==========================================================================================
Section DJ: DEMENTIA CHECKLIST & NEUROLOGICAL EXAM - FOLLOW-UP VISIT (Respondent)
==========================================================================================
HHID HRS HOUSEHOLD IDENTIFIER
Section: DJ Level: Respondent Type: Character Width: 6 Decimals: 0
This variable uniquely identifies an original HRS household across waves.
.................................................................................
217 010059-213467. Household Identification Number
==========================================================================================
PN HRS PERSON NUMBER IDENTIFIER
Section: DJ 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.
.................................................................................
131 010. Person Number
4 011. Person Number
55 020. Person Number
021. Person Number
16 030. Person Number
11 040. Person Number
041. Person Number
==========================================================================================
ADAMSSID ADAMS SUBJECT IDENTIFIER
Section: DJ Level: Respondent Type: Character Width: 5 Decimals: 0
This variable identifies an ADAMS subject in the ADAMS data files.
.................................................................................
217 00111-21271. ADAMS Subject Identification Number
==========================================================================================
DJNEURCOMP WHETHER NEUROLOGICAL EXAM COMPLETED
Section: DJ 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.
.................................................................................
200 1. YES
17 5. NO
==========================================================================================
DJRANGELAT NEUROLOGICAL EXAM - RANGE, EXTENT OF LATERAL GAZE
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NERANGELAT
RANGE/EXTENT OF LATERAL GAZE
.................................................................................
191 1. NORMAL -- complete gaze to left/right
5 2. ABNORMAL -- incomplete left or right gaze
3 3. ABNORMAL -- complete absence of left or right gaze
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
1 9. MISSING
17 Blank. Inap
==========================================================================================
DJRANGEVER NEUROLOGICAL EXAM - RANGE,EXTENT OF VERTICAL GAZE
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NERANGEVER
RANGE/EXTENT OF VERTICAL GAZE
.................................................................................
195 1. NORMAL -- complete up & down gaze
1 2. ABNORMAL -- incomplete up & down gaze
3 3. ABNORMAL -- complete absence of up & down gaze
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
1 9. MISSING
17 Blank. Inap
==========================================================================================
DJEYEBROWS NEUROLOGICAL EXAM - RAISE EYEBROWS
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NERAISE
FROWN WITH KNIT BROWS
.................................................................................
194 1. NORMAL -- no weakness noted
4 2. ABNORMAL -- inability to raise eyebrow
3. ABNORMAL -- inability to wrinkle forehead on left or
right(Specify left or right does not raised as high as other
side)
1 7. OTHER (SPECIFY)
8. CAN'T EXECUTE
1 9. MISSING
17 Blank. Inap
==========================================================================================
DJWIDESMIL NEUROLOGICAL EXAM - WIDE SMILE, SHOW TEETH
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NESMILE
WIDE SMILE- SHOW TEETH
.................................................................................
195 1. NORMAL -- no weakness noted
2. ABNORMAL -- flattened nasolabial fold
1 3. ABNORMAL -- inability to raise corner of mouth on left or
right (Specify left or right not raised)
3 7. OTHER (SPECIFY)
8. CAN'T EXECUTE
1 9. MISSING
17 Blank. Inap
==========================================================================================
DJPHARYNGE NEUROLOGICAL EXAM - PHARYNGEAL MOVEMENTS
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEPHARYN
PHARYNGEAL MOVEMENTS (subject opens mouth, says 'ah')
.................................................................................
194 1. NORMAL -- SYMMETRIC PALATE ELEVATION
4 2. ABNORMAL -- ONE SIDE NOT ELEVATED AS HIGH (SPECIFY LEFT OR
RIGHT NOT ELEVATED AS HIGH)
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
2 9. MISSING
17 Blank. Inap
==========================================================================================
DJFACIAL NEUROLOGICAL EXAM - UPDRS FACIAL EXPRESSION
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUFACIAL
FACIAL EXPRESSION
.................................................................................
179 1. NORMAL
18 2. ABNORMAL -- Minimal hypomimia, could be normal "Poker Face"
1 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
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
1 9. Missing
17 Blank. Inap
==========================================================================================
DJSPEECH NEUROLOGICAL EXAM - UPDRS SPEECH
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUSPEECH
SPEECH
.................................................................................
190 1. NORMAL
9 2. ABNORMAL -- Slight loss of expression, diction and/or volume
3. ABNORMAL -- Monotone, slurred but understandable; moderately
impaired
1 4. ABNORMAL -- Marked impairment, difficult to understand
5. ABNORMAL -- Unintelligible
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
9. Missing
17 Blank. Inap
==========================================================================================
DJF_NRIGHT NEUROLOGICAL EXAM - FINGER TO NOSE TOUCH, RIGHT REV
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NENOSETOUCHR
RIGHT FINGER-TO-NOSE TOUCHING
.................................................................................
160 1. NORMAL -- quickly, smooth and accurate
37 2. ABNORMAL -- slow but accurate
2 3. ABNORMAL -- dysmetria noted
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
1 9. MISSING
17 Blank. Inap
==========================================================================================
DJF_NLEFT NEUROLOGICAL EXAM - FINGER TO NOSE TOUCH, LEFT REV
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NENOSETOUCHL
LEFT FINGER-TO-NOSE TOUCHING
.................................................................................
159 1. NORMAL -- quickly, smooth and accurate
34 2. ABNORMAL -- slow but accurate
3 3. ABNORMAL -- dysmetria noted
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
4 9. MISSING
17 Blank. Inap
==========================================================================================
DJRF_TTAPP NEUROLOGICAL EXAM - UPDRS FINGER THUMB TAPPING, RIGHT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTHUMBTAPR
RIGHT FINGER-THUMB TAPPING
.................................................................................
112 1. NORMAL -- 4 taps/second
74 2. ABNORMAL -- Mild slowing and/or reduction in amplitude
9 3. ABNORMAL -- Moderately impaired. Definite and early
fatiguing. May have occasion arrests in movement.
4. ABNORMAL -- Severely impaired. Frequent hesitation in
initiating movements or arrests in ongoing movement.
1 5. ABNORMAL -- Can barely perform.
1 7. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
2 9. MISSING
17 Blank. Inap
==========================================================================================
DJLF_TTAPP NEUROLOGICAL EXAM - UPDRS FINGER THUMB TAPPING, LEFT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTHUMBTAPL
LEFT FINGER-THUMB TAPPING
.................................................................................
111 1. NORMAL -- 4 taps/second
67 2. ABNORMAL -- Mild slowing and/or reduction in amplitude
16 3. ABNORMAL -- Moderately impaired. Definite and early
fatiguing. May have occasion arrests in movement.
4. ABNORMAL -- Severely impaired. Frequent hesitation in
initiating movements or arrests in ongoing movement.
1 5. ABNORMAL -- Can barely perform.
1 7. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
3 9. MISSING
17 Blank. Inap
==========================================================================================
DJHANDMOVER NEUROLOGICAL EXAM - UPDRS HAND MOVEMENTS, RIGHT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUHANDMOVER
RIGHT HAND MOVEMENTS
.................................................................................
122 1. NORMAL
69 2. ABNORMAL -- Mild slowing and/or reduction in amplitude
6 3. ABNORMAL -- Moderately impaired. Definite and early
fatiguing. May have occasional arrests in movement.
1 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
2 9. MISSING
17 Blank. Inap
==========================================================================================
DJHANDMOVEL NEUROLOGICAL EXAM - UPDRS HAND MOVEMENTS, LEFT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUHANDMOVEL
LEFT HAND MOVEMENTS
.................................................................................
124 1. NORMAL
67 2. ABNORMAL -- Mild slowing and/or reduction in amplitude
6 3. ABNORMAL -- Moderately impaired. Definite and early
fatiguing. May have occasional arrests in movement.
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
3 9. MISSING
17 Blank. Inap
==========================================================================================
DJRAPIDHANDR NEUROL EXAM - UPDRS RAPID ALT HAND MOVE, RIGHT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEURAPIDHANDR
RIGHT RAPID ALTERNATING MOVEMENTS OF HANDS
.................................................................................
147 1. NORMAL--At least 3 pats/second and smooth
35 2. ABNORMAL -- Mild slowing and/or reduction in amplitude
14 3. ABNORMAL -- Moderately impaired. Definite and early
fatiguing. May have occasional arrests in movement.
1 4. ABNORMAL -- Severely impaired. Frequent hesitation in
initiating movements or arrests in ongoing movement.
2 5. ABNORMAL -- Can barely perform the task.
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
1 9. MISSING
17 Blank. Inap
==========================================================================================
DJRAPIDHANDL NEUROL EXAM - UPDRS RAPID ALT HAND MOVE, LEFT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEURAPIDHANDL
LEFT RAPID ALTERNATING MOVEMENTS OF HANDS
.................................................................................
125 1. NORMAL--At least 3 pats/second and smooth
42 2. ABNORMAL -- Mild slowing and/or reduction in amplitude
27 3. ABNORMAL -- Moderately impaired. Definite and early
fatiguing. May have occasional arrests in movement.
1 4. ABNORMAL -- Severely impaired. Frequent hesitation in
initiating movements or arrests in ongoing movement.
