Introduction and Informed Consent
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GUIDELINES FOR THE COMMUNITY SCREENING INTERVIEW FOR DEMENTIA (CSI-D) YORUBA VERSION ADMINISTRATION AND SCORING 2009 Olusegun Baiyewu, M.D. Adesola Ogunniyi, M.D. F:\Public\Study Documents\Ibadan documents\2009\Ibadan CSID Training Handbook.doc Page 1 of 59 05/25/11 1:22 PM Identifying Information The cover sheet will have identifying information printed from the computerized database. If there are changes in any of this information, record the updated information on the cover sheet. First blank item: Is volunteer currently living in a nursing home? Check yes or no. Contact Notes: Record the date and time of each attempt to contact the volunteer. If messages are left with family members, make a note of this. The last record on this sheet will indicate the final outcome, hopefully something like 01/15/09 Completed Interview. Introduction and Informed Consent Introduction: Read the instructions as written. Once the interviewer is familiar with the material, it will be possible to do this without reading it. Record start time: _____ Informed Consent: Every individual who agrees to be interviewed must sign the carbonized consent form or place his/her mark. This form indicates the subject’s consent to do the interview and must be signed. In most cases, the interviewers will briefly summarize the form for the participant. If the participant has any questions or concerns, they should be addressed at this time. In some instances, if the subject is reluctant to sign the form, the interviewer may suggest that they proceed with the interview in order to allow the subject to better understand what is involved. Usually, in such cases, we can proceed through the entire interview, then have the consent form completed at the end. Once the participant has signed the forms, the interviewer must also sign and date the forms. One of the forms is given to the study participant and the other two stay with the interview booklet. We give the signed consent form to the volunteer at the end of the interview, along with the incentive payment. Marital Status - Circle correct status. 1 = Never Married Ko ni iyawo/oko ri 2 = Married or Common Law Ni iyawo/oko 3 = Divorced Ko oko/iyawo sile 4 = Separated Oko ati aya ti pinya 5 = Widowed Opo 6 = Unknown A ko mo F:\Public\Study Documents\Ibadan documents\2009\Ibadan CSID Training Handbook.doc Page 2 of 59 05/25/11 1:22 PM If married, type of marriage: 1 = Alaya pupo (Polygamous) 2 = Alaya kan (Monogamous) Household Composition - Circle correct household composition. 1 = Lives alone O ndagbe 2 = Lives with spouse O ngbe pelu oko/aya 3 = With Spouse & Others Pelu oko/aya ati awon miran 4 = With family, no spouse Pelu ebi ko si oko/aya 5 = Other ______________ Awon miran Location of Interview - Circle correct location. 1 = Volunteer’s residence 2 = Relative’s residence 3 = Nursing Home 4 = Hospital 5 = Other ___________ 1. Paying Jobs: Do you currently have a paying job? Beko (No) Se eni ise ti o nmu owo wole lakoko yi? Beni (Yes) Type of job (Iru ise wo) ____________ Circle the number for “yes” or “no”. 2. Volunteer work: Do you do volunteer work? Beko (No) Nje e ma nse ise afara eni se lai gba owo? Beni (Yes) Circle the number for “yes” or “no”. 3. Relative with memory problems. Have any of your close relatives such as parents, brothers, sisters, or children had the problem of serious loss of memory? Nje ari ninu awon ebi yin ti o sun mo yin timotimo gege bi awon obi yin, egbon/aburo, tabi omo ti o ni idiwo ti o po lopolopo nipa riranti nkan? F:\Public\Study Documents\Ibadan documents\2009\Ibadan CSID Training Handbook.doc Page 3 of 59 05/25/11 1:22 PM Circle the number for “yes” or “no’. Ask approximate age of onset, if they give a range, record the mid-point. If they do not know, just check the appropriate relative. If more than one sibling is reported, record age of onset for the first (1) and second (2) sibling. 0………Beko (No) 1…….. Beni (Yes) Age of onset Ojo ori won nigbati o bere Baba (Father) __________ Mama (Mother) __________ Egbon/aburo okunrin (Brother) (1)__________ (2)__________ Egbon/aburo obinrin (Sister) (1)__________ (2)__________ Omokunrin (Son) (1)__________ (2)__________ Omobinrin (Daughter) (1)__________ (2)__________ IF YES, ASK #4. IF NO, PROCEED TO #5. 