Geriatric Assessment Paper
Anne M. Hendricks
Ferris State University
Abstract
This paper serves to assess a particular geriatric client while utilizing resources and information derived from the Gerontological Nursing course. A thorough assessment with considerations for life experience, culture, age and sensory function is performed. Assessment tools, including the Fulmer SPICES Tool, Hendrich II Fall Assessment, Geriatric Depression Scale and Mini Mental Status Exam, are applied. The nursing process is applied to develop three nursing diagnoses, care plans, interventions, outcomes and evaluations to improve the patient’s quality of life.
The Stochastic nursing theory is applied to the patient and a public policy is proposed which supports the care plan to meet this person’s holistic health needs.
Geriatric Assessment Paper
Thorough analysis of the needs of the geriatric population is important in whatever role we play in health care. The geriatric population is said to be the fastest growing population in the United States with statistics showing that by the year 2030, twenty percent of the population will be over the age of sixty-five (Boltz et al., 2008). Knowledge of life experiences, culture and individual health issues can affect the clients’ perception of themselves and others’ perceptions of the client. Another important concept to remember is that many nurses do not receive formal education in the treatment of the elderly population while in nursing school, and this can impact quality of care (Boltz et al., 2008). Knowledge of tools that have been developed to help serve this population will be helpful to the nurse who works with the geriatric population.
Assessment
The first step in caring for any person, especially an elder, would be a thorough assessment. A comprehensive assessment must be more than a gathering of information, or just another task to perform, but a way to listen to and assess the needs of the patient (Beveridge, 2008). Armstrong and Mitchell (2008), state that a holistic nursing assessment includes nursing knowledge, skills and experience coupled with listening, observing, measuring, interpreting and recording the data collected about the elder’s biological, psychological, social and spiritual needs.
Being aware of age-related changes that occur with the elderly is important in the physical assessment to determine natural changes that are taking place and to minimize issues associated with the changes (Smith and Cotter, 2008). A nurse may incorrectly diagnose a patient with a cognitive impairment when he/she actually has a sensory deficit, so it is important to distinguish one from the other.
The assessed patient “Mrs. D” was a seventy-nine year old widowed woman that lived alone and had recently lost her job. It was initially shocked to learn that a seventy-nine year old woman was still working. This represented a cultural obstacle to overcome. The obstacle was ageism. Ageism is a presumption of incapacity simply based upon chronological age (Ebersole et al., 2008). Cultural awareness requires awareness of the ageism in our society and within self (Ebersole et. al., 2008). According to Ebersole et al., (2008), 50% of women over sixty-five will be widowed effecting social status, self-image and income, therefore may work well past the age of retirement.
Many elders consider their functional abilities more important than any disease process that may exist and is an important consideration in the assessment of this population (Kresevic, 2008). Mrs. D. was quite upset about being fired from her job and stated it was because she “couldn’t hear”. Her job was to work the night shift at the hospice house and she answered phones. She lost her job because they told her she “could no longer perform the tasks required”. Her son was present during the initial interview and mentioned that his mother seemed to be more confused and answered inappropriately when conversing, especially over the phone. Awareness of sensory changes is important to geriatric analysis because, “… sensory organs are our windows on the world” (Ebersole et al., 2008, p. 338).
The biological theory that applies to Mrs. D. is the Stochastic Theory, which theorizes that aging is a result of an accumulation of errors in the synthesis of DNA (Ebersole et al., 2008). Specific type of Stochastic Theory would be the Wear-and-Tear Theory, which states that cells wear out over time and use and that internal/external stress cause a progressive decline in function (Ebersole et al., 2008). This theory was chosen because Mrs. D’s hearing loss could have been attributed to growing up on a farm with loud equipment and working in a factory in adult life which exposed her to loud, continuous noises. Age-related changes lead to hearing loss and about one half of those seventy-five to seventy-nine have presbycusis (Williams, 2000). It is important to determine the cause of hearing loss before deciding that the cause is “old age” because other treatable factors can contribute to hearing impairment such as infections or cerumen buildup (Ebersole et al., 2008).
Relevant Assessment Tools
The Fulmer Spices Tool was utilized to evaluate Mrs. D’s specific areas of need. SPICES is an acronym for: sleep, problems with eating, incontinence, confusion, evidence of falls, and skin breakdown and the tool identifies if further analysis is needed (Fulmer, 2007). From the SPICES protocol “Confusion” and “Evidence of falls” were identified as areas of concern (Fulmer, 2007). The tools chosen to focus further on Mrs. D. were the Geriatric Depression Scale (GDS short form), the Mini Mental Status Exam (MMSE), and the Hendrich II Fall Risk Assessment. Mrs. D. was scheduled with her primary physician for an auditory exam.
