Cognitive Dysfunction Screening Checklist

Date

MM slash DD slash YYYY

Owners Name

Species

Canine
Feline

Pet's Name

Age

Sex

Male
Female

Neutered

Yes
No

Cognitive dysfunction screening checklist

Confusion – awareness – spatial orientation

1. Gets stuck or can’t get around objects
2. Stares blankly at walls or floor
3: Can’t find / leaves dropped food
4: Goes into wrong side of door; walks into door / walls

1: Age first noticed

1: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

2: Age first noticed

2: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

3: Age first noticed

3: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

4: Age first noticed

4: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

Relationships – social interactions

1. Decreased interest in petting / avoids contact
2. Decreased greeting behavior
3: In need of constant contact, overdependent, “ clingy ”
4: Altered relationship with other household pets – less social
5: Agression

1: Age first noticed

1: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

2: Age first noticed

2: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

3: Age first noticed

3: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

4: Age first noticed

4: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

5: Age first noticed

5: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

Aggression

Response to stimuli

1. Decreased response to auditory stimuli (sounds)
2. Increased response, fear, phobia to auditory stimuli
3: Decreased response to visual stimuli (sights)
4: Increased response, fear, phobia to visual stimuli
5: Decreased responsiveness to food / odor

1: Age first noticed

1: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

2: Age first noticed

2: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

3: Age first noticed

3: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

4: Age first noticed

4: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

5: Age first noticed

5: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

Activity / anxiety – increased/repetitive

1. Pacing / wanders aimlessly
2. Snaps at air / licks air
3: Licking owners/ household objects
4: Vocalization
5: Increased appetite (eats quicker or more food)
6: Restless / agitation

1: Age first noticed

1: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

2: Age first noticed

2: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

3: Age first noticed

3: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

4: Age first noticed

4: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

5: Age first noticed

5: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

6: Age first noticed

6: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

Activity – apathy / depressed

1. Decreased interest in food / treats
2. Decreased exploration / activity
3: Decreased interest in social interactions / play
4: Decreased self-care

1: Age first noticed

1: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

2: Age first noticed

2: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

3: Age first noticed

3: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

4: Age first noticed

4: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

Sleep – wake cycles; reversed day/night schedule

1. Restless sleep/waking at nights
2. Increased daytime sleep

1: Age first noticed

1: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

2: Age first noticed

2: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

Learning and memory – housesoiling

1. Indoor elimination at sites previously trained
2. Decrease/loss of signaling
3: Goes outdoors, then returns indoors and eliminates
4: Elimination in crate or sleeping area
5: Incontinence

1: Age first noticed

1: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

2: Age first noticed

2: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

3: Age first noticed

3: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

4: Age first noticed

4: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

5: Age first noticed

5: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

Learning and memory – work, tasks, commands

1. Impaired working ability/decreased ability to perform learned tasks
2. Decreased responsiveness to commands and tricks
3: Inability/slow to learn new tasks (retrain)
4: Decreased recognition of familiar people / pets

1: Age first noticed

1: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

2: Age first noticed

2: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

3: Age first noticed

3: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe

4: Age first noticed

4: Score

Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe