Assessment Instrument

By: Michelle Muoz

LEI 4711 Fall 2016

I.

Introduction
The Recreational therapy department uses this in-house assessment tool to
determine the needs for services for older adults with Alzheimers disease. This ageappropriate assessment tool will be administered to provide the recreational therapist with
an analysis of the clients attitudes and functional skills such as physical, cognitive, and
social/emotional levels. This tool will also focus on the clients interests and present leisure
patterns, as well as leisure competencies. The results from the assessment will provide
reliable information about client needs for the recreational therapist to create the
appropriate goals and treatment programs, as well as, detail clients performance and
measure improvement at the end of treatment. This assessment tool includes the initial
assessment form and a short informational survey to identify the clients leisure
participation and patterns.

II.

Assessment Instrument Description

a. Population
The assessment tool is designed for older adults ages 65 and over who have been
diagnosed with Alzheimers disease. Alzheimers is the most common form of
dementia and it is a progressive brain disorder that impairs memory, thinking skills,
and ultimately the ability to function in daily life (National Institute on Aging, n.d.).
Alzheimers disease has three stages: preclinical stage (with no symptoms), a middle
stage with mild cognitive impairment, and a final stage which results in dementia
(National Institute on Aging, n.d.). The majority of individuals with Alzheimers

disease are 65 and older and symptoms of dementia gradually worsen over several years
(Alzheimers Association, n.d.).
The symptoms of Alzheimers disease progress over time and often interfere with
daily life. The symptoms are also unique to each individual. The earliest sign of the
disease is when the person begins to have difficulty recalling recent events and learning
new information. Many individuals may begin to lose items, struggle to find the right
words in a conversation, forget names, appointments or anniversaries, and get lost in
familiar places (Alzheimer's Society, 2014). There is no cure for Alzheimers disease,
but treatments for the symptoms are available. Therapeutic recreation and activities can
help reduce the effects of Alzheimers disease in an individuals life by providing
meaningful leisure tasks that can enhance the persons overall quality of life.
b. Target Area
The assessment instrument targets the individuals physical, cognitive,
social/emotional, and leisure domains. Other information that will be gathered include
clients work/school history, family and significant others, physicians orders
concerning allowed activity level, listed precautions, and admitting diagnoses. Since
most clients with Alzheimers disease are older adults, many have other impairments
such as with their vision or hearing. Many clients may use hearing aids, use glasses, or
may have severely impaired vision. The therapist will assess these physical aspects as
well as the clients ability to walk with or without assistance. The therapist will also
analyze the clients endurance by assessing the clients energy level, pain level, and
attention to tasks. These physical skills are assessed to ensure the client receives
appropriate program activities based on their ability level.

The therapist will assess the clients cognition through a series of questions that
evaluate his/her awareness, orientation, and memory. Individuals with Alzheimers
struggle with memory loss and are often confused and disoriented. The therapist
measures the clients cognitive level in relation to the leisure activities that he/she will
be participating in. The social/emotional domain will be targeted through assessment
questions that measure the clients social patterns and social skills, as well as, measure
his/her affect. The therapist will use observation to document clients skills, behaviors,
and attitudes. The clients leisure skills will be assessed by identifying his/her leisure
participation and patterns.
c. Response Mode
The assessment tool response mode will consist of checklists. The checklists
will involve lists of potential leisure activities, past leisure patterns, and functional
skills. The assessment will also incorporate short answers that will ask simple questions
to evaluate the persons needs in various aspects of life. The short informational survey
at the end consists of fill-in-the-blank responses to gather further information on the
clients past and present lifestyle.
d. Administration Guidelines
The assessment tool will be administered by a Certified Therapeutic Recreation
Specialist (CTRS) who specializes in the field of geriatrics. The CTRS will assess the
clients functional skills, as well as, their leisure participation and patterns to
appropriately plan intervention programs. The assessment tool will be used to measure
the clients skill levels in the functional domains such as physical, cognitive, and
social/emotional and target leisure related goals. With this information, the CTRS will

then establish potential needs and strengths, and guide the development of the treatment
plan. The client must be alert and oriented to be able to complete the assessment. If the
client is confused and disoriented, a family member or trusted caregiver can answer for
the client.
The CTRS will use checklists to mark off areas based on the client or
caregivers responses. The CTRS will ask the client or caregiver open-ended questions
and the therapist will then mark their responses in the short answer section. The fill-inthe-blank informational survey will be completed by the client or caregiver and will be
administered after the therapist has completed the checklist and short answer portions
of the assessment tool. The CTRS must use this assessment tool as a method to build
trust and rapport between the therapist and the client. The initial assessment tool should
last between 30 to 45 minutes.
III.

