Behavior Changes

Behavior Changes

For caregivers to complete. Form time: less than 2 min
Understanding underlying causes for behavior concerns

If you are concerned about an emergency event, like a stroke, do not complete this form and contact 911 or your primary care team
HottoID
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Name of Caregiver providing responses to these questions

First Name of CaregiverLast Name of Caregiver
Name of the person living with dementia or cognitive decline*

First NameLast Name
Date of birth of the person living with dementia or cognitive decline

MonthDayYear
Date
Date

MonthDayYear
Date
Age
AnxietyAppetite and eating problemIndifferent, uninterested, or decreased expressions of care/concernAgitationNight time behaviorsWaking up the caregiver at nightIrritabilityIncontinence of bladder (Leakage of urine)Incontinence of bowel (Leakage of stool)ConfusionDecreased participation in conversations, poor eye contact, loss of interests, slow movements or responsesDelusions and paranoiaFalls or motor disturbancesResisting assistance or careInappropriate sexual behavior like comments, touches, or sexual advancesHallucinationsRepeating words, motions, or behaviors (e.g., rocking, raising fist, pointing behavior)Difficulty sleepingIncreased sleepinessPacing or restlessness (cannot be still)WanderingLeaving stove onNone of the aboveOther
1 week or less2 weeks or less4 weeks or lessMore than 4 weeks
0 - None and/or never1 - Mild and/or occasionally2 - Moderate and/or sometimes3 - Severe and/or frequently4 - Very severe and/or daily
Verbal aggressionCursing/using profanity or lashing out verballyRaising voice or yelling or screamingPhysical aggressionThrowing or hitting or breaking thingsTrying to hurt self or others (e.g., grabbing, kicking, hitting, biting)None of the aboveOther
0 - None and/or never1 - Mild and/or occasionally2 - Moderate and/or sometimes3 - Severe and/or frequently4 - Very severe and/or daily
YesNo
NoneIncreased urine incontinence, urine accidents, or urinary frequencyBurning, pain, or discomfort with urinationChange in urine COLORChange in urine ODORFeverI'm concerned they have an UTICurrently taking an antibiotic for an UTI or just completed an antibiotic for UTI in the last 2 weeksOther
NoneHard poopNo poop in the last 3 days or moreLess than 3 episodes of poop a weekStraining to make a poopI'm concerned they have constipationGeneralized abdominal or rectal pain (pointing to those areas)Decreased appetiteOther
NoneVocal complaints: verbal - words expressing discomfort or pain, e.g. "ouch", "that hurts"; cursing during movement; exclamations of protest, e.g. "stop", "that's enough"Vocal complaints: nonverbal - sighs, gasps, moans, groans, criesFacial grimaces/winces: furrowed brow, narrowed eyes, clenched teeth, tightened lipis, jaw drop, distorted expressionsBracing: clutching or holding onto furniture, equipment or affected area during movementRestlessness: constant or intermittent shifting of position, rocking, intermittent or constant hand motions, inability to keep stillRubbing: massaging affected areaPushing away when touchedUnable to reassure or distract from painOther
NoneChange in the caregiver(s)Major life change with the usual caregiver(s)New individual(s) in the homeDeparture of an individual that is usually presentChange in routine/schedule (meals, meds, outings, bedtime, etc)Other
YesNo
What changes in meds and over-the-counter drugs has happened in the prior 1 month? Include dosage changes.*
Redirecting the behaviorOffering choices but limitedSimplifying communication, including using verbal cuesUsing visual aidesTaking a pause/time out/dropping it/cooling off/walking awayRolling with the conversation/delusion/joining the realityIdentifying situations and triggers that happen prior to the behaviorCommunicating with song/singingDoing a family meetingMeals: eating with hands (hands as utensils)Setting regular day and bedtime routinesStarting a group or social activityMusic/art activityRegular physical activity/exerciseYou, as caregiver, taking a break/doing self-careYou, as caregiver, resetting expectationsYou, as caregiver, bringing in additional caregiving supportNot relevantNone of the aboveOther
Is there anything else you would like us to know? Please explain below.*
SourceEnv
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