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Microsoft word - 3d best practice resource guide-jan. 2007 _final_.doc





Developed by:
Toronto Best Practice in LTC Initiative
January 2007
This resource guide was developed by a sub-committee of the
Toronto Best Practice Implementation Steering Committee:

Helen Ferley, Co-Chair
Administrator
Seniors' Health Centre – North York General Hospital
Patty Carnegy, Co-Chair
Staff Education Coordinator
Toronto Homes for the Aged
Josephine Santos
Regional Best Practice Coordinator, Long-Term Care – Toronto Region
Ministry of Health and Long-Term Care
Host Agency: Seniors' Health Centre – North York General Hospital
Sue Bailey
Psychogeriatric Resource Consultant
The Psychogeriatric Resource Consultation Program of Toronto
Providence Healthcare
Anne Stephens
Clinical Nurse Specialist, Gerontology
St. Michael's Hospital
Cindy Stephens
Director of Nursing
Cummer Lodge
Vania Sakelaris
LTC Program Consultant
Acute Services and Community Health Divisions
Ministry of Health and Long-Term Care
The Best Practice in Long-Term Care Initiative is funded by the
Ontario Ministry of Health and Long-Term Care.
Table of Contents
Introduction 4 Background Best Practice Recommendations Addressed in the Resource Guide Tips on Successful Best Practice Implementation Practice Resources – Putting Together Delirium, Depression and Dementia Best Practice Recommendations Addressed in this Section What You Will Find in this Section Screening Assessment Flow Diagram for Delirium, Depression and Dementia Recognizing Delirium, Depression and Dementia Assessment Tool Reference Guide Delirium Resources Delirium Definition Best Practice Recommendations Addressed in this Section What You Will Find in this Section Confusion Assessment Method (CAM) Instrument Confusion Assessment Method (CAM) Instrument: Original Version Confusion Assessment Method (CAM) Instrument: Shortened Version Worksheet Assess for Causes of Delirium Decision Tree: Strategies for Delirium Interventions/Safety Considerations for Delirium Depression Resources Depression Definition Best Practice Recommendations Addressed in this Section What You Will Find in this Section Geriatric Depression Scale (GDS) Geriatric Depression Scale (GDS) Geriatric Depression Scale – GDS-4: Short Form Geriatric Depression Scale – GDS-4: Short Form Cornell Scale for Depression Cornell Scale for Depression Suicide Risk in the Older Adult Suicide Risk in the Older Adult Decision Tree: Strategies for Depression


Table of Contents
Dementia Resources Dementia Definition Best Practice Recommendations Addressed in this Section What You Will Find in this Section Common Types of Dementia Folstein Mini Mental Status Exam (MMSE) Folstein Mini Mental Status Exam (MMSE) Clock Drawing Test (CDT) Clock Drawing Test (CDT) Mini-Cog Dementia Screen Mini-Cog Dementia Screen Cohen Mansfield Agitation Inventory (CMAI) Cohen Mansfield Agitation Inventory (CMAI) Decision Tree: Strategies for Dementia Care Strategies for Dementia Education Resources Website List of Available Resources Teaching Resources for Families and Friends of Residents


Background
Demographic research shows that the proportion of Canadians who are seniors are expected to increase dramatically. According to the 1999 Health Canada statistics, adults 65 years and over will account for almost 18% of our country's population by 2021. The majority of older adults will continue to live productively in the community with or without support. Currently in Ontario, about 70,000 of the elderly population with average age of 83 years, resides in long-term care homes (Smith, 2004). It has also been reported that 80% - 90% of long-term care home residents live with some form of mental illness and/or cognitive impairment (Canadian Coalition for Senior's Mental Health (CCSMH), 2006; Rovner et al., 1990; Drance, 2005). Delirium, depression and dementia (3D's) are often under recognized in the geriatric population. Lack
of recognition impacts on the quality of life, morbidity and mortality of the older adult. To enhance the
health, quality of life and safety of older adults, it is important to further develop the knowledge and skills
of the healthcare team. This resource guide will assist the healthcare professional to consistently assess,
implement and evaluate treatment.
The Toronto Best Practice Implementation Steering Committee was developed to review best practices
and develop processes for implementation in long term care homes. Based on the 2004 Ontario
Classification results, the committee identified delirium, depression and dementia as one of the Best
Practice topics to be implemented.
The goal of this resource guide is to provide resources for health professionals. There are many best practices available; however, the committee focused on the recommendations from the following guidelines: • Registered Nurses' Association of Ontario (2004). Caregiving Strategies for Older Adults with Delirium, Dementia and Depression. Toronto, Canada: Registered Nurses' Association of Ontario. • Registered Nurses' Association of Ontario (2003). Screening for Delirium, Dementia and Depression in the Older Adults. Toronto, Canada: Registered Nurses' Association of Ontario. Educational programs, services and other sources were reviewed by the committee and some have been included in the resource guide. PLEASE NOTE:
The screening tools found in this Resource Guide should only be
used in combination with a full head-to-toe assessment.

