UCLA Alzheimer's and Dementia Care Program

January 26, 2017

UCLA Alzheimer's and Dementia Care Program

Initial Assessment & Care Plan

Date:

Name:MRN:

DOB:Sex:

Phone Number:
Mailing address:
Primary language spoken:

Caregiver/Decision maker:

Name/Relationship:
Involvement in care:
Mailing Address:
Phone Number:

Email:
Best time to reach this person during business hours?

Patient permission to contact this person:

Additional Family/Caregivers:

Name/Relationship:

Involvement in care:

Mailing Address:

Phone Number:

Email:
Patient permission to contact this person:

Primary Care Physician:

Geriatrician:
Psychiatrist:

Neurologist:
Chief Complaint: (Name)is referred to the UCLA Alzheimer’s and Dementia Care Program by (referring MD) for co-management ofdementia-related issues and coordination of dementia care.

Past Medical History:

Pertinent Family Medical History:

Family members (blood relatives) w/memory problems? If Yes, list:

History of Present Illness: (Name) is an (age) year old (male/female) with (diagnosis) with an estimated onset in(year/unknown year of onset).

Dementia Evaluation

MRI/CT-scan Brain (Either is acceptable):

Other (e.g., PET Brain):
TSH:
Vitamin B12:
Other (e.g., RPR, HIV):

Dementia Medications:

Medications for Mood and Behavior Problems:

Other medications:

Allergies/Intolerances:

Recent Hospitalizations/ER Visits/Nursing Home stays:

Admission Date-Discharge Date: Hospital/Nursing Home, primary diagnosis

Social History:

Primary Language:

Marital Status:

Children:
Education:
Occupation:

Activity/Exercise:
Alcohol:
Sexually active:

Driving Habits:

Firearms:

Living Situation:

Housing (stairs/levels):

Length at Residence:

Lives with:

Caregivers (non-paid and paid):

Safety Concerns:

Wandering:

Falls:

Financial Situation:

(NAME) owns (his/her) home, however (does/does not) own any additional property. Otherwise, (Name) retirement resources includes savings/social security/pension/family). (Name’s) finances are handled by (Name). (NAME)(does/does not) have long-term care insurance.

Advance Directives:

Advance Directives/Living Will:

(on file: YES/NO)
DPOA/Alternate Decision Maker:
POLST (include selections):
Summary of discussion/Specific choices:

DAILY ACTIVITIES:

Task / NoHelpNeeded / HelpNeeded / WhoHelps?
Feeding
Gettingfrombedtochair
Gettingtothetoilet
Gettingdressed
Bathingorshowering
Walkingacrosstheroom(includes usingcaneorwalker)
Usingthetelephone
Takingyourmedicines
Preparingmeals
Managingmoney(likekeeping trackofexpensesorpayingbills)
Moderatelystrenuoushousework suchasdoingthelaundry
Shoppingforpersonalitemslike toiletries, groceriesor medicines
Climbingaflightofstairs
Gettingtoplacesbeyond
walkingdistance(e.g.bybus,taxi, orcar)

Decision-making capacity at the time of visit, it is my opinion that (name) is:

Able to make his/her own medical decisions / ☐ /
Notable make his/her own medical decisions / ☐ /
Uncertain – May require additional testing / ☐ /

REVIEW OF SYSTEMS: (Limited ROS by cognitive impairment, but obtained from caregiver)

14 point ROS completed and negative other than stated below.

PHYSICAL EXAMINATION:

Vital Signs:
General Appearance:
Eyes:
Neck:
Lungs:
CV:
GI:
Neurologic:

Motor:
Proximal arm strength, tested by abduction of arms at shoulder:
Distal arm strength, tested by extension of hands at wrists:
Able to do a deep knee bend?:
Able to walk on toes?
Able to walk on heels?
(Central) Facial droop present?
Pronator drift present?
Rest tremor present?
Action/postural tremor present?
Tone in arms: Normal/Muscle Atrophy
Tone in legs: Normal/Muscle Atrophy

Gait:
Able to stand from a chair without use of hands?
Walks only with an assistive device?
Base:
Arm Swing:
Able to tandem walk?
Romberg:
Pull back test:

Cognitive Testing:

MMSE (Include breakdown if available)

MOCA (Include breakdown if available)

Neuropsychologic testing/Other

Cornell Scale for Depression in Dementia = (Scores greater than 12 indicate probable depression)

NPI-Q Severity: (total) Distress:(total)

Delusions (Severity: , Distress: )

Hallucinations (Severity: , Distress: )

Agitation (Severity: , Distress: )

Depression (Severity: , Distress: )

Anxiety (Severity: , Distress: )

Apathy/Indifference (Severity: , Distress: )

Elation (Severity: , Distress: )

Irritability/Liability (Severity: , Distress: )

Motor Disturbance (Severity: , Distress: )

Nighttime Behaviors (Severity: , Distress: )

Appetite changes (Severity: , Distress: )

Caregiver Patient Health Questionnaire (PHQ-9) =

SUMMARY:

(Name) is an (AGE) year old (Male/female) with *** Dementia with an estimated onset in ***, with behaviors that include: ***. (Name) is independent/dependent with ADLs and is independent/dependent with IADLs. (Name) lives with *** and (his/her) stated goal is to remain there as long as possible. (Name) and his/her family presented today interested in receiving educational information about dementia, respite care, as well as methods of dealing with (his/her) behavioral disturbances.

Patient/Caregiver Goal

MEDICAL - Care Plan

BEHAVIORAL - Care plan

SOCIAL - Care Plan

FOLLOW-UP: Phone call in one week to discuss care plan and response from Dr. ***

The evaluation took *** minutes, more than half the time was spent on counseling on items mentioned in the careplan above.