The GDS (Appendix A) was chosen because it takes about 5 to 7 minutes to complete, may be used with healthy, medically ill and mild to moderately cognitively impaired older adults, and it has been extensively used in community settings (Greenburg, 2007). GDS has 92% sensitivity and 89% specificity when evaluated against diagnostic criteria (Greenburg, 2007). The validity and reliability of the tool have been supported through both clinical practice and research in differentiating depressed from non-depressed adults with a high correlation (r = .84, p < .001) (Sheikh & Yesavage, 1986). My patient scored a 9 and 5-9 show mild depression may be present (Greenburg, 2007).
The Mini-Mental Status Examination (Appendix B) offers a quick and simple way to test cognitive function by testing the individual’s orientation, attention, calculation, recall, language and motor skills (Kurlowicz & Wallace, 1975). The examination was given in a quiet, well-lit room, and spoken loud enough for Mrs. D. to express understanding to the questions. According to Ebersole et al., (2008), eliminating distractions can help an elder with auditory deficits to focus. No time limit was placed on the test and it was scored right away as suggested. The individual can receive a maximum score of 30 points and a score below 20 usually indicates cognitive impairment (Kurlowicz & Wallace, 1975). The patient scored a 23 which shows adequate cognition.
The Hendrich II Fall Risk Model is intended to be used in the acute care setting but was chosen for its brevity, medication analysis, and focus on adults at risk for falls (Gray-Miceli, 2007). The Hendrich II Model focuses on interventions for specific areas of risk rather than on a single, summed general risk score (Gray-Miceli, 2007). Categories of medications increasing fall risk as well as adverse side effects from medications leading to falls are built into this tool (Gray-Miceli, 2007). My patient scored a 3 overall, a score of above 5 is considered high risk for fall (Gray-Miceli, 2007). The patient has history of falls but not in the past two weeks.
Diagnoses
The first diagnosis derived is impaired verbal communication as defined by NANDA as decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols (Wilkinson & Ahern, 2008). Subjective data to support this diagnosis would be the patient’s statement that she was fired because she can’t hear and because she can’t perform her job due to auditory issues. The son also mentioned that she is sometimes confused or answers inappropriately. Objective data supporting this diagnosis include difficulty expressing thoughts verbally and difficulty in comprehending and maintaining usual communication patterns. According to Wilkinson and Ahern (2008), related factors for this diagnosis are absence of significant others, altered perception, physiological barriers, psychological barriers, side effects of medication, and stress. Mrs. D. lives alone, and often answers incorrectly or not at all when asked questions. Mrs. D has mild orthostatic hypotension secondary to antihypertensive medications. Mrs. D may be stressed because she works the night shift. The MMSE score was 23 out of 30 showing that the patient has adequate cognition when she is able to hear the questions. Mrs. D. expresses a desire to communicate and socialize which is a strength that can be utilized in our care planning.
The second nursing diagnosis, disturbed auditory sensory perception, is defined by NANDA as the change in the amount of incoming stimuli accompanied by a diminished or impaired response to stimuli (Wilkinson & Ahern, 2008). Subjective data supporting this diagnosis is Mrs. D’s loss of employment for not being able to perform the job, and the son’s complaint that the patient answers inappropriately, especially over the phone. The Objective data supporting this diagnosis are change in sensory acuity, disorientation, impaired communication, poor concentration, and restlessness. The primary care physician also found sufficient hearing loss and recommended bilateral hearing aids. Related factors are altered sensory reception from poor auditory function, insufficient environmental stimuli at home, and psychological stress of working night shift and needing the income.
The third nursing diagnosis is risk for falls and is defined in NANDA as increased susceptibility to falling that may cause physical harm (Wilkinson & Ahern, 2008). Subjective data: Mrs. D. admits to falling in the past on more than one occasion. Objective data: the patient has orthostatic hypotension of less than 10 points systolic and diastolic change, which according to Ebersole et al., (2008) renders her a slight risk for fall. Mrs. D. takes antihypertensive medication and is diabetic both of which increase fall risk (Ebersole et al., 2008). The environmental assessment reveals throw rugs and no handrails in the bathroom. Mrs. D. also does not like to turn on the light at night when going to the bathroom to “save electricity”. Mrs. D is also visually impaired and wears glasses for correction, but admits that she does not always wear glasses at night when going to the bathroom. Mrs. D has many related factors for fall risk which, according to Wilkinson & Aher (2008), are: age over 65, history of falls, lives alone, use of assistive devices, decreased strength in lower extremities, hearing impairment, impaired balance, orthostatic hypotension, neuropathy, urgency or incontinence, visual impairment and throw rugs.
