Alzheimer's Foundation of America Memory Screening Test - US Version

This test is derived from 2 tests, the Brief Alzheimer Screen (BAS) and the Memory Impairment Screen (MIS)
This test is designed for the purpose of comparing memory testing items (09/19/2013 - still developing).

Instructions: fill in the 6 digit ID code, follow the directions,
click in the circles to indicate responses (e.g., correct / incorrect).

DATE      TIME (24hr) 

SITE ID Code:      Partipant ID Code 

Unless specified, each question should only be asked once.

DescriptionRead to SubjectEnter information
1. Time Orientation "What is the date?"
(exact only)
Correct    Incorrect
[]      []
2.Word repetition--get the subject's attention, then say the words:
Give the participant 3 tries to repeat the words. If unable after 3 tries, go to next item. This is not scored.
“I am going to say three words that I want you to remember. The words are:
        - BALL
        - FLAG
        - TREE
Please say them for me now"
Not scored
3. Backwards test. Click the participant’s answers as "right" or "wrong". “Please spell the word ‘WORLD’ backwards”.
  right / wrong
[]  /  [ ]   D
[]  /  [ ]   L
[]  /  [ ]   R
[]  /  [ ]   O
[]  /  [ ]   W
4.Recall: "What were the three words I asked you to remember?"

  right / wrong
[]  /  [ ]   "BALL"
[]  /  [ ]   "FLAG"
[]  /  [ ]   "TREE"
Memory Impairment Screen (MIS)
5. MIS Overview: Four items from different categories are learned by identifying each item when it’s category cue is presented. Memory is tested by free recall after a delay with interference. The category cues for those items are also tested to see if they will still elicit cued recall of those items.
DescriptionRead to SubjectEnter information
Controlled Learning: Read the words on the right. If the subject has difficulty immediately repeating the words, you can repeat all 4 words up to 3 times.

“I am going to say 4 words for you to learn and remember. Each word belongs to a different category. Please repeat all 4 word that I say out loud after I finish saying them.
        - History
        - Factory
        - Policeman
        - Toothbrush”

(Click the left button to the left of each word correctly repeated on the first effort.)

correct  /  wrong
 []  /   []   "HISTORY"

 []  /   []   "FACTORY"

 []  /   []   "POLICEMAN"

 []  /   []   "TOOTHBRUSH"

Then say:

“To help you learn these words, I will tell you the category cue for each word and ask you to tell me the word that goes with each category cue.
When I read each category cue to you, tell me which one of these words goes with that category cue.”


Read each category cue aloud to the subject.
If the subject does not know the word, say

"Each WORD is a CUE", and have the subject say the "word".

Then go to the next category cue.
If the subject missed any of the words, the sequence of presenting categories should be repeated once.

Pace acquisition at a rate that is comfortable for the subject.
Check the box to the left of the category cue to indicate
whether the subject states the correct word the first time the cue is read.

correct  / incorrect
  []  /   []   "BUILDING" - (FACTORY)
(if incorrect, say "FACTORY is a BUILDING, say FACTORY")

  []  /   []   "PERSONAL ITEM" - (TOOTHBRUSH)
(if incorrect, say "TOOTHBRUSH is a PERSONAL ITEM, say TOOTHBRUSH")

  []  /   []   "SCHOOL SUBJECT" - (HISTORY)
(if incorrect, say "HISTORY is a SCHOOL SUBJECT, say HISTORY")

  []  /   []   "CITY EMPLOYEE" - (POLICEMAN)
(if incorrect, say "POLICEMAN is a CITY EMPLOYEE, say POLICEMAN")

When all four words have been identified by category, tell the subject,

“Later, I will ask you to recall the words.”
6. ANIMAL NAMING - first 30 seconds “In 30 seconds, tell me as many animals as you can think of... Ready, GO
(Click to start ->) (0) [] You may click the numbers or use the right arrow to advance the count or the left arrow to reduce it.
 0     1         2        3        4
 5     6         7        8        9
10   11       12      13      14
15   16       17      18      19
20+
CATEGORY FLUENCY 
7. ANIMAL NAMING - second 30 seconds

EITHER

If the subject named at least 4 animals in the first 30 seconds, say: “In the next 30 seconds,
tell me as many more and different animals as you can think of,... Ready, GO


OR

If the subject named less than 4 animals in the first 30 seconds, say: “In the next 30 seconds,
tell me more animals, think of the zoo, the farm, and the jungle,... Ready, GO


(Click to start ->) (0) [] You may click the numbers or use the right arrow to advance the count or the left arrow to reduce it.
    0 []
    1 []        2 []       3 []       4 []         5 []
    6 []        7 []       8 []       9 []       10 []
  11 []      12 []     13 []     14 []       15 []
  16 []      17 []     18 []     19 []     20+ []

CATEGORY FLUENCY
 
8. Free Recall: Elicit Free Recall. Allow 20 seconds for Free Recall of all four words. Stop if no more words have been recalled for 10 seconds. Indicate Free Recall by clicking a button to the left of each word that was retrieved by free recall.

“Tell me as many of the 4 words you can remember, in any order.”

recalled  /  missed
  []  /   []  "HISTORY"

  []  /   []  "FACTORY"

  []  /   []  "POLICEMAN"

  []  /   []  "TOOTHBRUSH"

9. Cued Recall: Immediately after concluding Free Recall, elicit Cued Recall Read the appropriate category cue to the subject in the order shown and ask the subject to recall the word that was learned with that cue.

Allow 5 seconds for recall of each word cued.
Indicate Cued Recall retrieval by clicking the appropriate button to the left of each word.

"What was the BUILDING" -
"What was the PERSONAL ITEM" -
"What was the SCHOOL SUBJECT" -
"What was the CITY EMPLOYEE" -  
correct  /  wrong
  []  /   []   (FACTORY)

  []  /   []   (TOOTHBRUSH)

  []  /   []   (HISTORY)

  []  /   []   (POLICEMAN)

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  -----   Click this box to reset.

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Start TIME (24hr):      End TIME (24hr):      Total Time (seconds): 

RESULTS:    

Copyright material. For use on National Memory Screening Day 2013 only.
Other use restricted.

See this link for powerpoint slides of Dementia and Alzheimer Screening, with BAS data.
See this link for earlier neuropsychiatric examination elements:
See this link for review of dementia and memory screening tests:
See this link for journal article addressing need for dementia screening.

Electronic form developed by J. Wesson Ashford, MD, PhD for www.Medafile.com
For comments, email to drjwa2@gmail.com
See www.memtrax.net or www.memtrax.com for visual memory tests.

Input from the Alzheimer's Foundation of America (AFA) Memory Screening Advisory Board

There is no individual or agency that takes responsibility for the results obtained
with this test or this form.