DEMENTIA PROFORMA

Symptoms checklist in history for cognitive decline

1. Cognitive domains

A. Memory- working(attention), recent and remote

B. Language

C. Visuospatial function

D. Calculation

E. Executive functions-planning, judgement, set shifting, social sense etc

2. Functions

A. Cooking

B. House keeping

C. Managing functions and ceremony

D. Bathing and personal hygiene

E. Continence

F. Dressing

G. Self feeding

H. Shopping

I. Office working

J. Mobility (out door or indoor navigation)

K. Driving

L. Gadget using

M. Worship

N. Hobbies

3. Mood/mental phenonmenon

A. Apathy/interest in surrounding

B. Depression

C. Crying or laughing spells in perspective

D. Panic attacks

E. Liableness and irritability

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F. Euphoria

G. Illusion

H. Delusion

I. Hallucination

J. Intrusive thoughts and behaviour

K. Acute confusional state

L. Diurnal variation

M. Wandering

4. Drives

A. Appetite/food faddism

B. Weight loss or gain

C. Hyper or hypo sexuality

D. Sleep

5. Motor phenomenon

A. Tremor

B. Myoclonus

C. Seizure

D. Ataxia

E. Gait change

F. Bradykinesia

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Higher Mental Function Examination

I. Patient Information
1. Name
2. Age/Sex
3. Address
4. Religion
5. Occupation
6. Education
7. Handedness
8. Spoken language
II. Behavioural Observations
1. Physical appearance
2. Emotional status
3. Level of consciousness
4. Level of co-operation
III. Attention
1. Digit span – Forward and backward
• Directions- Ask patients to repeat a series of numbers after the
examiner in increasing order. Present numbers at rate of 1/sec. Avoid
natural sequences like 2,4,6 and avoid speaking in a format. Continue
till patient fails to repeat all numbers correctly. Repetition in
backward fashion similarly.
• Scoring- Forward - 5 to 7
• Backward – at least (Forward minus 2)
2. Sustained attention –Vigilance- ‘A’ Random Letter test
• Read out a long series of letters and ask the patient to tap once the
letter “A” is spoken. No mistake should be made by normal
individuals.
• Scoring- Note errors of Omission, Commission and perseveration.
IV. Language

1. Spontaneous speech
• Test- “Tell me about your work or illness?” Listen carefully for
impairment in articulation, prosody, grammer, fluency or any
paraphasia and neologism.
• Normal Fluency (100-150 words/min, sentence length more than
seven words)
o Verbal fluency
• Animal or vegetables naming test (60 sec)
• Scoring- <13 is impaired

o FAS test (pa,ma,ka for hindi speaking person)-

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• Exclude proper noun or morphological varients- 60 sec for each

letter
Scoring – Less than 12 per words per letter is impaired

2. Comprehension

•
Pointing commands – ask at least 4 objects in room or body parts.
•
Yes or no response (ask at least 7 questions):eg. Is this a hotel?
Is it raining today?
• Complex command eg. The lion was killed by the tiger, which
animal is dead? The boy was slapped by girl, who got hit?
3. Repetition (Normal person can repeat sentence of 19 syllables)

• Airoplane
• Community hospital
• Ganga Jamuna Saraswati
• Saraswati shisu bhal bidya mandir
• Pani varsa cham cham chata lekar nikale hum
Scoring – Note type of error Additions/ommissions/Paraphasias/Grammatical

4. Naming and Word finding

Colors - Red Blue Yellow Pink

Body parts - Eye Leg Teeth Thumb

Clothing and room objects - Door/Watch/Shoe/Shirt

Parts of objects – chain of wrist watch/Shoe lashes/Buckle of belt/ Nib of pen

Scoring – less than 4 in any category is abnormal

5.Reading (Reading aloud)

Letters- G D E Q M O P X B A

Numbers-5 8 9 6 23 59 678 321

Give a paragraph to read

Reading Comprehension (ask something about written sentence)

‘The boy and girl walked in the sun’

Q-Did the boy go alone?

Q-Was it raining when the boy and girl went for walk?

