1.
2.
3.
STANDARDIZED MINI-MENTAL STATE EXAMINATION
[SMMSE]
A USER’ S GUIDE
Dr. D. Willia m Molloy
a nd
Dr. Rog er Cla rnette
4.
5.
First published 1999
New Grange Press, Troy, Ontario, Canad a
ISBN 0-9694645-8-4
Copyrig ht ' Dr Da vid William Molloy 1989,1990
This ed ition c opyrig ht ' Dr Da vid William Molloy 1998, 1999
All rights reserved . No part of this book may be reprod uc ed in any
form or by any elec tronic or mec hanic al means, inc lud ing
information storage and retrieval systems, without permission in
writing from Dr D. W. Molloy, exc ept by a reviewer who c an quote
brief passages in a review.
1. Cognition testing
2.Cognition sc reening
3. Cognition measurement instrument
Published in 1999 by
To ord er further c opies of this book, test sheets or answer c ard s,
please c ontac t New Grange Press. At: New Grange Press
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1,
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Printed in Canad a
This b ook is d ed ic a ted to
Ron a nd Gina Fra ser.
6.
7.
Acknowledgements:
I would like to tha nk Dr. Ma rsha ll Folstein for his sup p ort
a nd a d vic e in the d evelop m ent of the SMMSE. Sp ec ia l
tha nks to Tim Sta nd ish, w ho ha s b een a true a nd fa ithful
friend a nd c ollea g ue for over a d ec a d e, w hile we
worked tog ether a nd refined , ed ited a nd red efined this
instrum ent. Jud y Lever, the Nurse Clinic ia n w ho runs our
c linic a l p rog ra m , ha s b een a kind a nd help ful friend
w hose p rofessiona l b eha viour ha s b een a sourc e of
insp ira tion a nd sup p ort. Sp ec ia l tha nks a lso to Rosa lie
Jub elius, w ho ha s led a nd org a nized our Geria tric
Resea rc h Group a nd org a nized our resea rc h in the la st
d ec a d e. I would like to offer tha nks to Dr. Irene Tuttle,
And rea Vertesi, Brett Sa nd erson, Lori Pokora d i, Ela ine
Princ ip i, Step ha nie Sm ith, Sa c ha Dub ois a nd Ang ela
Stiller for their ha rd work a nd d ed ic a tion. My c ollea g ues
a t Mc Ma ster --- Shirley Ha w key, Wend y Mc Pherson,
Mic hel Bed a rd , Dr. Gord on Guya tt, Dr. John Kelton, Dr.
Kevin Sm ith, Dr. Alexa nd ra Pa p p a ia nnou, Dr. Mic heline
Ga g non, Dr. Da vid Cowa n a nd Dr. Christop her Pa tterson
ha ve a lwa ys sup p orted our efforts. Other c ollea g ues, Dr.
Rog er Cla rnette, Dr. Da vid Stra ng , Dr. Jim O’ Brien Dr. Des
O’ Neill, Dr. Wa rren Da vid son, Dr. Ea rl De Cotea u, Dr. Pa ul
Ca ld well a nd Dr. Mic ha el Ba rrie ha ve a ll ma d e this
c a reer fun a nd enjoya b le. I a m g ra teful to Gloria La
a nd Betty Hia m for their p a tienc e a nd sup p ort in ed iting
a nd p rod uc tion.
8.
9.
CONTENTS
1.0
Introduction
11.
2.0
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
2.11
2.12
2.13
Genera l Guidelines
Set Up
Ad m inistra tion
Sc oring
Tim e Lim its
Prop s
Reg istra tion
"World "
Seria l Sevens
Wa tc h a nd p enc il
"No ifs, a n d s o r b u t s "
Write Sentenc e
Overla p p ing Penta g ons
Fold ing Pa p er
13.
13.
13.
13.
14.
14.
15.
15.
16.
16.
16.
16.
16.
17.
3.0
Sta nda rdized Mini-Menta l Sta te Exa mina tion
18.
4.0
4.1
4.2
4.3
Specific Scoring Guidelines
Sc oring the Fig ures
Sc oring "WORLD" Ba c kwa rd s
Sc oring Seria l Sevens
5.0
Adjusting Scores
30.
6.0
Tota l Scores
33.
7.0
Dia gnostic Algorithm
35.
8.0
8.1
The Alzheimer’s Journey
SMMSE Tota l Sc ores a nd Disea se Prog ression
36.
37.
9.0
38.
9.1
9.2
9.3
9.4
Using the Pa ttern of Deficits to Differentia te
Between Dementia s
Alzheimer’ s Disea se
Va sc ula r Dem entia
Lew y Bod y Dem entia
Dep ression
10.0
Ca re Pla n for Alzheim er’ s Disea se
44.
11.0
Ca re Pla n for Sp ec ia l Defic its on SMMSE
45.
12.0
SMMSE Sc oring Sheet
References
48.
49.
23.
23.
24.-28.
29.
38.
40.
41.
42.
10.
11.
1.0 Introduction
The p op ula tion is a g ing . Eld erly fra il a d ults a re the m ost
ra p id ly g row ing g roup in d evelop ed c ountries. More
a nd m ore p hysic ia ns a re c om ing to rec og nize the
im p orta nc e of c og nitive testing in the a ssessm ent of
old er a d ults. Ab out 10% of p eop le a g ed 70 or m ore a nd
a third of those a g ed 85 a nd over ha ve d em entia . Yet
this is often m issed , p a rtic ula rly in the ea rly sta g es.
The "m ini-m enta l" is the m ost w id ely used sc reening test
of m enta l func tion in this a g e g roup This short b ooklet
d esc rib es a sta nd a rd ized version of this test a nd show s
how p hysic ia ns a nd other hea lth c a re p rofessiona ls c a n
use a nd interp ret it. This short b ooklet d esc rib es som e
uses tha t they ma y not b e a wa re of p reviously.
Sinc e Dr. Ma rsha ll Folstein first d evelop ed the Mini-Menta l
Sta te Exa m ina tion (MMSE) in 1975, it ha s b ec om e w id ely
used a s a sc reening test for c og nitive im p a irm ent a nd it
is routinely used a s a n inc lusion/ exc lusion c riterion a nd
outc om e m ea sure in c linic a l tria ls. The test c overs a
va riety of c og nitive d oma ins, inc lud ing orienta tion to
tim e a nd p la c e, short a nd long term m em ory,
reg istra tion, rec a ll, c onstruc tiona l a b ility, la ng ua g e a nd
the a b ility to und ersta nd a nd follow c om ma nd s. This test
should never b e used a lone. It is used in c onjunc tion
w ith a c orrob ora tive history.
The test usua lly ta kes a b out ten m inutes to c om p lete
a nd c a n b e used relia b ly a fter a short tra ining p eriod b y
p hysic ia ns, nurses a nd other hea lth-c a re p rofessiona ls.
The orig ina l MMSE ha d few instruc tions for a d m inistra tion
a nd sc oring . These were left to the d isc retion of ea c h
ra ter. Different ra ters d evelop ed their ow n uniq ue styles
a nd tec hniq ues of a d m inistra tion a nd sc oring . This led to
w id e d ifferenc es a nd lowered the relia b ility of the test.
The Sta nd a rd ized Mini-Menta l Sta te Exa m ina tion wa s
d evelop ed to p rovid e c lea r uneq uivoc a l g uid elines for
a d m inistra tion a nd sc oring . The SMMSE ta kes less tim e to
a d m inister a nd ha s sig nific a ntly red uc ed the va ria b ility
of the MMSE.
12.
The intra ra ter va ria b ility is sig nific a ntly lower w ith the
SMMSE (86%, P<0.003) a nd the interra ter va ria nc e wa s
red uc ed b y 76%, c om p a red to the MMSE. Intra c la ss
c orrela tion for the MMSE wa s 0.69 c om p a red to 0.90 for
the SMMSE. The m ea n d ura tion of a ssessm ents wa s 13.4
m inutes for the MMSE, c om p a red to 10.5 m inutes for the
SMMSE (p <0.004).
The instruc tions for a d m inistra tion a nd sc oring the SMMSE
a re short a nd c ryp tic . Som e further b a c kg round ,
d isc ussion a nd exp la na tion of these rules a nd g uid elines
ma y b e useful.
13.
2.0 Genera l Guidelines
2.1 Set Up
Before setting up , ra ters ensure tha t sub jec ts ha ve
hea ring a nd vision a id s to ma ximize c ommunic a tion.
Hea ring is tested by a sking "Wha t is your na me?"
Sub jec ts a re a d vised tha t they will b e a sked some
q uestions; "Would it b e a ll right to a sk you some q uestions
a b out your memory?"
Ra ters should ha ve their p rop s rea d y (p enc il a nd p a p er).
Ra ters a lso need a c loc k to mea sure time. La mina ted
c a rd s a re p rovid ed , p rinted with "CLOSE YOUR EYES" a nd
the two five-sid ed figures to sta nd a rd ize these p a rts of
the test.
2.2 Administration
The ra ter introd uc es the test by sa ying, "I a m going to a sk
you some q uestions a nd give you some p rob lems to
solve. Plea se try to a nswer a s b est you c a n." The SMMSE
p rovid es exa c t verb a tim instruc tions to a d minister ea c h
item in the test. Ra ters should a sk q uestions exa c tly a s
they a p p ea r in the SMMSE.
2.3 Scoring
Ra ters a re tra ined to sc ore resp onses. Some ta sks a re
ea sier tha n others. For exa mp le, w hen one rea d s the
sta tement "Close your eyes," if sub jec ts c lose their eyes,
they sc ore a p oint. If they d o not, they lose a p oint. Other
p a rts of the test a re not so ea sy. Sc oring the sp elling of
"World " b a c kwa rd s c a n b e p rob lema tic given the
p ermuta tions a nd c omb ina tions of p otentia l resp onses.