Best Practice Recommendations Addressed in the Resource Guide
The following recommendations from the RNAO Best Practice Guidelines on Screening for 3D's in Older Adults will be addressed in this resource guide: • Nurses should maintain a high index of suspicion for delirium, depression and dementia in the older • Nurses should be aware of the differences in the clinical features of 3D's and use a structured assessment method to facilitate this process. • Nurses should objectively assess for cognitive changes by using one or more standardized tools in order to substantiate clinical observations. • When the nurse determines the resident is exhibiting features of 3D's, a referral for a medical diagnosis should be made to specialized geriatric services, specialized geriatric psychiatry services, neurologists, and/or members of the multidisciplinary team, as indicated by screening findings. From the RNAO Best Practice Guidelines on Caregiving Strategies for Older Adults with 3D's, the following recommendations will be addressed: • In order to target the individual root causes of delirium, nurses working with other disciplines must select and record multi-component care strategies and implement them simultaneously. • Nurses must be aware of multi-component care strategies for depression: non-pharmacological interventions and pharmacological caregiving strategies. • Nurses should have knowledge of the most common presenting symptoms of: Alzheimer Disease, Vascular Dementia, Frontotemporal Lobe Dementia, Lewy Body Dementia and be aware that there are mixed dementias. • Nurses should know their clients, recognize their retained abilities, understand the impact of the environment, and relate effectively when tailoring and implementing their caregiving strategies. • Nurses caring for clients with dementia should be knowledgeable about non-pharmacological interventions for managing behaviour to promote physical and psychological well-being. • Nurses caring for clients with dementia should be knowledgeable about pharmacological interventions and should advocate for medications that have fewer side effects.


Tips on Successful Best Practice Implementation
Below are suggested implementation tips to assist long-term care homes that are considering implementing best practices on delirium, depression and dementia. • Liaise with the Best Practice Regional Coordinator to get started with implementation plan. • Select a dedicated person (e.g., clinical resource nurse, PIECES trained nurse, best practice champion nurse) who will provide leadership and support to the implementation of the guidelines. • Identify the key resource people in your LTC Home, e.g., PIECES trained nurses, U-First trained • Establish a working group comprised of key stakeholders and members who are committed in leading the implementation initiative. • Keep a work plan to track activities, responsibilities and timelines. • Collaborate with your local Psychogeriatric Resource Consultant (PRC) to provide education sessions and ongoing support for implementation. • Foster culture of learning through team work, collaborative assessment and treatment planning. • Access additional resources/services available in your community such as Psychogeriatric Resource Consultant, Crisis team, Geriatric Mental Health Outreach team, Alzheimer Society, etc. • Link with other LTCH in your area that are implementing the 3D's BPG. • Monitor and evaluate the progress of implementation.