1 5. ABNORMAL -- Can barely perform the task.
1 7. OTHER (SPECIFY)
8. CAN'T EXECUTE
3 9. MISSING
17 Blank. Inap
==========================================================================================
DJHAND_A NEUROLOGICAL EXAM - INTERLOCKING THUMBS
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEINTTHUMB
HAND PRAXIS TASKS: INTER-LOCKING FINGERS
A). Inter-locking fingers
.................................................................................
146 1. NORMAL -- performs correctly
48 2. ABNORMAL -- performs incorrectly
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
6 9. MISSING
17 Blank. Inap
==========================================================================================
DJHAND_B NEUROLOGICAL EXAM - MIRRORED FINGERS
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEMIRRORFING
HAND PRAXIS TASKS: MIRRORED FINGERS
B). Mirrored fingers
.................................................................................
130 1. NORMAL -- performs correctly
65 2. ABNORMAL -- performs incorrectly
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
5 9. MISSING
17 Blank. Inap
==========================================================================================
DJTONUSNECK NEUROLOGICAL EXAM - UPDRS RIGIDITY MUSCLE TONUS (NECK)
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTONUSNEC
RIGHT Rigidity MUSCLE TONUS (neck)
.................................................................................
125 1. NORMAL -- normal muscle tone, no rigidity
29 2. ABNORMAL -- Slight
26 3. ABNORMAL -- Mild to moderate
4 4. ABNORMAL -- Marked, but full range of motion easily achieved
2 5. ABNORMAL -- Severe, range of motion achieved with difficulty
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
14 9. MISSING
17 Blank. Inap
==========================================================================================
DJTONUSUPR NEUROL EXAM - UPDRS RIGIDITY MUSCLE TONUS (UPPER EX), R
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTONUSUPR
RIGHT Rigidity MUSCLE TONUS (upper extremity)
.................................................................................
180 1. NORMAL -- normal muscle tone, no rigidity
13 2. ABNORMAL -- Slight or detectable only when activated by
mirror or other movements
5 3. ABNORMAL -- Mild to moderate
4. ABNORMAL -- Marked, but full range of motion easily achieved
1 5. ABNORMAL -- Severe, range of motion achieved with difficulty
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
1 9. MISSING
17 Blank. Inap
==========================================================================================
DJTONUSUPL NEUROL EXAM - UPDRS RIGIDITY MUSCLE TONUS (UPPER EX), L
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTONUSUPL
LEFT Rigidity MUSCLE TONUS (upper extremity)
.................................................................................
179 1. NORMAL -- normal muscle tone, no rigidity
12 2. ABNORMAL -- Slight or detectable only when activated by
mirror or other movements
5 3. ABNORMAL -- Mild to moderate
1 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
17 Blank. Inap
==========================================================================================
DJTONUSLOWR NEUROL EXAM - UPDRS RIGIDITY MUSCLE TONUS (LOWER EX), R
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTONUSLOWR
RIGHT Rigidity MUSCLE TONUS (lower extremity)
.................................................................................
147 1. NORMAL -- normal muscle tone, no rigidity
27 2. ABNORMAL -- Slight or detectable only when activated by
mirror or other movements
13 3. ABNORMAL -- Mild to moderate
1 4. ABNORMAL -- Marked, but full range of motion easily achieved
2 5. ABNORMAL -- Severe, range of motion achieved with difficulty
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
10 9. MISSING
17 Blank. Inap
==========================================================================================
DJTONUSLOWL NEUROL EXAM - UPDRS RIGIDITY MUSCLE TONUS (LOWER EX), L
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTONUSLOWL
LEFT Rigidity MUSCLE TONUS (lower extremity)
.................................................................................
144 1. NORMAL -- normal muscle tone, no rigidity
27 2. ABNORMAL -- Slight or detectable only when activated by
mirror or other movements
18 3. ABNORMAL -- Mild to moderate
4. ABNORMAL -- Marked, but full range of motion easily achieved
2 5. ABNORMAL -- Severe, range of motion achieved with difficulty
1 7. OTHER (SPECIFY)
8. CAN'T EXECUTE
8 9. MISSING
17 Blank. Inap
==========================================================================================
DJRCOGWHL NEUROLOGICAL EXAM - COGWHEEL PHENOMENON, RIGHT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NECOGWHEELR
RIGHT COGWHEEL PHENOMENON
.................................................................................
196 1. NORMAL -- no cogwheeling noted
3 2. ABNORMAL -- slight or noticeable rhythmicity throughout
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
1 9. MISSING
17 Blank. Inap
==========================================================================================
DJLCOGWHL NEUROLOGICAL EXAM - COGWHEEL PHENOMENON, LEFT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NECOGWHEELL
LEFT COGWHEEL PHENOMENON
.................................................................................
195 1. NORMAL -- no cogwheeling noted
3 2. ABNORMAL -- slight or noticeable rhythmicity throughout
3. OTHER (SPECIFY)
8. CAN'T EXECUTE
2 9. MISSING
17 Blank. Inap
==========================================================================================
DJUPPERMSA NEUROLOGICAL EXAM - UPPER EX MOTOR STRENGTH
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUPPERMSA
UPPER EXTREMITY MOTOR STRENGTH
.................................................................................
164 1. WRIST EXTENSION
30 2. TRICEPS PULL
23 Blank. Inap
==========================================================================================
DJUPPERMS NEUROLOGICAL EXAM - UPPER EXTREMITY MOTOR STRENGTH
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUPPERMS
UPPER EXTREMITY MOTOR STRENGTH
.................................................................................
182 1. NORMAL -- No strength difference between R and L trials
12 2. ABNORMAL -- SPECIFY WEAKNESS(L OR R)
7. OTHER
8. CAN'T EXECUTE
6 9. MISSING
17 Blank. Inap
==========================================================================================
DJTREMFACE NEUROLOGICAL EXAM - UPDRS TREMOR AT REST (FACE, LIP, CHIN)
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTREMFACE
TREMOR AT REST (face, lip, chin)
.................................................................................
197 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.
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
9. MISSING
17 Blank. Inap
==========================================================================================
DJTREMHANDSR NEUROLOGICAL EXAM - UPDRS TREMOR AT REST (HANDS), RIGHT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTREMHANDSR
RIGHT TREMOR AT REST (hands)
.................................................................................
180 1. NORMAL - ABSENT
16 2. ABNORMAL - SLIGHT AND INFREQUENTLY PRESENT
4 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
9. MISSING
17 Blank. Inap
==========================================================================================
DJTREMHANDSL NEUROLOGICAL EXAM - UPDRS TREMOR AT REST (HANDS), LEFT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTREMHNDSL
LEFT TREMOR AT REST (hands)
.................................................................................
175 1. NORMAL - ABSENT
21 2. ABNORMAL - SLIGHT AND INFREQUENTLY PRESENT
4 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
9. MISSING
17 Blank. Inap
==========================================================================================
DJTREMFEETR NEUROLOGICAL EXAM - UPDRS TREMOR AT REST (FEET), RIGHT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTREMFEETR
RIGHT TREMOR AT REST (feet)
.................................................................................
197 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.
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
17 Blank. Inap
==========================================================================================
DJTREMFEETL NEUROLOGICAL EXAM - UPDRS TREMOR AT REST (FEET), LEFT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTREMFEETL
LEFT TREMOR AT REST (feet)
.................................................................................
198 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.
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
1 9. MISSING
17 Blank. Inap
==========================================================================================
DJPRONAT NEUROLOGICAL EXAM - PRONATOR DRIFT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEPRONATOR
PRONATOR DRIFT (arms out-stretched, palms up, eyes closed)
.................................................................................
168 1. NORMAL -- absence of drift
28 2. ABNORMAL -- spontaneous drift of either/both hands
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
4 9. MISSING
17 Blank. Inap
==========================================================================================
DJSTRENGTH NEUROLOGICAL EXAM - STRENGTH DIFFERENCE, DOWN PRESSURE
Section: DJ 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)
.................................................................................
130 1. NORMAL -- no strength difference, equal rebound
61 2. ABNORMAL -- unequal rebound
1 7. OTHER (SPECIFY)
8. CAN' T EXECUTE
8 9. MISSING
17 Blank. Inap
==========================================================================================
DJACTIONHNDSR NEUROL EXAM - UPDRS ACTION OR POSTURAL HAND TREMOR, RIGHT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUACTIONHNDSR
RIGHT ACTION OR POSTURAL TREMOR OF HANDS
.................................................................................
128 1. NORMAL - Absent
69 2. ABNORMAL - Slight; present with action
2 3. ABNORMAL - Moderate in amplitude, present with action
4. ABNORMAL - Moderate in amplitude with posture holding as
well as action
5. ABNORMAL - Marked in amplitude; interferes with feeding
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
1 9. MISSING
17 Blank. Inap
==========================================================================================
DJACTIONHNDSL NEUROL EXAM - UPDRS ACTION OR POSTURAL HAND TREMOR, LEFT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUACTIONHNDSL
LEFT ACTION OR POSTURAL TREMOR OF HANDS
.................................................................................