Exp lic it instruc tions a re p rovid ed to sc ore this ta sk.
Ba sic a lly, sup erimp ose the a nswers on the c orrec t
temp la te a nd sc ore the numb er of letters oc c urring in
the c orrec t ord er to give the sub jec t the ma ximum
numb er of p oints.
Prob lems c a n a rise in sc oring the orienta tion to p la c e.
For exa mp le c ountry, p rovinc e/ sta te/ c ounty, c ity/ town,
b uild ing a nd floor a re a sked in ord er of size from the
la rgest geo-p olitic a l unit to the sma llest. Dec id e in
a d va nc e w ha t will b e a c c ep ted a s c orrec t a nswers. In
genera l, use the loc a l terms p eop le use to d esc rib e their
loc a tion. In some c a ses, if c ounty is more imp orta nt tha n
sta te, then this is used .
The na me of the b uild ing ma y b e p rob lema tic . We work
in the Hend erson site of the Ha milton Civic hosp ita ls,
14.
c a lled a fter Nora Fra nc is Hend erson w ho help ed found
it. We merged with the Ched oke-Mc Ma ster hosp ita ls a nd
a re now known a s the Ha milton Hea lth Sc ienc es
Corp ora tion. We sc ore a c orrec t p oint for a ny of these
b ec a use this is so c onfusing.
We work on the g round floor, if you c ome in one
entra nc e. We a re in the b a sement if you c ome in
a nother. We a c c ep t b a sement, ground or ma in floor.
In the c ommunity, the instruc tions a nd sc oring c a n b e
mod ified to a sk "Wha t street is this?" a nd "Wha t room is
this?" or "Wha t numb er is this house?".
2.4 Time Limits
We ha ve p rovid ed time limits for ea c h a nswer. Ra ters
b egin to time from the end of the instruc tion. Sub jec ts
a re not told they a re b eing timed a nd this is mea sured
inc onsp ic uously to a void a d d ed p ressure. If the sub jec t
ta kes longer tha n the a llotted time, the ra ter sa ys "Tha nk
you, tha t wa s fine" a nd p roc eed s to the next q uestion. If
the sub jec t is trying ha rd to c omp lete a ta sk, for
exa mp le, the five sid ed figures a nd goes over time, the
ra ter d oes not interrup t until the p erson is finished a nd
sc ores the ta sk a t the one minute ma rk. The sub jec t will
not sc ore the p oint if it wa s not c omp leted d uring the
a llotted time p eriod . If sub jec ts give more tha n one
a nswer, sc ore the la st a nswer only.
2.5 Props
The p rop s a re a p otentia l sourc e of va ria b ility in the
a d ministra tion a nd sc oring. If it is left to the ra ter to write
out "Close Your Eyes" or to d ra w the two five-sid ed
figures, they c a n b e ha nd written on the sp ur of the
moment on sc ra p s of p a p er. The q ua lity of the exa mp le
c a n va ry wid ely. The SMMSE p rovid es the instruc tion
"Close Your Eyes" a nd the two five-sid ed figures on
op p osite sid es of a la mina ted c a rd . They a re in la rge
p la in font, c lea rly written a nd ea sy to rea d .
15.
2.6 Registra tion
The MMSE orig ina lly offered three word s "Ap p le,"
"Ta b le," a nd "Penny" to test reg istra tion a nd rec a ll. In
som e c a ses, w here sub jec ts were tested rep ea ted ly, a s
soon a s the ra ter sa id "I a m g oing to na m e three
ob jec ts a nd I wa nt you to rep ea t them b a c k to m e,"
even b efore they sa id the word s, the sub jec t offered
"Ap p le, Ta b le, Penny." It b ec a m e ob vious tha t we
need ed a lterna te form s of these three word s. We
c rea ted a lterna te three-word sets w ith the sa m e word
freq uenc y e.g ., "Ba ll, Ca r, Ma n" a nd "Bull, Wa r, Pa n."
The ra ter slow ly na m es the three ob jec ts to test the
sub jec t’ s a b ility to reg ister this new informa tion. The
ra ter ma y not rep ea t the word s, so it is im p orta nt to sa y
them c lea rly a nd c ontrol for d istra c tions d uring this
ta sk. The sub jec t is g iven 20 sec ond s to rep ea t them .
One p oint is g iven for ea c h word c orrec tly rec a lled
a fter the first a d m inistra tion. The ord er of rec a ll is not
im p orta nt. After the sub jec t ha s rec a lled a s ma ny a s
he or she c a n, the ra ter sc ores the num b er of c orrec t
item s rec a lled .
If the sub jec t ha s not rep ea ted (reg istered ) the three
word s, the ra ter c a n then help the sub jec t to reg ister
the three item s for the d ela yed rec a ll ta sk. The ra ter
sa ys the word s a t one sec ond interva ls a nd then a sks
the sub jec t to rep ea t the word s until a ll three a re
rep ea ted . The ra ter c a n rep ea t until they a re lea rned ,
to a ma ximum of five tim es. The sub jec t is then a d vised
tha t he or she w ill b e a sked to rec a ll them la ter.
"Rem em b er these word s b ec a use I a m g oing to a sk
you to na m e them la ter."
2.7 "WORLD"
In this ta sk the sub jec t is a sked to sp ell "World ." After
suc c essfully sp elling it, he or she is a sked to sp ell it
b a c kwa rd s. The num b er of letters in the c orrec t
(reverse) ord er is the sc ore. A sim p le m ethod of
sc oring this ta sk a nd a list of p ossib le a nswers a nd
exa m p les is p rovid ed . (sec . 4.2 Sc oring WORLD
Ba c kwa rd s)
16.
17.
2.8 Seria l Sevens
2.13 Folding Pa per
The seria l sevens ta sk is p resented a s a n a lterna tive to
sp elling "World " b a c kwa rd s. The two ta sks a re not
eq uiva lent. The seria l sevens is a n ea sier ta sk, a nd the
sc oring is ea sier. It c a n b e used a s a n a lterna te to
sp elling WORLD b a c kwa rd s in p eop le w ho a re illitera te.
The ra ter hold s up a p iec e of p a p er a nd sa ys "Ta ke this
p iec e of p a p er in your (non-d om ina nt) ha nd , fold the
p a p er in ha lf onc e w ith b oth ha nd s a nd p ut it d ow n
on the floor." Thirty sec ond s a re a llowed a nd one p oint
is g iven for ea c h step p rop erly exec uted . The nond om ina nt ha nd is used b ec a use p eop le w ill
a utoma tic a lly ta ke ob jec ts w ith their d om ina nt ha nd .
This test is g iven a t the end so the ra ter c a n ob serve
the ha nd tha t the p erson used to w rite in the p revious
ta sk. If the sub jec t uses the rig ht ha nd sa y "Ta ke this
p iec e of p a p er in yo ur le ft ha nd " a nd vic e versa .
When you g ive the instruc tions, hold the p iec e of
p a p er out in front of the p erson, out of rea c h, a nd d o
not a llow the p erson to ta ke the p a p er until you ha ve
g iven the three instruc tions. Hold the p a p er in the
sub jec t’ s m id line a nd p ush it forwa rd w hen you ha ve
g iven the instruc tions, not b efore.
2.9 Wa tch a nd Pencil
Sub jec ts a re a sked to na m e a wa tc h a nd p enc il. Use a
tra d itiona l wood en p enc il w ith a n era ser on the end .
Use a wa tc h w ith tra d itiona l fa c e. "Cloc k" or "tim e" a re
not a c c ep ted . Ten sec ond s a re a llowed for ea c h.
2.10 "No ifs, a nd s or b uts "
Sub jec ts a re a sked to rep ea t this p hra se. Sub jec ts ha ve
ten sec ond s to resp ond a nd must sa y the p hra se
verb a tim . Ra ters should enunc ia te the p hra se c lea rly,
b ec a use sub jec ts w ith hig h freq uenc y hea ring loss
(p resb yc usis) ma y not hea r the sib ila nts a nd w ill rep ea t
"No if, a nd or b ut." This is a c lue tha t there is hig h
freq uenc y hea ring loss a nd these sub jec ts should ha ve
their hea ring a ssessed .
2.11 Write Sentence
The sub jec t is g iven the p enc il a nd p a p er a nd a sked
to w rite a c om p lete sentenc e. Thirty sec ond s a re g iven
a nd the sentenc e must ha ve a sub jec t, verb a nd
ob jec t. Sp elling m ista kes a re ig nored .
2.12 Overla pping Penta gons
Give the sub jec t the p enc il, w ith the era ser, a nd a
c lea n p iec e of p a p er. Exa m p les a re p rovid ed to sc ore
this ta sk. Ma ny old er a d ults d ra w sha ky, w ig g ly lines w ith
unc lea r a ng les tha t a re m ore c urved tha n stra ig ht.
These a re a c c ep ta b le, a s long a s the p erson ha s two
five-sid ed fig ures intersec ting to form a four-sid ed
fig ure.
After ea c h ta sk we rec om m end using a n enc oura g ing
rema rk suc h a s, "Well d one! Tha t wa s very g ood . Now,
if you d on’ t mind , I would like yo u t o "
If the sub jec t a sks "How wa s tha t?", we usua lly resp ond
w ith "Very g ood ." If the sub jec t a sks "Are we finished
now ?" we rep ly "Alm ost. You a re d oing very well. If you
d on’ t mind , I would like yo u t o ."
18.
STANDARDIZED MINI-MENTAL STATE EXAM
(SMMSE)
3.0 ADMINISTRATION
Introd uc e yourself a nd try to g et the sub jec t’ s
c onfid enc e. Before you c om m enc e, g et the sub jec t’ s
p erm ission to a sk q uestions.
