Screening for Delirium, Dementia and Depression in Older Adults

Screening for Delirium, Dementia and Depression in Older AdultsAppendix J: Cornell Scalefor DepressionClient Name:Date:Administered at (check one): Assessment By: Discharge:Mood-related Signs1. Anxietyanxious expression, ruminations, worrying❏Cyclic Functions12. Diurnal variation of mood symptomsworse in the morning❏762. Sadnesssad expression, sad voice, tearfulness❏13. Difficulty falling asleeplater than usual for this client❏3. Lack of reactivity to pleasant events ❏14. Multiple awakenings during sleep ❏4. Irritabilityeasily annoyed, short tempered❏15. Early morning awakeningearlier than usual for this client❏Behavioural Disturbance5. Agitationrestlessness, handwringing, hairpulling6. Retardationslow movements, slow speech, slow reactions7. Multiple physical complaints(score 0 if GI symptoms only)8. Loss of interestless involved in usual activities(score only if change occurred acutely,e.g., less than 1 month)❏❏❏❏Ideational Disturbance16. Suicidefeels life is not worth living, has suicidalwishes, or makes suicide attempt17. Poor self-esteemself-blame, self-depreciation, feelingsof failure18. Pessimismanticipation of the worst19. Mood-congruent delusionsdelusions of poverty, illness, or loss❏❏❏❏Physical Signs9. Appetite losseating less than usual10. Weight loss(score 2 if greater that 5 lbs. in 1 month)11. Lack of energyfatigues easily, unable to sustain activities(score only if change occurred acutely,e.g., in less than 1 month)❏❏❏Scoring SystemRatings should be based on symptoms and signsoccurring during the week prior to interview. No scoreshould be given if symptoms result from physicaldisability or illness.0 = absent1 = mild or intermittent2 = severeN/A = unable to evaluateReprinted with permission of Dr. George Alexopoulos.