128 1. NORMAL - Absent
69 2. ABNORMAL - Slight; present with action
2 3. ABNORMAL - Moderate in amplitude, present with action
4. ABNORMAL - Moderate in amplitude with posture holding as
well as action
5. ABNORMAL - Marked in amplitude; interferes with feeding
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
1 9. MISSING
17 Blank. Inap
==========================================================================================
DJRANKLE NEUROLOGICAL EXAM - ANKLE CLONUS, RIGHT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEANKLECLONR
RIGHT ANKLE CLONUS
Right
.................................................................................
185 1. NORMAL -- absent
2. ABNORMAL -- present
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
15 9. MISSING
17 Blank. Inap
==========================================================================================
DJLANKLE NEUROLOGICAL EXAM - ANKLE CLONUS, LEFT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEANKLECLONL
LEFT ANKLE CLONUS
Left
.................................................................................
186 1. NORMAL -- absent
2. ABNORMAL -- present
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
14 9. MISSING
17 Blank. Inap
==========================================================================================
DJLEGAGILR NEUROLOGICAL EXAM - UPDRS LEG AGILITY, RIGHT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEULEGAGILR
RIGHT LEG AGILITY
.................................................................................
139 1. Absent
50 2. Mild Slowing and/or reduction in amplitude
2 3. ABNORMAL - Moderately impaired. Definite and early
fatiguing. May have occasional arrests in movement.
4. ABNORMAL -- Severly 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
9 9. MISSING
17 Blank. Inap
==========================================================================================
DJLEGAGILL NEUROLOGICAL EXAM - UPDRS LEG AGILITY, LEFT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEULEGAGILL
LEFT LEG AGILITY
.................................................................................
129 1. Absent
53 2. Mild Slowing and/or reduction in amplitude
7 3. ABNORMAL - Moderately impaired. Definite and early
fatiguing. May have occasional arrests in movement.
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
10 9. MISSING
17 Blank. Inap
==========================================================================================
DJRPROPRIC NEUROLOGICAL EXAM - PROPRIOCEPTION, RIGHT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEPROPRIOCEPR
RIGHT KINESTHESIS
.................................................................................
120 1. PRESENT
59 2. ABSENT
8. CAN'T EXECUTE
21 9. MISSING
17 Blank. Inap
==========================================================================================
DJLPROPRIC NEUROLOGICAL EXAM - PROPRIOCEPTION, LEFT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEPROPRIOCEPL
LEFT KINESTHESIS
.................................................................................
131 1. PRESENT
48 2. ABSENT
8. CAN'T EXECUTE
21 9. MISSING
17 Blank. Inap
==========================================================================================
DJRVIBRAT NEUROLOGICAL EXAM - VIBRATING SENSATION, RIGHT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEVIBRATINGR
RIGHT VIBRATING SENSATION
.................................................................................
106 1. PRESENT
77 2. ABSENT
8. CAN'T EXECUTE
17 9. MISSING
17 Blank. Inap
==========================================================================================
DJLVIBRAT NEUROLOGICAL EXAM - VIBRATING SENSATION, LEFT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEVIBRATINGL
LEFT VIBRATING SENSATION
.................................................................................
110 1. PRESENT
75 2. ABSENT
8. CAN'T EXECUTE
15 9. MISSING
17 Blank. Inap
==========================================================================================
DJRPLANTAR NEUROLOGICAL EXAM - PLANTAR RESPONSE, RIGHT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEPLANTARR
RIGHT PLANTAR RESPONSE
.................................................................................
120 1. NORMAL -- plantar flexion of great toe
20 2. ABNORMAL -- extension of great toe
38 3. ABNORMAL -- no reflex present
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
22 9. MISSING
17 Blank. Inap
==========================================================================================
DJLPLANTAR NEUROLOGICAL EXAM - PLANTAR RESPONSE, LEFT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEPLANTARL
LEFT PLANTAR RESPONSE
.................................................................................
116 1. NORMAL -- plantar flexion of great toe
24 2. ABNORMAL -- extension of great toe
39 3. ABNORMAL -- no reflex present
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
21 9. MISSING
17 Blank. Inap
==========================================================================================
DJARISECH NEUROLOGICAL EXAM - UPDRS ARISING FROM CHAIR
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUARISING
ARISING FROM CHAIR
.................................................................................
133 1. NORMAL
12 2. Slow; or may need more than one attempt
33 3. Pushes self up from arms of seat
7 4. Tend to fall back and may have to try more than one time,
but can get up without help.
3 5. Unable to arise without help
7. Other (Specify)
8. CAN'T EXECUTE
12 9. MISSING
17 Blank. Inap
==========================================================================================
DJROMBERG NEUROLOGICAL EXAM - ROMBERGS SIGN
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEROMBERGS
ROMBERG'S SIGN (stand with feet together for 10-15 seconds)
.................................................................................
171 1. NORMAL -- normally still or slight weaving
10 2. ABNORMAL -- falls to one side with eyes closed
1 3. ABNORMAL -- falls to one side with eyes open
4. ABNORMAL -- needs widened base to stay in one place
3 7. OTHER (SPECIFY)
1 8. CAN'T EXECUTE
14 9. MISSING
17 Blank. Inap
==========================================================================================
DJPOSTSTABIL NEUROLOGICAL EXAM - POSTURAL STABILITY
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUPOSTSTABIL
POSTURAL STABILITY
.................................................................................
111 1. NORMAL
36 2. Retropulsion, but recovers unaided.
34 3. Absence of postural response; would fall if not caught by
examiner
4. Very unstable, tends to lose balance spontaneously
1 5. Unable to stand without help
7. Other (Specify)
8. CAN'T EXECUTE
18 9. MISSING
17 Blank. Inap
==========================================================================================
DJGAIT NEUROLOGICAL EXAM - UPDRS GAIT: WALK 10 PACES
Section: DJ 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
.................................................................................
93 1. NORMAL -- normal gait
65 2. ABNORMAL -- Walks slowly, may shuffle with short steps, but
no festination (hastening steps) or propulsion
23 3. ABNORMAL -- Walks with difficulty, but requires little or no
assistance; may have some festination, short steps, or
propulsion
1 4. ABNORMAL -- Severe disturbance of gait, requiring assistance
5. ABNORMAL -- Cannot walk at all, even with assistance
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
18 9. MISSING
17 Blank. Inap
==========================================================================================
DJPIVOT NEUROLOGICAL EXAM - GAIT: PIVOT WHILE TURNING
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUPIVOT
GAIT - and also time gait task
B). Pivot while turning
.................................................................................
85 1. NORMAL -- pivots on narrow base
48 2. ABNORMAL -- Hesitates
29 3. ABNORMAL -- Widens base or moves feet
19 4. ABNORMAL -- Turns slowly or awkwardly
1 7. OTHER (SPECIFY)
8. CAN' T EXECUTE
18 9. MISSING
17 Blank. Inap
==========================================================================================
DJTIMED1_COMP NEUROLOGICAL EXAM - TIMED GAIT TR 1 COMPLETED
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTIMED1_COMP
GAIT - and also time gait task
C). Timed gait task
Trial 1 Completed
.................................................................................
181 1. Completed
8. CAN'T EXECUTE
19 9. MISSING
17 Blank. Inap
==========================================================================================
DJTIMED1 NEUROLOGICAL EXAM - TIMED GAIT TR 1 TIME (SEC)
Section: DJ Level: Respondent Type: Numeric Width: 2 Decimals: 0
Ref: NEUTIMED1
GAIT - and also time gait task
C). Timed gait task
Trial 1 Time (sec)
.................................................................................
181 2.12-18.88. Seconds
36 Blank. Inap
==========================================================================================
DJTIMED2_COMP NEUROLOGICAL EXAM - TIMED GAIT TR 2 COMPLETED
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUTIMED2_COMP
GAIT - and also time gait task
C). Timed gait task
Trial 2 Completed
.................................................................................
180 1. Completed
8. CAN'T EXECUTE
20 9. MISSING
17 Blank. Inap
==========================================================================================
DJTIMED2 NEUROLOGICAL EXAM - TIMED GAIT TR 2 TIME (SEC)
Section: DJ Level: Respondent Type: Numeric Width: 2 Decimals: 0
Ref: NEUTIMED2
GAIT - and also time gait task
C). Timed gait task
Trial 2 Time (sec)
.................................................................................
180 1.5-16.97. Seconds
37 Blank. Inap
==========================================================================================
DJTIMEDFL NEUROLOGICAL EXAM - TYPE OF FLOOR SURFACE
Section: DJ Level: Respondent Type: Numeric Width: 2 Decimals: 0
Ref: NEUTIMEDFL
TYPE OF FLOOR SURFACE
.................................................................................
87 1. Linoleum/tile/wood
92 2. Low-pile carpet
2 3. High-pile carpet
4. Concrete
7. Other(specify)
98. DON'T KNOW
36 Blank. Inap
==========================================================================================
DJTIMEDAID NEUROLOGICAL EXAM - TYPE OF AID USED
Section: DJ Level: Respondent Type: Numeric Width: 2 Decimals: 0
Ref: NEUTIMEDAID
TYPE OF AID USED
.................................................................................
