Screening for Delirium, Dementia and Depression in Older Adults
Screening for Delirium, Dementia and Depression in Older Adults
Screening for Delirium, Dementia and Depression in Older Adults
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<strong>Screen<strong>in</strong>g</strong> <strong>for</strong> <strong>Delirium</strong>, <strong>Dementia</strong> <strong>and</strong> <strong>Depression</strong> <strong>in</strong> <strong>Older</strong> <strong>Adults</strong>LEVEL 3 – PHYSIOLOGIC CONTROLPHYSIOLOGIC MEASUREMENTSRecorded ValuesNormal RangesTemperature (36-37ºC) Periods of apnea/hyponea?1 = yes, 2 = noSystolic BP (SBP) (100-160) Oxygen therapy prescribed?Diastolic BP (DBP) (50-90 ) 0 = no, 1 = yes, but not on,2 = yes, on now70O2 saturation(93 or above)Respiration (14-22)(count 1 m<strong>in</strong>ute)Heart Rate (HR) (60-100)Regular/Irregular(Circle one)VITAL FUNCTION STABILITYCount abnormal SBP <strong>and</strong>/or DBP as one value; count abnormal <strong>and</strong>/or irregular HR as one;count apnea <strong>and</strong>/or abnormal respiration as one; <strong>and</strong> abnormal temperature as one.2 BP, HR, TEMP, RESPIRATION with<strong>in</strong> normal range with regular pulse.1 Any one of the above <strong>in</strong> abnormal range.0 Two or more <strong>in</strong> abnormal range.OXYGEN SATURATION STABILITY2 O2 sat <strong>in</strong> normal range (93 or above)1 O2 sat 90 to 92 or is receiv<strong>in</strong>g oxygen0 O2 below 90
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