Pfeffer FAQ

Trust the FAQ informant data over clinical impression. Patients with early to moderate Alzheimer's disease frequently appear functional in brief clinical interactions — the social facade of dementia preservation is well described. The informant observes the patient across hundreds of real-life situations over weeks and months, capturing errors, safety near-misses, and compensatory strategies invisible in a 15-minute clinical visit. If the FAQ informant is reliable and knowledgeable, a score of 12 represents clinically significant functional impairment. Consider whether the informant might be over-rating impairment due to caregiver burden — a brief caregiver burden screen can clarify this.

Patient self-completion is not recommended for cognitively impaired patients, as anosognosia causes systematic underestimation of impairment. For patients with mild impairment and intact cognition, patient self-report can be used with caution. When no informant is available, document this limitation clearly, consider contacting a family member by telephone, review available occupational therapy functional assessments, and supplement with direct functional observation tasks if available.

Ask the informant to estimate the patient's current capability: 'If [patient name] had to start managing their own finances today, do you think they could do it on their own, with some difficulty, with help, or not at all?' Base the score on the patient's current overall cognitive and functional level. A patient with normal cognition who simply never managed finances would typically score 0 (could do it normally if required). A patient with moderate dementia would typically score 2 to 3 (would need help or be unable).

A FAQ rise of 6 points over 12 months represents substantial functional decline suggesting active Alzheimer's disease progression. This warrants comprehensive clinical review: medication assessment (is cholinesterase inhibitor or memantine prescribed and optimized?), cognitive testing to document progression, brain imaging if not recently obtained, vascular risk factor management, and a care planning conversation with patient and family about current and future care needs, safety concerns, and advance care planning. A social work referral for caregiver support assessment is also indicated.

The FAQ was developed and primarily validated in Alzheimer's disease. It is commonly used in other dementias including vascular dementia, Lewy body dementia, and FTD, where it provides useful functional information. However, impairment patterns differ by dementia type: FTD may show early impairment in judgment-based tasks before memory-based tasks; vascular dementia may show step-wise decline; LBD may show fluctuating functional performance. FAQ scores should be interpreted in the context of the specific dementia etiology and clinical course.