PRACTICE RESOURCES –
PUTTING TOGETHER DELIRIUM,
DEPRESSION AND DEMENTIA
Best Practice Recommendations addressed in this section
• Nurses should maintain a high index of suspicion for delirium, dementia and depression in the older • Nurses should be aware of the differences in the clinical features of 3D's and use a structured assessment method to facilitate this process. • Nurses should objectively assess for cognitive changes by using one or more standardized tools in order to substantiate clinical observations. • When the nurse determines the resident is exhibiting features of 3D's, a referral for a medical diagnosis should be made to specialized geriatric services, specialized geriatric psychiatry services, neurologists, and/or members of the multidisciplinary team, as indicated by screening findings. What you will find in this section
• Screening Assessment Flow Diagram for Delirium, Depression and Dementia • Recognizing Delirium, Depression and Dementia • Assessment Tool Reference Guide Screening Assessment Flow Diagram for
Delirium, Depression and Dementia
Routine Nursing Assessment
1. Initiate client contact
2. Establish
4. Document behavioural presentations High Index of Suspicion Are there any behavioural or functional cues that reflect a change No Continue to provide from baseline data? Screening Assessment
1. Assess
2. Determine Screening Tools 3. Review Table for Delirium? Dementia? Referrals to one or all of the following
Urgent medical referral Specialized geriatric services Geriatric psychiatry, Neurology 3. Interdisciplinary Implement nursing caregiving strategies Urgent medical referral Ongoing assessment or discharge Adapted from: Registered Nurses' Association of Ontario (2003). Screening for Delirium, Dementia and Depression in the Older Adults. Toronto, Canada: Registered Nurses' Association of Ontario. Recognizing Delirium, Depression and Dementia (3D's)
Residents may have more than 1D present at the same time and symptoms may overlap.
Depression
Dementia
Delirium is a medical emergency Depression is a term used when Dementia is a gradual and which is characterized by an acute a cluster of depressive progressive decline in mental and fluctuating onset of confusion, symptoms (as identified on the processing ability that affects disturbances in attention, SIG E CAPS depression criteria) short-term memory, disorganized thinking and/or is present on most days, for communication, language, decline in level of consciousness. most of the time, for at least 2 judgment, reasoning, and abstract weeks and when the symptoms are of such intensity that they are out of the ordinary for that individual. Delirium cannot be accounted for Depression is a biologically Dementia eventually affects long- by a preexisting dementia; based illness that affects a term memory and the ability to however, can co-exist with person's thoughts, feelings, perform familiar tasks. Sometimes behaviour, and even physical there are changes in mood and • Sudden Onset: Hours to days • Recent changes in mood that persist for at least 2 weeks. • Often reversible with treatment • Usually reversible with • Slow, chronic progression, • Often fluctuates over 24 hour and irreversible period and often worse at • Often worse in the morning Thinking
• Fluctuations in alertness, • Cognitive decline with cognition, perceptions, concentration and thinking, problems in memory plus one or more of the following: aphasia, apraxia, agnosia, and/or executive functioning. Psychotic
• Misperceptions and illusions • Delusions of poverty, guilt, • Signs may include delusions somatic symptoms of theft/persecution and/or hallucinations depending on type of dementia. • Disturbed but with no set • May be disturbed with an pattern. Differs night to night • Early morning awakening or individual pattern occurring • Fluctuations in emotions – • Depressed mood especially in outbursts, anger, crying, • Prevalence of depression may • Changes in appetite (over increase in dementia; or under eating) however, apathy is a more common symptom and may ideation/plan; hopelessness be confused with depression. Psychomotor
• Hyperactive delirium: • Hyperactive: • Wandering/exit Activities
agitation, restlessness, • Withdrawn (may be related to co-existing depression). • Hypoactive delirium: unarousable, very sleepy motivation/interest • Mixed delirium: combination of hyperactive and hypoactive manifestations Depression
Screening
Confusion Assessment
Geriatric Depression
Mini Mental Status Exam
Method (CAM) – An
Scale (GDS)
(Folstein) measures
algorithm used to screen for
Interpretation of the 15 cognitive functioning
delirium:
Question GDS Screen: Interpretation of Score: Screen for delirium is positive < 4 = Indicates absence if the person has features 1 & 2 plus either 3 or 4 as listed 10-20 = moderate < 10 = severe cognitive (1) Presence of acute onset and fluctuating > 7 = Indicates probable Clock Drawing Test (CDT)
(2) Inattention AND Mini-Cog Dementia Screen
(3) Disorganized Cornell Scale for
Interpretation of Score: Depression
0 to 2 = high likelihood of (4) Altered level of Interpretation of Score: cognitive impairment 1.4 = No psychiatric 3 to 5 = low likelihood of cognitive impairment. Assess for causes: 4.8 = Non-depressive I WATCH DEATH [Infections,
If behavioural issues,
Withdrawal, Acute metabolic,
consider using Cohen-
Toxins, drugs, CNS pathology,
12.3 = Probable major Mansfield Agitation
Hypoxia, Deficiencies,
Inventory (CMAI)
Endocrine, Acute vascular,
Trauma, Heavy metals]
24.8 = Major depressive disorder SIG E CAPS (DSM-IV
Criteria)
Interpretation of Score:
> 5 = Indicates probable depression Assessment of Suicide
Risk in the Older Adult
(critical if depression is
present and/or history of
depression)
Laboratory
Delirium workup includes the Depression workup includes the Dementia workup includes the following tests: following tests: following tests: • Hgb, WBC, Na, K, Ca, O2 • TSH, B12, folate, Ca, • CBC, TSH, Blood glucose, sats, Blood gases, Urea, Albumin, FBS, Ferritin, Iron, Electrolytes, including Ca Creatinine, Liver function tests, Chest X-ray, Urinalysis and Culture, Alcohol/drug/toxicology screen DSM-IV Criteria
Diagnostic Criteria: Diagnostic Criteria: Diagnostic Criteria: A. Disturbance of consciousness Five (or more) of the following A. The development of multiple (i.e, reduced clarity of symptoms have been present cognitive deficits manifested awareness of the during the same two-week environment) with reduced period and represent a change ability to focus, sustain or shift from previous functioning; at ability to learn new information least one of the symptoms is or to recall previously learned B. A change in cognition (such as either (1) depressed mood or (2) memory deficit, disorientation, loss of interest or pleasure. 2. one (or more) of the following language disturbance) or the 1. depressed mood most of cognitive disturbances: development of a perceptual the day, nearly every day disturbance that is not better 2. marked diminished interest accounted for by a preexisting, or pleasure in normal b) apraxia (impaired ability Depression
DSM-IV Criteria
established or evolving to carry out motor 3. significant weight loss or activities despite intact C The disturbance motor function) develops over a short c) agnosia (failure to period of time (usually nearly every day recognize or identify hours to days) and objects despite intact tends to fluctuate during retardation nearly every day sensory function) the course of the day. 6. fatigue or loss of energy D. There is evidence from the nearly every day functioning (e.g., history, physical examination 7. feelings of worthlessness or planning, organizing, or laboratory findings that the sequencing, abstracting) disturbance is caused by the 8. diminished ability to think or B. The cognitive deficits in the direct physiological above criteria (Criteria A1 consequences of a general and A2) each cause medical condition. 9. recurrent thought of death significant impairment in or suicidal thoughts/actions social or occupational functioning and represent a significant decline from a previous level of functioning. • Attending Physician ASAP • Attending Physician and if (consider delirium as a suicidal risk consider • Geriatric Mental Health medical emergency and may transfer to Emergency require transfer to an • Psychogeriatric Emergency Department) • Geriatric Mental Health Consultant (PRC) • Psychogeriatric Consultant (PRC) including Psychogeriatric including Psychogeriatric including Psychogeriatric Resource Person (PRP) Resource Person (PRP) Resource Person (PRP) [PIECES trained staff] [PIECES trained staff] [PIECES trained staff] For issues of violence or abuse, follow LTCH protocols. Glossary of Terms
Delusions
• False belief not shared by one's culture • Incorrect beliefs not based on reality • A sensory experience without any real world stimulus, may be visual, auditory, tactile, gustatory or olfactory Illusions
• Misperception of real stimuli Psychomotor
• Pacing and physical restlessness, hyperactive behaviour Agitation
Psychomotor

