAL -- Mild degree of slowness and poverty of movement
which is definitely abnormal. Alternatively, some reduced
amplitude.
3 4. ABNORMAL -- Moderate slowness, poverty or small amplitude of
movement
7 5. ABNORMAL -- Marked slowness, poverty or small amplitude of
movement
7. OTHER (SPECIFY)
8. CAN' T EXECUTE
4 9. MISSING
20 Blank. Inap
==========================================================================================
CJMYOCLONU NEUROLOGICAL EXAM - MYOCLONUS
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: MYOCLONUS
MYOCLONUS
.................................................................................
289 1. NORMAL -- absent
2 2. ABNORMAL -- mild myoclonus
1 3. ABNORMAL -- occasional myoclonus
4. ABNORMAL -- frequent myoclonus
5. ABNORMAL -- severe myoclonus
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
3 9. MISSING
20 Blank. Inap
==========================================================================================
CJPOSTURE NEUROLOGICAL EXAM - UPDRS POSTURE
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUPOSTURE
POSTURE
.................................................................................
107 1. NORMAL -- normal, erect
129 2. ABNORMAL -- Not quite erect, slightly stooped; could be
normal for older person
42 3. ABNORMAL -- Moderately stooped posture, definitely abnormal;
can be slightly leaning to one side (Specify if leaning to
right, left or neither)
6 4. ABNORMAL -- Severly stooped posture with kyphosis; can be
moderately leaning to one side (Specify if leaning to right,
left or neither)
1 5. ABNORMAL -- Marked flexion with extreme abnormality of
posture
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
10 9. MISSING
20 Blank. Inap
==========================================================================================
CJCOMB NEUROLOGICAL EXAM - PRAXIS, COMB YOUR HAIR
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEPRAXCOMB
PRAXIS TASKS (PRETEND TO COMB YOUR HAIR)
.................................................................................
257 1. NORMAL, PERFORMS CORRECTLY
33 2. ABNORMAL (SPECIFY)
7. OTHER (SPECIFY)
3 8. CAN'T EXECUTE
2 9. MISSING
20 Blank. Inap
==========================================================================================
CJHAMMER NEUROLOGICAL EXAM - PRAXIS, HAMMER A NAIL
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEPRAXHAMMER
PRAXIS TASKS (PRETEND TO HAMMER A NAIL)
.................................................................................
243 1. NORMAL, PERFORMS CORRECTLY
47 2. ABNORMAL (SPECIFY)
7. OTHER (SPECIFY)
3 8. CAN'T EXECUTE
2 9. MISSING
20 Blank. Inap
==========================================================================================
CJBRUSH NEUROLOGICAL EXAM - PRAXIS, BRUSH YOUR TEETH
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEPRAXBRUSH
PRAXIS TASKS (PRETEND TO BRUSH YOUR TEETH)
.................................................................................
225 1. NORMAL, PERFORMS CORRECTLY
64 2. ABNORMAL (SPECIFY)
7. OTHER (SPECIFY)
2 8. CAN'T EXECUTE
4 9. MISSING
20 Blank. Inap
==========================================================================================
CJCHKDONE WHETHER DEMENTIA CHECKLIST COMPLETED
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CHKDONE
DEMENTIA CHECKLIST COMPLETED
.................................................................................
315 1. YES
2. NO
==========================================================================================
CJA1 DEMENTIA, DSM IV, MEM IMPAIRMENT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA1
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
1. Memory Impairment 'short or long term)
.................................................................................
202 1. YES
110 2. NO
3 8. DK
Blank. Inap
==========================================================================================
CJA2 DEMENTIA, DSM IV, APHASIA
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA2
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
2. Aphasia
.................................................................................
20 1. YES
287 2. NO
7 8. DK
1 Blank. Inap
==========================================================================================
CJA3 DEMENTIA, DSM IV, APRAXIA
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA3
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
3. Apraxia
.................................................................................
39 1. YES
259 2. NO
16 8. DK
1 Blank. Inap
==========================================================================================
CJA4 DEMENTIA, DSM IV, AGNOSIA
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA4
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
4. Agnosia
.................................................................................
8 1. YES
297 2. NO
9 8. DK
1 Blank. Inap
==========================================================================================
CJA5 DEMENTIA, DSM IV, EXEC FUNCTION DISTURBANCE
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA5
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
5. Disturbance in executive functioning
.................................................................................
95 1. YES
210 2. NO
8 8. DK
2 Blank. Inap
==========================================================================================
CJA6 DEMENTIA, DSM IV, SOCIAL OR OCCUP IMPAIRMENT
Section: CJ 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
.................................................................................
45 1. YES
58 2. NO
8. DK
212 Blank. Inap
==========================================================================================
CJA7 DEMENTIA, DSM IV, SIGNIFICANT DECLINE
Section: CJ 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
.................................................................................
102 1. YES
1 2. NO
8. DK
212 Blank. Inap
==========================================================================================
CJA8 DEMENTIA, DSM IV, COG DEFICITS DURING DELIRIUM
Section: CJ 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
103 2. NO
8. DK
212 Blank. Inap
==========================================================================================
CJA1MET DEMENTIA - CRITERIA FOR CKA1
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA1MET
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
CHECKLIST IS MET IF CKA1=YES
.................................................................................
113 0. NO
202 1. YES
==========================================================================================
CJA2MET DEMENTIA - CRITERIA FOR CKA2 - CKA5
Section: CJ 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
.................................................................................
194 0. NO
121 1. YES
==========================================================================================
CJA3MET DEMENTIA - CRITERIA FOR CKA6 AND CKA7
Section: CJ 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
.................................................................................
