Established Dementia

6 Cognitive Domains (DSM-V Neurocog Disorders Criteria)

Language: word-finding difficulties, using wrong words or phrases, grammatical errors, difficulty understanding speech of others, difficulty understanding written material

Learning and Memory: difficulty recalling recent events, repeating self, misplacing objects, losing track of actions already performed, increasing reliance of lists and/or reminders

Perceptual-motor/visuospatial: poor sense of direction, getting lost in the home and other familiar places, getting lost while driving familiar routes, relying on maps/GPS for directions, bumping into objects, misjudging distances/getting into car accidents, difficulty using familiar appliances

Executive: difficulty with multi-stage tasks, planning, organizing, multi-tasking, following directions, making decisions, keeping up with rapidly shifting conversations

Complex Attention: normal tasks take longer, especially when there are competing stimuli present, easily distracted, tasks need to be simplified, difficulty holding information in mind to perform calculations or dial a phone number

Social Recognition: disinhibition or apathy, loss of empathy, inappropriate behavior, poor insight, poor judgement

Treatment History

Current outpatient neurologist

Date of last outpatient visit

HIPAA: Only the year will appear in summaries

Date of diagnosis

HIPAA: Only the year will appear in summaries

Medication adjustments made at last outpatient visit

Polypharmacy screen done this appointment

Functional Status

Where does the patient currently reside

Able to perform ADLs

Able to perform IADLs

Who assists the patient with ADLs (family, health aide, etc.)

Currently employed

Issues with job performance

Currently driving

Requires walking aide for ambulation

Has experienced falls (frequency and severity)

Established Dementia

6 Cognitive Domains (DSM-V Neurocog Disorders Criteria)

Treatment History

Functional Status

Workup for treatable causes of Memory Impairment

Other Previous Workup