172 1. None
7 2. Walking stick or cane
3. Crutches
2 4. Walking frame
7. Other (specify)
98. DON'T KNOW
36 Blank. Inap
==========================================================================================
DJHYPOKINES NEUROLOGICAL EXAM - UPDRS BODY BRADYKINESIA AND HYPOKINESIA
Section: DJ 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).
.................................................................................
168 1. NORMAL -- None
16 2. ABNORMAL -- Minimal slowness, giving movement a deliberate
character; could be normal for some persons, Possibly
reduced amplitude.
11 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
1 5. ABNORMAL -- Marked slowness, poverty or small amplitude of
movement
7. OTHER (SPECIFY)
8. CAN' T EXECUTE
1 9. MISSING
17 Blank. Inap
==========================================================================================
DJMYOCLONU NEUROLOGICAL EXAM - MYOCLONUS
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: MYOCLONUS
MYOCLONUS
.................................................................................
198 1. NORMAL -- absent
2. ABNORMAL -- mild myoclonus
1 3. ABNORMAL -- occasional myoclonus
4. ABNORMAL -- frequent myoclonus
5. ABNORMAL -- severe myoclonus
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
1 9. MISSING
17 Blank. Inap
==========================================================================================
DJPOSTURE NEUROLOGICAL EXAM - UPDRS POSTURE
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEUPOSTURE
POSTURE
.................................................................................
73 1. NORMAL -- normal, erect
81 2. ABNORMAL -- Not quite erect, slightly stooped; could be
normal for older person
35 3. ABNORMAL -- Moderately stooped posture, definitely abnormal;
can be slightly leaning to one side (Specify if leaning to
right, left or neither)
1 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
9 9. MISSING
17 Blank. Inap
==========================================================================================
DJCOMB NEUROLOGICAL EXAM - PRAXIS, COMB YOUR HAIR
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEPRAXCOMB
PRAXIS TASKS (PRETEND TO COMB YOUR HAIR)
.................................................................................
169 1. NORMAL, PERFORMS CORRECTLY
30 2. ABNORMAL (SPECIFY)
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
1 9. MISSING
17 Blank. Inap
==========================================================================================
DJHAMMER NEUROLOGICAL EXAM - PRAXIS, HAMMER A NAIL
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEPRAXHAMMER
PRAXIS TASKS (PRETEND TO HAMMER A NAIL)
.................................................................................
159 1. NORMAL, PERFORMS CORRECTLY
39 2. ABNORMAL (SPECIFY)
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
2 9. MISSING
17 Blank. Inap
==========================================================================================
DJBRUSH NEUROLOGICAL EXAM - PRAXIS, BRUSH YOUR TEETH
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: NEPRAXBRUSH
PRAXIS TASKS (PRETEND TO BRUSH YOUR TEETH)
.................................................................................
129 1. NORMAL, PERFORMS CORRECTLY
70 2. ABNORMAL (SPECIFY)
7. OTHER (SPECIFY)
8. CAN'T EXECUTE
1 9. MISSING
17 Blank. Inap
==========================================================================================
DJCHKDONE WHETHER DEMENTIA CHECKLIST COMPLETED
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CHKDONE
DEMENTIA CHECKLIST COMPLETED
.................................................................................
217 1. YES
2. NO
==========================================================================================
DJA1 DEMENTIA, DSM IV, MEM IMPAIRMENT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA1
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
1. Memory Impairment 'short or long term)
.................................................................................
134 1. YES
80 2. NO
3 8. DK
Blank. Inap
==========================================================================================
DJA2 DEMENTIA, DSM IV, APHASIA
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA2
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
2. Aphasia
.................................................................................
5 1. YES
210 2. NO
2 8. DK
Blank. Inap
==========================================================================================
DJA3 DEMENTIA, DSM IV, APRAXIA
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA3
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
3. Apraxia
.................................................................................
38 1. YES
167 2. NO
12 8. DK
Blank. Inap
==========================================================================================
DJA4 DEMENTIA, DSM IV, AGNOSIA
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA4
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
4. Agnosia
.................................................................................
5 1. YES
209 2. NO
3 8. DK
==========================================================================================
DJA5 DEMENTIA, DSM IV, EXEC FUNCTION DISTURBANCE
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA5
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
5. Disturbance in executive functioning
.................................................................................
46 1. YES
167 2. NO
3 8. DK
1 Blank. Inap
==========================================================================================
DJA6 DEMENTIA, DSM IV, SOCIAL OR OCCUP IMPAIRMENT
Section: DJ 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
.................................................................................
20 1. YES
39 2. NO
1 8. DK
157 Blank. Inap
==========================================================================================
DJA7 DEMENTIA, DSM IV, SIGNIFICANT DECLINE
Section: DJ 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
.................................................................................
57 1. YES
2 2. NO
8. DK
158 Blank. Inap
==========================================================================================
DJA8 DEMENTIA, DSM IV, COG DEFICITS DURING DELIRIUM
Section: DJ 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
59 2. NO
8. DK
158 Blank. Inap
==========================================================================================
DJA1MET DEMENTIA - CRITERIA FOR CKA1
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA1MET
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
CHECKLIST IS MET IF CKA1=YES
.................................................................................
84 0. NO
133 1. YES
==========================================================================================
DJA2MET DEMENTIA - CRITERIA FOR CKA2 - CKA5
Section: DJ 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
.................................................................................
145 0. NO
72 1. YES
==========================================================================================
DJA3MET DEMENTIA - CRITERIA FOR CKA6 AND CKA7
Section: DJ 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
.................................................................................
198 0. NO
19 1. YES
==========================================================================================
DJA4MET DEMENTIA - CRITERIA FOR CKA8
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKA4MET
CHECKLIST ONE
CHECKLIST FOR DEMENTIA (DSM-IV)
CHECKLIST IS MET IF CKA8=YES
.................................................................................
158 0. NO
59 1. YES
==========================================================================================
DJAMET DEMENTIA - WHETHER OVERALL DSM IV CRITERIA MET
Section: DJ 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
.................................................................................
198 0. NO
19 1. YES
==========================================================================================
DJB1 DEMENTIA, DSM III R, SHORT TERM MEMORY
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB1
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
1. Short Term Memory
.................................................................................
129 1. YES
85 2. NO
3 8. DK
==========================================================================================
DJB2 DEMENTIA, DSM III R, LONG TERM MEMORY
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB2
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
2. Long Term Memory
.................................................................................
30 1. YES
184 2. NO
3 8. DK
==========================================================================================
DJB3 DEMENTIA, DSM III R, ABSTRACT THINKING
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB3
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
3. Abstract thinking
.................................................................................
21 1. YES
193 2. NO
3 8. DK
==========================================================================================
DJB4 DEMENTIA, DSM III R, JUDGEMENT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB4
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
4. Judgement
.................................................................................
33 1. YES
181 2. NO
3 8. DK
==========================================================================================
DJB5 DEMENTIA, DSM III R, OTHER HIGHER CORTICAL FUNCTIONING
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB5
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
5. Other Higher Cortical Functioning
.................................................................................
45 1. YES
169 2. NO
3 8. DK
Blank. Inap
==========================================================================================
DJB6 DEMENTIA, DSM III R, PERSONALITY CHANGE
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB6
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
6. Personality Change
.................................................................................
20 1. YES
192 2. NO
3 8. DK
2 Blank. Inap
==========================================================================================
DJB7 DEMENTIA, DSM III R, SOCIAL OR OCCUP IMPAIRMENT
Section: DJ 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
.................................................................................
17 1. YES
7 2. NO
1 8. DK
192 Blank. Inap
==========================================================================================
DJB8 DEMENTIA, DSM III R, SIGNIFICANT DECLINE
Section: DJ 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
.................................................................................
23 1. YES
2. NO
8. DK
194 Blank. Inap
==========================================================================================
DJB9 DEMENTIA, DSM III R, COG DEFICITS DURING DELIRIUM
Section: DJ 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
23 2. NO
8. DK
194 Blank. Inap
==========================================================================================
DJB1MET DEMENTIA, DSM III R - CRITERIA FOR CKB1 AND CKB2
Section: DJ 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
.................................................................................
191 0. NO
26 1. YES
==========================================================================================
DJB2MET DEMENTIA, DSM III R - CRITERIA FOR CKB3 - CKB6
Section: DJ 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
.................................................................................
157 0. NO
60 1. YES
==========================================================================================
DJB3MET DEMENTIA, DSM III R - CRITERIA FOR CKB7 AND CKB8
Section: DJ 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
.................................................................................
199 0. NO
17 1. YES
1 Blank. Inap
==========================================================================================
DJB4MET DEMENTIA, DSM III R - CRITERIA FOR CKB9
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKB4MET
CHECKLIST TWO
CHECKLIST FOR DEMENTIA (DSM-III-R)
CHECKLIST MET IF CKB9=NO
.................................................................................
193 0. NO
23 1. YES
1 Blank. Inap
==========================================================================================
DJBMET DEMENTIA, DSM III R - WHETHER OVERALL DSM III R CRITERIA MET
Section: DJ 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
.................................................................................