270 0. NO
45 1. YES
==========================================================================================
CJA4MET DEMENTIA - CRITERIA FOR CKA8
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA4MET
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
CHECKLIST IS MET IF CKA8=YES
.................................................................................
212 0. NO
103 1. YES
==========================================================================================
CJAMET DEMENTIA - WHETHER OVERALL DSM IV CRITERIA MET
Section: CJ 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
.................................................................................
270 0. NO
45 1. YES
==========================================================================================
CJB1 DEMENTIA, DSM III R, SHORT TERM MEMORY
Section: CJ 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
114 2. NO
2 8. DK
==========================================================================================
CJB2 DEMENTIA, DSM III R, LONG TERM MEMORY
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB2
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
2. Long Term Memory
.................................................................................
65 1. YES
244 2. NO
6 8. DK
==========================================================================================
CJB3 DEMENTIA, DSM III R, ABSTRACT THINKING
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB3
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
3. Abstract thinking
.................................................................................
55 1. YES
253 2. NO
7 8. DK
==========================================================================================
CJB4 DEMENTIA, DSM III R, JUDGEMENT
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB4
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
4. Judgement
.................................................................................
72 1. YES
238 2. NO
5 8. DK
==========================================================================================
CJB5 DEMENTIA, DSM III R, OTHER HIGHER CORTICAL FUNCTIONING
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB5
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
5. Other Higher Cortical Functioning
.................................................................................
98 1. YES
210 2. NO
6 8. DK
1 Blank. Inap
==========================================================================================
CJB6 DEMENTIA, DSM III R, PERSONALITY CHANGE
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB6
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
6. Personality Change
.................................................................................
48 1. YES
259 2. NO
6 8. DK
2 Blank. Inap
==========================================================================================
CJB7 DEMENTIA, DSM III R, SOCIAL OR OCCUP IMPAIRMENT
Section: CJ 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
.................................................................................
37 1. YES
22 2. NO
8. DK
256 Blank. Inap
==========================================================================================
CJB8 DEMENTIA, DSM III R, SIGNIFICANT DECLINE
Section: CJ 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
.................................................................................
58 1. YES
1 2. NO
8. DK
256 Blank. Inap
==========================================================================================
CJB9 DEMENTIA, DSM III R, COG DEFICITS DURING DELIRIUM
Section: CJ 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
58 2. NO
8. DK
257 Blank. Inap
==========================================================================================
CJB1MET DEMENTIA, DSM III R - CRITERIA FOR CKB1 AND CKB2
Section: CJ 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
.................................................................................
255 0. NO
60 1. YES
==========================================================================================
CJB2MET DEMENTIA, DSM III R - CRITERIA FOR CKB3 - CKB6
Section: CJ 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
.................................................................................
185 0. NO
130 1. YES
==========================================================================================
CJB3MET DEMENTIA, DSM III R - CRITERIA FOR CKB7 AND CKB8
Section: CJ 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
.................................................................................
279 0. NO
36 1. YES
Blank. Inap
==========================================================================================
CJB4MET DEMENTIA, DSM III R - CRITERIA FOR CKB9
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB4MET
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
CHECKLIST MET IF CKB9=NO
.................................................................................
258 0. NO
57 1. YES
Blank. Inap
==========================================================================================
CJBMET DEMENTIA, DSM III R - WHETHER OVERALL DSM III R CRITERIA MET
Section: CJ 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
.................................................................................
280 0. NO
35 1. YES
==========================================================================================
CJC1 PROB AD, DEMENTIA, ESTABLISHED BY CKAMET OR CKBMET
Section: CJ 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
314 Blank. Inap
==========================================================================================
CJC2 PROB AD, PROGRESSION OF COGNITIVE SYMPTOMS
Section: CJ 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
314 Blank. Inap
==========================================================================================
CJC3 PROB AD, ABSENCE OF OTHER CONDITIONS SUFFICIENT TO CAUSE DEM
Section: CJ 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
314 Blank. Inap
==========================================================================================
CJC4 PROB AD, RPT OF MED EVAL TO RULE OUT OTHER CAUSES OF DEMENTIA
Section: CJ 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
314 Blank. Inap
==========================================================================================
CJC5 PROB AD, ONSET AFTER AGE 40
Section: CJ 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
314 Blank. Inap
==========================================================================================
CJC1MET PROB AD - CRITERIA FOR CKC1 - CKC5
Section: CJ 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
314 Blank. Inap
==========================================================================================
CJCMET PROB AD - CRITERIA FOR CKC1MET
Section: CJ 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
314 Blank. Inap
==========================================================================================
CJD1 POSS AD - CRITERIA FOR CKAMET OR CKBMET
Section: CJ 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)
.................................................................................
13 1. YES
6 2. NO
8. DK
296 Blank. Inap
==========================================================================================
CJD2 POSS AD, PROGRESSION OF COGNITIVE SYMPTOMS
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKD2
CHECKLIST FOUR
Checklist for Possible Alzheimer's Disease
2. Progression of symptoms over time
.................................................................................
18 1. YES
1 2. NO
8. DK
296 Blank. Inap
==========================================================================================
CJD3 POSS AD, ONSET AFTER AGE 40
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKD3
CHECKLIST FOUR
Checklist for Possible Alzheimer's Disease
3. Onset after age 40
.................................................................................
19 1. YES
2. NO
8. DK
296 Blank. Inap
==========================================================================================
CJD4 POSS AD, ATYPICAL ONSET, PRESENTATION OR PROGRESSION
Section: CJ 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
.................................................................................
