Diagnostic and Statistical Manual, 5th revision - DSM5
Inventory for Neurocognitive Impairment and Global Assessment of Severity

       DATE:           TIME (24hr): 

I) Learning and memory

      A) Recent memory
[]   0 = Memory for daily events unquestioned.
[]   1 = Occasional failures to recall recent events, placement of keys, no effect on daily function.
[]   2 = Increase of failures to recall recent events, loses keys, defect interferes with daily activities.
[]   3 = New material lost after distraction.
[]   4 = No capacity to retain new information.
[]   5 = No capacity to obtain information.

      B) Remote memory
[]   0 = Clarity with considerable details in recollection of events from childhood, early adulthood.
[]   1 = Memory for significant events of the past, but some uncertainty and lack of details.
[]   2 = Clear deficits in memory of personal history, some difficulty recalling names of familiar friends, relatives. Recalls place of birth, names of schools, occupation, major past events.
[]   3 = Unable to recall any significant historical events or places of schooling. May occasionally forget name of spouse or most frequent caregiver.
[]   4 = Difficulties with awareness of environment, sometimes able to distinguish familiar persons from unfamiliar persons, knows own name.
[]   5 = No comprehension of the nature of surroundings.

      C) Orientation
[]   0 = Fully oriented.
[]   1 = Some difficulty with time relationships, date not known, difficulty with year. May have problems with getting lost.
[]   2 = Usually disoriented in time, often disoriented to place.
[]   3 = Orientation to person only.
[]   4 = Body disorientation.
[]   5 = Totally lost, oblivious to posture.

II) Complex Attention
[]   0 = Can sustain attention for normal amount of time. Can divide attention without distraction.
[]   1 = Has mild lapses of attention, misses some details, not impairing daily function.
[]   2 = Has frequent distraction of attention, difficulty staying of subject, focusing on a task.
[]   3 = Attention impaired in daily activities; processing speed clearly slowed.
[]   4 = Poor attention to any specific activity without constant external input. Can be engaged only sporadically and briefly.
[]   5 = Unable to attend to any task or issue. No attention to surroundings or environmental events.

III) Executive Function, planning, decision-making, inhibition
      A) Judgement, problem solving, abstract thinking
[]   0 = Solves everyday problems well: judgment good in relation to past performance.
[]   1 = Mild difficulty in handling complex problems, similarities, differences, social judgment usually maintained.
[]   2 = Moderately impaired in handling problems; social judgment usually impaired.
[]   3 = Unable to make judgments, decisions, or solve problems.
[]   4 = Unable to carry a thought long enough to determine a purposeful course of action.
[]   5 = No response to any confronted problem.

IV) Language function, aphasia (dominant hemisphere)
[]   0 = Conversational, no searching for words.
[]   1 = Reticent conversation, searches for synonyms, word/name finding difficulties evident.
[]   2 = Vocabulary limitations noted in conversation, difficulty in naming objects.
[]   3 = Conversation limited to use of simple words and sentences. Can name simple objects but not uncommon objects.
[]   4 = Speech limited to single simple words, difficulty repeating single words, uncomprehending.
[]   5 = All verbal abilities lost, mute, unresponsive.

V) Perceptual-motor function

      A) Visuospatial organization, agnosia (non-dominant hemisphere)
[]   0 = No difficulty with three-dimensional perspectives; identifies the purpose of complex objects and can use them.
[]   1 = Mild difficulty copying complex three-dimensional perspectives, has difficulty recalling the purpose of unusual objects.
[]   2 = Considerable difficulty in reproducing simple drawings, can use simple objects only.
[]   3 = Unable to use writing implement for copying a simple design, misidentifies objects.
[]   4 = Can respond meaningfully only to some very familiar objects, e.g., may hold brush by handle, take pencil in hand, cannot full use these objects.
[]   5 = Unresponsive to objects in the environment.

      B) Home activities, motor coordination, praxis
[]   0 = Life at home, hobbies, crafts, intellectual interests well maintained.
[]   1 = Life at home, hobbies, intellectual interests only slightly impaired, trouble operating new appliances.
[]   2 = Mild impairment of function at home; more complicated hobbies and interests abandoned.
[]   3 = Only simple chores preserved, restricted interests poorly sustained, mild incoordination. Difficulty following instructions.
[]   4 = No significant function in home outside of own room. Dyspractic
[]   5 = Poor mobility, difficulty ambulating. May require manipulation and assistance. Apractic. May develop contractures of limbs.

VI) Social Cognition

      A) Community affairs, social function, and interactions with others
[]   0 = Independent function at usual level in job, shopping, business, and financial affairs, volunteer, and social groups.
[]   1 = Only doubtful or mild impairment, if any, in these activities.
[]   2 = Unable to function independently at these activities though may still be engaged in some; may still appear normal to casual inspection.
[]   3 = No pretense of independent function outside of home.
[]   4 = Impaired interactions with other individuals, loss of proper social interactions.
[]   5 = No interactions with other persons, frequent catastrophic reactions.

      B) Personal care, habits, hygiene
[]   0 = Fully capable of self-care, well-dressed and groomed by self.
[]   1 = Mild impairment of self-grooming, may need occasional prompting, needs some help in meeting nutritional needs.
[]   2 = Needs occasional prompting for dressing and grooming, needs help with nutritional needs.
[]   3 = Requires assistance in dressing, hygiene, keeping of personal effects. Able to feed self, but unable to prepare any of own food.
[]   4 = Requires full assistance with personal care, dressing, difficulty feeding self, frequent incontinence, diapers may be used.
[]   5 = Unable to dress self, difficulty with being fed, fully incontinent.


  TOTAL  DSM5 Global Assessment of Neurocognitive Impairment Severity:      (range = 0 - 50)

  0 -    5     normal, depending on age, education, complaints
  6 -  10     possible cognitive impairment
11 -  20     mild cognitive impairment
21 -  30     moderate cognitive impairment
31 -  40     severe cognitive impairment
41 -  50     profound/complete cognitive impairment


Electronic form coded by J. Wesson Ashford, M.D., Ph.D., August 27, 2021

This form was orginally developed at the University of Kentucky in 1987, to extend the Clinical Dementia Rating Scale (CDR).
The present form is an updated version of the form published in 1992, Global Assessment of Dementia:
Ashford JW, Kumar V, Barringer M, Becker M, Bice J, Ryan N, Vicari S.
Assessing Alzheimer severity with a global clinical scale.
Int Psychogeriatr. 1992 Summer;4(1):55-74.

The present modification uses the outline of cognitive impairment diagnoses provided by DSM5.
The DSM5 is protected by copyright by the American Psychiatry Association. See:
Reference: Sachdev PS, Blacker D, Blazer DG, Ganguli M, Jeste DV, Paulsen JS, Petersen RC.
Classifying neurocognitive disorders: the DSM-5 approach.
Nat Rev Neurol. 2014 Nov;10(11):634-42.

The Quick Dementia Rating System (QDRS) has 8 items which are substantively similar to this form:
Galvin JE, Tolea MI, Chrisphonte S. PLoS One. 2020;15(10):e0240422.

This electronic form is not protected by copyright.
There is no individual or agency that takes responsibility for the results obtained
with this test or this form.