203 0. NO
14 1. YES
==========================================================================================
DJC1 PROB AD, DEMENTIA, ESTABLISHED BY CKAMET OR CKBMET
Section: DJ 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. YES
2. NO
8. DK
217 Blank. Inap
==========================================================================================
DJC2 PROB AD, PROGRESSION OF COGNITIVE SYMPTOMS
Section: DJ 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. YES
2. NO
8. DK
217 Blank. Inap
==========================================================================================
DJC3 PROB AD, ABSENCE OF OTHER CONDITIONS SUFFICIENT TO CAUSE DEM
Section: DJ 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. YES
2. NO
8. DK
217 Blank. Inap
==========================================================================================
DJC4 PROB AD, RPT OF MED EVAL TO RULE OUT OTHER CAUSES OF DEMENTIA
Section: DJ 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. YES
2. NO
8. DK
217 Blank. Inap
==========================================================================================
DJC5 PROB AD, ONSET AFTER AGE 40
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKC5
CHECKLIST THREE
Checklist for Probable Alzheimer's Disease
5. Onset after age 40
.................................................................................
1. YES
2. NO
8. DK
217 Blank. Inap
==========================================================================================
DJC1MET PROB AD - CRITERIA FOR CKC1 - CKC5
Section: DJ 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. YES
217 Blank. Inap
==========================================================================================
DJCMET PROB AD - CRITERIA FOR CKC1MET
Section: DJ 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. YES
217 Blank. Inap
==========================================================================================
DJD1 POSS AD - CRITERIA FOR CKAMET OR CKBMET
Section: DJ 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)
.................................................................................
7 1. YES
2. NO
8. DK
210 Blank. Inap
==========================================================================================
DJD2 POSS AD, PROGRESSION OF COGNITIVE SYMPTOMS
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKD2
CHECKLIST FOUR
Checklist for Possible Alzheimer's Disease
2. Progression of symptoms over time
.................................................................................
7 1. YES
2. NO
8. DK
210 Blank. Inap
==========================================================================================
DJD3 POSS AD, ONSET AFTER AGE 40
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKD3
CHECKLIST FOUR
Checklist for Possible Alzheimer's Disease
3. Onset after age 40
.................................................................................
7 1. YES
2. NO
8. DK
210 Blank. Inap
==========================================================================================
DJD4 POSS AD, ATYPICAL ONSET, PRESENTATION OR PROGRESSION
Section: DJ 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
4 2. NO
8. DK
210 Blank. Inap
==========================================================================================
DJD5 POSS AD, PRESENCE OF SYSTEMIC OR BRAIN DISORDER, NOT SOLE CA
Section: DJ 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
.................................................................................
1 1. YES
5 2. NO
8. DK
211 Blank. Inap
==========================================================================================
DJD6 POSS AD, NO RPT OF MED EVAL TO RULE OUT OTHER DEM
Section: DJ 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
.................................................................................
5 1. YES
1 2. NO
8. DK
211 Blank. Inap
==========================================================================================
DJD1MET POSS AD - CRITERIA FOR CKD1 - CKD3
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKD1MET
CHECKLIST FOUR
Checklist for Possible Alzheimer's Disease
CHECKLIST MET IF CKD1-CKD3=YES
.................................................................................
0. NO
7 1. YES
210 Blank. Inap
==========================================================================================
DJD2MET POSS AD - CRITERIA FOR CKD4 - CKD6
Section: DJ 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
7 1. YES
210 Blank. Inap
==========================================================================================
DJDMET POSS AD - CRITERIA FOR CKD1MET AND CKD2MET
Section: DJ 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
.................................................................................
0. NO
7 1. YES
210 Blank. Inap
==========================================================================================
DJE1 PROB VASC DEM - CRITERIA FOR CKAMET OR CKBMET
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKE1
CHECKLIST FIVE
Checklist for Probable Vascular Dementia
1. Dementia based on DSM-III-R or DSM- IV criteria
.................................................................................
1. YES
2. NO
8. DK
217 Blank. Inap
==========================================================================================
DJE2 PROB VASC DEM, IMPAIRMENT IN MEM AND 2 OTHER COG DOMAINS
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKE2
CHECKLIST FIVE
Checklist for Probable Vascular Dementia
2. Impairment in memory and two other cognitive domains.
.................................................................................
1. YES
2. NO
8. DK
217 Blank. Inap
==========================================================================================
DJE3 PROB VASC DEM, SOCIAL OR OCCUP IMPAIRMENT
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKE3
CHECKLIST FIVE
Checklist for Probable Vascular Dementia
3. Impairment in occupational and social functioning and in daily activities is
not due solely to physical effects of stroke.
.................................................................................
1. YES
2. NO
8. DK
217 Blank. Inap
==========================================================================================
DJE4 PROB VASC DEM, CVD BASED ON HIST OR EXAM
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKE4
CHECKLIST FIVE
Checklist for Probable Vascular Dementia
4. Cerebrovascular disease (CVD) based history or examination. This may include
focal signs on neurologic examination that are consistent with stroke (with or
without history of stroke).
.................................................................................
1. YES
2. NO
8. DK
217 Blank. Inap
==========================================================================================
DJE5 PROB VASC DEM, EVIDENCE OF RELEVANT CVD NOTED ON BRAIN IMAGI
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKE5
CHECKLIST FIVE
Checklist for Probable Vascular Dementia
5. Evidence of relevant CVD noted on report of brain imaging.
.................................................................................
1. YES
2. NO
8. DK
217 Blank. Inap
==========================================================================================
DJE6 PROB VASC DEM, ONSET OF DEM WITHIN 3 MOS OF STROKE
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKE6
CHECKLIST FIVE
Checklist for Probable Vascular Dementia
6. Temporal relationship between stroke and dementia (onset of dementia
generally within three months of stroke).
.................................................................................
1. YES
2. NO
8. DK
217 Blank. Inap
==========================================================================================
DJE7 PROB VASC DEM, DETERIORATION IN FUNCTION
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKE7
CHECKLIST FIVE
Checklist for Probable Vascular Dementia
7. Abrupt or stepwise deterioration in mental function or fluctuating course.
.................................................................................
1. YES
2. NO
8. DK
217 Blank. Inap
==========================================================================================
DJE8 PROB VASC DEM, SPECIFIC BRAIN IMAGING INDICATE DAMAGE
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKE8
CHECKLIST FIVE
Checklist for Probable Vascular Dementia
8. Specific brain imaging findings, indicating damage to regions important for
higher cerebral function
.................................................................................
1. YES
2. NO
8. DK
217 Blank. Inap
==========================================================================================
DJE1MET PROB VASC DEM - CRITERIA FOR CKE1 - CKE5
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKE1MET
CHECKLIST FIVE
Checklist for Probable Vascular Dementia
CHECKLIST MET IF CKE1-CKE5=YES
.................................................................................
0. NO
1. YES
217 Blank. Inap
==========================================================================================
DJE2MET PROB VASC DEM - CRITERIA FOR CKE6, CKE7, OR CKE8
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKE2MET
CHECKLIST FIVE
Checklist for Probable Vascular Dementia
CHECKLIST MET IF AT LEAST ONE OF CKE6-CKE8=YES
.................................................................................
0. NO
1. YES
217 Blank. Inap
==========================================================================================
DJEMET PROB VASC DEM - CRITERIA FOR CKE1MET AND CKE2MET
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKEMET
CHECKLIST FIVE
Checklist for Probable Vascular Dementia
OVERALL CHECKLIST FIVE CRITERIA MET=YES IF CKE1MET AND CKE2MET=YES
.................................................................................
0. NO
1. YES
217 Blank. Inap
==========================================================================================
DJF1 POSS VASC DEM, EST BY CKAMET OR CKBMET
Section: DJ 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.
.................................................................................
2 1. YES
1 2. NO
8. DON'T KNOW
214 Blank. Inap
==========================================================================================
DJF2 POSS VASC DEM, IMPAIRMENT IN MEM AND 2 OTHER COG DOMAINS
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKF2
CHECKLIST SIX
Checklist for Possible Vascular Dementia
2. Impairment in memory and two other cognitive domains
.................................................................................
3 1. YES
2. NO
8. DON'T KNOW
214 Blank. Inap
==========================================================================================
DJF3 POSS VASC DEM, SOCIAL OR OCCUP IMPAIRMENT
Section: DJ 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
.................................................................................
2 1. YES
1 2. NO
8. DON'T KNOW
214 Blank. Inap
==========================================================================================
DJF4 POSS VASC DEM, CVD BASED ON HIST OR EXAM
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKF4
CHECKLIST SIX
Checklist for Possible Vascular Dementia
4. Cerebrovascular disease (CVD) based history or examination. This may include
focal signs on neurologic examination that are consistent with stroke (with or
without history of stroke).
.................................................................................
3 1. YES
2. NO
8. DON'T KNOW
214 Blank. Inap
==========================================================================================
DJF5 POSS VASC DEM, BRAIN IMAGING HAS NOT BEEN DONE
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKF5
CHECKLIST SIX
Checklist for Possible Vascular Dementia
5. Brain imaging has not been done.
.................................................................................
1. YES
3 2. NO
8. DON'T KNOW
214 Blank. Inap
==========================================================================================
DJF6 POSS VASC DEM, UNCLEAR REL BET STROKE AND DEMENTIA
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKF6
CHECKLIST SIX
Checklist for Possible Vascular Dementia
6. There is an absence of a clear temporal relationship between stroke and
dementia
.................................................................................