3 1. YES
15 2. NO
1 8. DK
296 Blank. Inap
==========================================================================================
CJD5 POSS AD, PRESENCE OF SYSTEMIC OR BRAIN DISORDER, NOT SOLE CA
Section: CJ 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
.................................................................................
6 1. YES
13 2. NO
8. DK
296 Blank. Inap
==========================================================================================
CJD6 POSS AD, NO RPT OF MED EVAL TO RULE OUT OTHER DEM
Section: CJ 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
.................................................................................
16 1. YES
3 2. NO
8. DK
296 Blank. Inap
==========================================================================================
CJD1MET POSS AD - CRITERIA FOR CKD1 - CKD3
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKD1MET
CHECKLIST FOUR
Checklist for Possible Alzheimer's Disease
CHECKLIST MET IF CKD1-CKD3=YES
.................................................................................
6 0. NO
13 1. YES
296 Blank. Inap
==========================================================================================
CJD2MET POSS AD - CRITERIA FOR CKD4 - CKD6
Section: CJ 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
19 1. YES
296 Blank. Inap
==========================================================================================
CJDMET POSS AD - CRITERIA FOR CKD1MET AND CKD2MET
Section: CJ 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
.................................................................................
6 0. NO
13 1. YES
296 Blank. Inap
==========================================================================================
CJE1 PROB VASC DEM - CRITERIA FOR CKAMET OR CKBMET
Section: CJ 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 1. YES
2. NO
8. DK
314 Blank. Inap
==========================================================================================
CJE2 PROB VASC DEM, IMPAIRMENT IN MEM AND 2 OTHER COG DOMAINS
Section: CJ 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 1. YES
2. NO
8. DK
314 Blank. Inap
==========================================================================================
CJE3 PROB VASC DEM, SOCIAL OR OCCUP IMPAIRMENT
Section: CJ 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 1. YES
2. NO
8. DK
314 Blank. Inap
==========================================================================================
CJE4 PROB VASC DEM, CVD BASED ON HIST OR EXAM
Section: CJ 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 1. YES
2. NO
8. DK
314 Blank. Inap
==========================================================================================
CJE5 PROB VASC DEM, EVIDENCE OF RELEVANT CVD NOTED ON BRAIN IMAGI
Section: CJ 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 1. YES
2. NO
8. DK
314 Blank. Inap
==========================================================================================
CJE6 PROB VASC DEM, ONSET OF DEM WITHIN 3 MOS OF STROKE
Section: CJ 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 1. YES
2. NO
8. DK
314 Blank. Inap
==========================================================================================
CJE7 PROB VASC DEM, DETERIORATION IN FUNCTION
Section: CJ 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 1. YES
2. NO
8. DK
314 Blank. Inap
==========================================================================================
CJE8 PROB VASC DEM, SPECIFIC BRAIN IMAGING INDICATE DAMAGE
Section: CJ 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 1. YES
2. NO
8. DK
314 Blank. Inap
==========================================================================================
CJE1MET PROB VASC DEM - CRITERIA FOR CKE1 - CKE5
Section: CJ 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 1. YES
314 Blank. Inap
==========================================================================================
CJE2MET PROB VASC DEM - CRITERIA FOR CKE6, CKE7, OR CKE8
Section: CJ 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 1. YES
314 Blank. Inap
==========================================================================================
CJEMET PROB VASC DEM - CRITERIA FOR CKE1MET AND CKE2MET
Section: CJ 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 1. YES
314 Blank. Inap
==========================================================================================
CJF1 POSS VASC DEM, EST BY CKAMET OR CKBMET
Section: CJ 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
1 2. NO
8. DON'T KNOW
311 Blank. Inap
==========================================================================================
CJF2 POSS VASC DEM, IMPAIRMENT IN MEM AND 2 OTHER COG DOMAINS
Section: CJ 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
.................................................................................
4 1. YES
2. NO
8. DON'T KNOW
311 Blank. Inap
==========================================================================================
CJF3 POSS VASC DEM, SOCIAL OR OCCUP IMPAIRMENT
Section: CJ 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
.................................................................................
4 1. YES
2. NO
8. DON'T KNOW
311 Blank. Inap
==========================================================================================
CJF4 POSS VASC DEM, CVD BASED ON HIST OR EXAM
Section: CJ 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).
.................................................................................
4 1. YES
2. NO
8. DON'T KNOW
311 Blank. Inap
==========================================================================================
CJF5 POSS VASC DEM, BRAIN IMAGING HAS NOT BEEN DONE
Section: CJ 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 1. YES
2. NO
3 8. DON'T KNOW
311 Blank. Inap
==========================================================================================
CJF6 POSS VASC DEM, UNCLEAR REL BET STROKE AND DEMENTIA
Section: CJ 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
.................................................................................
2 1. YES
2 2. NO
8. DON'T KNOW
311 Blank. Inap
==========================================================================================
CJF7 POSS VASC DEM, SUBTLE ONSET AND VARIABLE COURSE OF COG DEFICITS
Section: CJ 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
2 2. NO
8. DON'T KNOW
311 Blank. Inap
==========================================================================================
CJF1MET PROB VASC DEM - CRITERIA FOR CKF1 - CKF4
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKF1MET
CHECKLIST SIX
Checklist for Possible Vascular Dementia
CHECKLIST MET IF CKF1-CKF4=YES
.................................................................................
1 0. NO
3 1. YES
311 Blank. Inap
==========================================================================================
CJF2MET PROB VASC DEM - CRITERIA FOR CKF5 - CKF7
Section: CJ 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
4 1. YES
311 Blank. Inap
==========================================================================================
CJFMET PROB VASC DEM - CRITERIA FOR CKF1MET AND CKF2MET
Section: CJ 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
.................................................................................