• Physical slowing of speech, movement and thinking, hypoactive behaviour References: ŶAmerican Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.
ŶPIECES Consultation Team (2005-2006). Putting the PIECES Together. Fifth Edition. ŶRegistered Nurses' Association of Ontario (2003). Screening for Delirium, Dementia and Depression in Older Adults. Toronto, Canada: Registered Nurses' Association of Ontario. ŶVancouver Island Health Authority (2006). The 3Ds. Comparison of Depression, Delirium, and Dementia Ontario Psychogeriatric Association (OPGA) (2005). Toronto Region Best Practice in LTC Initiative Basics of the 3Ds. Assessment Tool Reference Guide
Description of Tool
Refer to…
• To help identify individuals who may be Assessment Method suffering from delirium or an acute confusional (CAM) Instrument Delirium
• Useful for differentiating delirium and dementia • Acronym for finding the cause of delirium Geriatric Depression • May assist in supporting a diagnosis of Scale and Geriatric depression (an adjunct to clinical assessment) Depression Scale • Provides quantitative rating of depression (GDS –4 Short Form) Cornell Scale for • Used to assess for depression in dementia Depression
• Should have assessment information that suggests depression before using • If there are nervous problems or a depressed mood use the acronym SIG E CAPS (Sleep disturbance, loss of Interest, feelings of Guilt, low Energy, Concentration and cognitive difficulties, Appetite disturbance, Psychomotor changes, Suicidal ideation) to describe Suicide Risk in the • Helps identify suicidal risk in individuals with a Folstein Mini-Mental • Tend to be used together; screen for cognitive impairment which may suggest dementia or Clock Drawing Test • These screening tests do not provide diagnoses but rather should be viewed as part of the whole assessment picture • Assesses areas of cognitive function that assists to differentiate if an organic brain disorder may be present and to what degree • Clock: tests abstraction, attention, concentration and visuospatial constructional skills Mini-Cog Dementia • 3-minute cognitive screen developed in a purposively ethnolinguistically diverse sample • Detects clinically significant cognitive impairment as well as or better than the MMSE in multiethnic elderly individuals • Easier to administer to non-English speakers, and less biased by low education and literacy • Used to assess the frequency of manifestations Page 62 Agitation Inventory of agitated behaviour; specific forms of this scale offer the opportunity for care teams to rate the degree of disruptiveness the behaviours create DELIRIUM
RESOURCES
Delirium Definition
Delirium is a medical emergency which is characterized by an acute and fluctuating onset of confusion, disturbances in attention, disorganized thinking and/or decline in level of consciousness. Delirium cannot be accounted for by a preexisting dementia; however, can co-exist with dementia.
Predisposing Factors May Include:
• Infection
• Dehydration/Malnutrition • Alcohol/drug • Alcohol/drug surgery/anesthetic • Worsening of a chronic illness • Hypo or hyperglycemia • Constipation • Recent injury (recent fall) • Recent loss (family member, friend, pet) • Ill-fitting hearing aides or glasses Best Practice Recommendations addressed in this section
• Nurses should maintain a high index of suspicion for 3D's in the older adult. • Nurses should be aware of the differences in the clinical features of 3D's and use a structured assessment method to facilitate this process. • Nurses should objectively assess for cognitive changes by using one or more standardized tools in order to substantiate clinical observations. • In order to target the individual root causes of delirium, nurses working with other disciplines must select and record multi-component care strategies and implement them simultaneously. What you will find in this section
Delirium Assessment Tool
The assessment tools listed below are not inclusive but have been selected by the Toronto Best Practice Implementation Steering Committee to screen for delirium. The evidence does not support a specific tool and one tool is not considered superior to another. It is stressed that screening tools can augment, but not replace a comprehensive "head to toe" nursing assessment. Thus, it is recommended that LTC Homes should use the screening tools in combination with the "head to toe" nursing assessment on admission. Confusion Assessment Method (CAM) Instrument
I WATCH DEATH
Decision Tree: Strategies for Delirium
Interventions/Safety Considerations for Delirium
Confusion Assessment Method (CAM) Instrument
This screening tool assists with the identification of individuals who may be suffering from delirium or an acute confusional state. It is useful for differentiating delirium and dementia. It is important to note that CAM is not meant to be a diagnostic tool. The diagnosis of delirium requires: a comprehensive review of an individual's cognitive status and medical history, a physical examination, laboratory investigations, and a medication review. How to Administer the CAM?
Information is gathered from an interview with the person and from discussions with carers and family members, a review of the person's chart, as well as observations made by the interviewer; all of which is used to make a determination about each feature in the delirium algorithm. Please take note: it is not likely that the members of the care team will administer and score the CAM but rather use it as a framework for assessing the person. If in using the framework the care team identifies a number of indications of delirium (particularly the 4 listed in the algorithm below) they should maintain a high index of suspicion and raise the possibility of a delirium to the care team. Features of the CAM:
The CAM has two parts, a nine-item questionnaire and a diagnostic algorithm for delirium. (An algorithm is a step-by-step procedure for solving a problem.) • The questions focus on features of delirium, all of which are part of the DSM-IV-R diagnostic criteria for delirium. • It can be used as a rating scale, but also includes open-ended questions if the person administering the scale would like to collect more detailed clinical information. 2. Diagnostic Algorithm for Suspecting Delirium Diagnostic Algorithm for Suspecting Delirium
The algorithm includes 4 key features of delirium: 1. Acute onset and fluctuating course 2. Inattention 3. Disorganized 4. Altered level of consciousness (LOC) • Vigilant (hyperalert, overly sensitive to environmental stimuli, startled very easily) • Lethargic (drowsy, easily aroused) • Stupor (difficult to arouse) Delirium should be suspected if features (1) and (2) and either (3) or (4) are present. In such cases, further investigation is warranted to confirm a diagnosis of delirium. Remember: Delirium can be a life-threatening event.
Addressograph with Resident's Name: Confusion Assessment Method (CAM) Instrument
Original Version