Planning
It is important in Mrs. D’s case to incorporate all three nursing diagnoses into her plan of care as well as the family, physician, nursing staff, audiology and social work in the plan’s development. The most important part of planning is educating the patient regarding the assessment findings and options so that she can set her own care plan. When performing the nursing process it is necessary to correlate with the patient, resources and caregivers to be effective (Ebersole et. al., 2008). According to Ebersole et. al., (2008), the nurse needs to empower the patient to make decisions regarding healthcare. There are five major steps in the process of making a decision which include identifying the problem or situation, listing the options for solving the problem, discussing the potential outcomes of the situation based on the different options, evaluating the different options to determine the best one for the situation and making the decision (Carpenito, 1995). The nurse will provide the education to the patient and the family.
Implementation
Putting the care plan into action involves using evidence-based outcomes and interventions. Also identify funding sources or existing programs to help meet the client’s needs. In order to implement the care plan it is important for everybody involved to play a role. Mrs. D and her son need to be open and receptive to education regarding hearing loss and safety issues. Other healthcare personnel would be her physician, audiologist, her insurance and nurse. Community resources include Area Agency on Aging and the local senior center.
Nursing needs to assess Mrs. D’s home environment for safety hazards such as throw rugs, poor lighting, clutter, and lack of handrails. The nurse then provides education on how to remedy these problems allowing Mrs. D and her son to be part of the decision. Mrs. D and her son agree to get rid of the throw rugs, add handrails by the commode and shower as well as a shower chair. Mrs. D. elects to have a flashlight by her bed and motion sensor nightlights in her bedroom, hallway and bathroom.
The nurse also needs to help Mrs. D. with insurance coverage issues and procurement of appropriate hearing aids. Motivation is also an important factor to consider when purchasing a hearing aid as it is up to the client to decide if the inconvenience is worth the effort to restore hearing to a functional level (Macincuk and Roland, 2002). Mrs. D has the strength of desire to maintain communication with others.
The nurse and audiologist will work together to educate Mrs. D regarding hearing aid use and care. Follow up will be needed on a weekly basis for a couple of months to ensure success of the hearing aid usage and comfort. According to Ebersole et al., (2008), follow up appointment to ensure proper usage and fit of hearing aids can ensure success. Mrs. D and her son will be educated about eliminating distractions during communications, the need for social stimulation and appropriate expectations for hearing aids.
The nurse will educate Mrs. D on the need to socialize and maintain out of the home interests. The recent loss of job can be a large source of depression and isolation (Ebersole et al., 2008). Identifying activities of interest that are accessible to Mrs. D will be important. Focusing on Mrs. D’s strengths of being comfortable with driving and her desire to remain independent is also important.
Goals
Mrs. D. will be assisted with investigation of her insurance plan to determine what health care providers she can use, what her benefits for hearing aids are, and what resources are available in the community. This will all be done within one week.
Mrs. D will compensate for auditory deficits by procuring and utilizing appropriate assistive devices. Mrs. D will choose some type of amplified phone device and a provider for hearing aids that will best suit her needs within the week. Ebersole et al., (2008), states that it may be best to choose a business that has many choices of hearing aids and does not promote a particular brand (2008). Mrs. D will have two days to schedule appointments for the amplified phone and audiologist. The appointments may take longer due to scheduling issues but should be able to happen within one month. Once Mrs. D has her new phone and hearing aids, the goal would be verbalization and demonstration of acceptance of her appearance and the use of the hearing devices.
Evidenced-based practice studies with clients who have purchased a hearing aid indicate that it may take from one month up to one year to receive the full benefit from this new appliance, although typically is about one month (Taylor, 2007). It is also important to note that there is a significant adjustment period in which Mrs. D should return for adjustments to her hearing aid, typically consisting of several visits in the first one to two month period (Taylor, 2007). Mrs. D will keep her appointments for follow up with her audiologist every week for the first month and then monthly for two months, and then annually (unless she is having problems).