1 0. NO
3 1. YES
311 Blank. Inap
==========================================================================================
CJG1 CIND, SHORT TERM OR LONG TERM MEMORY IMPAIRMENT
Section: CJ 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
.................................................................................
112 1. YES
11 2. NO
3 8. DK
189 Blank. Inap
==========================================================================================
CJG2 CIND, EXECUTIVE FUNCTION
Section: CJ 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)
.................................................................................
102 1. YES
17 2. NO
7 8. DK
189 Blank. Inap
==========================================================================================
CJG3 CIND, LANGUAGE
Section: CJ 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)
.................................................................................
75 1. YES
49 2. NO
2 8. DK
189 Blank. Inap
==========================================================================================
CJG4 CIND, PRAXIS
Section: CJ 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)
.................................................................................
29 1. YES
87 2. NO
10 8. DK
189 Blank. Inap
==========================================================================================
CJG5 CIND, ORIENTATION
Section: CJ 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)
.................................................................................
22 1. YES
103 2. NO
1 8. DK
189 Blank. Inap
==========================================================================================
CJG6 CIND, BASED ON DSRS SCORE
Section: CJ 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
.................................................................................
27 1. YES
92 2. NO
7 8. DK
189 Blank. Inap
==========================================================================================
CJG7 CIND, DOES NOT MEET CRITERIA FOR CKAMET OR CKBMET
Section: CJ 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
.................................................................................
107 1. YES
19 2. NO
8. DK
189 Blank. Inap
==========================================================================================
CJG1MET CIND - CRITERIA FOR CKG1 - CKG6
Section: CJ 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
.................................................................................
0. NO
126 1. YES
189 Blank. Inap
==========================================================================================
CJG2MET CIND - CRITERIA FOR CKG7
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKG2MET
CHECKLIST SEVEN
Checklist for Cognitive Impairment, Not Demented
CHECKLIST MET IF CKG7=YES
.................................................................................
19 0. NO
107 1. YES
189 Blank. Inap
==========================================================================================
CJGMET CIND - CRITERIA FOR CKG1MET AND CKG2MET
Section: CJ 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
.................................................................................
19 0. NO
107 1. YES
189 Blank. Inap
==========================================================================================
CJH1 MCI, MEMORY COMPLAINT BY INFORMANT
Section: CJ 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. YES
2. NO
8. DK
315 Blank. Inap
==========================================================================================
CJH2 MCI, MEMORY IMPAIRMENT BY MEASUREMENT ON MEMORY TASKS
Section: CJ 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. YES
2. NO
8. DK
315 Blank. Inap
==========================================================================================
CJH3 MCI, BASED ON MMSE SCORE
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKH3
CHECKLIST EIGHT
Checklist for Mild Cognitive Impairment (MCI)
3. MMSE > 24
.................................................................................
1. YES
2. NO
8. DK
315 Blank. Inap
==========================================================================================
CJH4 MCI, BASED ON CDR MEMORY SCORE AND OVERALL CDR
Section: CJ 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. YES
2. NO
8. DK
315 Blank. Inap
==========================================================================================
CJH5 MCI, NOT DUE TO MCKOR DEPRESSION
Section: CJ 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. YES
2. NO
8. DK
315 Blank. Inap
==========================================================================================
CJH6 MCI, MEETS CRITERIA FOR CIND
Section: CJ 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. YES
2. NO
8. DK
315 Blank. Inap
==========================================================================================
CJH1MET MCI - CRITERIA FOR CKH1 - CKH6
Section: CJ 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. YES
315 Blank. Inap
==========================================================================================
CJHMET MCI - CRITERIA FOR CKH1MET
Section: CJ 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. YES
315 Blank. Inap
==========================================================================================
CJI1 MAJOR DEPRESSION BASED ON NPI, CIDI, OR CLINICAL OR MEDICAL HISTORY
Section: CJ 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
.................................................................................
6 1. YES
2. NO
8. DK
309 Blank. Inap
==========================================================================================
CJI2 DEPRESSION, IMPAIRMENT NOT EXPLAINED BY OTHER ETIOLOGY
Section: CJ 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.
.................................................................................
6 1. YES
2. NO
8. DK
309 Blank. Inap
==========================================================================================
CJI3 DEPRESSION, MEETS CRITERIA FOR CIND
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKI3
CHECKLIST NINE
Checklist for Depression
3. Meets criteria for Cognitive Impairment
.................................................................................
3 1. YES
3 2. NO
8. DK
309 Blank. Inap
==========================================================================================
CJI1MET DEPRESSION - CRITERIA FOR CKI1, CKI2, AND CKI3
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKI1MET
CHECKLIST NINE
Checklist for Depression
CHECKLIST MET IF CKI1-CKI3=YES
.................................................................................
3 0. NO
3 1. YES
309 Blank. Inap
==========================================================================================
CJIMET DEPRESSION - CRITERIA FOR CKI1MET
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKIMET
CHECKLIST NINE
Checklist for Depression
OVERALL CHECKLIST NINE CRITERIA MET=YES IF CKI1MET=YES
.................................................................................
3 0. NO
3 1. YES
309 Blank. Inap
==========================================================================================
CJJ1 NEUROPSYCHIATRIC DISORDER - CLINICAL OR MEDICAL HISTORY
Section: CJ 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
.................................................................................
7 1. YES
2. NO
8. DK
308 Blank. Inap
==========================================================================================
CJJ2 NEUROPSYCHIATRIC DISORDER, NOT OTHERWISE EXPLAINED
Section: CJ 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
.................................................................................