Before the q uestionna ire is a d m inistered , try to g et the
sub jec t to sit d ow n fa c ing you. Assess the sub jec t’ s
a b ility to hea r a nd und ersta nd very sim p le
c onversa tion, e.g . Wha t is your na m e? If the sub jec t
uses hea ring or visua l a id s, p rovid e these b efore
sta rting .
If the sub jec t a nswers inc orrec tly, sc ore 0. Do not hint,
p rom p t, or p rovid e a ny p hysic a l c lues suc h a s hea d
sha king . Do not a sk the q uestion a g a in.
If the sub jec t a nswers "Wha t d id you sa y?", d o not
exp la in or eng a g e in c onversa tion. Sim p ly rep ea t the
q uestion to a ma ximum of three tim es.
If the sub jec t interrup ts e.g . "Wha t is this for?" - just rep ly:
I w ill e xp la in in a few m inutes, w hen we a re finished .
Now if we c ould just p roc eed p lea se...."
If the sub jec t exc eed s the tim e lim it, b ut seem s to b e
strug g ling w ith a n a nswer, d o not c ut them off. Allow
them to a nswer the q uestion, b ut ma rk them
a c c ord ing ly e.g . sc ore 0 for not a nswering w ithin the
a llowed tim e lim it.
The follow ing eq uip m ent is req uired to a d m inister the
instrum ent:
a wa tc h
a p enc il
b la nk p a p er
"CLOSE YOUR EYES" c a rd
c op y of two 5-sid ed fig ures,
intersec ting to ma ke a 4-sid ed fig ure
19.
Section 1 - Orienta tion
[Allow 10 sec ond s for ea c h rep ly]
[Sc ore 1 p oint for ea c h c orrec t a nswer]
Sa y: I a m going to a sk you some questions a nd give
you some problems to solve. Plea se try to a nswer the
best tha t you ca n.
1. Ask: Wha t yea r is this?
[ Ac c ep t exa c t a nswers only, ta king the la st a nswer g iven ]
2. Ask: Wha t sea son is this?
[During la st week of old sea son or the first week of
a new sea son, a c c ep t either sea son]
3. Ask: Wha t month is this?
[On the first d a y of the m onth or, on the la st d a y of
the m onth, a c c ep t either m onth]
4. Ask: Wha t is toda y’s da te?
[Ac c ep t p revious or next d a y’ s d a te, e.g . on the
7th, a c c ep t the 6th or 8th.]
5. Ask: Wha t da y of the week is this?
[ Ac c ep t exa c t a nswers only ]
6. Ask: Wha t country a re we in?
[ Ac c ep t exa c t a nswers only ]
7. Ask: Wha t province/ sta te/ county a re we in?
[ Ac c ep t exa c t a nswers only ]
8. Ask: Wha t city/ town/ etc. a re we in?
[ Ac c ep t exa c t a nswers only ]
20.
21.
9. (In Hom e)
Ask: Wha t is the street a ddress of this house?
[Ac c ep t street na m e a nd house num b er, or eq uiva
lent in rura l a rea s]
(In Com munity or c linic )
Ask: Wha t is the na me of this building?
[Dec id e a hea d of tim e w ha t is a rea sona b le,
a c c ep ta b le a nswer, a nd a c c ep t tha t a nswer only]
Sa y: Now spell it ba ckwa rds plea se.
[Allow 30 sec ond s to sp ell b a c kwa rd s]
[Sc ore one point for eac h letter given in the c orrec t
reverse) ord er.]
[See exa m p les of SMMSE sp elling ’ WORLD’ b a c k
wa rd s Sc oring in 4.2]
10. (In Hom e)
Ask: Wha t room a re we in?
[ Ac c ep t exa c t a nswers only ]
(In Com munity)
Ask: Wha t floor of the building a re we on?
[ Ac c ep t exa c t a nswers only ]
Section 2 - Cognition
11. Sa y: I a m going to na me three objects. After I ha ve
sa id a ll three objects, I wa nt you to repea t them.
Remember wha t they a re, beca use I a m going to
a sk you to na me them a ga in in a few minutes.
[Say them slowly at a pproximately 1 sec ond intervals]
For rep ea ted use:
12. Sa y: Spell the word WORLD.
[Only rep ea t to a ma ximum of three times until the
sub jec ts und ersta nd s]
[You ma y help the sub jec t to sp ell it c orrec tly. If the
sub jec t c a nnot sp ell it, even with a ssista nc e, sc ore 0]
Ba ll
Ca r
Ma n
Bell
Bill
Bull
Ja r
Ta r
Wa r
Fa n
Ca n
Pa n
Sa y: Plea se repea t the three items for me
[Score 1 point for each correct reply on the first attempt.
Allow 20 sec ond s for rep ly, if sub jec t d id not rep ea t a ll
three, rep ea t until they a re lea rned , or up to a
ma ximum of 5 tim es, b ut only sc ore first a ttem p t]
13. Ask: Now wha t were the three objects tha t I a sked
you to remember?
[Allow 10 sec ond s for ea c h rep ly]
[Sc ore 1 p oint for ea c h c orrec t resp onse reg a rd less
of ord er.]
14. [Show w ristwa tc h]
Ask: Wha t is this ca lled?
[Allow 10 sec ond s for ea c h rep ly]
[Sc ore 1 p oint for c orrec t resp onse]
[Ac c ep t only w ristwa tc h, wa tc h, or tim ep iec e]
15. [Show p enc il]
Ask: Wha t is this ca lled?
[Allow 10 sec ond s for ea c h rep ly]
[Score 1 point for correct response. Accept "pencil" only]
16. Sa y: I’d like you to repea t this phra se a fter me:
"no ifs, a nd s or b uts"
[Allow 10 sec ond s for ea c h rep ly]
[Sc ore 1 p oint for c orrec t rep etition - must b e exa c t]
17. [Ha nd sub jec t the c a rd with ’CLOSE YOUR EYES’ on it.]
Sa y: Plea se rea d the words on this ca rd a nd then
do wha t it sa ys.
[Allow 10 sec ond s. Rep ea t instruc tions up to three
tim es if nec essa ry]
[Sc ore 1 p oint only if sub jec t c loses eyes]
22.
18. [Ha nd sub jec t a p enc il a nd p a p er.]
Sa y: Write a ny complete sentence on tha t piece of
pa per for me.
[Allow 30 sec ond s.]
[Sc ore 1 point if the sentenc e c ontains a subjec t,
verb and objec t, and makes sense. Ignore spelling
errors]
23.
4.0 Specific Scoring Guidelines
4.1 Scoring the Figures
The sub jec t must d ra w two 5-sid ed fig ures
intersec ted b y a 4-sid ed fig ure.
19. [Pla c e d esig n, p enc il, era ser a nd p a p er in front of
sub jec t]
Sa y: Copy this design plea se.
[Allow multip le tries until sub jec t is finished . Allow up
to one m inute]
[Sc ore 1 p oint if sub jec t ha s d ra w n a 4-sid ed fig ure
b etween two 5-sid ed fig ures]
[See exa m p les of sc oring the fig ure 4.0]
20. [OBSERVE IN WHICH HAND; THE SUBJECT HELD THE
PENCIL, or a sk if the sub jec t is rig ht, or left-ha nd ed .
Ta ke a p iec e of c lea n, letter- size p a p er; hold it up in
front of the sub jec t]
Sa y: Ta ke this pa per in your right/ left ha nd (opposite
to domina nt ha nd), fold it in ha lf once with both
ha nds a nd put the pa per down on the floor.
[Allow 30 sec ond s]
[Sc ore 1 p oint for ea c h instruc tion c orrec tly
exec uted , ma ximum of 3 p oints]
Correct
Score 1
Incorrect
Score 0
Correct
Score 1
Incorrect
Score 0
Correct
Score 1
Incorrect
Score 0
Tota l Test Sc ore
Ad justed
Sc ore
Time completed: ____________ (seconds)
25.
24
4.2 Scoring WORLD backwards
This task ac c ounts for 17% of the total sc ore. It’s essential
to sc ore it relia bly. There are many d ifferent ways and
"systems" for sc oring world bac kward s. Originally, Dr.
Folstein ad vised that the sc ore is "the number of letters in
the c orrec t ord er." We suggest the following method
bec ause it is so simple and foolproof. Sc ore ORDER not
SEQUENCE. Simply write d own the c orrec t response: D L R
O W. Now plac e the last five letters the subjec t said
below. Now d raw lines between the same letters on the
response given and DLROW. These lines MAY NOT CROSS.
The person’s sc ore is the maximum number of lines that
c an be d rawn, without c rossing any.
There are many d ifferent ways to sc ore this task, but we
have found this method to be simple, relia ble and easy to
a pply.
L
R O W
D
L
R O W 5
L
D
L
D
R R W O
D
L
D
R W O D
D
L
DL
DLD
DLDR
DLLOR
DLLRW
DLLW
DLO
DLOD
DLODR
DLOLD
DLOLW
DLOR
R O W
L O W R O
D
DLOL
D
D
Sc oring exa m p les of WORLD sp elled b a c kwa rd s
3
DLORD
DLORL
DLORW
R O W
3
DLOW
DLOWD
DLOWR
R O W
DLR
3
DLRLD
DLRLO
R O W
D O W R
DLRLW
3
DLRO
DLROD
D
L
L
R O W
DLROL
1
DLROO
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
R
O
W
R
O
R
W
W
O
O
O
O
O
O
O
O
O
O
O
O
O
R
R
R
R
R
R
R
R
W
W
W
W
W
O
W
O
O
O
O
Score
1
2
2
3
3
4
3
3
3
3
3
3
4
3
3
3
4
4
4
4
3
3
4
4
4
4
4
4
27.
26.