Mrs. D will also need to regain interest in former activities and report an increased interest in social interactions. Mrs. D will express understanding and satisfaction with usage of her new amplified phone at her weekly nursing visits. Mrs. D also needs to find an appropriate support system outside of the home. Mrs. D has agreed to attend the senior center in her community at least once a week and will journal regarding her visits at least once per week. Mrs. D also has offered to drive a neighbor to the senior center at least once a week.
After education, Mrs. D and her son will be able to identify risks that increase susceptibility to falls, and avoid physical injury from falls. Mrs. D and her son will provide a safe environment by eliminating throw rugs, placing handrails next to the commode and shower, place rubber shower mats and grab bars in bath, a bath chair and proper lighting in one week. Mrs. D and her son accessed the Area Agency on Aging in their county to procure a shower chair and handrails for the bath. Mrs. D will remain free from falls for three months.
Evaluation
Ensuring Mrs. D is making progress with her resource awareness and procurement of assistive hearing devices as well as adapting to them is important. Mrs. D must meet the goals at the times set and report for follow up visits at her audiologist at the weekly then monthly appointment times. The nurse and the audiologist will verify this. Mrs. D’s comfort and expression of satisfaction with her new assistive hearing devices will be imperative or further implementation adjustment and future reevaluation must occur. If Mrs. D is fully satisfied and is able to express appropriate usage and care of her assistive hearing devices she should be relinquished to follow up in one year for further evaluation by her audiologist.
Mrs. D will also show improvement in social interactions and activities by the end of two months which will be verified by her journaling regarding her weekly visits to the senior center and her expression of satisfaction with phone communication. Mrs. D will also express fulfillment of her commitment to drive her neighbor at least once per week to the senior center, verification of this will be from the neighbor. Mrs. D. should also verbally express a feeling of satisfaction with her social life.
It will also be important to ask Mrs. D’s son if he feels that Mrs. D is more appropriate with her responses, especially over the phone, and if she seems less “confused”. Asking if he feels that she is remaining active and sociable would be helpful to evaluate the plan.
Thorough evaluation of Mrs. D’s home for safety issues will occur at one week, two weeks and then one month. If clutter, throw rugs, or lack of lighting and handrails is noted then further education, implementation and evaluation will be required. Mrs. D and her son will express knowledge and satisfaction with the changes at each visit. Mrs. D will remain free from falls at each nursing visit for at least three months.
Policy
Disabling processes are described as those that increase the needs of the individual and lead to isolation and dependency (Chiriboga, Ottenbacher, and Haber, 1999). Some statistics for hearing loss state that 60% of people over the age of 65 have some degree of hearing loss which is one of the health-related problems to affect the elderly population (Gulya, 1995). Of this population, 25-50% has hearing loss significant enough to impact their inter-personal relationships (Gulya, 1995). According to Ebersole et al., (2008), hearing loss is under-diagnosed and under-treated. Only ten percent of internists recommend their patients receive a hearing test and only twenty-five percent receive a hearing aid (Ebersole et al., 2008). These statistics are compounded by the fact that Medicare does not cover the cost of hearing aids, which can cost a minimum of $500 per ear up to thousands of dollars (Ebersole, 2008).
Health care law requires a hearing exam by a physician before an audiology test can occur (Ebersole et al., 2008). Medical clearance from a doctor stating that other conditions do not exist such as visible congenital deformity, drainage, dizziness, cerumen accumulation, pain or a significant audiometric air bone gap needs to happen before hearing aid procurement (Ebersole et al., 2008).
Healthy people 2010 had several goals for vision and hearing. Included in their objectives were increasing the number of people who have a hearing exam, referrals for an exam from their primary care physician, increasing the use of appropriate protective equipment and practices for those that are exposed to excessive noise and access to adaptive equipment (Ebersole et al., 2008). I propose that we follow the recommendations set forth by Healthy people 2010.
A specific proposal might be called “Patient-centered Elder Care” and follow a similar plan found in the United Kingdom. This policy dictates a minimum standard of care for elders including audiology care (Beveridge, 2008). Medicare coverage of hearing aids and easier access to audiology exams will improve the quality of life for many elders in the United States.
Conclusion
When working with the elderly, it is especially important to complete a thorough assessment covering all levels of care including physical needs as well as their social situation, functional status, cognitive impairments and any cultural or spiritual issues present. Knowledge of life experiences, culture and individual health issues can affect the clients’ perception of themselves and others’ perceptions of the client.
Hearing loss significantly impacts the health and well-being of the elderly population; some feel that loss of hearing is worse than loss of sight (Ebersole et al., 2008). Mrs. D. lost her job at least partly due to her auditory losses, and she seemed confused to her son because of her inability to comprehend questions due to lack of hearing. Helping her achieve a higher level of sensory input will greatly affect her quality of life and her socialization.