7 1. YES
2. NO
8. DK
308 Blank. Inap
==========================================================================================
CJJ3 NEUROPSYCHIATRIC DISORDER, MEETS CRITERIA FOR CIND
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKJ3
CHECKLIST TEN
Checklist for Psychiatric Disorder
3. Meets criteria for Cognitive Impairment, No Dementia
.................................................................................
6 1. YES
1 2. NO
8. DK
308 Blank. Inap
==========================================================================================
CJJ1MET NEUROPSYCHIATRIC DISORDER, CRITERIA FOR CKJ1 - CKJ3
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKJ1MET
CHECKLIST TEN
Checklist for Psychiatric Disorder
CHECKLIST MET IF CKJ1-CKJ3=YES
.................................................................................
1 0. NO
6 1. YES
308 Blank. Inap
==========================================================================================
CJJMET NEUROPSYCHIATRIC DISORDER, CRITERIA FOR CKJ1MET
Section: CJ 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
.................................................................................
1 0. NO
6 1. YES
308 Blank. Inap
==========================================================================================
CJK1 LIFELONG HISTORY OF MENT RET, LD, LOW BASELINE INTELLECT
Section: CJ 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.
.................................................................................
1 1. YES
2. NO
8. DK
314 Blank. Inap
==========================================================================================
CJK2 MENT RET, LD, LOW BASELINE INTELLECT NOT EXPLAINED BY OTHER ETIOLOGY
Section: CJ 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
.................................................................................
1 1. YES
2. NO
8. DK
314 Blank. Inap
==========================================================================================
CJK3 MENT RET, LD, LOW BASELINE INTELLECT, MEETS CRITERIA FOR CIND
Section: CJ 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
.................................................................................
1 1. YES
2. NO
8. DK
314 Blank. Inap
==========================================================================================
CJK1MET MENT RET, LD, LOW BASELINE INTELLECT - CRITERIA FOR CKK1 - CKK3
Section: CJ 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
1 1. YES
314 Blank. Inap
==========================================================================================
CJKMET MENT RET, LD, LOW BASELINE INTELLECT - CRITERIA FOR AKJMET
Section: CJ 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
1 1. YES
314 Blank. Inap
==========================================================================================
CJL1 HISTORY OF PAST ALCOHOL ABUSE
Section: CJ 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. YES
2. NO
8. DK
315 Blank. Inap
==========================================================================================
CJL2 ALCOHOL ABUSE PAST, DISCONTINUED AT LEAST SIX MONTHS PRIOR TO EVAL
Section: CJ 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. YES
2. NO
8. DK
315 Blank. Inap
==========================================================================================
CJL3 PAST ALCOHOL ABUSE, NOT EXPLAINED BY OTHER ETIOLOGY
Section: CJ 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. YES
2. NO
8. DK
315 Blank. Inap
==========================================================================================
CJL4 PAST ALCOHOL ABUSE, MEETS CRITERIA FOR CIND
Section: CJ 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. YES
2. NO
8. DK
315 Blank. Inap
==========================================================================================
CJL1MET PAST ALCOHOL ABUSE - CRITERIA FOR CKL1 - CKL4
Section: CJ 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. YES
315 Blank. Inap
==========================================================================================
CJLMET PAST ALCOHOL ABUSE - CRITERIA FOR CKL1MET
Section: CJ 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. YES
315 Blank. Inap
==========================================================================================
CJM1 HISTORY OF PAST AND CURRENT ALCOHOL ABUSE
Section: CJ 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.
.................................................................................
3 1. YES
2. NO
8. DK
312 Blank. Inap
==========================================================================================
CJM2 HAS ABUSED ALCOHOL IN THE PAST SIX MONTHS
Section: CJ 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.
.................................................................................
2 1. YES
2. NO
1 8. DK
312 Blank. Inap
==========================================================================================
CJM3 CURRENT ALCOHOL ABUSE, NOT EXPLAINED BY OTHER ETIOLOGY
Section: CJ 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.
.................................................................................
3 1. YES
2. NO
8. DK
312 Blank. Inap
==========================================================================================
CJM4 CURRENT ALCOHOL ABUSE, MEETS CRITERIA FOR CIND
Section: CJ 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
.................................................................................
1. YES
3 2. NO
8. DK
312 Blank. Inap
==========================================================================================
CJM1MET CURRENT ALCOHOL ABUSE - CRITERIA FOR CKM1 - CKM4
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKM1MET
CHECKLIST THIRTEEN
Checklist for Alcohol Abuse (current)
CHECKLIST MET IF CKM1-CKM4=YES
.................................................................................
3 0. NO
1. YES
312 Blank. Inap
==========================================================================================
CJMMET CURRENT ALCOHOL ABUSE - CRITERIA FOR CKM1MET
Section: CJ 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
.................................................................................
3 0. NO
1. YES
312 Blank. Inap
==========================================================================================
CJN1 STROKE HIST BASED ON CLINICAL, MED HISTORY, OR NEUROLOGICAL EXAM
Section: CJ 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.
.................................................................................
14 1. YES
2. NO
8. DK
301 Blank. Inap
==========================================================================================
CJN2 STROKE SYMPTOM ONSET WITHIN THREE MONTHS AFTER REPORTED STROKE
Section: CJ 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
.................................................................................
11 1. YES
3 2. NO
8. DK
301 Blank. Inap
==========================================================================================
CJN3 STROKE, IMPAIRMENT NOT EXPLAINED BY OTHER ETIOLOGY
Section: CJ 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
.................................................................................
14 1. YES
2. NO
8. DK
301 Blank. Inap
==========================================================================================
CJN4 STROKE, MEETS CRITERIA FOR CIND
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKN4
CHECKLIST FOURTEEN
Checklist for Stroke
4. Meets criteria for Cognitive Impairment, No Dementia
.................................................................................