DLRRD
DLRW
DLW
DLWO
DLWOR
DLWRO
DO
DOL
DOLD
DOLOW
DOLRD
DOLRW
DOLW
DOLWR
DOR
DORL
DORLD
DORLW
DOROL
DOROW
DORW
DORWD
DORWR
DOW
DOWLD
DOWLW
DOWR
DOWRL
DOWRW
DR
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
L
L
L
L
L
L
L
L
R
R
R
W
W
W
W
O
O
O
O
O
R
R
R
R
R
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
3
4
3
3
3
4
2
2
2
3
3
4
3
3
2
2
2
3
3
4
3
3
3
3
3
3
3
3
3
2
DRL
DRLD
DRLO
DRLOW
DRLWE
DRLWO
DRO
DROLW
DROR
DROW
DROWL
DRW
DRWLD
DW
DWL
DWLR
DWLRO
DWOLD
DWORD
DWORL
DWROR
LD
LDO
LDORL
LDORW
LDOWR
LDROW
LDRWO
LDWO
LLRD
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
R
R
R
R
R
R
R
R
R
R
R
R
R
L
L
R
R
O
O
O
O
O
O
O
W
W
W
W
W
W
W
W
W
W
O
W
W
W
R
L
L
L
L
L
L
L
L
L
O
O
O
R
R
R
R
O
O
W
W
W
W
W
2
2
3
4
3
3
3
4
3
4
4
3
3
2
2
3
4
2
2
2
3
1
2
2
3
3
4
3
2
2
28.
LODLO
LORD
LORDW
LORL
LORW
LOW
LOWL
LRO
LROR
LROW
LWROW
ODLWR
D
L
L
L
O
O
O
L
L
L
L
L
L
L
L
L
R
R
R
R
O
O
O
O
O
O
O
O
R
R
O
O
O
O
O
O
OLD
OLDW
OLWRD
RDLOW
D
L
RDOLD
RO
D
L
R
WOR
WORLD
WRL
WRLD
WROLD
W
W
W
W
W
W
O
WOLD
WOLDW
W
W
W
W
W
WDLRO
W
O
W
W
W
W
W
W
W
2
2
3
2
3
3
3
3
3
4
4
3
1
2
2
4
2
2
1
4
1
2
1
1
1
1
1
Scoring of Seria l Sevens:
(w rite d ow n sub jec t s rep ly)
Sa y: Subtra ct 7 from 100 a nd keep subtra cting 7 from
wha ts left.
Onc e sub jec t sta rts - d o not interrup t - a llow him / her to
p roc eed until five sub tra c tions ha ve b een ma d e. If
sub jec t stop s b efore five sub tra c tions ha ve b een
ma d e, rep ea t the orig ina l instruc tion keep sub tra c ting
seven from w ha t s le ft . (ma ximum 3 tim es)
Score a s follows:
99, 86, 79, 72, 65
5 points
[ [
(a ll c orrec t)
[
[
[
93, 88, 81, 74, 67
[ x [ [ [
4 points
(4 c orrec t,1 w rong )
92, 85, 78, 71, 64
x [ [ [ [
(4 c orrec t 1 w rong )
93, 87, 80, 73, 64
3 points
[ x
(3 c orrec t, 2 w rong )
[ [ [
92, 85, 78, 71, 63
X
[ [ [
X
4 points
3 points
(3 c orrec t 2 w rong )
93, 87, 80, 75, 67
2 points
[
(2 c orrec t, 3 w rong )
X
[
X
X
93, 87, 81, 75, 69,
1 point
[
(1 c orrec t, 4 w rong )
X
X
X
X
30.
31.
5.0 Adjusting Scores
It is important to score the test as fairly as possible for
everyone. People who have physical,non-cognitive
disabilities should not score lower just because they are
physically unable to perform certain tasks.For example,an
arm amputee obviously cannot "fold the paper in half once
with both hands",as item 20 directs.Modify the test by asking
the subject to take the paper in his or her hand,crumple it up
and throw it on the floor.If the test cannot be modified,then
omit the task.If an item has been omitted because of
physical disability,it is important to take this into account
when scoring the test.The score from this task is subtracted
from the total score (30) to give a new total. The person’s
score is then adjusted to this new total score.
Here is the formula for calculating adjusted scores:
Formula
Actual Sc ore
X30
Explanation Ad d up the Multip ly the
sc ore on a ll a c tua l
the item s
sc ore b y 30
tha t the
p erson wa s
p hysic a lly
a b le to d o.
Exa m p le
Proc ess
The tota l p oints of a ll the
item s tha t a p erson c a n
p hysic a lly d o is the
ma ximum ob ta ina b le
sc ore. Ta ke the num b er
from the p revious b ox
a nd d ivid e it b y the
ma ximum ob ta ina b le
sc ore to g et the fina l
SMMSE sc ore
A b lind p erson c a nnot rea d "Close Your Eyes", w rite
a sentenc e or c op y the two five-sid ed fig ures.
These item s (17,18 a nd 19) a re om itted . The
ma ximum sc ore of these three item s is 3 p oints.
Person’s
Multip ly b y: Person c ould not d o items
17, 18 or 19. Maximum
tota l sc ore
obtaina ble sc ore on
on test is:
these items is 3. Subtrac t 3
from 30 = 27.
Divid e by this number.
15
Calc ulatio n
Maximum Obtainable Score
30
27
(15 x 30) / 27 = 16.66
Fina l SMMSE sc ore (a fter round ing ) is 17
Note: SMMSE sc ores a re p rovid ed in w hole num b ers, so
fra c tions a re round ed off in the c onventiona l ma nner.
For 0.5 or g rea ter, round up to the next hig her w hole
num b er. For 0.49, or lower, round d ow n to the next
lower w hole num b er.
The follow ing a re exa m p les of d isa b ilities tha t ma y
exem p t p eop le from c erta in ta sks in the SMMSE.
Physic a l d isa b ilities:
The d isa b ility should b e p erma nent. Som etim es p eop le
ha ve tem p ora ry p hysic a l p rob lem s tha t effec t SMMSE
p erforma nc e. In these c a ses, let the p rob lem resolve
b efore testing them . Som e p hysic a l p rob lem s ma y ta ke
m onths to resolve a nd it ma y not b e p ra c tic a l to wa it.
In these c a ses, c a refully d oc um ent the situa tion a nd
p ro c e e d .Exa m p le s o f p hysic a l d isa b ilitie s inc lud e :
a m p uta tion, c hronic d eform ity from a rthritis, p a ra lysis of
lim b s, b lind ne ss/ p o o r visio n eve n w ith g la sse s,
p erma nent hea ring loss even w ith func tioning hea ring
a id .
La ng ua g e:
Som etim es la ng ua g e d iffic ulties im p a ir a p erson’ s a b ility
to p erform c erta in ta sks on the SMMSE. If Eng lish is not
the sub jec t’ s first la ng ua g e, try to sc ore the p erson in his
or her first la ng ua g e. Tra nsla tions of the SMMSE a re
a va ila b le. It c a n b e d iffic ult to d ec id e w hen to exem p t
a p erson from c erta in ta sks. One a p p roa c h is to try a s
ma ny of the ta sks a s p ossib le to eva lua te the p erson’s
p erforma nc e. If the sub jec t seem s to und ersta nd som e
q uestions ea sily a nd others not, this is likely d ue to
c o g nitive im p a irm e nt. If the p e rso n ha s c o nsiste nt
p rob lem s und ersta nd ing the q uestions, it is likely d ue to
la ng ua g e d iffic ulties a nd the sc ore c a n b e a d justed
a c c ord ing ly. If in d oub t, g et a tra nsla tor or g ive the test
in his or her na tive la ng ua g e. Ma ke sure you a re not
m issing hea ring im p a irm ent.
Sp eec h:
Som e p eop le ha ve severe sp eec h p rob lem s, so their
sc ores a re out of p rop ortion to their overa ll level of
func tion. They sc ore lower b ec a use they c a nnot a nswer
32.
w ithin the p resc rib ed tim e lim its. Som e ma y reverse
word s a nd ma y sa y "Winter" w hen they m ea n "Sum m er".
These d efic its unfortuna tely b ia s the test a g a inst these
p eop le. It is im p orta nt to b e c onsistent a nd a d here to
the rules of a d m inistra tion, ob serving the tim e lim its a nd
sc oring g uid elines. Note c a n b e ma d e of these fa c tors
a nd p e rfo rm a nc e in no n-c o g nitive te sts, like ADL
func tion, should b e a ssessed .
Ed uc a tion:
Low ed uc a tion or ed uc a tion in a la ng ua g e other tha n
Eng lish c a n a ffec t sc ores. Genera lly, these lim ita tions
should not exem p t a p erson from som e of the SMMSE
ta sks. Note should b e ma d e tha t these fa c tors ma y
c a use lower sc ores a nd the fina l tota l ma y not reflec t
the p erson’ s true c og nitive func tion.
The p erson’ s d isa b ility should b e c lea rly noted on the
SMMSE sc ore sheet. Item s tha t a re a ffec ted b y this
d isa b ility should a lso b e c lea rly noted . The c a lc ula tion
of the a d justed sc ore is d one a t the b ottom of the
SMMSE sc ore sheet.
33.
6.0 Tota l Scores
The SMMSE provid es a short, relia ble measure of
c ognition. The level of c ognitive impairment helps to
quantify the severity of impairment and stage d ementia.
Serial sc ores provid e useful information a bout func tion
over time and c an be used to measure d isease
progression and treatment effec ts.
If a person presents with memory loss and c ognitive
impairment, analysis of the pattern of sc ores also helps to
pinpoint the spec ific d efic its and provid es important c lues
to the c ause of the problem.
Sc ores of 30 usually ind ic ate no impairment. People who
have rec eived a good d eal of ed uc ation, with no
obvious sensory, language or c ommunic ation problems,
usually sc ore 30.
SMMSE sc ores are related to age and ed uc ation level.