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6.Writing – Dictate letter, numbers

- Names of common object or body parts

-Write a sentence- about job or weather

FRONTAL LOBE
1. Attention/working memory: Digit span
2. Set Shifting- Trail making test A

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3. Trail B Test

4. Sequencing test (programming)

Motor Luria T "fist–edge–palm." Examiner demonstrates and patient performs 3
series with examiner and 3 series alone.
Score
a. 6 correct consecutive series : 3
b. At least 3 correct consecutive series : 2
c. Fails alone, but performs 3 correct consecutive series with the examiner: 1
d. Cannot perform 3 correct consecutive series even with the examiner: 0
Implication-Frontal lobe lesions - impaired in tasks requiring temporal organization &
execution of successive actions. Simplification (two gestures instead of three) and
Perseveration (inappropriate repetition of the same gestures) may be observed

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Graphic Luria Test

5. Verbal Similarities Test

Tests verbal abstract thinking, analysis of relationships, formation of verbal concepts
and logical thinking. Subjects have to conceptualize the links between two objects
from the same category. Patients with Frontal lobe dysfunction are unable to
establish an abstract link between the items.
Directions – Give 5 pairs of objects like ‘car-airplane’ and ask the patient how these
are alike.
Scoring-
a. Highly pertinent abstract similarity/classification- 2
b. Relevant similarity – 1
c. Differences/ similarities not pertinent/ failure to respond- 0
6. Verbal fluency test
Directions- Patients asked to state words starting from ‘S’, except proper nouns in
60s
Score
a. >9 words: 3 ; 6-9 words: 2; 3-5 words: 1; <3 words: 0
Implication -Patients with frontal lobe lesions are disturbed in non-routine situations
in which self-organized cognitive strategies have to be made. Literal fluency tasks
require non-routine retrieval from semantic memory and thus, verbal fluency is
reduced with frontal lesions (left > right)
7. Conflicting instructions/Sensitivity to interference
Direction - Pt asked to tap twice when examiner taps once & vice versa. Examiner
demonstrates 3 trials of 1-1-1 & 2-2-2. Then test in the following manner - 1-1-2-1-2-
2-2-1-1-2
Scoring
a. No error: 3
b. 1-2 errors: 2
c. > 2 errors: 1
d. Pt taps like the examiner at least 4 consecutive times: 0
Implication - Demonstrates deficits in behavioral self-regulation - tasks of verbal
commands conflict with sensory information. Patients with a frontal lobe lesion- fail
to obey the verbal command & tend to imitate the examiner
8. Inhibitory control - GO-NO-GO TEST
Directions- Pt asked to tap once when examiner taps once & stop when examiner
tap twice
Score
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a. No error: 3
b. 1-2 errors: 2
c. > 2 errors: 1
d. Pt taps like the examiner at least 4 consecutive times: 0
Significance – Difficulty in withholding a response- lesion in ventral part of frontal
lobes.

9. Proverb Interpretation
Tests fund of general information and abstract thinking
Directions - Give 5 commonly used proverbs, keeping in mind the educational and
social background of the patient. Ask them to explain what it means. Examiner can
repeat but without paraphrasing or explaining. Continue only till the patient fails on
2 consecutive proverbs.
Scoring - Grade response as 0= Concrete, 1= Semiabstract, 2= Abstract. Max
points=10. Score < 5 is abnormal

10. Environmental autonomy

Directions - Pts hands kept supine on a rest. Examiner touches & places his hands
close to pt’s hands. If pt takes the hand, instruct not to do so and repeat the act.
Scoring - Pt does not take the examiner’s hands: 3
a. Hesitates and asks what he/she has to do: 2
b. Takes the hands without hesitation: 1
c. Takes the examiner’s hand even after being told not to do so: 0
Tests excessive dependence on environmental cues.
Sensory stimuli can activate patterns of responses that are normally inhibited in
normal controls. For example-
d. the sight of a movement -an order to imitate - imitation behavior
e. the sight of an object - an order to use it - utilization behavior
f. the sensory perception of objects- an order to take it- prehension behavior
11. Judgement – ask patient “what you will do if this place catches fire”
12. Insight

Temporal lobe
Memory
1. Recent memory

Orientation – Time- day, date, month, year, season

Place- hospital, floor, city, state and country

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Person- “What is your name”

“What is your age”,

“Who is he/she (family member, doctor etc)”

2. Remote memory

(Ask personal information which can be verified and historic facts in respect to
patient’s knowledge before onset of illness)

Personal information

• Where were you born…………………………………………….

• What is your date of birth………………………………………..
• Name of first school………………………………………………..
• Where it was located………………………………………………..
• Where do you work…………………………………………………
• When were you married……………………………………………

Historical facts
• Independence Day……………………………………………..
• Sita was wife of ....................................................
• First prime minister of India…………………………………..
• Ravana was king of…………………………………….

4. New learning ability (Integration of total memory system: recognition,

registration, retention, storage, recall)

o Direction - Correct any errors made on immediate repetition

o To eliminate mental rehearsal use interference between presentation and
recall
o Scoring - Less than 3words after 10 min is abnormal
o Give Verbal Cues- Semantic (One word was a colour), Phonemic cues ( It was
sounding like) Contexual cues (It was a flower ) to identify retrieval defect.