11 1. YES
3 2. NO
8. DK
301 Blank. Inap
==========================================================================================
CJN1MET STROKE - CRITERIA FOR CKN1 - CKN4
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKN1MET
CHECKLIST FOURTEEN
Checklist for Stroke
CHECKLIST MET IF CKN1-CKN4=YES
.................................................................................
5 0. NO
9 1. YES
301 Blank. Inap
==========================================================================================
CJNMET STROKE - CRITERIA FOR CKN1MET
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKNMET
CHECKLIST FOURTEEN
Checklist for Stroke
OVERALL CHECKLIST FOURTEEN CRITERIA MET=YES IF CKN1MET=YES
.................................................................................
5 0. NO
9 1. YES
301 Blank. Inap
==========================================================================================
CJO1 OTHER NEUROL COND, PRESENCE OF NEUROLOGICAL CONDITION
Section: CJ 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
.................................................................................
6 1. YES
2. NO
8. DK
309 Blank. Inap
==========================================================================================
CJO2 OTHER NEUROL COND, NOT EXPLAINED BY OTHER ETIOLOGY
Section: CJ 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
.................................................................................
6 1. YES
2. NO
8. DK
309 Blank. Inap
==========================================================================================
CJO3 OTHER NEUROL COND, MEETS CRITERIA FOR CIND
Section: CJ 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
.................................................................................
5 1. YES
1 2. NO
8. DK
309 Blank. Inap
==========================================================================================
CJO1MET OTHER NEUROL COND - CRITERIA FOR CKO1 - CKO3
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKO1MET
CHECKLIST FIFTEEN
Checklist for Other Neurological Condition
CHECKLIST MET IF CKO1-CK03=YES
.................................................................................
1 0. NO
5 1. YES
309 Blank. Inap
==========================================================================================
CJOMET OTHER NEUROL COND - CRITERIA FOR CKO1MET
Section: CJ 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
.................................................................................
1 0. NO
5 1. YES
309 Blank. Inap
==========================================================================================
CJP1 OTHER MEDICAL COND, PRESENCE OF MEDICAL CONDITION
Section: CJ 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.
.................................................................................
25 1. YES
2. NO
8. DK
290 Blank. Inap
==========================================================================================
CJP2 OTHER MEDICAL COND, NOT EXPLAINED BY OTHER ETIOLOGY
Section: CJ 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
.................................................................................
25 1. YES
2. NO
8. DK
290 Blank. Inap
==========================================================================================
CJP3 OTHER MEDICAL COND, MEETS CRITERIA FOR CIND
Section: CJ 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
.................................................................................
23 1. YES
2 2. NO
8. DK
290 Blank. Inap
==========================================================================================
CJP1MET OTHER MEDICAL COND - CRITERIA FOR CKP1 - CKP3
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKP1MET
CHECKLIST SIXTEEN
Checklist for Other Medical Condition
CHECKLIST MET IF CKP1-CKP3=YES
.................................................................................
2 0. NO
23 1. YES
290 Blank. Inap
==========================================================================================
CJPMET OTHER MEDICAL COND - CRITERIA FOR CKP1MET
Section: CJ 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
.................................................................................
2 0. NO
23 1. YES
290 Blank. Inap
==========================================================================================
CJQ1 PRESENCE OF CEREBROVASCULAR OR CARDIOVASCULAR CONDITIONS
Section: CJ 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
.................................................................................
15 1. YES
2. NO
8. DK
300 Blank. Inap
==========================================================================================
CJQ2 IMPAIRMENT NOT LINKED TO ONE FOCAL VASCULAR LESION
Section: CJ 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.
.................................................................................
15 1. YES
2. NO
8. DK
300 Blank. Inap
==========================================================================================
CJQ3 GRADUAL ONSET OF CEREBROVASCULAR OR CARDIOVASCULAR SYMPTOMS
Section: CJ 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
1 2. NO
8. DK
301 Blank. Inap
==========================================================================================
CJQ4 CIND SECONDARY TO VASCULAR DISEASE, NOT EXPLAINED BY OTHER ETIOLOGY
Section: CJ 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
.................................................................................
15 1. YES
2. NO
8. DK
300 Blank. Inap
==========================================================================================
CJQ5 CIND SECONDARY TO VASCULAR DISEASE, MEETS CIND CRITERIA
Section: CJ 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
.................................................................................
12 1. YES
3 2. NO
8. DK
300 Blank. Inap
==========================================================================================
CJQ1MET CIND SECONDARY TO VASCULAR DISEASE, CRITERIA FOR CKQ1 - CKQ5
Section: CJ 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
.................................................................................
4 0. NO
11 1. YES
300 Blank. Inap
==========================================================================================
CJQMET CIND SECONDARY TO VASC DISEASE - CRITERIA FOR CKQ1MET
Section: CJ 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
.................................................................................
4 0. NO
11 1. YES
300 Blank. Inap
==========================================================================================
CJR1 MILD AMBIGUOUS, IMPAIRMENT NOT EXPLAINED BY ETIOLOGY IN CIND
Section: CJ 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
.................................................................................
30 1. YES
2. NO
8. DK
285 Blank. Inap
==========================================================================================
CJR2 MILD AMBIGUOUS, GRADUAL ONSET AND PROGRESSION OF SYMPTOMS
Section: CJ 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
.................................................................................
25 1. YES
5 2. NO
8. DK
285 Blank. Inap
==========================================================================================
CJR3 MILD AMBIGUOUS, MEETS CRITERIA FOR CIND
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKR3
CHECKLIST EIGHTEEN
Checklist for Mild Ambiguous
3. Meets criteria for Cognitive Impairment, No Dementia
.................................................................................
