Standard procedure questions and instructions

Use these instructions and prompts to administer the Westmead Post-Traumatic Amnesia (PTA) Scale in clinical settings.

The following instructions and acceptable prompts and responses reflect the validated protocol for administering the Westmead PTA Scale with patients in hospital who have a suspected moderate to severe traumatic brain injury (TBI).

On this page:

• Scoring
• First day of testing
• From day 2 of testing
• When a patient doesn’t know or doesn’t answer
• Rehearsing with the patient
• Standard procedure for testing when the usual assessor is not available
• Testing children

Scoring

Answers to each question are written down in the spaces provided on the scoresheet. Give a score of 1 if correct or 0 if incorrect. No half marks are given. When a patient requires a prompt as outlined in the standard procedures below, place an asterisk next to the answer box. This indicates the question was administered differently from the others. It has no bearing on how you score the question.

First day of testing

Ask the patient the following 7 questions. Refer to the notes for each question for related prompts for clarification on their responses. Record the score out of 7 on the scoresheet.

Q1. How old are you?

Ask for clarification if the patient states; for example, that they will be “30 next year”. The acceptable clarifications are: “So that makes you how old at the moment?” or “How old are you now?”

Q2. What is your date of birth?

If the patient has difficulty with the concept of “date of birth”, ask “When is your birthday?”, then follow with “What year were you born in?”

Some patients may have difficulty providing a date of birth for a range of reasons. This can include different cultures expressing date of birth in different ways, or childhood circumstances may mean a person does not know their actual date of birth. You may need to ask a family member what the patient would have given as their date of birth before their injury and use this as the correct answer throughout testing.

Q3. What month are we in?

The patient must name the month or identify which numerical month we are in. For example, if it is June, they can say, “We are in the sixth month.”

Q4. What time of day is it: morning, afternoon or night?

The patient should answer with one of the 3 choices given in the question.

Q5. What day of the week is it?

You may add for emphasis, “What day of the week is it today?”

Q6. What year are we in?

Acceptable responses are “2026” or the shorter form of “26”.

An acceptable alternative prompt is, “The year is 20 what?”

Q7. What is the name of this place?

The patient must give the name of the hospital. For example, “Westmead Hospital”.

The patient does not score a point for just saying “hospital”.

If the patient cannot name the hospital, give them a choice of 3 options, being mindful of providing the names of 2 other hospitals of similar size and locality.

If there is only one hospital in the locality, provide the names of hospitals in nearby towns or other health facilities (e.g. GP clinic or medical centre), or another community service. Use the same alternative choices each day to maintain consistency.

Once you complete the questions and record the results for day 1, rehearse any incorrectly answered questions with the patient.

Prepare the patient for the memory questions which will start from day 2 of testing.

• Provide your name to the patient and tell them they will be asked the following day if they remember your face and first name.
• If you are not going to be available for testing on the following day (for example, if it’s going to be the weekend), still ask the patient to remember your face and name, because they will be asked to identify you from a photograph on the following day.

• Select and name 3 pictures from the A4 page of 3x3 picture cards. If using individual picture cards, randomly select and name the 3 pictures. Tell the patient clearly that they will be asked tomorrow if they remember which picture cards they were shown. Note on the scoresheet which 3 cards were shown to the patient and in which order.

From day 2 of testing

From the second day of testing onwards, all 12 questions are administered. Repeat the questions from day 1 above, then ask the below questions, taking note of the relevant prompts to clarify their responses.

Record the results on the scoresheet.

Q8. Have you seen my face before?

This question requires a simple yes/no answer.  Even if the patient answers “no” to this question, Question 9 should still be asked.

An acceptable alternative is, “Have you seen me before?”

If the usual assessor is not available on the day of testing (either because it is the weekend or because of an unplanned absence), present a photograph of the usual assessor along with photographs of 2 other staff members of similar appearance. Ask the patient, “Who do you have to remember?”

Q9. What is my name?

Only the first name is required.

If the patient fails to respond spontaneously, give them a choice of 3 names. The options should start with the same letter and have the same number of syllables.

For example: Lisa, Linda or Lesley.

If using the photograph in the absence of the usual assessor, ask, “What is their name?”

Q10, 11 and 12. What were the 3 pictures [you were shown/you selected] yesterday?

The patient scores one point for each correctly named picture card.