3 1. YES
2. NO
8. DON'T KNOW
214 Blank. Inap
==========================================================================================
DJF7 POSS VASC DEM, SUBTLE ONSET AND VARIABLE COURSE OF COG DEFICITS
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKF7
CHECKLIST SIX
Checklist for Possible Vascular Dementia
7. There was a subtle onset and variable course (plateau or improvement) of
cognitive deficits.
.................................................................................
2 1. YES
1 2. NO
8. DON'T KNOW
214 Blank. Inap
==========================================================================================
DJF1MET PROB VASC DEM - CRITERIA FOR CKF1 - CKF4
Section: DJ 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
2 1. YES
214 Blank. Inap
==========================================================================================
DJF2MET PROB VASC DEM - CRITERIA FOR CKF5 - CKF7
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKF2MET
CHECKLIST SIX
Checklist for Possible Vascular Dementia
CHECKLIST MET IF CKF5-CKF7=YES
.................................................................................
0. NO
3 1. YES
214 Blank. Inap
==========================================================================================
DJFMET PROB VASC DEM - CRITERIA FOR CKF1MET AND CKF2MET
Section: DJ 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
2 1. YES
214 Blank. Inap
==========================================================================================
DJG1 CIND, SHORT TERM OR LONG TERM MEMORY IMPAIRMENT
Section: DJ 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
.................................................................................
74 1. YES
6 2. NO
3 8. DK
134 Blank. Inap
==========================================================================================
DJG2 CIND, EXECUTIVE FUNCTION
Section: DJ 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)
.................................................................................
63 1. YES
12 2. NO
8 8. DK
134 Blank. Inap
==========================================================================================
DJG3 CIND, LANGUAGE
Section: DJ 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)
.................................................................................
49 1. YES
26 2. NO
8 8. DK
134 Blank. Inap
==========================================================================================
DJG4 CIND, PRAXIS
Section: DJ 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)
.................................................................................
11 1. YES
59 2. NO
13 8. DK
134 Blank. Inap
==========================================================================================
DJG5 CIND, ORIENTATION
Section: DJ 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)
.................................................................................
15 1. YES
66 2. NO
2 8. DK
134 Blank. Inap
==========================================================================================
DJG6 CIND, BASED ON DSRS SCORE
Section: DJ 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
.................................................................................
17 1. YES
64 2. NO
2 8. DK
134 Blank. Inap
==========================================================================================
DJG7 CIND, DOES NOT MEET CRITERIA FOR CKAMET OR CKBMET
Section: DJ 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
.................................................................................
75 1. YES
7 2. NO
8. DK
135 Blank. Inap
==========================================================================================
DJG1MET CIND - CRITERIA FOR CKG1 - CKG6
Section: DJ 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
.................................................................................
2 0. NO
81 1. YES
134 Blank. Inap
==========================================================================================
DJG2MET CIND - CRITERIA FOR CKG7
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKG2MET
CHECKLIST SEVEN
Checklist for Cognitive Impairment, Not Demented
CHECKLIST MET IF CKG7=YES
.................................................................................
8 0. NO
75 1. YES
134 Blank. Inap
==========================================================================================
DJGMET CIND - CRITERIA FOR CKG1MET AND CKG2MET
Section: DJ 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
.................................................................................
10 0. NO
73 1. YES
134 Blank. Inap
==========================================================================================
DJH1 MCI, MEMORY COMPLAINT BY INFORMANT
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJH2 MCI, MEMORY IMPAIRMENT BY MEASUREMENT ON MEMORY TASKS
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJH3 MCI, BASED ON MMSE SCORE
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJH4 MCI, BASED ON CDR MEMORY SCORE AND OVERALL CDR
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJH5 MCI, NOT DUE TO MCKOR DEPRESSION
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJH6 MCI, MEETS CRITERIA FOR CIND
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJH1MET MCI - CRITERIA FOR CKH1 - CKH6
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJHMET MCI - CRITERIA FOR CKH1MET
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJI1 MAJOR DEPRESSION BASED ON NPI, CIDI, OR CLINICAL OR MEDICAL HISTORY
Section: DJ 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
.................................................................................
7 1. YES
2. NO
8. DK
210 Blank. Inap
==========================================================================================
DJI2 DEPRESSION, IMPAIRMENT NOT EXPLAINED BY OTHER ETIOLOGY
Section: DJ 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.
.................................................................................
7 1. YES
2. NO
8. DK
210 Blank. Inap
==========================================================================================
DJI3 DEPRESSION, MEETS CRITERIA FOR CIND
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKI3
CHECKLIST NINE
Checklist for Depression
3. Meets criteria for Cognitive Impairment
.................................................................................
7 1. YES
2. NO
8. DK
210 Blank. Inap
==========================================================================================
DJI1MET DEPRESSION - CRITERIA FOR CKI1, CKI2, AND CKI3
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKI1MET
CHECKLIST NINE
Checklist for Depression
CHECKLIST MET IF CKI1-CKI3=YES
.................................................................................
0. NO
7 1. YES
210 Blank. Inap
==========================================================================================
DJIMET DEPRESSION - CRITERIA FOR CKI1MET
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKIMET
CHECKLIST NINE
Checklist for Depression
OVERALL CHECKLIST NINE CRITERIA MET=YES IF CKI1MET=YES
.................................................................................
0. NO
7 1. YES
210 Blank. Inap
==========================================================================================
DJJ1 NEUROPSYCHIATRIC DISORDER - CLINICAL OR MEDICAL HISTORY
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKJ1
CHECKLIST TEN
Checklist for Psychiatric Disorder
1. Presence of a neuropsychiatric disorder (includes bipolar disorder,
schizophrenia, personality disorder) based on clinical and medical history
.................................................................................
4 1. YES
2. NO
8. DK
213 Blank. Inap
==========================================================================================
DJJ2 NEUROPSYCHIATRIC DISORDER, NOT OTHERWISE EXPLAINED
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKJ2
CHECKLIST TEN
Checklist for Psychiatric Disorder
2. Impairment can not be better explained by another etiology listed under
Cognitive Impairment, Not Demented
.................................................................................
4 1. YES
2. NO
8. DK
213 Blank. Inap
==========================================================================================
DJJ3 NEUROPSYCHIATRIC DISORDER, MEETS CRITERIA FOR CIND
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKJ3
CHECKLIST TEN
Checklist for Psychiatric Disorder
3. Meets criteria for Cognitive Impairment, No Dementia
.................................................................................
3 1. YES
1 2. NO
8. DK
213 Blank. Inap
==========================================================================================
DJJ1MET NEUROPSYCHIATRIC DISORDER, CRITERIA FOR CKJ1 - CKJ3
Section: DJ 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
3 1. YES
213 Blank. Inap
==========================================================================================
DJJMET NEUROPSYCHIATRIC DISORDER, CRITERIA FOR CKJ1MET
Section: DJ 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
3 1. YES
213 Blank. Inap
==========================================================================================
DJK1 LIFELONG HISTORY OF MENT RET, LD, LOW BASELINE INTELLECT
Section: DJ 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.
.................................................................................
3 1. YES
2. NO
8. DK
214 Blank. Inap
==========================================================================================
DJK2 MENT RET, LD, LOW BASELINE INTELLECT NOT EXPLAINED BY OTHER ETIOLOGY
Section: DJ 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
.................................................................................
3 1. YES
2. NO
8. DK
214 Blank. Inap
==========================================================================================
DJK3 MENT RET, LD, LOW BASELINE INTELLECT, MEETS CRITERIA FOR CIND
Section: DJ 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
.................................................................................
3 1. YES
2. NO
8. DK
214 Blank. Inap
==========================================================================================
DJK1MET MENT RET, LD, LOW BASELINE INTELLECT - CRITERIA FOR CKK1 - CKK3
Section: DJ 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
3 1. YES
214 Blank. Inap
==========================================================================================
DJKMET MENT RET, LD, LOW BASELINE INTELLECT - CRITERIA FOR AKJMET
Section: DJ 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
3 1. YES
214 Blank. Inap
==========================================================================================
DJL1 HISTORY OF PAST ALCOHOL ABUSE
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJL2 ALCOHOL ABUSE PAST, DISCONTINUED AT LEAST SIX MONTHS PRIOR TO EVAL
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJL3 PAST ALCOHOL ABUSE, NOT EXPLAINED BY OTHER ETIOLOGY
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJL4 PAST ALCOHOL ABUSE, MEETS CRITERIA FOR CIND
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJL1MET PAST ALCOHOL ABUSE - CRITERIA FOR CKL1 - CKL4
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJLMET PAST ALCOHOL ABUSE - CRITERIA FOR CKL1MET
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJM1 HISTORY OF PAST AND CURRENT ALCOHOL ABUSE
Section: DJ 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.
.................................................................................
1 1. YES
2. NO
8. DK
216 Blank. Inap
==========================================================================================
DJM2 HAS ABUSED ALCOHOL IN THE PAST SIX MONTHS
Section: DJ 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.
.................................................................................
1 1. YES
2. NO
8. DK
216 Blank. Inap
==========================================================================================
DJM3 CURRENT ALCOHOL ABUSE, NOT EXPLAINED BY OTHER ETIOLOGY
Section: DJ 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.