27 1. YES
3 2. NO
8. DK
285 Blank. Inap
==========================================================================================
CJR1MET MILD AMBIGUOUS - CRITERIA FOR CKR1 - CKR3
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKR1MET
CHECKLIST EIGHTEEN
Checklist for Mild Ambiguous
CHECKLIST MET IF CKR1-CKR3=YES
.................................................................................
8 0. NO
22 1. YES
285 Blank. Inap
==========================================================================================
CJRMET MILD AMBIGUOUS - CRITERIA FOR CKR1MET
Section: CJ 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
.................................................................................
8 0. NO
22 1. YES
285 Blank. Inap
==========================================================================================
CJS1 DEM UNDETERMINED ETIOLOGY, EST BY DSM III OR DSM IV CRITERIA
Section: CJ 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
.................................................................................
8 1. YES
1 2. NO
8. DK
306 Blank. Inap
==========================================================================================
CJS2 DEMENTIA UNDETERMINED ETIOLOGY PROGRESSION OF SYMPTOMS OVER TIME
Section: CJ 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
1 2. NO
8. DK
306 Blank. Inap
==========================================================================================
CJS3 DEMENTIA UNDETERMINED ETIOLOGY, ATYPICAL FEATURES
Section: CJ 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
.................................................................................
9 1. YES
2. NO
8. DK
306 Blank. Inap
==========================================================================================
CJS1MET DEMENTIA UNDETERMINED ETIOLOGY - CRITERIA FOR CKS1 - CKS3
Section: CJ 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
8 1. YES
306 Blank. Inap
==========================================================================================
CJSMET DEMENTIA UNDETERMINED ETIOLOGY - CRITERIA FOR CKS1MET
Section: CJ 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
8 1. YES
306 Blank. Inap
==========================================================================================
CJT1 PD, DEM ESTABLISHED BY DSM III OR DSM IV CRITERIA
Section: CJ 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 1. YES
2. NO
8. DK
314 Blank. Inap
==========================================================================================
CJT2 PD, DIAGNOSIS OF PD
Section: CJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKT2
CHECKLIST TWENTY
Checklist for Parkinson's Dementia
2. Diagnosis of Parkinson's disease
.................................................................................
1 1. YES
2. NO
8. DK
314 Blank. Inap
==========================================================================================
CJT3 PD, COG SYMPTOMS PRIMARILY SUBCORTICAL
Section: CJ 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 1. YES
2. NO
8. DK
314 Blank. Inap
==========================================================================================
CJT4 PD, ONSET OF COG SYMPTOMS AT LEAST 1 YR PAST MOTOR SYMPTOMS
Section: CJ 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 1. YES
2. NO
8. DK
314 Blank. Inap
==========================================================================================
CJT1MET PD - CRITERIA FOR CKT1 - CKT4
Section: CJ 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 1. YES
314 Blank. Inap
==========================================================================================
CJTMET PD - CRITERIA FOR CKT1MET
Section: CJ 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 1. YES
314 Blank. Inap
==========================================================================================
CJU1 PROB LEWY BODY DEMENTIA EST BY DSM III OR DSM IV CRITERIA
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJU2 PROB LEWY BODY DEMENTIA, FLUCTUATING COGNITION
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJU3 PROB LEWY BODY DEMENTIA, RECURRENT VISUAL HALLUCINATIONS
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJU4 PROB LEWY BODY DEMENTIA, MOTOR FEATURES OF PARKINSONISM
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJU5 PROB LEWY BODY DEMENTIA, REPEATED FALLS
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJU6 PROB LEWY BODY DEMENTIA, SYNCOPE
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJU7 PROB LEWY BODY DEMENTIA, LOSS OF CONSCIOUSNESS
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJU8 PROB LEWY BODY DEMENTIA, NEUROLEPTIC SENSITIVITY
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJU9 PROB LEWY BODY DEMENTIA, SYSTEMATIZED DELUSIONS
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJU10 PROB LEWY BODY DEMENTIA, OTHER MODAL HALLUCINATIONS
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJU11 PROB LEWY BODY DEMENTIA, REM SLEEP DISORDER
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJU12 PROB LEWY BODY DEMENTIA, DEPRESSIVE SYMPTOMS
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJU1MET PROB LEWY BODY DEMENTIA - CRITERIA FOR CKU1
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJU2MET PROB LEWY BODY DEMENTIA - CRITERIA FOR CKU2 - CKU4
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJUMET PROB LEWY BODY DEM - CRITERIA FOR CKU1MET AND CKU2MET
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJV1 PSP, DEMENTIA EST BY DSM III OR DSM IV CRITERIA
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJV2 PSP, IMPAIRMENT OF VOLUNTARY DOWNWARD GAZE
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJV3 PSP, IMPAIRMENT NOT EXPLAINED BY ANOTHER DEMENTIA TYPE
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJV1MET PSP, CRITERIA FOR CKV1 - CKV3
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJVMET PSP, CRITERIA FOR CKV1MET
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJW1 NORMAL PRESSURE HYDROCEPHALUS, EST BY DSM III OR DSM IV CRITERIA
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJW2 NORMAL PRESSURE HYDROCEPHALUS, REPORT FROM NEUROIMAGING
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJW3 NORMAL PRESSURE HYDROCEPHALUS, NOT EXPLAINED BY OTHER DEMENTIA TYPE
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJW1MET NORMAL PRESSURE HYDROCEPHALUS, CRITERIA FOR CKW1 - CKW3
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJWMET NORMAL PRESSURE HYDROCEPHALUS - CRITERIA FOR CKW1MET
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJX1 HUNTINGTONS DEMENTIA, EST BY DSM III OR DSM IV CRITERIA
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJX2 HUNTINGTONS, DIAGNOSIS OF HUNTINGTONS DISEASE
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJX1MET HUNTINGTONS DEMENTIA, CRITERIA FOR CKX1 AND CKX2
Section: CJ 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
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==========================================================================================
CJXMET HUNTINGTONS DEMENTIA, CRITERIA FOR CKX1MET
Section: CJ 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
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==========================================================================================
CJY1 FRONTAL LOBE, INSIDIOUS ONSET AND SLOWLY PROGRESSIVE
Section: CJ 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
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==========================================================================================
CJY2 FRONTAL LOBE, PROFOUND FAILURE ON FRONTAL LOBE TESTS
Section: CJ 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
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==========================================================================================
CJY3 FRONTAL LOBE, PERCEPTUAL SPATIAL DISORDERS ARE ABSENT
Section: CJ 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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==========================================================================================
CJY4 FRONTAL LOBE, UNIQUE SPEECH DISTURBANCES