Directions for the CAM: Answer the following questions.
Score 1 for answers in bold letters.
Questions Initial
Assessment
Acute Onset
1. Is there evidence of an acute
change in mental status from the person's baseline? Inattention
Ƒ Not present at any time during Ƒ Not present at any time during The questions listed under this topic are repeated for each topic where applicable. Ƒ Present at some time during
Ƒ Present at some time during
2. a) Did the person have difficulty interview, but in mild form
interview, but in mild form
focusing attention, for example, being easily distractible, or having Ƒ Present at some time during
Ƒ Present at some time during
difficulty keeping track of what was interview, in marked form
interview, in marked form
Ƒ Uncertain
Ƒ Uncertain
2. b) (If present or abnormal) Did this behaviour fluctuate during the interview, that is, tend to come and go or increase and decrease in Ƒ Not applicable Ƒ Not applicable severity? 2. c) (If present or abnormal) Description of behaviour: Description of behaviour: Please describe this behaviour Disorganized Thinking
3. Was the person's thinking
disorganized or incoherent, such as
rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject
to subject?
Altered Level of Consciousness
Ƒ Alert (normal) Ƒ Alert (normal) 4. Overall, how would you rate this person's level of consciousness? Ƒ Vigilant (hyperalert, overly
Ƒ Vigilant (hyperalert, overly
sensitive to environmental stimuli,
sensitive to environmental
startled very easily)
stimuli, startled very easily)
Ƒ Lethargic (drowsy, easily aroused)
Ƒ Lethargic (drowsy, easily
aroused)

Ƒ Stupor (difficult to arouse)
Ƒ Stupor (difficult to arouse)
Ƒ Coma (unarousable)
Ƒ Coma (unarousable)
Ƒ Uncertain
Ƒ Uncertain
Questions Initial
Assessment
Disorientation
5. Was the person disoriented at any
time during the interview, such as thinking that he or she was somewhere other than the hospital,
using the wrong bed, or misjudging
the time of day?
Memory Impairment
6. Did the person demonstrate any
memory problems during the interview, such as inability to remember events in the hospital or
difficulty remembering instructions?
Perceptual Disturbances
7. Did the person have any evidence of Ƒ Yes
perceptual disturbances, for example, hallucinations, illusions, or misinterpretations (such as thinking
something was moving when it was
not)?
Psychomotor Agitation
8. Part 1
At any time during the interview, did
the person have an unusually increased level of motor activity, such as restlessness, picking at
bedclothes, tapping fingers, or
making frequent sudden changes of
position?
Psychomotor Retardation
8. Part 2
At any time during the interview, did
the person have an unusually decreased level of motor activity, such as sluggishness, staring into
space, staying in one position for a
long time, or moving very slowly?
Altered Sleep-Wake Cycle
9. Did the person have evidence of
disturbance of the sleep-wake cycle, such as excessive daytime sleepiness with insomnia at night?
Score
Assessor

Scoring
To have a positive CAM result, the person must have: (1) Presence of acute onset and fluctuating course
AND (2) Inattention AND EITHER (3) Disorganized thinking OR (4) Altered level of consciousness
Addressograph with Resident's Name: Confusion Assessment Method (CAM) Instrument
Shortened Version Worksheet

