Fillable CBAS Record Of Dementia Stages For CBAS Screening - Final CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES

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CBAS Record Of Dementia Stages For CBAS Screening - Final CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES

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CBAS Record of Dementia Stages for CBAS Screening - Final.doc Draft L-8
Page 1
CBAS Record of Dementia Stages for CBAS Screening
Client Name:
Evaluator’s Name:
Position:
Date:
Resources used to determine data:
Stage 1: No cognitive impairment
Unimpaired individuals experience no memory problems and none are evident to a health care professional
during a medical interview.
Stage 2: Very mild decline
Individuals at this stage feel as if they have memory lapses, forgetting familiar words or names or the location
of keys, eyeglasses or other everyday objects. But these problems are not evident during a medical
examination or apparent to friends, family or co-workers.
Stage 3: Mild cognitive decline
Check all that apply:
Word- or name-finding problems noticeable to family or close associate
Decreased ability to remember names when introduced to new people
Performance issues in social and work settings noticeable to others
Reading a passage and retaining little material
Losing or misplacing a valuable object
Decline in ability to plan or organize
Stage 4: Moderate cognitive decline
Check all that apply:
Decreased knowledge of recent events.
Impaired ability to perform challenging mental arithmetic. For example, to count backward from 100
by 7s.
Decreased capacity to perform complex tasks, such as marketing, planning dinner for guests, or
paying bills and managing finances.
Reduced memory of personal history.
The affected individual may seem subdued and withdrawn, especially in socially or mentally
challenging situations.
Stage 5: Moderately severe cognitive decline
Check all that apply:
Be unable during a medical interview to recall such important details as their current address, their
telephone number, or the name of the college or high school from which they graduated.
Become confused about where they are or about the date, day of the week or season.
CBAS Record of Dementia Stages for CBAS Screening - Final.doc Draft L-8
Page 2
Have trouble with less challenging mental arithmetic; for example, counting backward from 40 by 4s
or from 20 by 2s.
Need help choosing proper clothing for the season or the occasion.
Usually retain substantial knowledge about themselves and know their own name and the names of
their spouse or children.
Usually require no assistance with eating or using the toilet.
Stage 6: Severe cognitive decline
Check all that apply:
Lose most awareness of recent experiences and events as well as of their surroundings.
Recollect their personal history imperfectly, although they generally recall their own name.
Occasionally forget the name of their spouse or primary caregiver but generally can distinguish
familiar from unfamiliar faces.
Need help getting dressed properly; without supervision, may make such errors as putting pajamas
over daytime clothes or shoes on wrong feet.
Experience disruption of their normal sleep/waking cycle.
Need help with handling details of toileting (flushing toilet, wiping and disposing of tissue properly).
Have increasing episodes of urinary or fecal incontinence.
Experience significant personality changes and behavioral symptoms, including suspiciousness and
delusions (for example, believing that their caregiver is an impostor); hallucinations (seeing or hearing
things that are not really there); or compulsive, repetitive behaviors such as hand-wringing or tissue
shredding.
Tend to wander and become lost.
Stage 7: Very severe cognitive decline
Check all that apply:
Frequently individuals lose their capacity for recognizable speech, although words or phrases may
occasionally be uttered Individuals need help with eating and toileting and there is general
incontinence.
Individuals lose the ability to walk without assistance, then the ability to sit without support, the ability
to smile, and the ability to hold their head up. Reflexes become abnormal and muscles grow rigid.
Swallowing is impaired.
Conclusion:
Client has no signs or is in the early stages of dementia (exhibiting signs from stages 1 and 2)
Client is in the early to mid stages of dementia (exhibiting signs from stages 2 through 3)
Client is in the moderate stages of dementia (exhibiting signs through stage 4)
Client is in the moderate to late stages of dementia (exhibiting signs from 5 – 7)
CBAS Record of Dementia Stages for CBAS Screening - Final.doc Draft L-8
Page 3
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Completed 3 July 2020

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