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ALZHEIMER'S DISEASE MIRECC TREATMENT EVALUATION SUPPLEMENT

MIRECC Treatment Evaluation Project
Form Based on CA DHS Alzheimer's Research Centers of CA
Tx Eval Supplement (IHA-UCSF: MUDS 99, Version 01/2001)
MIRECC Treatment Evaluation Supplement Version 01/17/01

1. Site ID:

2. Patient UPIN:

3. Date (MMDDYYYY):

4. Reasno:

5. GPEU ID:

Time (24 hr)

A. Prescriber Behavior


(Complete section A only at initial entry into the Treatment Evaluation Study.)

There is a wide range of opinion about the effectiveness of FDA approved anti-Alzheimer's medications in clinical practice. If the patient fulfilled the FDA approved diagnostic criteria for drug treatment of dementia (i.e. mild to moderate Alzheimer's disease), please answer 1 of the following 2 questions, depending on your treatment action or recommendation.

1. If you decided to prescribe ____________ (a FDA approved anti-Alzheimer's medication or recommend it to the patient's medical provider, please select one or more reasons for your decision:

(a) This type of patient sometimes responds well.
(b) My/our routine is to give this drug a trial.
(c) The patient/family wanted it and there was little risk.
(d) My/our routine is to recommend that AD patient discuss this drug with their medical provider.
(e) Other reasons (please specify)

If other, please specify

OR

--

(a) Patient too impaired.
(b) Concerns about other medical problems.
(c) Concerns about caregiver monitoring.
(d) Other reasons (please specify)

If other, please specify

B. Extrapyramidal Signs - UPDRS Scale*


(*Acta Neural Scand 1997 Dec;96(6):366-371. The UPDRS scale as a means of identifying extrapyramidal signs in patients suffering from dementia with Lewy Bodies. Ballard C, McKeith I, Burn D, Harrison R, O'Brien J, Lowery K, Campbell M, Perry R.)

Rater:

3. Facial expression:

(a) Normal.
(b) Minimal hypomimia: could be normal "Poker Face."
(c) Slight but definitely abnormal diminution of the facial expression.
(d) Moderate hypomimia: lips parted some of the time.
(e) Masked or fixed faces with severe or complete loss of facial expression: lips parted 1/4 inch or more.

4. Tremor at rest:

(a) Absent.
(b) Slight and infrequently present.
(c) Mild in amplitude and persistent. Or moderate in amplitude, but intermittently present.
(d) Moderate in amplitude and present most of the time.
(e) Marked in amplitude and present most of the time.

5. Action or postural tremor of hands:

(a) Absent.
(b) Slight: present in action.
(c) Moderate in amplitude: present with action.
(d) Moderate in amplitude with posture holding as well as action.
(e) Marked in amplitude: interferes with feeding.

6. Rigidity: (judge on passive movement of wrist, elbows and shoulders with patient relaxed in sitting position. Cogwheeling to be ignored.)

(a) Absent.
(b) Slight or detectable only when activated by mirror or other movements.
(c) Mild to moderate.
(d) Marked, but full range of motion easily achieved.
(e) Severe: range of motion achieved with difficulty.

7. Body bradykinesia and hypokinesia: (Combining slowness, hesitancy, decreased armswing, small amplitude, and poverty in movement in general.)

(a) Absent.
(b) Slight: present in action.
(c) Moderate in amplitude: present with action.
(d) Moderate in amplitude with posture holding as well as action.
(e) Marked in amplitude: interferes with feeding.
C. Neuropsychiatric Inventory Questionnaire (NPI-Q)*
(Developed by Daniel Kaufer, MD. All rights reserved, Jeffrey Cummings, MD. With permission for VA MIRECC & State of California ARCCs)

8. Informant:

(01) Spouse or Spouse equivalent
(02) Son
(03) Son-in-law
(04) Daughter
(05) Daughter-in-law
(06) Other relative(s)
(07) Friend
(08) Neighbor
(09) Paid caregiver
(10) Patient self-report
(11) Other

Please answer the following questions based on changes that have occurred since he/she first began to experience memory problems.

