Screening for Delirium, Dementia and Depression in Older Adults

Nursing Best Practice GuidelineAppendix C:Assessment Tool Reference GuideToolDescription of toolRefer to . . .Extensive NursingAssessment/Mental StatusQuestions• Sample questions to be used for nurse-clientinterview.Appendix DMini-Mental Status Exam(MMSE)• Most widely used mental status assessment;a good tool to substantiate clinical observationsin nursing.• Measures: memory, orientation, language,attention, visuospatial and constructional skills.Appendix E59Clock Drawing Test• May assist in supporting a diagnosis ofdementia or in indicating to a clinician areasof difficulty experienced by a client.• Complements other tests which focus onmemory/language.Appendix FNeecham Confusion Scale• Measures level of confusion in processing,behaviour and physiologic control.Appendix GConfusion AssessmentMethod (CAM) Instrument• To help identify individuals who may be sufferingfrom delirium or an acute confusional state.• Useful for differentiating delirium and dementia.Appendix HEstablishing a Diagnosis ofDepression in the Elderly[Sig: E Caps]• If there are nervous problems or a depressedmood, use the acronym Sig: E Caps to describe.Appendix ICornell Scale forDepression• Provides a quantitative rating of depressionin individuals with or without dementia.• Utilizes information from the caregiver as wellas the client.Appendix JGeriatric Depression Scaleand Geriatric DepressionScale (GDS – 4 Short Form)• May assist in supporting a diagnosis ofdepression (an adjunct to clinical assessment).• Provides a quantitative rating of depression.Appendix K & LSuicide Risk in theOlder Adult• Helps identify suicidal risk in individuals witha depressed mood.Appendix M