0 min 5 min 10 min 30 min

Yellow

Honesty

Elephant

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Rose

5. Visual memory (5 Hidden objects) –

• Direction-Name each item as it is hidden, Provide interfering stimuli for 5 min,

ask patient to name and indicate location, If cannot locate ask name of
hidden object.
• Score – less than 4 is abnormal

PARIETAL LOBE
1. Neglect- 3 components
• Decrease awareness(sensory) also k/a inattention
• Decrease exploratory or orienting act (motor) also k/a akinesia
• Decrease motivation also k/a agnosia
Tests-
a. Simultaneous bilateral stimulation
• Visual
• Tactile
• auditory
b. Visual target cancellation
• Line bisection( ask pt to divide line into two equal parts)

------------------------------------------------------------------------------------

• Word cancellation

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Note: differentiate visual hemineglact from hemianopia

2. Simultagnosia-
Direction- ask patients to encircle all “A” in following picture

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Significance- test abilty to intigrate visual information in the centre of gaze

with more peripheral information

3. Apraxia
Direction- 3 steps
1. Ask to pantomime a task (without object)
2. Ask to imitate examiner ( examiner pantomime a task)
3. Give a real abject and ask to do a task
Give different tasks for buccofacial (candle blowing, drinking with
straw etc), limb(flip a coin,salute, hair combing etc) and trunk(batting
posture, boxing position etc). Test both individually with different
task
Scoring- Failure at step 1 suggest ideomotor apraxia
- Failure at step 2 suggest possibility of ideational apraxia
- Failure at step 3 suggest ideational apraxia
Significance- tests motor planning and execution

4. Constructional ability
Direction- 2 steps
1. Reproduction of two and three dimensional diagrams( at least two
of each type)
2. Drawing on command
a) Clock drawing
b) Daisy in flower pot
c) House in perspective
Scoring- 0,1,2,3 for poor, fair, good and excellent
Significance- test constructive praxis/visuo-constructive ability involving
integration parietal lobe with occipital and frontal lobe
Clock drawing test- Stahelin et al. 1997
Direction- ask pt to draw a wall clock by drawing a large circle, putting
numbers from 1-12 and two hands showing time 10:20.
If pt unable to initiate draw a circle and again ask.
Scoring- give 3 for putting no. 12 in position, 1 for 12 numbers, 1 for hands
and 1 for correct time. Less than 4 suggest definite impairment.
Significance- test constructional apraxia, visuospatial orientation,
hemineglact, right left orientation, planning and sequencing.

5. Calculation
Direction- 3 steps

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1. Verbal simple
2. Verbal complex
3. Written complex
At least one for addition, subtraction, multiplication and division
at each step. Max time for one calculation in verbal complex is 20
seconds and for written complex 30 seconds
Significance- localizes dominant parietal lobe.
6. Right left orientation
Direction- 4 steps
1. Identification on self (eg show your left hand)
2. Cross command on self (eg touch your left ear with right hand)
3. Identification on examiner ( eg show my right hand)
4. Cross command on examiner ( eg touch my left hand with your
right hand)
9% male and 17% of female demonstrate difficulty
Significance- localizes to dominant parietal lobe.
7. Finger agnosia
Direction- 3 steps
1. Non verbal finger recognition ( touch pt’s finger in eye closed state
and have eye opened and ask pt to point same finger on
examiner’s hand.
2. Identification of named finger on examiner
3. Verbal identification(naming) of fingers on self and examiner eg.
What is the name of this finger
Significance- part of Gerstmann’s syndrome (dominant parietal lobe lesion)
8. Geographic orientation
Direction- Ask to draw a map. It pt unable to do, draw a suitable out line and
ask to mark major cities.

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9. Cortical sensation
o Stereognosis
Appreciation of size and shape- put familiar objects like coin, key etc in hand
with eye closed and ask to identify
o Graphesthesia
Ability to recognise letters and numbers in palm or dorsum of foot with
pencil or blunt pin ( with eye closed)
o Two point discrimination
With a divider, eye closed touch two points simultaneously and ask pt to tell
how many pins were pricked to him.
Finger tip- normal 2-4 mm
Palm- normal 8-12 mm
Dorsum of foot- normal 30-40 mm

Significance- localizes to contra lateral parietal lobe but only in presence of

normal primary sensations.

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OCCIPITAL LOBE

1. Prosopagnosia- show photographs of familiar faces

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2. Visual object agnosia- show photographs of familiar objects

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