.................................................................................
1 1. YES
2. NO
8. DK
216 Blank. Inap
==========================================================================================
DJM4 CURRENT ALCOHOL ABUSE, MEETS CRITERIA FOR CIND
Section: DJ 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
1 2. NO
8. DK
216 Blank. Inap
==========================================================================================
DJM1MET CURRENT ALCOHOL ABUSE - CRITERIA FOR CKM1 - CKM4
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKM1MET
CHECKLIST THIRTEEN
Checklist for Alcohol Abuse (current)
CHECKLIST MET IF CKM1-CKM4=YES
.................................................................................
1 0. NO
1. YES
216 Blank. Inap
==========================================================================================
DJMMET CURRENT ALCOHOL ABUSE - CRITERIA FOR CKM1MET
Section: DJ 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
.................................................................................
1 0. NO
1. YES
216 Blank. Inap
==========================================================================================
DJN1 STROKE HIST BASED ON CLINICAL, MED HISTORY, OR NEUROLOGICAL EXAM
Section: DJ 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.
.................................................................................
5 1. YES
2. NO
8. DK
212 Blank. Inap
==========================================================================================
DJN2 STROKE SYMPTOM ONSET WITHIN THREE MONTHS AFTER REPORTED STROKE
Section: DJ 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
.................................................................................
4 1. YES
1 2. NO
8. DK
212 Blank. Inap
==========================================================================================
DJN3 STROKE, IMPAIRMENT NOT EXPLAINED BY OTHER ETIOLOGY
Section: DJ 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
.................................................................................
5 1. YES
2. NO
8. DK
212 Blank. Inap
==========================================================================================
DJN4 STROKE, MEETS CRITERIA FOR CIND
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKN4
CHECKLIST FOURTEEN
Checklist for Stroke
4. Meets criteria for Cognitive Impairment, No Dementia
.................................................................................
5 1. YES
2. NO
8. DK
212 Blank. Inap
==========================================================================================
DJN1MET STROKE - CRITERIA FOR CKN1 - CKN4
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKN1MET
CHECKLIST FOURTEEN
Checklist for Stroke
CHECKLIST MET IF CKN1-CKN4=YES
.................................................................................
1 0. NO
4 1. YES
212 Blank. Inap
==========================================================================================
DJNMET STROKE - CRITERIA FOR CKN1MET
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKNMET
CHECKLIST FOURTEEN
Checklist for Stroke
OVERALL CHECKLIST FOURTEEN CRITERIA MET=YES IF CKN1MET=YES
.................................................................................
1 0. NO
4 1. YES
212 Blank. Inap
==========================================================================================
DJO1 OTHER NEUROL COND, PRESENCE OF NEUROLOGICAL CONDITION
Section: DJ 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
.................................................................................
5 1. YES
2. NO
8. DK
212 Blank. Inap
==========================================================================================
DJO2 OTHER NEUROL COND, NOT EXPLAINED BY OTHER ETIOLOGY
Section: DJ 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
.................................................................................
5 1. YES
2. NO
8. DK
212 Blank. Inap
==========================================================================================
DJO3 OTHER NEUROL COND, MEETS CRITERIA FOR CIND
Section: DJ 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
.................................................................................
3 1. YES
2 2. NO
8. DK
212 Blank. Inap
==========================================================================================
DJO1MET OTHER NEUROL COND - CRITERIA FOR CKO1 - CKO3
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKO1MET
CHECKLIST FIFTEEN
Checklist for Other Neurological Condition
CHECKLIST MET IF CKO1-CK03=YES
.................................................................................
2 0. NO
3 1. YES
212 Blank. Inap
==========================================================================================
DJOMET OTHER NEUROL COND - CRITERIA FOR CKO1MET
Section: DJ 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
.................................................................................
2 0. NO
3 1. YES
212 Blank. Inap
==========================================================================================
DJP1 OTHER MEDICAL COND, PRESENCE OF MEDICAL CONDITION
Section: DJ 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.
.................................................................................
6 1. YES
2. NO
8. DK
211 Blank. Inap
==========================================================================================
DJP2 OTHER MEDICAL COND, NOT EXPLAINED BY OTHER ETIOLOGY
Section: DJ 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
.................................................................................
6 1. YES
2. NO
8. DK
211 Blank. Inap
==========================================================================================
DJP3 OTHER MEDICAL COND, MEETS CRITERIA FOR CIND
Section: DJ 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
.................................................................................
5 1. YES
1 2. NO
8. DK
211 Blank. Inap
==========================================================================================
DJP1MET OTHER MEDICAL COND - CRITERIA FOR CKP1 - CKP3
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKP1MET
CHECKLIST SIXTEEN
Checklist for Other Medical Condition
CHECKLIST MET IF CKP1-CKP3=YES
.................................................................................
1 0. NO
5 1. YES
211 Blank. Inap
==========================================================================================
DJPMET OTHER MEDICAL COND - CRITERIA FOR CKP1MET
Section: DJ 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
.................................................................................
1 0. NO
5 1. YES
211 Blank. Inap
==========================================================================================
DJQ1 PRESENCE OF CEREBROVASCULAR OR CARDIOVASCULAR CONDITIONS
Section: DJ 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
.................................................................................
12 1. YES
2. NO
8. DK
205 Blank. Inap
==========================================================================================
DJQ2 IMPAIRMENT NOT LINKED TO ONE FOCAL VASCULAR LESION
Section: DJ 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.
.................................................................................
12 1. YES
2. NO
8. DK
205 Blank. Inap
==========================================================================================
DJQ3 GRADUAL ONSET OF CEREBROVASCULAR OR CARDIOVASCULAR SYMPTOMS
Section: DJ 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
.................................................................................
10 1. YES
2 2. NO
8. DK
205 Blank. Inap
==========================================================================================
DJQ4 CIND SECONDARY TO VASCULAR DISEASE, NOT EXPLAINED BY OTHER ETIOLOGY
Section: DJ 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
.................................................................................
12 1. YES
2. NO
8. DK
205 Blank. Inap
==========================================================================================
DJQ5 CIND SECONDARY TO VASCULAR DISEASE, MEETS CIND CRITERIA
Section: DJ 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
.................................................................................
11 1. YES
1 2. NO
8. DK
205 Blank. Inap
==========================================================================================
DJQ1MET CIND SECONDARY TO VASCULAR DISEASE, CRITERIA FOR CKQ1 - CKQ5
Section: DJ 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
.................................................................................
3 0. NO
9 1. YES
205 Blank. Inap
==========================================================================================
DJQMET CIND SECONDARY TO VASC DISEASE - CRITERIA FOR CKQ1MET
Section: DJ 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
.................................................................................
3 0. NO
9 1. YES
205 Blank. Inap
==========================================================================================
DJR1 MILD AMBIGUOUS, IMPAIRMENT NOT EXPLAINED BY ETIOLOGY IN CIND
Section: DJ 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
.................................................................................
13 1. YES
2. NO
8. DK
204 Blank. Inap
==========================================================================================
DJR2 MILD AMBIGUOUS, GRADUAL ONSET AND PROGRESSION OF SYMPTOMS
Section: DJ 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
.................................................................................
10 1. YES
3 2. NO
8. DK
204 Blank. Inap
==========================================================================================
DJR3 MILD AMBIGUOUS, MEETS CRITERIA FOR CIND
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKR3
CHECKLIST EIGHTEEN
Checklist for Mild Ambiguous
3. Meets criteria for Cognitive Impairment, No Dementia
.................................................................................
13 1. YES
2. NO
8. DK
204 Blank. Inap
==========================================================================================
DJR1MET MILD AMBIGUOUS - CRITERIA FOR CKR1 - CKR3
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKR1MET
CHECKLIST EIGHTEEN
Checklist for Mild Ambiguous
CHECKLIST MET IF CKR1-CKR3=YES
.................................................................................
3 0. NO
10 1. YES
204 Blank. Inap
==========================================================================================
DJRMET MILD AMBIGUOUS - CRITERIA FOR CKR1MET
Section: DJ 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
.................................................................................
3 0. NO
10 1. YES
204 Blank. Inap
==========================================================================================
DJS1 DEM UNDETERMINED ETIOLOGY, EST BY DSM III OR DSM IV CRITERIA
Section: DJ 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
.................................................................................
3 1. YES
2. NO
8. DK
214 Blank. Inap
==========================================================================================
DJS2 DEMENTIA UNDETERMINED ETIOLOGY PROGRESSION OF SYMPTOMS OVER TIME
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKS2
CHECKLIST NINETEEN
Checklist for Dementia Undetermined Etiology
2. Progression of symptoms over time
.................................................................................
3 1. YES
2. NO
8. DK
214 Blank. Inap
==========================================================================================
DJS3 DEMENTIA UNDETERMINED ETIOLOGY, ATYPICAL FEATURES
Section: DJ 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
.................................................................................
3 1. YES
2. NO
8. DK
214 Blank. Inap
==========================================================================================
DJS1MET DEMENTIA UNDETERMINED ETIOLOGY - CRITERIA FOR CKS1 - CKS3
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKS1MET
CHECKLIST NINETEEN
Checklist for Dementia Undetermined Etiology
CHECKLIST MET IF CKS1-CKS3=YES
.................................................................................