There is an inverse relationship between SMMSE sc ores
and age. People aged 18 to 50 sc ore a med ian of 29
and those aged 51 to 64 have a med ian of 28. After 65,
there is a stead y, grad ual d ec line, so at age 75, the
med ian is a bout 27 and it falls to 26 by age 80 and
beyond .
SMMSE sc ores are d irec tly related to the level of
ed uc ation and formal sc hooling. The med ian is 29 for
ind ivid uals with at least 9 years of sc hooling, 26 for those
with 5-8 years and 22 for those with 0-4 years of sc hooling.
In general, sc ores of 26 to 30 are c onsid ered "normal."
Sc ores between 20 and 25 are c onsistent with mild
c ognitive impairment.
Sc ores between 10 and 19 are c onsistent with mod erate
c ognitive impairment.
Sc ores between 0 and 9 are c onsid ered severe c ognitive
impairment.
These are very general rules. The test sc ores have to be
taken in c ontext with the history and other find ings. It is
unreasona ble to expec t that this short test is valid and / or
relia ble in everyone. Consid er a fit and healthy 75-yearold retired sc hool teac her. Family c omplain that she is
forgetting names, repeating questions and stories, and
35.
34.
that this is progressive. She sc ores 27 on the SMMSE
w hic h is in the "norma l" ra ng e. However the three
p oints a re lost b ec a use she c ould not rem em b er a ny
of the three word s in the rec a ll sec tion, w hic h
rep resents new lea rning a b ility. This is a hig hly
sig nific a nt find ing in this woma n. Ta ke a c a reful history
from the fa m ily a nd inq uire a b out func tion in
instrum enta l a c tivities of d a ily living (IADL) suc h a s
ma na g ing fina nc es, d riving , ta king m ed ic a tions,
shop p ing , a nd c ooking . If there is im p a irm ent in IADL
a nd the p erson is rep ea ting q uestions a nd stories - this
should b e investig a ted further b ec a use it is sug g estive
of ea rly Alzheimer’ s Disea se.
7.0 Dia gnostic Algorithm
Here is a sim p le d ia g nostic a lg orithm to g uid e the
a ssessm ent of old er a d ults p resenting w ith c og nitive
im p a irm ent. Ma ny p a tients a re in d enia l or la c k
insig ht. Ta ke a c orrob ora tive history from som eone
w ho know s the sub jec t, p riva tely a nd a wa y from the
p a tient.
1. Taking the history (p a tient a nd c orrob ora tive
p riva tely)
Pa tient a g ed 40 yea rs or old er
Gra d ua l onset m em ory loss
Prog ressive c ourse
Norma l hea ring
history
YES
YES
YES
YES
2. Screening for short term memory loss
Get the p a tient to reg ister the three word s a nd
then d istra c t b y d oing "WORLD" b a c kwa rd s. Now
a sk the p a tient to rem em b er the three word s:
Pa tient not a b le to rem em b er the three word s,
e.g . b a ll, c a r, ma n.
YES
3. Complete SMMSE
Com p lete SMME a nd sta g e the d efic it.
Note the p a ttern of d efic its.
YES
4. Physica l exa m
Norma l g a it, tone, reflexes, p ower,
sensa tion, a nd extra -oc ula r m ovem ents
YES
5. La bora tory screening
Norma l B12, TSH, CBC, g luc ose,
Crea tinine, ESR a nd others a s ind ic a ted .
YES
6. CT Sca n
Consistent w ith AD
YES
7. Rule out delirium/ depression
Ab senc e of m ood c ha ng e, veg eta tive sig ns, loss
of weig ht a nd / or energ y, insom nia , "d on’ t know "
a nswers a nd a nhed onia
YES
8. Rule out other d em entia
Vascular dementia,Lewy body,frontal lobe etc.
YES
9. Alzheim er d isea se
Sta g e a nd trea t
YES
36.
37.
8.0 The Alzheimer’s Journey
8.1 SMMSE Tota l Scores a nd Disea se
Progression
Alzheimer’s disease is the most c ommon c ause of
c ognitive impairment in old er ad ults and may be involved
in at least 70% of all d ementias. In the past, Alzheimer’s was
c onsid ered a d iagnosis of exc lusion. Now we c an make
the d iagnosis with greater c ertainty, by taking a c areful
history, measuring c ognitive func tion, performing a
d irec ted physic al examination and using spec ific
la boratory tests.
SMMSE Sc ores, Sta g es of Disea se a nd Area s of
Imp a irment in Alzheimer’ s Disea se
Alzheimer’s presents with grad ual, progressive short-term
memory loss and word -find ing d iffic ulties. With aging,
there is a progressive loss of short-term memory.
Alzheimer’s begins very gradually and at the start the
c hanges are mild and subtle.
Nobody is quite sure when Alzheimer’s "begins". It may be
"present" for many years before it bec omes obvious
c linic ally. When memory loss is c linic ally signific ant, it starts
to impair func tion. At this stage, it is important to rule out
reversible c auses of c ognitive impairment, suc h as
d epression, d elirium, hearing loss and hypothyroid ism.
Area of Functiona l Impa irment
SMMSE Sc ores
Sta g e
ADL
Com munic a t
ion
The natural history of this d isease is shown here. This figure
shows the slope of progression of "typic al" Alzheimer’s.
There is signific ant varia bility bec ause of d ifferenc es in
age, ed uc ation level, language skills etc .
30
Ea rly Dia g nosis
Mid - Mod erate
Severe
Mem ory
25
30-25
ma y b e
Norma l
24-21
21-10
9-0
m ild / ea rly
m od era te
severe
p rob lem s
w ith d riving ,
fina nc es,
shop p ing
a ssista nc e
w ith
d ressing ,
g room ing ,
toileting
Prob lem s
w ith ea ting ,
wa lking
word-finding, sentence
sp eec h
fragments,
repeating,
d isturb a nc es
"empty"
goes off
speech,vagu (i.e. slurring ,
topic
e terms
stuttering )
loses track (i.e.this,that)
subjec tive
three item
problems
rec a ll
with names orienta tion
or
misplac ing (tim e then
p la c e)
objec ts
WORLD
sp elling ,
la ng ua g e
a nd 3 step
c om ma nd
a ll a rea s
show
ob vious
d efec its
Yea rs
2-4 yea rs
2-3 yea r
2-3 yea rs
These a re g enera l g uid elines to the p rog ression of the
d isea se. There is muc h ind ivid ua l va ria b ility.
S
M 20
M
S 15
E
10
5
0
1
2
3
4
5
6
Ye a r s
7
8
9
38.
9.0 Using the Pattern of Deficits to Distinguish
between the Different Dementias.
Different d ementias affec t d ifferent parts of the brain and
c ause a variety of c ognitive d efic its. Eac h d ementia
impairs c ognition in its own c harac teristic way. The spec ific
pattern of d efic its provid es valua ble c lues to the
und erlying pathology. Knowled ge of these patterns
together with the c linic al find ings, provid es important
d iagnostic c lues to the und erlying c ause of the c ognitive
impairment.
For example, in Alzheimer’s the first defic it is in short-term
memory and word -find ing. Disorientation to time and
plac e follow. Problems with language oc c ur later in the
disease. Alzheimer’s is a "c ortic al" dementia, so c hanges in
gait, tone and swallowing oc c ur late.
Lewy Bod y d ementia impairs visuo-spatial func tion and
an early d efic it is a pparent in the a bility to d raw the fivesid ed figures. Lewy Bod y d isease affec ts c ortic al (gray
matter) and sub-c ortic al (white matter) struc tures,
ac c ounting for the early problems with tone and gait.
People with vasc ular d ementia often have d iffuse
problems in language, orientation and memory whic h
seem to oc c ur simultaneously. Vasc ular d ementias have
varia ble d efic its d epend ing on the struc tures affec ted .
This is a c ortic al and sub-c ortic al pattern.
The pattern of d efic its not only provid es important c lues to
the und erlying pathologic al proc ess, but the total sc ore
on the SMMSE quantifies the d efic it and stages the
d isease proc ess. This initial sc ore will provid e a useful
baseline to measure the rate of d ec line and the
effec tiveness of treatments over time.
9.1 Alzheimer’s Disease
In Alzheimer’s Disease, the pattern of defic its is very typic al
and pred ic ta ble. The first d efic it oc c urs in short-term
memory so the person repeats questions and stories. Then
the person bec omes d isoriented to time:d ate, d ay,
season, month and plac e. Later, the person has problems
spelling "WORLD" bac kward s. Only then is language
affec ted . These patients often d eny that they have any
problems with their memory and seem c ompletely
unaware of the severity of their problems.
Gait or swallowing are not affec ted until the later stages,
39.
when the person is severely d emented . If the person
presents with c hanges in tone, d iffic ulty walking with falls or
d iffic ulty swallowing early, then c hanc es are it is not
Alzheimer’s or there are other problems c ausing these
symptoms and signs.
Progression of the defic its in Alzheimer’s typic ally is as
follows:
1 Short-term memory loss
2. Disorientation to time, d ate, d ay, season, month etc .
3. Can’t spell "WORLD" bac kward s and are d isoriented
to plac e
4. Problems with language e.g. three-step c ommand .
(d iffic ulty with five-sid ed figures a ppear later.)
Typical features:
Grad ual, progressive short-term memory loss, then nominal
a phasia (d iffic ulty with names, find ing the right noun) --person repeats statements and questions over and over
again. No c hanges in tone or problems walking or
swallowing. CT sc an may show atrophy of the med ial
temporal lobe.
The typic al pattern of d efic its on the SMMSE is shown. The
numbers represents the ord er of d efic its in eac h d omain.