Instrument Development and Trial

a. Norm-referenced or Criterion-referenced
The assessment instrument is a criterion-referenced testing tool. These tools
are used to measure functional skills and client attitudes and compare the responses
or scores to the actual tasks or attitudes. The norm-referenced testing tool will not
be used. Individuals with Alzheimers disease may not have all of the same
symptoms. Each client should be treated and assessed individually since the
progression of the disease may vary. The results of the assessment will be measured
against predetermined criteria on what the clients are expected to know and be able
to do in their specific stage of the disease. This criterion-referenced assessment will
allow the CTRS to plan meaningful and specific programs that focus on the clients

performance at the end of the treatment. This will then lead to information on the
clients improvement over time.
b. Functional-environment
The functional-environment where the assessment will take place should be
controlled by the therapist. The therapist will be able to observe clients behaviors in a
natural setting when interacting during the assessment process. The naturalistic
observation will allow the therapist to record the clients behaviors and actions in a
natural environment where the person feels comfortable and relaxed. Clients skills will
be measured in the physical, cognitive, social/emotional, and leisure environments. The
therapist should prepare the individual for the assessment and initiate with
nonthreatening conversation.

IV.

Assessment Report Form

ALZHEIMERS DISEASE
RECREATIONAL THERAPY ASSESSMENT

Date: ____________ Assessment #________________ Staff:___________________ Unit:______________________

Client Background Information:

Last Name: __________________________ First Name: _________________________ M.I. ________
Date of Birth: _____________________________ Date of Admission: _________________________
Birthplace: __________________________________________________________________________
Education: __________________________________________________________________________
Occupation: ___________________________ Retirement Date: ______________________________
Marital Status:

Spouse Name/Caregiver: ______________________________________________________________

Family/Caregiver Phone Number: _____________________ Relationship: _____________________
Children: ___________________________________________________________________________
Residence History: ___________________________________________________________________
Diagnosis: __________________________________________________________________________
Physicians Orders for Activity: ________________________________________________________
____________________________________________________________________________________
Primary/Preferred Language: __________________________________________________________

FUNCTIONAL SKILLS RELATED TO LEISURE

Physical
Sight/Vision:

Hearing:

___ Normal

___ Normal

___ Partial or Impaired (corrected with lenses)

___ Hearing impaired (corrected)

___ Partial or Impaired (not corrected with lenses)

___ Hearing Impaired (not corrected)

___ Legally Blind (no vision) __ L or __ R

___ Deaf (no hearing) __ L or __ R

Ambulation:

Strength and Motor Coordination:

___ Normal

___ Normal

___ Ambulates with difficulty (no aids)

___ Minor difficulty

___ Ambulates with aids (crutches, cane, walker, scooter)

___ Moderate difficulty

___ Wheelchair (difficulty in use)

___ Weakness

___ Wheelchair (unable to use independently)

___ No ambulation

Allergies:
___ No
___ Yes, __________________________________

Cognitive:
Orientation:

Oral Language:

___ Normal

___ Articulate

___ Confused & disoriented occasionally

___ Average articulation

___ *Confused & disoriented often

___ Poor articulation

___ *Confused & disoriented all of the time

___ No oral articulation

**If checked, caregiver must answer the remainder

of the assessment to gather information accurately.

Thought Process and Decision Making:

Memory:

___ Excellent

___ Clear recall of recent or past events

___ Average

___ Vague recall of recent or past events

___ Poor

___ No recall of events

Social/Emotional:
Social Skills:

Emotional:

___ Listens and understands when others are speaking

___ Displays appropriate affect

___ Does not listen or understand

___ Engages in cooperative behavior

___ Enjoys group interactions

___ Loses emotional control

___ Participates voluntarily

___ Displays passivity

___ Engages in conversation

___ Agitation

___ Seeks social contacts

___ Tolerance for frustration

___ No interest in social contacts

___ Displays Frustration behavior

LEISURE PREFERENCES
*Check with RED pen for current interests and BLUE pen for past interests.
Household Tasks:
o
o
o
o
o
o
o
o

Cooking
Laundry
Cleaning
Shopping
Washing Dishes
Decorating Home
Home Repairs
Other: ___________________

Leisure Interests:
o
o
o
o
o
o
o
o
o

o
o

Travel
Games
Sports
Crafts
Reading
Photography
Gardening
Movies/TV
Music
Nature
Other:
________________________
________________________
________________________
________________________