0. NO
3 1. YES
214 Blank. Inap
==========================================================================================
DJSMET DEMENTIA UNDETERMINED ETIOLOGY - CRITERIA FOR CKS1MET
Section: DJ 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
.................................................................................
0. NO
3 1. YES
214 Blank. Inap
==========================================================================================
DJT1 PD, DEM ESTABLISHED BY DSM III OR DSM IV CRITERIA
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKT1
CHECKLIST TWENTY
Checklist for Parkinson's Dementia
1. Dementia established by DSM-III-R or DSM-IV criteria (based on clinical and
neuropsychological assessment information
.................................................................................
1. YES
2. NO
8. DK
217 Blank. Inap
==========================================================================================
DJT2 PD, DIAGNOSIS OF PD
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKT2
CHECKLIST TWENTY
Checklist for Parkinson's Dementia
2. Diagnosis of Parkinson's disease
.................................................................................
1. YES
2. NO
8. DK
217 Blank. Inap
==========================================================================================
DJT3 PD, COG SYMPTOMS PRIMARILY SUBCORTICAL
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKT3
CHECKLIST TWENTY
Checklist for Parkinson's Dementia
3. Cognitive symptoms primarily subcortical in nature
.................................................................................
1. YES
2. NO
8. DK
217 Blank. Inap
==========================================================================================
DJT4 PD, ONSET OF COG SYMPTOMS AT LEAST 1 YR PAST MOTOR SYMPTOMS
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKT4
CHECKLIST TWENTY
Checklist for Parkinson's Dementia
4. Onset of cognitive symptoms at least one year after onset of motor symptoms
.................................................................................
1. YES
2. NO
8. DK
217 Blank. Inap
==========================================================================================
DJT1MET PD - CRITERIA FOR CKT1 - CKT4
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKT1MET
CHECKLIST TWENTY
Checklist for Parkinson's Dementia
CHECKLIST MET IF CKT1-CKT4=YES
.................................................................................
0. NO
1. YES
217 Blank. Inap
==========================================================================================
DJTMET PD - CRITERIA FOR CKT1MET
Section: DJ Level: Respondent Type: Numeric Width: 1 Decimals: 0
Ref: CKTMET
CHECKLIST TWENTY
Checklist for Parkinson's Dementia
OVERALL CHECKLIST TWENTY CRITERIA MET=YES IF CKT1MET=YES
.................................................................................
0. NO
1. YES
217 Blank. Inap
==========================================================================================
DJU1 PROB LEWY BODY DEMENTIA EST BY DSM III OR DSM IV CRITERIA
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJU2 PROB LEWY BODY DEMENTIA, FLUCTUATING COGNITION
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJU3 PROB LEWY BODY DEMENTIA, RECURRENT VISUAL HALLUCINATIONS
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJU4 PROB LEWY BODY DEMENTIA, MOTOR FEATURES OF PARKINSONISM
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJU5 PROB LEWY BODY DEMENTIA, REPEATED FALLS
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJU6 PROB LEWY BODY DEMENTIA, SYNCOPE
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJU7 PROB LEWY BODY DEMENTIA, LOSS OF CONSCIOUSNESS
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJU8 PROB LEWY BODY DEMENTIA, NEUROLEPTIC SENSITIVITY
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJU9 PROB LEWY BODY DEMENTIA, SYSTEMATIZED DELUSIONS
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJU10 PROB LEWY BODY DEMENTIA, OTHER MODAL HALLUCINATIONS
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJU11 PROB LEWY BODY DEMENTIA, REM SLEEP DISORDER
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJU12 PROB LEWY BODY DEMENTIA, DEPRESSIVE SYMPTOMS
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJU1MET PROB LEWY BODY DEMENTIA - CRITERIA FOR CKU1
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJU2MET PROB LEWY BODY DEMENTIA - CRITERIA FOR CKU2 - CKU4
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJUMET PROB LEWY BODY DEM - CRITERIA FOR CKU1MET AND CKU2MET
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJV1 PSP, DEMENTIA EST BY DSM III OR DSM IV CRITERIA
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJV2 PSP, IMPAIRMENT OF VOLUNTARY DOWNWARD GAZE
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJV3 PSP, IMPAIRMENT NOT EXPLAINED BY ANOTHER DEMENTIA TYPE
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJV1MET PSP, CRITERIA FOR CKV1 - CKV3
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJVMET PSP, CRITERIA FOR CKV1MET
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJW1 NORMAL PRESSURE HYDROCEPHALUS, EST BY DSM III OR DSM IV CRITERIA
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJW2 NORMAL PRESSURE HYDROCEPHALUS, REPORT FROM NEUROIMAGING
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJW3 NORMAL PRESSURE HYDROCEPHALUS, NOT EXPLAINED BY OTHER DEMENTIA TYPE
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJW1MET NORMAL PRESSURE HYDROCEPHALUS, CRITERIA FOR CKW1 - CKW3
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJWMET NORMAL PRESSURE HYDROCEPHALUS - CRITERIA FOR CKW1MET
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJX1 HUNTINGTONS DEMENTIA, EST BY DSM III OR DSM IV CRITERIA
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJX2 HUNTINGTONS, DIAGNOSIS OF HUNTINGTONS DISEASE
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJX1MET HUNTINGTONS DEMENTIA, CRITERIA FOR CKX1 AND CKX2
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJXMET HUNTINGTONS DEMENTIA, CRITERIA FOR CKX1MET
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJY1 FRONTAL LOBE, INSIDIOUS ONSET AND SLOWLY PROGRESSIVE
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJY2 FRONTAL LOBE, PROFOUND FAILURE ON FRONTAL LOBE TESTS
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJY3 FRONTAL LOBE, PERCEPTUAL SPATIAL DISORDERS ARE ABSENT
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJY4 FRONTAL LOBE, UNIQUE SPEECH DISTURBANCES
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJY5 FRONTAL LOBE, COMMON AFFECTIVE SYMPTOMS
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJY6 FRONTAL LOBE SIGNS AND OTHER PHYSICAL SIGNS
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJY7 FRONTAL LOBE, NORMAL EEG
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJY8 FRONTAL LOBE, BRAIN IMAGING
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJY9 FRONTAL LOBE, OTHER SUPPORTIVE DIAGNOSTIC FEATURES
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJY10 FRONTAL LOBE, EXCLUSIONARY FEATURES (LIST)
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJY1MET FRONTAL LOBE, CRITERIA FOR CKY1
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJY2MET FRONTAL LOBE, CRITERIA FOR CKY2
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJY3MET FRONTAL LOBE, CRITERIA FOR CKY3
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJY4MET FRONTAL LOBE, CRITERIA FOR CKY4
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJY5MET FRONTAL LOBE, CRITERIA FOR CKY10
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJYMET FRONTAL LOBE - CRITERIA FOR CKY1MET - CKY5MET
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJZ1 POSS LEWY BODY DEMENTIA EST BY DSM III OR DSM IV CRITERIA
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJZ2 POSS LEWY BODY DEMENTIA, FLUCTUATING COGNITION
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJZ3 POSS LEWY BODY DEMENTIA, RECURRENT VISUAL HALLUCINATIONS
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJZ4 POSS LEWY BODY DEMENTIA, MOTOR FEATURES OF PARKINSONISM
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJZ5 POSS LEWY BODY DEMENTIA, REPEATED FALLS
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJZ6 POSS LEWY BODY DEMENTIA, SYNCOPE
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJZ7 POSS LEWY BODY DEMENTIA, LOSS OF CONSCIOUSNESS
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJZ8 POSS LEWY BODY DEMENTIA, NEUROLEPTIC SENSITIVITY
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJZ9 POSS LEWY BODY DEMENTIA, SYSTEMATIZED DELUSIONS
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJZ10 POSS LEWY BODY DEMENTIA, OTHER MODAL HALLUCINATIONS
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJZ11 POSS LEWY BODY DEMENTIA, REM SLEEP DISORDER
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJZ12 POSS LEWY BODY DEMENTIA, DEPRESSIVE SYMPTOMS
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJZ1MET POSS LEWY BODY DEMENTIA - CRITERIA FOR CKZ1
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJZ2MET POSS LEWY BODY DEMENTIA - CRITERIA FOR CKZ2 - CKZ4
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJZMET POSS LEWY BODY DEMENTIA - CRITERIA FOR CKZ1MET AND CKZ2MET
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJAA1 SEVERE HEAD TRAUMA, DEM ESTABLISHED BY CKAMET OR CKBMET
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJAA2 SEVERE HEAD TRAUMA, SEVERE COGNITIVE SEQUELAE
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJAA3 SEVERE HEAD TRAUMA, IMPAIRMENT NOT OTHERWISE EXPLAINED
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJAA1MET SEVERE HEAD TRAUMA - CRITERIA FOR CKAA1 - CKAA3
Section: DJ 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
217 Blank. Inap
==========================================================================================
DJAAMET SEVERE HEAD TRAUMA - CRITERIA FOR CKAA1MET
Section: DJ 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
217 Blank. Inap
|