Observed Behavior Checklist
for Alzheimer's and Dementia

 

As a caregiver, you are in a good position to notice unusual behavior in your older family member. If you are wondering if these behaviors may indicate dementia or the onset of Alzheimer's disease, the following checklist may be useful.

The checklist and answers may be printed out so that you can show your family member's doctor or other trained professional the types of behaviors that have you worried. They will then be able to guide you to the next best step for you to take. Possible steps could be a full medical exam, a geriatric evaluation, or a medicine review for interactions.
Checklist

 

Initial Dementia Screen: Observed Behavior Checklist

Based on your family member's behavior in the last two months, please check "yes" or "no" in response to each question below. If you do not understand a question, please check "unsure". Check the square button in the "highest concern" column for the three behaviors that concern you the most.

Responses to this checklist do not offer a diagnosis of dementia; however, they may suggest the need for further medical evaluation. You are encouraged to discuss these symptoms with your doctor.

Please note: None of this information is saved or recorded. It is only asked for your records and so that you may print your online responses. You may choose not to answer, but the printout will not have that information available for your convenience.

Woman Looking Out of a Window

 

Your Name:

Today's Date

Name of Your Family Member:

Family Member's Date of Birth:

Your Relationship to the Family Member:

Does This Person Live With You? Yes No

Observed Behavior
 Yes No Unsure Highest
Concern
Does he/she often repeat himself/herself or ask the same questions over and over?
Is he/she more forgetful, such as missing appointments or forgetting conversations?
Does he/she lose things often, such as keys, purse, important papers, or money etc.?
Does he/she need reminders to do things like chores, shopping, or taking medicine?
Does he/she lose track of thoughts in a conversation or have trouble remembering words?
Does he/she seem sad, down in the dumps, or cry more often than in the past?
Has he/she started having trouble doing math, paying bills, or keeping a checkbook?
Does he/she seem less interested in family activities, social activities, or hobbies?
Have you noticed changes in personal hygiene, dressing, bathing, or using the bathroom?
Has he/she become irritable, angry, agitated, or suspicious?
Has he/she started seeing, hearing or believing things that are not real?
Has he/she had a personality change, such as saying hurtful things or acting inappropriately?
Are you concerned about his/her driving, or has he/she stopped driving?
Are you concerned about his/her judgment, such as trusting strangers, recklessly spending money, or making decisions that are not consistent with his/her previous behavior?
Does, he/she have difficulty operating simple household appliances, for example, the oven, thermostat, remote control, microwave, or telephone?
Does he/she become upset, anxious, or nervous, especially when separated from family?
Does he or she sometimes seem confused by time, for example confusing night and day or frequently misjudging how much time has elapsed?

Adapted from Mundt JC, Freed DM, Griest JH. Lay person-based screening for elderly detection of Alzheimer's disease; development and validation of an instrument. J Gerontol B Psychol Soc Sci. 2000; 55B: 153-170. Adapted, compiled, and expanded by Kate Barrett, LCSW, Orange County Department on Aging with consultation from D. Kaufer, MD, UNC Memory Disorders Clinic, Chapel Hill, NC, 2004.

 

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