Fall risk is another identified area that offers easy and inexpensive resolution. In the United States direct care costs related to falls are estimated at more than $20 billion and projected to rise (Ebersole et al., 2008). Falls account for forty percent of nursing home admissions annually and of persons that fall, twenty to thirty percent suffer moderate to severe injuries (National Center for Injury Prevention and Control, 2006). Mrs. D. and her son were able to affect easy, quick and inexpensive changes that will protect Mrs. D from potential injury, trauma and expensive medical bills. Based upon Mrs. D’s needs and input, the care plan allows for patient control and satisfaction (Ebersole et al., 2008).
References
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Appendix A
Geriatric Depression Scale: Short Form
Choose the best answer for how you have felt over the past week:
1. Are you basically satisfied with your life? YES / NO
2. Have you dropped many of your activities and interests? YES / NO
3. Do you feel that your life is empty? YES / NO
4. Do you often get bored? YES / NO
5. Are you in good spirits most of the time? YES / NO
6. Are you afraid that something bad is going to happen to you? YES / NO
7. Do you feel happy most of the time? YES / NO
8. Do you often feel helpless? YES / NO
9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO
10. Do you feel you have more problems with memory than most? YES / NO
11. Do you think it is wonderful to be alive now? YES / NO
12. Do you feel pretty worthless the way you are now? YES / NO
13. Do you feel full of energy? YES / NO
14. Do you feel that your situation is hopeless? YES / NO
15. Do you think that most people are better off than you are? YES / NO
Answers in bold indicate depression. Score 1 point for each bolded answer.
Score > 5 points is suggestive of depression.
Score > 10 points is almost always indicative of depression.
Score > 5 points should warrant a follow-up comprehensive assessment.
Appendix B
Mini-Mental Status Examination
The Mini-Mental Status Examination offers a quick and simple way to quantify cognitive function and screen for cognitive loss. It tests the individual’s orientation, attention, calculation, recall, language and motor skills.
Each section of the test involves a related series of questions or commands. The individual receives one point for each correct answer.
To give the examination, seat the individual in a quiet, well-lit room. Ask him/her to listen carefully and to answer each question as accurately as he/she can.
Don’t time the test but score it right away. To score, add the number of correct responses. The individual can receive a maximum score of 30 points.
A score below 20 usually indicates cognitive impairment.
The Mini-Mental Status Examination
Name: ____________________________________ DOB: __________________
Years of School; _____________________________ Date of Exam: ___________
Orientation to Time Correct Incorrect
What is today’s date?
What is the month?
What is the year?
What is the day of the week today?
What season is it?
Total: ____
Orientation to Place
Whose home is this?
What room is this?
What city are we in?
What county are we in?
What state are we in?
Total: ____
Immediate Recall
Ask if you may test his/her memory. Then say “ball”, “flag”, “tree” clearly and slowly, about 1 second for each. After you have said all 3 words, ask him/her to repeat them – the first repetition determines the score (0-3):
Ball
Flag
Tree
Total: ____
Attention
A) Ask the individual to begin with 100 and count backwards by 7. Stop after 5 subtractions. Score the correct subtractions.
93
86
79
72
65
Total: _____
B) Ask the individual to spell the word "WORLD” backwards. The score is the number of letters in correct position.
D
L
R
O
W
Total: _____
Delayed Verbal Recall
Ask the individual to recall the 3 words you previously asked him/her to remember.
Ball
Flag
Tree
Total: _____
Naming
Show the individual a wristwatch and ask him/her what it is. Repeat for pencil.
Watch
Pencil
Repetition
Ask the individual to repeat the following: “No if, ands, or buts”
3-Stage Command
Give the individual a plain piece of paper and say, “Take the paper in your hand, fold it in half, and put it on the floor.”
Takes
Folds
Puts
Reading
Hold up the card reading: “Close your eyes” so the individual can see it clearly.
Ask him/her to read it and do what it says. Score correctly only if the individual actually closes his/her eyes.
Writing
Give the individual a piece of paper and ask him/her to write a sentence. It is to be written spontaneously. It must contain a subject and verb and be sensible.
Copying
Give the individual a piece of paper and ask him/her to copy a design of two intersecting shapes. One point is awarded for correctly copying the shapes. All angles on both figures must be present, and the figures must have one overlapping angle.
Total Score: _____
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