If the patient can spontaneously recall only one or 2 pictures, use the alternative script outlined below to pick the remaining picture(s).

Score one point for each picture that is correct, regardless of whether it was recalled spontaneously or recognised following the prompt.

If the patient cannot spontaneously recall all 3 picture cards from the previous day, show them the A4 3x3 layout (or place all 9 picture cards face-up on the table) as a prompt. The patient must correctly identify the 3 target pictures, either by naming them, pointing to them, or by saying yes/no as they are shown them one at a time.

Different versions of the A4 3x3 layout should be used as a prompt (or a different distribution of the 9 pictures if physical cards are being used) to ensure the patient is recalling the picture rather than its position on the page.

When the patient scores 12 out of 12 on the test, change the pictures to be remembered.

The new pictures are selected the same way as the original set. Record the new pictures and the date they were chosen on the scoresheet.

A new set of pictures is regarded as different from the previous set if at least one of the pictures is changed. If the patient or assessor manages to pick the same 3 cards, they must pick all the cards again.

When a patient doesn’t know or doesn’t answer

The following adaptation applies when the patient indicates they don’t know an answer or they don’t provide an answer. It does not apply if the patient has already offered an incorrect answer.

Repeat the question and give the patient 3 answers from which to choose (one of which is the correct answer). Present the options in sequential order.

If this procedure is necessary for multiple questions, modify the position of the correct answer (for example, the correct answer should not always be the second option given). Use the following examples for guidance.

If a patient continues to respond that they “don’t know”, or does not answer the question, the score is 0 and clinical judgement is required to interpret their lack of response. They may be unwilling or unable to participate in PTA testing for a range of reasons. Their inability or unwillingness to participate can change regularly, so lack of response on one day should not be used as a reason to cease testing altogether.

Rehearsing with the patient

At the end of testing, rehearse the correct answers with the patient for the following day. In some circumstances it is beneficial to rehearse after each incorrect question. This decision depends on whether one approach tends to cause the patient agitation or anxiety, and what will enable their best performance across the whole test.

Rehearsing involves the following:

1. Go through the incorrect items with the patient. For example: “John, you got a couple of items wrong: today is Monday; and it is morning.”
2. Remind the patient what they have to remember for the following day.
3. Introduce the patient to a set of new pictures if they have scored 12 out of 12 (by slowly showing and naming the 3 new pictures and asking the patient to repeat them).
4. Say, “John, I will be coming to see you tomorrow and I want you to remember my name – Lesley.”
5. If you know a different assessor will be administering the test on the following day, then show the patient a photograph of yourself, and use the instruction, “John, I will not be coming to see you tomorrow, but I still want you to remember me by this, my photograph, and that my name is Lesley.”

Check whether the patient has encoded the memory items properly. To do this, distract the patient for a couple of minutes with some idle conversation, such as, “What TV shows do you enjoy watching?” Then ask the patient what they need to remember for the following day. Tell the patient whether they were right or wrong and correct any mistakes. Then before leaving, show the patient the 3 pictures again and say, “John, I want you to remember my name, Lesley, and the 3 pictures I have shown you – bird, flower and cup.”

This extended rehearsal procedure ensures the patient has had the opportunity to encode the information properly.

Discourage the patient from writing down what they have to remember, or from talking to others about it. It is important they remember the information independently.

Standard procedure for testing when the usual assessor is not available

It is crucial that testing occurs every day by someone who is familiar with correct testing procedures.

Regular assessors may need to provide training for other team members who will be responsible for completing the Westmead PTA Scale when they are absent. The substitute assessors need to use the correct photographs and know which picture cards the patient was asked to remember.

Details of specific adaptations used to assist the patient with testing should also be known, as per the results noted on the scoresheet.

More about what to do when testing is interrupted

Testing children

The standard procedures apply to testing children aged 8 years and older (Marosszeky et al 1993; Briggs et al, 2016; Briggs et al, 2023). One or both parents may be present, and they must understand the purpose of testing and the importance of not prompting or rehearsing with their child.

Ask about any existing developmental issues prior to the child’s injury, and whether the parent believes their child would have been able to answer the questions pre-injury.

The Sydney Post-Traumatic Amnesia Scale (SYPTAS) is a reliable PTA assessment tool for children aged 4 years to 7 years 11 months (Lah et al 2017).

References