Crafts:
o
o
o
o
o
o
o

Social Interests:
o
o
o
o
o

Visiting family
Visiting friends
Planning social functions
Entertaining
Reminiscing: Are there any
topics of preference/enjoys
most?
o Other: _________________

Games:
o
o
o
o
o
o
o
o

Bingo
Board Games
Cards
Puzzles
Mahjong
Darts
Billiards
Other:
______________________
______________________
______________________
______________________

Music:
Knitting
Sewing
Woodworking
Painting
Sculpting
Ceramics
Other:
___________________________
___________________________
___________________________
___________________________

o Likes to listen to music

o Likes to play music
o Play an instrument?
______________________
o What kind of music?
______________________
______________________
Movies/TV:
o Likes to watch movies/TV
o What kind of movies/TV
shows?
______________________
______________________

Reading:

o Client enjoys reading

o Client does not read
o What does she/he read?
___________________

__________________
__________________
__________________
__________________
Sports/Exercise:
o
o
o
o
o
o
o
o
o
o
o
o
o

Hockey
Football
Soccer
Volleyball
Tennis
Croquet
Horseshoes
Golf
Yoga
Running/Jogging
Walking/hiking
Dancing
Other:
_________________________
_________________________
_________________________
_________________________

Pets:
o
o
o
o

Does he/she have a pet?

Likes animals
Interested in pet therapy
What kind of pets?
________________________
________________________
________________________
________________________

COMMENTS:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

QUESTIONNAIRE FOR CLIENT/CAREGIVER

1. How did this person spend his/her time before the time he/she was diagnosed with Alzheimers
disease? Note details related to routines and habits.
_____________________________________________________________________________
_____________________________________________________________________________
______________________________________
2. Is there anything the client wants the therapist to know in regards to his/her life, work, and/or
family?
_____________________________________________________________________________
_____________________________________________________________________________
______________________________________
3. Describe the clients needs. (social, cognitive stimulation, sensory, practical life, etc.)
_____________________________________________________________________________
_____________________________________________________________________________
______________________________________

Information collected from:

o Client
o Family member(s): _______________________________________________________
o Caregiver(s): ____________________________________________________________

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SUMMARY OF ASSESSMENT

____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
___________________________________________________

SIGNATURE ______________________________________ DATE _______________

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Recreational Therapy Informational Survey

Client Name: __________________
Date: ________________________
Purpose: The All About Me informational survey is used to get to know you and to learn more
about the activities that you enjoy participating in the most. This survey will help your therapist
tailor activities and programs that will meet your specific leisure needs.
Directions: Please fill in the blanks below with your information using a pen or pencil.

All About Me
My friends call me ____________. I lived in ____________; prior to that I lived in
____________ and ____________. My favorite thing about home is ____________.
I am a ____________ (farmer, artist, fisherman, golfer). When I was young I used
to love to ____________. Some of my favorite things are ____________ and
______________. I am very good at _______________ and I am proud of
________________. My favorite place to visit is ______________. I like to read
____________, and listen to ____________. My favorite leisure pastime is
____________. My favorite foods are ____________. Three things I would like
others to know about me are ____________, ________________, and
_________________.

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V.

Summary and Conclusion

This assessment tool will be used to gather informational data on a clients
functional skills, attitudes, and leisure interests. The tool will consist of checklists, short
answer questions, and an informational survey to be able to collect reliable and valid
data about the clients past and current lifestyle. The assessment will target functional
abilities and the leisure preferences and patterns of the client. After administering the
assessment tool for the Alzheimers client, the therapist will be able to plan and develop
appropriate intervention programs and activities according to the responses gathered
from the assessment. The client results will help the therapist create programs that will
effectively meet the interests of the individual. Goals will also be made according to
the clients needs and abilities. The recreational therapy assessment tool for Alzheimers
clients aims to provide the therapist with a measure of the clients abilities and leisure
interests to ultimately be able to construct programs that will benefit the clients overall
life.

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Reference:
National Institute on Aging: About Alzheimer's Disease. (n.d.). Retrieved October 21, 2016,
from https://www.nia.nih.gov/alzheimers/topics/alzheimers-basics
Alzheimer's Association: Alzheimer's Disease & Dementia. (n.d.). Retrieved October 21, 2016,
from http://www.alz.org/alzheimers_disease_what_is_alzheimers.asp
Alzheimer's Society: What is Alzheimer's disease? (2014). Retrieved October 21, 2016, from
https://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=100

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