What domains should be considered when assessing a geriatric patient's premorbid personality, particularly those with dementia, and what questions should be asked to create a comprehensive template?

Premorbid Personality Assessment Template for Geriatric Patients with Dementia

A comprehensive premorbid personality assessment should systematically evaluate five core domains using structured informant-based tools: cognitive functioning, functional abilities (IADLs and ADLs), behavioral/neuropsychiatric characteristics, personality traits, and social/occupational functioning—all obtained through corroborative history from reliable informants who knew the patient before symptom onset. 1

Essential Domains to Assess

1. Cognitive Domain (Baseline Functioning)

Obtain informant report of the patient's cognitive abilities before dementia onset using validated instruments:

• Memory function: Ask "How was their memory for recent events, appointments, conversations before the problems started?" 1
• Executive function: "How did they handle complex tasks like financial planning, organizing events, or problem-solving?" 1
• Language abilities: "Were they articulate, verbose, or more reserved in communication?" 1
• Visuospatial skills: "Could they navigate new places, read maps, or handle spatial tasks easily?" 1

Recommended tools: Use the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) or Everyday Cognition scale (ECog) to systematically capture premorbid cognitive baseline 1

2. Functional Domain (Premorbid Independence)

Document baseline functional capacity across activity levels:

Advanced IADLs (ask about capabilities 5-10 years before symptom onset):

• Financial management: "Did they handle bills, banking, investments independently?" 1
• Technology use: "Were they comfortable with phones, computers, devices?" 1
• Work/hobbies: "What was their occupational level and leisure activities?" 1
• Travel: "Could they navigate unfamiliar areas independently?" 1

Basic IADLs:

• Meal preparation, medication management, household tasks, driving ability 1

Recommended tools: Lawton Instrumental Activities of Daily Living Scale or Functional Activities Questionnaire (FAQ) completed retrospectively for premorbid state 1

3. Behavioral and Personality Domain (The Core of Premorbid Personality)

This is the most critical domain for understanding personality continuity and predicting behavioral symptoms:

Personality traits using the Five-Factor Model framework:

• Neuroticism: "Were they anxious, worried, emotionally reactive, or calm and stable?" 2, 3
• Extraversion: "Were they outgoing and sociable versus reserved and solitary?" 2
• Openness: "Were they curious, creative, open to new experiences versus conventional?" 2, 3
• Agreeableness: "Were they cooperative, trusting, warm versus suspicious or hostile?" 2, 3
• Conscientiousness: "Were they organized, disciplined, reliable versus disorganized?" 2

Emotional regulation patterns:

• Attachment style: "How did they form and maintain close relationships—secure, anxious, or avoidant?" 4
• Hostility/aggression: "Did they have a temper or express anger easily?" 4
• Affective temperament: "Were they generally optimistic, pessimistic, or emotionally stable?" 5

Recommended approach: Have family members complete the NEO Five-Factor Inventory (NEO-FFI) retrospectively for the patient's "usual self" before illness onset 2, 3

4. Neuropsychiatric Symptom Baseline

Establish whether any behavioral symptoms existed before dementia:

• Mood history: "Did they have depression, anxiety, or mood swings before memory problems?" 1, 6
• Psychotic symptoms: "Any history of paranoia, suspiciousness, or unusual beliefs?" 3
• Behavioral patterns: "Were they impulsive, disinhibited, or rigid in routines?" 1

Recommended tools: Use the Mild Behavioral Impairment Checklist (MBI-C) to distinguish longstanding personality traits from new-onset symptoms 1

5. Social and Occupational Functioning

Document premorbid social engagement and work history:

• Educational attainment and occupational complexity 7
• Social network size and quality of relationships 7
• Community involvement and leisure activities 7
• Marital/family relationship patterns 4

Critical Questions to Ask Informants

Opening frame: "I need to understand what [patient's name] was like before the memory/thinking problems began—their usual personality and abilities."

Specific Question Templates:

1. "Thinking back 5-10 years ago, before you noticed any problems, how would you describe their personality?" 2, 3

2. "Were they generally a worrier or more laid-back and calm?" (assessing neuroticism) 2, 3

3. "How did they handle stress or setbacks—did they bounce back easily or struggle?" (emotional regulation) 4

4. "Were they outgoing and social or more private and reserved?" (extraversion) 2

5. "How organized and detail-oriented were they in daily life?" (conscientiousness) 2

6. "Did they have a history of depression, anxiety, or other mental health concerns before the dementia symptoms?" 1, 6

7. "What level of independence did they have in managing finances, medications, and household tasks?" 1

8. "How did they typically express emotions—openly or kept things to themselves?" 4

Common Pitfalls and How to Avoid Them

Pitfall #1: Single informant bias - Using the same informant for both premorbid personality and current symptoms creates retrospective bias, particularly for depression 6. Solution: Obtain premorbid personality information from a secondary informant (not the primary caregiver) whenever possible, or use multiple informants 6.

Pitfall #2: Confusing longstanding traits with new symptoms - Families may attribute current behavioral symptoms to "always being that way" 1. Solution: Explicitly ask "Is this behavior new or changed from how they were 5-10 years ago?" Use the MBI-C which specifically assesses change in behavior 1.

Pitfall #3: Relying on patient self-report - Patients with dementia lack insight into their own personality changes 7. Solution: Always obtain corroborative history from reliable informants who knew the patient well before symptom onset 1, 7.

Pitfall #4: Failing to use standardized instruments - Unstructured interviews reduce diagnostic accuracy and make longitudinal tracking unreliable 7. Solution: Use validated tools like NEO-FFI for personality, IQCODE for cognition, and FAQ for function 1, 2, 3.

Documentation Template Structure

Section 1: Informant Information

• Relationship to patient, duration of relationship, frequency of contact 1

Section 2: Premorbid Cognitive Baseline

• IQCODE or ECog scores with specific domain ratings 1

Section 3: Premorbid Functional Baseline

• FAQ or Lawton IADL scores retrospectively rated 1

Section 4: Premorbid Personality Profile

• NEO-FFI five-factor scores or narrative description covering all five domains 2, 3
• Attachment style and emotional regulation patterns 4

Section 5: Psychiatric History

• Any premorbid mood, anxiety, or psychotic symptoms 1, 6

Section 6: Social/Occupational History

• Education level, occupation, social engagement 7

Clinical Utility

Understanding premorbid personality helps predict which behavioral symptoms may emerge: higher premorbid neuroticism predicts delusions 3, higher agreeableness predicts hallucinations and aggressiveness 3, and secure attachment predicts more positive affect expression even in late-stage dementia 4. However, the relationship between premorbid personality and depression is confounded by informant bias and should be interpreted cautiously 6.