Screening for Delirium, Dementia and Depression in Older Adults

Nursing Best Practice GuidelineAltered level of consciousness4. Overall, how would you rate this client’s level of consciousness?❏ Alert (normal)❏ Vigilant (hyperalert, overly sensitive to environmental stimuli, startled very easily)❏ Lethargic (drowsy, easily aroused)❏ Stupor (difficult to arouse)❏ Coma (unarousable)❏ UncertainDisorientation5. Was the client disoriented at any time during the interview, such as thinking that heor she was somewhere other than the hospital, using the wrong bed, or misjudgingthe time of day?73Memory impairment6. Did the client demonstrate any memory problems during the interview, such asinability to remember events in the hospital or difficulty remembering instructions?Perceptual disturbances7. Did the client have any evidence of perceptual disturbances, for example,hallucinations, illusions, or misinterpretations (such as thinking something wasmoving when it was not)?Psychomotor agitation8. Part 1At any time during the interview, did the client have an unusually increased level ofmotor activity, such as restlessness, picking at bedclothes, tapping fingers, or makingfrequent sudden changes in position?Psychomotor retardation8. Part 2At any time during the interview, did the client have an unusually decreasedlevel of motor activity, such as sluggishness, staring into space, staying in oneposition for a long time, or moving very slowly?