Date Administered (d/m/y): FLUCTUATING
a) Is there evidence of an acute change in mental status from the person's baseline? b) Did the (abnormal) behaviour fluctuate during the day, that is, tend to come and go or increase and decrease in severity? INATTENTION

Did the person have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said? DISORGANIZED THINKING
Was the person's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? ALTERED LEVEL OF CONSCIOUSNESS
Overall, how would you rate the person's level of _Vigilant (hyper-alert) _Lethargic (drowsy, easily aroused) _Stupor (difficult to arouse) _Coma (can't arouse) Do any checks appear in this box? If all items in Box 1 are checked and at least one item in Box 2 is checked, a diagnosis of delirium is suggested. Adapted from: Inouye, SK, et al., (1990). Clarifying Confusion: The Confusion Assessment Method. A new method for detection of delirium. Annals of Internal Medicine, 113, 941-948.
I WATCH DEATH
Mnemonics may assist healthcare providers in systematically remembering common causes associated
with the potential for delirium in older adults. I WATCH DEATH is an acronym for finding the causes for
delirium. It is not meant to be a diagnostic tool.
How to Administer I WATCH DEATH?
Assess for each of the presenting symptoms by checking "yes" or "no". If answer is "yes" to any of the presenting symptoms, further investigation is warranted to confirm a diagnosis of delirium. Addressograph with Resident's Name: Assess for Causes of Delirium
Assessor: Date Administered (d/m/y): Mnemonic:
Presenting Symptoms
I WATCH DEATH
I I
nfections
Urinary tract infection (UTI) Other Infections: Specify: W Withdrawal
Sedatives-hypnotics A Acute metabolic
Electrolyte disturbance Acidosis/Alkalosis Hepatic/Renal failure T Toxins, drugs
Other drugs: Digoxin Cardiac medications Anticholinergics Psychotropics C CNS pathology
H Hypoxia
Pulmonary/Cardiac failure D Deficiencies
Thiamine (with alcohol abuse) E Endocrine
Hypo/Hyperglycemia Adrenal insufficiency Hyperparathyroid A Acute vascular
Hypertensive encephalophathy H Heavy Metals
Magnesium poisoning Decision Tree: Strategies for Delirium
Identify Risk
• Screening for 3D's/Clinical judgment
• Document: Mental status, ADL/IADLs • Identify changes from baseline
Maintain High Index of Suspicion
Ask & Observe
1. Altered mental status with abrupt onset?
2. Inattentive? Flight of ideas?
3. Disorganized thinking? Rambling, unclear?
4. Altered level of consciousness? No longer alert?
Maintain
Suspicion
1 & 2 and either 3 or 4
Prevention
Treatment
Strategies
• Target root causes Pharmacological
Multidisciplinary Awareness
Environmental Ɣ Know the person Physiological Stability
Lighting, noise, sleep? Ɣ Relate effectively O2 saturation, blood work,
Ɣ Recognize retained hydration, vision, hearing,
abilities nutrition, pain…….
Ɣ Manipulate the
environment
Behavioural Strategies Client Therapeutic Communication/
Ɣ Safety
Emotional Support
Ɣ Risk Ɣ Restraint reduction Education
Ɣ Older adults Ɣ Staff programs & documentation Ongoing monitoring, assessment & evaluation Adapted from: Registered Nurses' Association of Ontario (2004). Caregiving Strategies for Older Adults with Delirium, Dementia and Depression. Toronto, Canada: Registered Nurses' Association of Ontario. Interventions/Safety Considerations for Delirium
Category of Support
• Establish/maintain normal fluid and electrolyte balance. • Establish/maintain • Establish/maintain normal body temperature. • Establish/maintain normal sleep/wake patterns (treat with bright light for two hours in the early evening). • Establish/maintain normal elimination patterns. • Establish/maintain normal oxygenation (if residents experience low oxygen saturation treat with supplemental oxygen). • Establish/maintain normal blood glucose levels. • Establish/maintain normal blood pressure. • Minimize fatigue by planning care that allows for separate rest and activity • Increase activity and limit immobility. • Provide exercise to combat the effects of immobility and to "burn off" excess • Decrease caffeine intake to help reduce agitation and restlessness. discomfort/pain. • Promptly identify and treat infections. • Use short, simple sentences. • Speak slowly and clearly, pitching voice low to increase likelihood of being heard; do not act rushed, do not shout. • Identify self by name at each contact; call resident by his/her preferred • Repeat questions if needed, allowing adequate time for response. • Point to objects or demonstrate desired actions. • Tell residents what you want done – not what not to do. • Listen to what the resident says, observe behaviours and try to identify the message, emotion, or need that is being communicated. • Validation therapy: technique tries to find the reason behind the expressed • Resolution therapy: attempts to understand and acknowledge the confused resident's feelings. • Use non-verbal communication alone or in combination with verbal • Educate the resident (when not confused) and family. Environment
• Reality orientation: offer orienting information as a normal part of daily care • Repeat information as necessary for the confused person. • Provide orienting information and explain the situation, unfamiliar equipment (e.g., monitors, intravenous lines, oxygen delivery devices), the rules/regulations, plan for care, and the need for safety measures. • Remove unfamiliar equipment/devices as soon as possible. • Provide call bell and be sure it is within reach. The resident should understand its purpose and be able to use it. • Use calendar and clocks to help orient resident. • Limit possible misinterpretations or altered perceptions which may occur due to pictures, alarms, decorations, costumed figures, television, radio and call system. Work with resident to correctly interpret his/her environment. • Establish a consistent routine, use primary nursing and consistency in Category of Support
Environment
• Bring in items from the resident's home, allow the resident to wear his/her • Avoid room changes, especially at night. Put delirious, disruptive residents in a private room if at all possible. • Create an environment that is as "hazard free" as possible. • Provide adequate supervision of acutely confused/delirious residents. • Avoid physical restraint whenever possible, use a sitter or have a family member stay with the resident if safety is a concern. If restraints must be used, use the least restrictive of these. • Consider moving the resident closer to the nurses' station. • Environmental manipulations may be appropriate if many residents wander: wandering alarms, exit door alarms, or painting lines on floor in front of exits or rooms you do not want the resident to enter. Wandering can also be managed through "collusion", walking with resident, then you or other staff, "invite" him/her to return to ward/facility. • Have a plan to deal with disruptive behaviour; keep your hands in sight; avoid "threatening" gestures or movement; remove potentially harmful objects from resident, room, and the caregiver's person. Bear in mind that these episodes may not be remembered by residents. If they are remembered, often they are the cause of embarrassment. Sound and Light