Select "Yes" only if the symptom(s) has been present in the last month.
Select "No" only if the symptom(s) has not been present in the last month.
Otherwise, select "N/D." For each item marked "Yes":

a) Rate the SEVERITY of the symptom (how it affects the patient):
1 = Mild (noticeable, but not a significant change)
2 = Moderate (significant, but not a dramatic change)
3 = Severe (very marked or prominent, a dramatic change)

b) Rate the DISTRESS you experience due to that symptom (how it affects you):
0 = Not distressing at all
1 = Minimal (slightly distressing, not a problem to cope with)
2 = Mild (not very distressing, generally easy to cope with)
3 = Moderate (fairly distressing, not always easy to cope with)
4 = Severe (very distressing, difficult to cope with)
5 = Extreme or Very Severe (extremely distressing, unable to cope with)

Please answer each question honestly and carefully. Ask for assistance if you are not sure how to answer any questions.

9. Delusions
Does the patient believe that others are stealing from him/her or planning to harm him/her in some way?

Yes=1
No=2
N/D=9

SEVERITY

1
2
3

DISTRESS

0
1
2
3
4
5

10. Hallucinations
Does the patient act as if he/she hears voices? Does he/she talk to people who are not there?

Yes=1
No=2
N/D=9

SEVERITY

1
2
3

DISTRESS

0
1
2
3
4
5

11. Agitation/Aggression
Is the patient stubborn and resistive to help from others?

Yes=1
No=2
N/D=9

SEVERITY

1
2
3

DISTRESS

0
1
2
3
4
5

12. Depression (Dysphoria)
Does the patient act as if he/she is sad or in low spirits? Does he/she cry?

Yes=1
No=2
N/D=9

SEVERITY

1
2
3

DISTRESS

0
1
2
3
4
5

13. Anxiety
Does the patient become upset when separated from you? Does he/she have any other signs of nervousness such as shortness of breath, signing, unable to relax, or feeling excessively tense?

Yes=1
No=2
N/D=9

SEVERITY

1
2
3

DISTRESS

0
1
2
3
4
5

14. Elation/Euphoria
Does the patient appear to feel too good or act excessively happy?

Yes=1
No=2
N/D=9

SEVERITY

1
2
3

DISTRESS

0
1
2
3
4
5

15. Apathy/Indifference
Does the patient seem less interested in his/her usual activities and in the activities and plans of others?

Yes=1
No=2
N/D=9

SEVERITY

1
2
3

DISTRESS

0
1
2
3
4
5

16. Disinhibition
Does the patient seem to act impulsively, for example, talking to strangers as if he/she knows them, or saying things that may hurt people's feelings?

Yes=1
No=2
N/D=9

SEVERITY

1
2
3

DISTRESS

0
1
2
3
4
5

17. Irritability/Lability
Is the patient impatient and cranky? Does he/she have difficulty coping with delays or waiting for planned activities?

Yes=1
No=2
N/D=9

SEVERITY

1
2
3

DISTRESS

0
1
2
3
4
5

18. Motor Disturbance
Does the patient engage in repetitive activities such as pacing around the house, handling buttons, wrapping string, or doing other things repeatedly?

Yes=1
No=2
N/D=9

SEVERITY

1
2
3

DISTRESS

0
1
2
3
4
5

19. Nighttime Behaviors
Does the patient awaken you during the night, rise too early in the morning, or take excessive naps during the day?

Yes=1
No=2
N/D=9

SEVERITY

1
2
3

DISTRESS

0
1
2
3
4
5

20. Appetite/Eating
Has the patient lost or gained weight, or had a change in the type of food he/she likes?

Yes=1
No=2
N/D=9

SEVERITY

1
2
3

DISTRESS

0
1
2
3
4
5

D. Additional Medical/Clinical Status Questions

(Not included in ARCC Treatment Evaluation Supplement)

21. Since our last evaluation (or within 6 months of the initial visit), has Ms./Mr. ______ (Patient's name) been to the emergency room or urgent care, been hospitalized, or been placed in a nursing home or respite facility?

Yes=1
No=2
N/D=9

If yes, briefly describe:

If yes, please mark all that apply:

Illness, accident, or surgery requiring hospital admission or urgent care

Yes=1
No=2
N/D=9

Caregiver currently too frail or impaired to provide care

Yes=1
No=2
N/D=9

Placed in temporary respite

Yes=1
No=2
N/D=9

Placed in nursing home

Yes=1
No=2
N/D=9

22. Please circle all of the following that have been a problem in the last month:

Wandering

Yes=1
No=2
N/D=9

Verbally abusive and hostile

Yes=1
No=2
N/D=9

Physically aggressive/violent

Yes=1
No=2
N/D=9

Loss of mobility sufficient to require daily assistance

Yes=1
No=2
N/D=9

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