Figure 9.1 Typic al sequenc e of d efic its in all d omains:
Time
Plac e
Registration
World bac kward s
Short term Memory
Watc h, Penc il
No ifs, and s or buts
Close Your Eyes
Sentenc e
Five sid ed figures
Three step Command
------4 5 6---------------------7-----------------------------8 9---------------------1 2 3
----------------------------------------------------
Numbers ind ic ate the sequenc e of d efic its in Alzheimer
Disease, e.g. the first three points are usually lost in short
term memory, next in orientation to time etc .
40.
9.2 Va scula r Dementia
The rela tionship b etween Alzheim er’ s a nd va sc ula r
d em entia is not fully und erstood . They sha re ma ny
c om m on risk fa c tors. The thinking in this a rea is
evolving . The onset a nd p rog ression of d efic its in
Va sc ula r Dem entia is m ore va ria b le a nd less
p red ic ta b le tha n in Alzheim er’ s d isea se. Ma ny b elieve
tha t isola ted va sc ula r d em entia is ra re. Va sc ula r
d em entia freq uently c oexists w ith Alzheim er’ s (m ixed
d em entia ) a nd ma y m od ify the p rog ress of the
d efic its. There a re no ha rd a nd fa st rules, b ut ea rly
p rob lem s w ith la ng ua g e a nd visuosp a tia l func tions
sug g est va sc ula r or fronta l lob e involvem ent. This
p a ttern of d efic its ra ises susp ic ion of va sc ula r
involvem ent.
Figure 9.2 Seq uenc e of d efic its in va sc ula r d em entia :
Tim e
Pla c e
Reg istra tion
World b a c kwa rd s
Short term Mem ory
Wa tc h, Penc il
No ifs, a nd s or b uts
Close Your Eyes
Sentenc e
Five sid ed fig ures
Three step Com ma nd
-------5-----------------------------------------------------4-------------------3----------------------------------------------1
----2------
Prob lem s d ra w ing the fig ures or in follow ing the threestep c om ma nd oc c ur ea rly a nd a t the sa m e tim e a s
p rob lem s w ith m em ory a nd sp elling . The d efic its tend
to b e d iffuse, a ffec ting ma ny a rea s of func tion suc h a s
orienta tion, m em ory a nd la ng ua g e. La ng ua g e d efic its
a re usua lly seen muc h la ter in Alzheim er’ s d isea se. The
c linic a l c lues to va sc ula r d em entia a re step -like
p rog ression, history of tra nsient isc ha em ic a tta c k,
stroke, ea rly p rob lem s w ith g a it, ea rly inc ontinenc e a nd
d ep ression. There ma y b e sub tle c ha ng es on p hysic a l
exa m ina tion suc h a s p ositive Ba b inski, unila tera l
c ha ng es in tone, sensa tion or p ower. A CT sc a n ma y
show w hite ma tter c ha ng es or infa rc ts.
41.
9.3 Lewy Body Dementia
The c ha ra c teristic fea ture of Lewy Bod y Dementia is
ha lluc ina tions very ea rly in the d isea se p roc ess. Typ ic a lly,
there is sp onta neous inc rea sed tone. This looks like mild
Pa rkinson’ s (mild b ra d ykinesia a nd rig id ity), without the
tremor. Ha lluc ina tions ma y b e exa c erb a ted w hen
trea ted with Dop a mine, so it should b e introd uc ed very
c a refully, if a t a ll. Pa tients tend to wa lk "slump ed over" to
one sid e. They a re often very p a ra noid , a c c using their
sp ouse of ha ving a ffa irs etc . They will see b iza rre
ha lluc ina tions, like c hild ren p la ying or p eop le in the
house wea ring tuxed os etc . They b elieve these a re rea l
a nd will ta lk to them or c omp la in a b out them.
Symp toms fluc tua te, so tha t one d a y the p erson is a lert,
oriented a nd a p p rop ria te, a nd the next c onfused ,
ha lluc ina ting , d rowsy a nd letha rg ic . These p a tients fa ll,
a nd a re exq uisitely sensitive to neurolep tic s. If g iven
neurolep tic s, they b ec ome very rig id , letha rg ic , sleepy
a nd exp erienc e a d ra ma tic d eteriora tion in func tion.
These p a tients p resent with a c ha ra c teristic
c onstella tion of symp toms a nd sig ns a nd often ha ve
c ha ra c teristic d efic its in the SMMSE. They d evelop ea rly
visuosp a tia l p rob lems, so it is not surp rising tha t the first
d efic it on the SMMSE ma y b e d iffic ulty with the fivesid ed fig ures.
La ter, d isorienta tion to d a y a nd d a te, short-term
memory loss a nd the ina b ility to sp ell "WORLD"
b a c kwa rd s, oc c ur.
Althoug h not a b solute, the p a ttern of c og nitive d efic it
p rovid es va lua b le c lues to the und erlying p a tholog y.
The history, p hysic a l find ing s a nd c ha ra c teristic c ha ng es
on the SMMSE a ll help to d ia g nose their c ond ition.
This p a ttern of d efic its on the SMMSE, with the
c ha ra c teristic history a nd c linic a l find ing s sup p ort a
d ia g nosis of Lewy Bod y d ementia :
Time
Pla c e
Reg istra tion
World b a c kwa rd s
Short term Memory
Wa tc h, Penc il
No ifs, a nd s or b uts
Close Your Eyes
Sentenc e
Five sid ed fig ures
Three step Comma nd
--------4-------------------------------------------------------5--------------------3---------------------------------------------1
----2-------
42.
43..
These patients may improve with anti-c holinesterases like
Donepezil, Rivastigmine or Galantamine. For d elusions,
halluc inations and paranoia, a trial with low d oses of
Olanzepine may help the halluc inations, paranoia and
d elusions. They may get worse with Dopamine and this
should be introd uc ed c arefully, if at all. They may tolerate
low d ose SSRI s if they a re d ep ressed .
Old er ad ults with d epression are at risk from suic id e. In
d epressed , old er ad ults it is important to ask a bout suic id al
id eation. Ask "Did you ever go to bed at night and wish you
weren’t going to wake up in the morning?" If they answer
yes, ask "Did you ever think of killing yourself and end ing it
all?" If they say yes, ask if they have ever thought how they
would d o it. If they have thought of a method , suc h as
hanging or overd ose, or have suic id al urges e.g. to c rash
their c ar into another on the highway, then the suic id e risk is
signific antly inc reased and they should be referred and
monitored c losely.
If an anti-d epressant is presc ribed , it is important to ad vise
patients and families that it will take some time to work e.g.
three or four weeks. They should not stop taking the
med ic ation if it is not working in a few d ays or if they feel
better after a few weeks. Also, tell them that if they get sid e
effec ts and stop taking the anti-d epressant, they must c all
you immed iately to get a d ifferent med ic ation.
Many patients with d ementia bec ome d epressed .
Depression d oes not exc lud e d ementia. Many people with
d ementia have d epression that may be a feature of
d ementia and d oes not respond to treatment.
In the prac tic e of old -age med ic ine, the SMMSE is a very
useful test. But one c annot be d ogmatic in using this test
alone. The test must be interpreted in the c ontext of other
symptoms and signs. Dementia is a heterogeneous
d isease and these c ond itions are frequently mixed . For
example, Alzheimer’s, Lewy bod y, vasc ular d ementia and
d epression frequently c o-exist. It is important to be aware
that not every patient will fit neatly into a c onvenient
d iagnostic box. Many are not typic al and will be "mixed ".
In these c ases, gather information and keep an open mind
as you follow their progress. The "typic al" patterns with eac h
d isease are presented , but d o not be too d ogmatic
a pplying these "rules" in prac tic e. Many patients with
medic al problems have Alzheimer’s Disease and it is
important to treat the med ic al c ond itions and the
d ementia.
9.4 Depression
Unlike Alzheimer’s disease, these patients often c omplain of
memory loss. When asked questions they will often answer "I
don’t know". When you get "don’t knows" or "it doesn’t
matter," c onsid er d epression. When pressed , they may
know the answer, but just c ouldn’t be bothered.
They will often c omplain of low energy, anxiety or somatic
c omplaints in the bowel, saying that there is ind igestion or a
vague uneasy feeling related to the gastrointestinal trac t.
Somatic c omplaints seem refrac tory to treatment (e.g.
arthritis). Some d evelop somatic d elusions and bec ome
c onvinc ed that they have c anc er or something physic ally
wrong, but the d oc tor won’t tell them. They seem to
perform muc h worse than you would expec t from the
d egree of c ognitive impairment. For example, a person
with mild c ognitive d efic its d oes not wash or d ress
ind epend ently. This "d isa bility ga p" means they func tion
lower than expec ted . In c onversation, they d o not have
the obvious word -find ing d iffic ulties that the Alzheimer
patient exhibits.
They will often experienc e anhed onia, or lac k of pleasure in
anything. They will have mood c hange that they will
d esc ribe as a physic al feeling of being unwell that
d esc end s like a c loud they c an’t shake. This is often worse
in the morning and gets better as the d ay progresses. This
d iurnal variation is a typic al feature of d epression.
Other vegetative signs like loss of a ppetite, loss of energy,
sleep d isturbanc e that is c harac terized by early wakening
or d iffic ulty falling asleep. They d o not wake feeling
refreshed ; rather early morning may be their worst time.
They lose libid o and may even c onsid er suic id e.
All of the c ommon d ementias are progressive. At present
there are no treatments availa ble to stop or arrest these
d iseases, although there is a growing number of d rugs that
slow the progress and provid e symptomatic relief. It is
important to have a tentative d iagnosis, stage the d isease,
start treatment and follow c arefully to monitor response
and progress. The SMMSE is an invalua ble tool in this
proc ess.
44.
10.0 CARE PLAN FOR ALZHEIMER’S DISEASE
(a nd other dementia s)
SMMSE 25-20
Mild: Advance Planning, Safety and Early Treatment
Will
Powers of Attorney (financ ial and person c are)
Ad vanc ed Health Care Direc tive (Living Will)
Use a d osette for med ic ation
Calend ar remind er for a ppointments (kept by telephone)
45.
