We Care Hospice

Dementia / Alzheimer's Disease

       Patients with dementia must show all of the following characteristics

       (Check all that apply)

   _________Stage 7a or below according to the Functional Assessment Staging Scale (Refer to NHO guidelines for Non-Cancer Diseases

       _________Unable to ambulate without assistance

       _________Unable to dress without assistance

       _________Unable to bathe without assistance 

       _________Urinary and fecal incontinence, intermittent or constant

       _________No meaningful verbal communication: stereotypical phrases only or the ability to speak is limited to six or fewer intelligible words.

       _________Difficulty swallowing/eating

       Patients must have one of the following within the past 12 months

       (Check all that apply)

       _________Aspiration Pneumonia

       _________Pyelonephritis or other upper urinary tract infection

       _________Septicemia

       _________Decubitus ulcers, multiple, stage 3-4

       _________Fever, recurrent after antibiotics

       _________Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5 gm/dl. (despite feeding tube if present)

WORK SHEET FOR DETERMINING PROGNOSIS - DEMENTIA / ALZHEIMER'S DISEASE

This worksheet is designed as a fact-finding tool and is not intended to be used to formulate diagnoses