Section: CJ 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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==========================================================================================
CJY5 FRONTAL LOBE, COMMON AFFECTIVE SYMPTOMS
Section: CJ 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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==========================================================================================
CJY6 FRONTAL LOBE SIGNS AND OTHER PHYSICAL SIGNS
Section: CJ 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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==========================================================================================
CJY7 FRONTAL LOBE, NORMAL EEG
Section: CJ 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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==========================================================================================
CJY8 FRONTAL LOBE, BRAIN IMAGING
Section: CJ 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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==========================================================================================
CJY9 FRONTAL LOBE, OTHER SUPPORTIVE DIAGNOSTIC FEATURES
Section: CJ 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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==========================================================================================
CJY10 FRONTAL LOBE, EXCLUSIONARY FEATURES (LIST)
Section: CJ 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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==========================================================================================
CJY1MET FRONTAL LOBE, CRITERIA FOR CKY1
Section: CJ 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
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==========================================================================================
CJY2MET FRONTAL LOBE, CRITERIA FOR CKY2
Section: CJ 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
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==========================================================================================
CJY3MET FRONTAL LOBE, CRITERIA FOR CKY3
Section: CJ 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
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==========================================================================================
CJY4MET FRONTAL LOBE, CRITERIA FOR CKY4
Section: CJ 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
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==========================================================================================
CJY5MET FRONTAL LOBE, CRITERIA FOR CKY10
Section: CJ 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
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==========================================================================================
CJYMET FRONTAL LOBE - CRITERIA FOR CKY1MET - CKY5MET
Section: CJ 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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==========================================================================================
CJZ1 POSS LEWY BODY DEMENTIA EST BY DSM III OR DSM IV CRITERIA
Section: CJ 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
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==========================================================================================
CJZ2 POSS LEWY BODY DEMENTIA, FLUCTUATING COGNITION
Section: CJ 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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==========================================================================================
CJZ3 POSS LEWY BODY DEMENTIA, RECURRENT VISUAL HALLUCINATIONS
Section: CJ 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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==========================================================================================
CJZ4 POSS LEWY BODY DEMENTIA, MOTOR FEATURES OF PARKINSONISM
Section: CJ 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
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==========================================================================================
CJZ5 POSS LEWY BODY DEMENTIA, REPEATED FALLS
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJZ6 POSS LEWY BODY DEMENTIA, SYNCOPE
Section: CJ 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
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==========================================================================================
CJZ7 POSS LEWY BODY DEMENTIA, LOSS OF CONSCIOUSNESS
Section: CJ 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
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==========================================================================================
CJZ8 POSS LEWY BODY DEMENTIA, NEUROLEPTIC SENSITIVITY
Section: CJ 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
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==========================================================================================
CJZ9 POSS LEWY BODY DEMENTIA, SYSTEMATIZED DELUSIONS
Section: CJ 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
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==========================================================================================
CJZ10 POSS LEWY BODY DEMENTIA, OTHER MODAL HALLUCINATIONS
Section: CJ 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
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==========================================================================================
CJZ11 POSS LEWY BODY DEMENTIA, REM SLEEP DISORDER
Section: CJ 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
315 Blank. Inap
==========================================================================================
CJZ12 POSS LEWY BODY DEMENTIA, DEPRESSIVE SYMPTOMS
Section: CJ 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
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==========================================================================================
CJZ1MET POSS LEWY BODY DEMENTIA - CRITERIA FOR CKZ1
Section: CJ 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
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==========================================================================================
CJZ2MET POSS LEWY BODY DEMENTIA - CRITERIA FOR CKZ2 - CKZ4
Section: CJ 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
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==========================================================================================
CJZMET POSS LEWY BODY DEMENTIA - CRITERIA FOR CKZ1MET AND CKZ2MET
Section: CJ 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
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==========================================================================================
CJAA1 SEVERE HEAD TRAUMA, DEM ESTABLISHED BY CKAMET OR CKBMET
Section: CJ 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
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CJAA2 SEVERE HEAD TRAUMA, SEVERE COGNITIVE SEQUELAE
Section: CJ 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
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CJAA3 SEVERE HEAD TRAUMA, IMPAIRMENT NOT OTHERWISE EXPLAINED
Section: CJ 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
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==========================================================================================
CJAA1MET SEVERE HEAD TRAUMA - CRITERIA FOR CKAA1 - CKAA3
Section: CJ 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
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==========================================================================================
CJAAMET SEVERE HEAD TRAUMA - CRITERIA FOR CKAA1MET
Section: CJ 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
315 Blank. Inap
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