4. Nursing Home: Was it so serious that they had to be taken care of in a nursing home? Se o le tobe ti won nilati gba olutoju fun won? Circle the number for “yes” or “no” for the affected relative. Beko Beni Beko Beni (No) (Yes) (No) (Yes) Baba 0 1 (Father) Mama 0 1 (Mother) Egbon/aburo okunrin (kinni) 0 1 Egbon/aburo okunrin (keji) 0 1 (Brother) (1) Brother (2) Egbon/aburo obinrin (kinni) 0 1 Egbon/aburo obinrin (keji) 0 1 (Sister) (1) Sister (2) Omokunrin (kinni) 0 1 Omokunrin (keji) 0 1 (Son) (1) Son (2) Omobinrin (kinni) 0 1 Omobinrin (keji) 0 1 (Daughter) (1) Daughter (2) F:\Public\Study Documents\Ibadan documents\2009\Ibadan CSID Training Handbook.doc Page 4 of 59 05/25/11 1:22 PM 5. I’m now going to read to you a list of medical conditions. I want to know if a doctor has told you that you have any of these conditions? Please answer YES, NO, or DON’T KNOW for each condition. Mo fe ka awon ailera fun yin. Mo si fe mo pato eyiti Onisegun Oyinbo so fun yin pe e ni ninu awon ailera wonyi. E jowo e dahun pe ‘Beni’, ‘Beko’ tabi ‘Nkomo’ fun aisan kokan. Read the instructions to the volunteer. Then read the list of conditions. Check a response for each condition by putting a check “√” in the box. Ask for dates only where indicated. CONDITION BENI BEKO EMI KO MO (Yes) (No) (Don’t Know) Stroke or Mini-stroke Iroloworolese ti o po tabi ti o mo niwonba Date of most recent stroke: _____/_____/_____ Mon Day Year Parkinson’s Disease Arun egbon-riri Alzheimer Disease Arun gbigbagbe nkan ati aini iye ninu ti o ga julo Serious Memory Problems Arun gbigbagbe nkan eyi ti o ga Epilepsy Arun Warapa Heart Attack Arun okan olojiji Date of most recent stroke: _____/_____/_____ Mon Day Year Angina Arun aya riro lehin ise afarase Other heart problems Awon arun okan miran ________________________ ________________________ Vascular Disease Awon arun ti o je mo eje High Blood Pressure Ifunpa ti o ga Diabetes Arun atogbe F:\Public\Study Documents\Ibadan documents\2009\Ibadan CSID Training Handbook.doc Page 5 of 59 05/25/11 1:22 PM CONDITION BENI BEKO EMI KO MO (Yes) (No) (Don’t Know) Thyroid Disease Arun gege orun Kidney Disease Arun kindinrin Are you on Dialysis? Nje e wa lori itoju ti o nilo ero to nfa ito jade lara yin? Liver Disease (jaundice) Arun iba-ponju Lung Disease Arun fuku Cancer Arun Jejere Are you currently being treated for cancer? Chemotherapy or Radiation Nje e ngba itoju lowolowo fun arun jejere? _____________________ Malaria Arun Iba Arthritis Arun Lakuregbe Broken Bone in the last year Egungun ti o da larin odun kan sehin Depression Irewesi okan/ibanuje okan Nerves Arun ti o je mo aibale ara Been knocked unconscious Didaku lehin ijamba 6. Now I would like to write down the names of all medication(s) you currently take on a regular basis. I need to include vitamins and over-the-counter medicine, as well as herbal remedies that you have taken at least once a day over the past two weeks. Nisinsinyi, ma fe ki e daruko gbogbo awon ogun ti e tera mo lilo won ni asiko yi. Mo ni lati mo nipa awon ogun atun ara se ati awon ogun ti won nra lori igba, pelu awon ogun ibile bi agbo ti e ko le se alaimalo ni ekan lojumo lati bi ose meji sehin. Not taking any medications Medications not available Record name of medication as spelled on the label. The supervisor will correct the spelling prior to data entry. Check “yes” or “no” on whether or not the name was copied from the label. F:\Public\Study Documents\Ibadan documents\2009\Ibadan CSID Training Handbook.doc Page 6 of 59 05/25/11 1:22 PM If the volunteer does not take any medication, check the box. If the volunteer does take medications but we are not able to examine the labels, check box for “medications not available.” (PRESCRIPTIONS) (INFORMATION TAKEN FROM THE BOTTLE) AWON OOGUN ALAYE TO WA LARA IGO (YES) (NO) BENI BEKO (OVER-THE-COUNTER) (INFORMATION TAKEN FROM THE BOTTLE) EYI TI E RA NI ILE OOGUN ALAYE TO WA LARA IGO (YES) (NO) BENI BEKO • Cognitive Test 7. I would like for you to remember my name. My name is ______________________. Can you repeat this please? (name) (Interviewer may repeat name 3 times if necessary.) Ma fe ki e ranti oruko mi. Oruko mi ni _______________________ E jowo mo fe ki e pe oruko na tele mi? Interviewer reads the statement and tells his/her name. We ask the subject to repeat the name to confirm that they have heard and understood the name. The interviewer may give the name up to 3 repeats, if necessary. If subject says the name correctly on the first try, just record and go to the next item. 0……………………..... Nwon ko le tun so (Cannot repeat name) 1... Won tun oruko mi so daradara (Successfully repeats name) I want you to remember it because I will ask you my name a little later.