SMMSE 10-0
Severe: Plan for placement in Nursing Home
Consid er resp ite c a re Da y Progra ms
In-Home resp ite c a re
Short Sta y Resp ite Ca re in a Fa c ility
Nursing Home c a re
Ma y req uire a sec ure unit
Sup p ort c a regiver in re-sta rting life on their own;
Grief a nd b erea vement c ounseling for fa mily.
Ed uc a tion of Pa tients a nd Fa m ily b y the Alzheim er
Soc iety Fa m ily m em b er to a c c om p a ny to a p p ointm ent
Chec k Driving
Chec k sa fety in the hom e (kettles, b urners, c ooking )
- Consid er estrog en thera p y in fema les
- Vita m in E (400 to 1,000 IU, tw ic e d a ily)
- Consid er Enteric -c oa ted Asp irin (325m g onc e d a ily)
- Donep ezil (Aric ep t) 5m g -10m g onc e d a ily;
Riva stig a m ine (Exelon) up to 6m g tw ic e d a ily or
Ga la nta m ine (Rem inyl) up to 12m g tw ic e d a ily.
- Ging ko-Bilob a (GinkGold or Ginkola ) 40m g -80m g three
tim es d a ily b efore m ea ls.
SMMSE 19-11
Modera te: Ca regiver Support
Fa mily should fill d osette a nd sup ervise med ic a tion-ta king
Chec k, financ es, shopping, d iet and safety (getting lost etc .)
Provid e a d eq ua te sup p ort to fa mily/ sp ouse;
Homec a re sup p orts
Da y Ca re
Friend ly visitors
Wa nd ering Person Registry
11.0 CARE PLAN FOR SPECIFIC COGNITIVE
DEFICITS ON SMMSE:
Another useful fa c et of the SMMSE is tha t it help s to
hig hlig ht d efic its in sp ec ific d oma ins, e.g ., orienta tion to
tim e or p la c e, la ng ua g e, short term m em ory or visuosp a tia l p rob lem s. Awa reness of sp ec ific d efec ts c a n
d irec t hea lth c a re p rofessiona ls to d evelop stra teg ies
to m inim ize d isa b ility a nd ma xim ize func tion
Know led g e of the sp ec ific c og nitive d efic its is a lso
used to d evelop a sp ec ific c a re p la n to ta rg et these
d efic its.
See Ta b le 11.1 (next p a g e) This ta b le wa s rep rod uc ed
w ith kind p erm ission from And rea Vertesi.
46.
47.
Ta ble 11.1
Ca re Pla n for Specific Cognitive Deficits
SMMSE
Deficit
Deficit
Pla n
Question 1-5
Orienta tion to tim e
Dec rea sed orienta tion to tim e
Use of TV, new sp a p er, c loc k, c a lend a r, d ia ry, a la rm rem ind er
for m ed ic a tions, d osette for p ills, ensure g ood sleep a nd
hyg iene, keep ta sks routine.
Question 6-10
Orienta tion to pla ce
Dec rea sed orienta tion to
p la c e
Use of TV, ra d io, new sp a p er, ma p s, d ia ry, orienta tion sig ns, ta ke
fa m ilia r routes, a c c om p a ny to a p p ointm ents a nd w hen
d riving .
Question 11
Dec rea sed reg istra tion
Use one step instruc tions, d ec rea se c lutter, use p hysic a l
c ueing a long w ith verb a l c om ma nd s
Question 12
WORLD
Dec rea sed a ttention sp a n
Sim p lify instruc tions a nd the environm ent, d ec rea se
d istra c tions
Question 13
Rec a ll 3 ob jec ts
Dec rea sed short-term memory
Use c a lend a r, d ia ry, c loc ks a nd m em ory a id s
Question 14-15
Penc il, Wristwa tc h
Ap ha sia , word -find ing p rob lem,
p oor p erc ep tion
Sim p lify the environm ent, d ec rea se c lutter, exp la in ta sks a nd
exp la in the use of item s
Question 16
Com m on Phra se
Ap ha sia , la ng ua g e b a rrier,
d ec rea sed hea ring
Sp ea k slow ly, p ronounc e word s c lea rly, p osition yourself so
they c a n see your fa c e w hen you sp ea k
Question 17
Close your eyes
Ap ha sia , d ec rea sed vision,
d ec rea sed short-term m em ory
Sim p lify c om ma nd s to one step , use p ic tures a nd other visua l
c ues
Question 18
3 step c om ma nd
Apraxia and short-term memory
Sim p lify instruc tions to one or two step s, sp ea k slow ly a nd
c lea rly
Question 19
Sentenc e
Poor m em ory, d ec rea sed
p erc ep tion, p hysic a l
im p a irm ent
Help w ith w riting c heq ues a nd b ills, d irec t d ep osit b a nking ,
use vid eo or a ud io ta p es instea d of w riting letters
Question 20
Cop y d esig n
Ap ra xia , d ec rea sed p erc ep tion
Dec rea se c lutter, sim p lify the environm ent, help w ith wa shing
a nd d ressing
49.
48.
References
12.0 Smmse Scoring Sheet
Section 1
1. Yea r
1
6. Country
1
2. Sea son
1
7. Provinc e/ Sta te/ City
1
3. Month
1
8. City/ tow n
1
4. To d a y s d a te
1
9. Pla c e
1
5. Da y of the week
1
10. Floor of the b uild ing
1
Section 2
11. Word 1
1
Word 2
1
Word 3
1
12. DLROW or
5
Seria l Sevens
16. No if s,
a nd s o r b ut s
1
17. Sub jec t c loses
eyes
1
18. Sentenc e
1
13. Word 1
Word 2
Word 3
1
1
1
19. Four-sid ed fig ure
in two five-sid ed
fig ures
1
14. Wristwa tc h
1
1
15. Penc il
1
20.Ta kes p a p er in
c orrec t ha nd
Fold s it in ha lf
Puts it on the floor
Adjusted Score
Tota l Score
1
1
BØdard M, Molloy DW, Stand ish T, Guyatt GH, D’Souza J, et
al. Clinic al trials in c ognitively impaired old er ad ults:
Home versus c linic assessments. Journal of the Americ an
Geriatric s Soc iety,Vol. 43, 1995, pp. 1127-1130.
Crum. R.M. Anthony. J.C. Bassett. S.S. Folstein. M.F.
population-Based Norms for the Mini-Mental State
Examination, by age and ed uc ation level. JAMA 193, vol
269, p2386-2391.
Field SJ, Jac kson HJ, Hassett AM, Pattison P. Ability of the
Mini-Mental State Examination to d isc riminate d iagnostic
entities in a psyc hogeriatric population. International
Journal of Geriatric Psyc hiatry,Vol.10, 1995, pp.47-53.
Folstein MF, Folstein SE, Mc Hugh PR. "Mini-Mental State": A
prac tic al method for grad ing the c ognitive state of
patients for the c linic ian. Journal of Psyc hiatric Researc h,
Vol. 12, 1975, pp. 189-198.
Molloy D, Stand ish TIM. Mental status and
neuropsyc hologic al assessment. A guid e to the
stand ard ized mini-mental state examination. International
Psyc hogeriatric s,Vol.9, Suppl. 1, 1997, pp. 87-94.
Molloy DW, Silberfeld M, Darzins P, Guyatt GH, Singer PA, et
al. Measuring c a pac ity to c omplete an ad vanc e
d irec tive. Journal of the Americ an Geriatric s Soc iety,Vol.
44, 1996, pp.660-664.
Molloy DW, Alemayehu E, Roberts R. Relia bility of a
stand ard ized Mini-Mental State Examination c ompared
with the trad itional Mini-Mental State Examination.
Americ an Journal of Psyc hiatry,Vol. 148, 1991a, pp. 102105.
Molloy DW, Clarnette RM, Mc Ilroy WE, Guyatt GH, Rees L, et
al. Clinic al signific anc e of primitive reflexes in Alzheimer’s
d isease. Journal of the Americ an Geriatric s Soc iety,Vol.
39, 1991b, pp. 1160-1163.
Molloy DW, Guyatt GH, Wilson DB, Duke R, Rees L, et al.
Effec t of tetrahyd roaminoac rid ine on c ognition, func tion
and behaviour in Alzheimer’s disease. Canadian Medic al
Assoc iation Journal,Vol. 144, 1991c , pp. 29-34.
50.
About the Authors.........
Dr. William Molloy
MB, Bc h, BAO, MRCP(I), FRCP(C)
Dr. Willie Molloy wa s b orn in Wa terford , Irela nd a nd
q ua lified in med ic ine a t University College, Cork, in 1977.
He c a me to Ca na d a in 1981 a nd tra ined in geria tric s a t
the University of Ma nitob a , the University of Western
Onta rio a nd Mc Ma ster University.
A c onsulta nt geria tric ia n, he is c urrently Direc tor of the
Memory Clinic a nd the Geria tric Resea rc h Group a t
Ha milton Hea lth Sc ienc es Corp ora tion a nd a p rofessor of
med ic ine a t Mc Ma ster University. He is Ed itor-in-Chief of
Ma ture Med ic ine Ca na d a a nd the a uthor a nd c oa uthor of numerous b ooks, inc lud ing "Let Me Dec id e",
the b est-selling hea lth a nd p ersona l c a re d irec tive &
living Will, Common Sense Geria tric s, Vita l Choic es, Wha t
a re we going to d o now?, Alzheimer’ s Disea se, Set Me
Free, Ca p a c ity to Dec id e a nd The Fine Deta il a nd the
A.D. Guid e.
He is ma rried to Deb ora h, a nd they ha ve two sons,
Ja mes a nd Alexa nd er.
Dr Roger Clarnette
MB, BS, FRACP
Rog er wa s b orn in Hob a rt a nd g ra d ua ted from Mona sh
University med ic a l Sc hool in 1980.He tra ined in interna l
med ic ine a nd geria tric s a t Roya l Perth Hosp ita l a nd then
a t Mc Ma ster University in Onta rio with Willie Molloy.
He is a t p resent Consulta nt Physic ia nin the Dep t of
Reha b ilita tion a nd Aged Ca re a t Osb orne Pa rk Hosp ita l
a nd Sir Cha rles Ga ird ner Hosp ita l in Perth. He is a
memb er of the Gua rd ia nship a nd Ad ministra tion Boa rd
in Western Austra lia . He is ma rried to Donna a nd ha s two
d a ughters, Ca therine a nd Step ha nie, a nd a son, Henry.
51.
Other publications by New Grange Press
"Let Me Decide" ~ By Dr. D. W. Molloy
Through a ge, illness or a c c id ents, p eop le ma y lose their
c a p a c ity to und ersta nd the na ture a nd c onseq uenc es
of p rop osed hea lth c a re d ec isions. Hea lth c a re
d ec isions then fa ll to fa milies, friend s a nd p hysic ia ns w ho
ma y not b e a wa re of the p a tient’ s wishes a nd intent.
The hea lth c a re d irec tive c onta ined in this b ooklet lets
you p la n your own future hea lth c a re in a d va nc e. It
ma kes sure your wishes will b e known, should there c ome
a time w hen you c a n no longer und ersta nd your op tions
or c ommunic a te your c hoic es to others. Develop ed
over ma ny yea rs of resea rc h a nd c onsulta tion, the Let
me Dec id e hea lth a nd p ersona l c a re d irec tive"
Gives ea c h ind ivid ua l the op p ortunity to c hoose
d ifferent levels of trea tment a c c ord ing to his or
her wishes,
Help s relieve fa mily a nd friend s of resp onsib ility
for d ec isions in times of c risis
Guid es hea lth c a re p ra c titioners in ma king vita l
d ec isions w hen fa mily memb ers a re una va ila b le.
Ha s rec eived enthusia stic sup p ort from a wid e
va riety of ind ivid ua ls a nd group s, inc lud ing
d oc tors, p a tients, soc ia l workers, la wyers, c lergy
a nd a d voc a tes for the eld erly a nd the d isa b led .
This b ooklet is a n ea sy-to follow living Will, written in p la in
la ngua ge. It c onta ins c lea r exp la na tions of trea tment
op tions a nd a sa mp le Direc tive. Let Me Dec id e is
tra nsla ted in Frenc h, Germa n, Ita lia n, Ja p a nese, Sp a nish
a nd Swed ish w hic h a re a va ila b le on req uest. Let Me
Dec id e is a c omp lete hea lth c a re p rogra m with three
vid eos:
1. My Hea lth Ca re - I Dec id e
2. My Hea lth Ca re - Und ersta nd ing My Choic es
3. My Hea lth Ca re - Filling out the Direc tive
"Tra in the Tra iner" Workshop s a nd lec tures a re
a va ila b le on req uest.
Pric e: $10.00
53.
52
Visions and Voices:The Nurses Practitioner Today
by Christine Patterson
The nurse prac titioner movement in both Canada and the
United States began in the mid-1960s. In c ontrast to their
Americ an c olleagues, the progress of the NP movement in
Canada c ould be c ompared more to a phenomenon
waiting to be redisc overed than a progressive integration
of the role in the health c are system. Despite the past,
some provinc es have now legitimized the role through
legislation, marking this period of intense ac tivity as a
milestone in the evolution of the role.
Visions and Voic es: The Nurse Prac titioner Today is a
c omprehensive overview of the politic al, ec onomic al and
soc ial fac tors that influenc e advanc ed prac tic e roles of
nurses. In the book, c ontributors from different organizations
outline the politic al proc ess, educ ational c hallenges and
legal implic ations of advanc ed prac tic e. Nurse
prac titioners disc uss their roles and the problems fac ed in
role development. Physic ians relate their experienc e with
working with nurse prac titioners in different primary,
sec ondary and tertiary c are settings. This book is a unique,
detailed ac c ount of the c hallenges fac ed as professional
nursing redefines it role in health c are.
Sta nda rdized Mini-Menta l Sta te Exa mina tion
The Folstein m ini-m enta l sta te exa m ina tion (MMSE) is
the m ost w id ely used sc reening test of c og nition in
old er a d ults. The Sta nd a rd ized Mini-Menta l Sta te
Exa m ina tion (SMMSE) p rovid es c lea r, exp lic it
a d m inistra tion a nd sc oring g uid elines.
The SMMSE ta kes less tim e to a d m inister (10.5 m inutes)
tha n the MMSE (13.4 m inutes). The SMMSE ha s a
sig nific a ntly lower va ria b ility tha n the MMSE. The
intra ra ter va ria b ility is sig nific a ntly lower w ith the SMMSE
(86%p <0.003) a nd interra ter va ria nc e is lower b y 76%
c om p a red to the MMSE. Intra c la ss c orrela tion for the
MMSE wa s 0.69 c om p a red to 0.9 for the SMMSE. The
SMMSE is now w id ely used b ec a use it is the sa m e a s
the orig ina l Folstein a nd m ore relia b le.
The SMMSE c a n b e used in the d ia g nosis a nd
trea tm ent of d em entia . It is used to sta g e the d isea se,
d ifferentia te b etween the d ifferent d em entia s a nd
a ssess resp onse to trea tm ent.
Visions and Voic es is a c omprehensive overview of the
advanc ed prac tic e role of the nurse prac titioner in
Canada. It c learly artic ulates the issues fac ing nurse
prac titioners and highlights the c ritic al politic al, ec onomic al
and soc ial fac tors impac ting on the expanded prac tic e
role of nurses.....Essential reading for all c onsumers and
providers.
Charolette Noesgaard, President, Registered Nurses
Assoc iation of Ontario (1997-1998)
This is an exemplary book-long overdue and muc h
needed. The Ontario Primary Health Care Nurse
Prac titioner Programme greets Visions and Voic es with
enthusiasm. It is an important resourc e for both fac ulty and
learners.
Heather Hoxby Regional Co-ordinator
The story of the nurse prac titioner in Canada is, and
c ontinues to be ric h-pioneering adventure and politic al
intrigue. This book is an important resourc e for this story.
Linda Jones, Chairperson
Nurse Prac titioner’s Assoc iation of Ontario
Pric e $20.00
Pric e $5.00
54.
55.
"Capacity to Decide" ~ By Dr. D. W. Molloy, Dr. P. Darzins,
Dr. Strang
Ca p a c ity to Dec id e is a short, c omp rehensive b ook
w hic h d esc rib es a new six-step c a p a c ity a ssessment to
mea sure d ec ision-sp ec ific c a p a c ity, with c lea r instruc tions
on its use. This b ook d esc rib es how this new a ssessment
p roc ess p roc ess c a n b e a p p lied to mea sure c a p a c ity for:
p ersona l c a re,
hea lth c a re,
p rop erty a nd fina nc es,
a d va nc e d irec tives,
Wills a nd Powers of Attorney
d riving
sexua lity a nd intima c y
For m ore informa tion or to ord er w rite to:
There a re litera lly hund red s of help ful hints for interviewing
a nd d ea ling with issues suc h a s d ep ression, d elusions,
d enia l in the a ssessment p roc ess.You will lea rn how to
d ea l with d ifferent threshold s of und ersta nd ing a nd
id iosync hra tic va lues a nd b eliefs. Other top ic s c overed
inc lud e d riving, sexua lity a nd intima c y.
This p roc ess ha s b een d evelop ed d uring c onsulta tion
with litera ly hund red s of p rofessiona ls, inc lud ing d oc tors,
nurses, p hysic ia trists, fina nc ia l a d visors, rea l esta te a gents,
a c c ounta nts, la wyers, soc ia l workers, oc c up a tiona l
thera p ists, p hysiothera p ists a nd la y p eop le. It ha s b een
a p p lied wid ely in c linic a l p ra c tic e, in the a ssessment of a
wid e ra nge of ind ivid ua ls whose c a p a c ity wa s
c ha llenged .
C a p a c ity to Dec id e is p ra c tic a l guid e a nd a n
inva lua b le tool for hea lth c a re workers, memb ers of the
lega l p rofession a nd a nyone w ho need s to mea sure
c a p a c ity in p a tients or c lients.
This p roc ess ha s a lso b een used wid ely in the c ourt
system, w here d ec isions a b out on c a p a c ity a re in
d isp ute. "Ca p a c ity to Dec id e", ha s ma ny figures, ta b les
a nd c ha rts d esc rib ing d ec isiona l a id s whic h a re used in
the p roc ess.
It is written for p rofessiona ls a nd la yp ersons. This b ook is a
"must" for a nyone w ho d ea ls with c lients or p a tients
w hose c a p a c ity ma y b e c a lled into in q uestion.
Pric e $24.00
Newgra nge Press
428 Orkney Roa d
R.R.1 Troy, Onta rio
Ca na da L0R 2B0
Tel: (905) 628 0354
Fa x: (905) 628 4901
e-mail: [email protected]
Website: www.netcom.ca/ ~idecide
Newgra nge Press (Irela nd)
The Sta bles, Woodstown,
Wa terford, Irela nd
Tel: 353 51 870152
Fa x: 353 51 871214
Newgra nge Press (Austra lia )
Tel: 08 9346 8107
PO Box 7077
Fa x: 08 9346 8232
Shenton Pa rk
ema il: cla [email protected] u
W Aust 6008
Newgra nge Press (Ja pa n)
100-1, Ka shiya ma ,
Ha bikino, Osa ka
(583-0886), Ja pa n
Tel: 81 729 542000
Fa x: 81 729 547560