• Keep the environment calm and quiet with adequate, but soft, indirect light and limit noise levels. • Provide glasses and hearing aides to maximize sensory perception. • Consider the use of night lights to combat nighttime confusion. • Use music which has an individual significance to the confused and agitated resident to prevent the increase in or decrease agitated behaviours. • Encourage residents to be involved in, and to control, as much of their care • Be sure to allow them to set their own limits, and do not force residents to do things they do not want to, as this is likely to cause disruptive behaviours. Reminiscing can also help increase self-esteem. Social Interaction
• Encourage family and friends to visit, but visits work best when scheduled, and numbers of visitors and lengths of visits should be limited so as not to overwhelm the resident. • Consider involving the resident in programming so as to decrease his/her social isolation (physiotherapy and occupational therapy may be potential options). Behavioural
• Changing staffing patterns or altering care routine (including amount/type of Management
• One to one supervision. • Pay attention to residents. • Talk with/counsel residents; give verbal reprimands. • Removal of resident from the situation; time out; seclusion/isolation. • Positive reinforcement of desired behaviours; removal of reinforcer of undesired behaviour. • Physical or chemical restraint as a last resort. Category of Support
Cognitive and
• Diversion can be used to distract the resident from the disruptive Attentional
behaviours that she/he is currently engaging in. Limitation
• Divide activities into small steps in order to simplify them and decrease likelihood of causing disruptive behaviours. • Determine what triggered or caused the disruptive behaviour, and try to prevent its occurrence. • In general, limit use of medications (to the extent possible) in residents with acute confusion and disruptive behaviours. • Regularly evaluate each medication used and consider discontinuing. If this is not possible, use the minimal number of medications in the lowest effective doses. • Monitor for intended and adverse effects of medications. • Treat pain in the delirious resident; however, be alert for narcotic induced confusion and disruptive behaviours. • Avoid medicating residents to control wandering, as medications are likely to make them drowsy and light-headed, increasing the risk for falls. • Be sure to monitor for side, untoward or paradoxical effects. Other Interventions
• Consult with a Nurse Specialist/Geriatrics or Psychiatry for severe disruptive behaviours, psychosis, or if symptoms do not resolve in 48 hours. • Provide reassurance to residents both during and after acute confusion/delirious episodes. • Acknowledge resident's feelings/fears. • Allow residents to engage in activities that limit anxiety. • Avoid demanding abstract thinking for delirious residents, keep tasks • Limit choices, and offer decision-making only when residents are capable of making these judgments. Adapted from: Rapp, C. G., & The Iowa Veterans Affairs Nursing Research Consortium (1998). Research-Based Protocol: Acute confusion/delirium. In M. G. Titler (Series Ed.). Series on Evidence-Based Practice for Older Adults (pp. 10-13). Iowa City, IA: The University of Iowa College of Nursing Gerontology Nursing Interventions Research Center, Research Dissemination Core. DEPRESSION
RESOURCES
Depression Definition
Depression is a term used when a cluster of depressive symptoms (as identified on the SIG E CAPS depression criteria) is present on most days, for most of the time, for at least 2 weeks and when the symptoms are of such intensity that they are out of the ordinary for that individual. Depression is a biologically based illness that affects a person's thoughts, feelings, behaviour, and even physical health. Predisposing Factors May Include:
Chronic or other medical conditions especially those that result in pain or loss of function, e.g., arthritis, CVA, CHF, etc. Exposure to drugs, e.g., hypnotics, analgesics and antihypertensives. • Psychological Unresolved conflicts, e.g., anger or guilt. Memory loss or dementia. Losses of family and friends (bereavement). Loss of job/income. Best Practice Recommendations addressed in this section
• Nurses should maintain a high index of suspicion for 3D's in the older adult. • Nurses should be aware of the differences in the clinical features of 3D's and use a structured assessment method to facilitate this process. • Nurses should objectively assess for cognitive changes by using one or more standardized tools in order to substantiate clinical observations. • Nurses must be aware of multi-component care strategies for depression: non-pharmacological interventions and pharmacological caregiving strategies. What you will find in this section
Depression Assessment Tools
The assessment tools listed below are not inclusive but have been selected by the Toronto Best
Practice Implementation Steering Committee to screen for depression. The evidence does not
support a specific tool and one tool is not considered superior to another. It is stressed that
screening tools can augment, but not replace a comprehensive "head to toe" nursing
assessment. Thus, it is recommended that LTC Homes should use the screening tools in
combination with the "head to toe" nursing assessment on admission.
Geriatric Depression Scale (GDS)
Geriatric Depression Scale – GDS-4: Short Form
Cornell Scale for Depression
SIG E CAPS
Suicide Risk in the Older Adult
Decision Tree: Strategies for Depression
Geriatric Depression Scale (GDS)
This screening tool may assist in supporting a diagnosis of depression. It should be used as an adjunct to clinical assessment. It provides quantitative rating of depression. The GDS is used for cognitively intact individuals and is not validated in dementia. The scale is designed as screening tool and is not diagnostic. How to Administer the GDS?
Place a check mark for every "yes" answer to the questions and then add the check mark to obtain a total number. Below is a glossary of the GDS Scorecard. Absence of significant depression Borderline depression Probable depression A score of > 5 requires further investigation to confirm diagnosis of depression. Is Depression Present?
Next Steps
• Low GDS and no clinical signs Possible
• High GDS, no clinical signs Further investigation required • Low GDS, with clinical signs • Intermediate GDS score with or without clinical signs • Other subjective or objective indicators of depression Probable
• High GDS with clinical signs Further investigation required Definite Yes
• Previous history of depression Further investigation required with current clinical signs present • Recent medical diagnosis of Addressograph with Resident's Name: Geriatric Depression Scale (GDS)
Assessor: Date Administered (d/m/y): _ Ask the following questions:

1. Do you feel pretty worthless the way you are now? 2. Do you often get bored? 3. Do you often feel helpless? 4. Are you basically satisfied with your life? 5. Do you prefer to stay at home rather than doing new things? 6. Are you in good spirits most of the time? 7. Are you afraid that something bad is going to happen to you? 8. Do you feel that your life is empty? 9. Do you feel happy most of the time? 10. Do you feel full of energy? 11. Do you think it is wonderful to be alive now? 12. Do you feel that your situation is hopeless? 13. Have you dropped many of your activities and interests? 14. Do you think that most people are better off than you are ? 15. Do you feel that you have more problems with your memory than most? Total Number of
Glossary: Geriatric Depression Scale Scorecard
4 or less: Indicates absence of 5-7: Indicates borderline More than 7: Indicates significant depression probable depression Is Depression Present?
No:

Low GDS and no clinical signs Possible: High GDS, no clinical signs
Low
Intermediate GDS score with or without clinical signs Other subjective or objective indicators of depression Probable:
High GDS with clinical signs Definite Yes:
Previous history of depression with current clinical signs present Recent medical diagnosis of depression Clinical Signs:
Adapted from DSM IV Diagnostic Criteria for Major Depressive Disorder Additional Comments: Overall impression or other related comments:
Geriatric Depression Scale – GDS-4: Short Form
This screening tool may assist in supporting a diagnosis of depression. It should be used as an adjunct to clinical assessment. It provides quantitative rating of depression. The GDS is used for cognitively intact individuals and is not validated in dementia. This short form GDS can be used as a quick screening tool and is not meant to be used for diagnostic purposes. How to Administer the GDS-4: Short Form?
Answer the 4 questions with either "yes" or "no". Score 1 for every answer in capitals. A score of 1 or more indicates a possible depression and further investigation is required to confirm the diagnosis of depression. Addressograph with Resident's Name: Geriatric Depression Scale – GDS-4: Short Form
Assessor: Date Administered (d/m/y): Ask the following 4 questions:
1. Are you basically satisfied with Ƒ Yes Ƒ NO
2. Do you feel that your life is empty? Ƒ YES Ƒ No
3. Are you afraid that something bad is going to happen to you? 4. Do you feel happy most of the time? Ƒ Yes Ƒ NO
Total Score
Answers in capitals score 1. For GDS-4 score of 1 or more indicates possible depression. Cornell Scale for Depression
This screening tool provides a quantitative rating of depression in individuals with or without dementia. The scale was designed to utilize information obtained from carers/family, as well as an interview with the person. Frequent coexistence of depression and dementia in older people suggested the need for a depression-rating instrument designed specifically for use in this group. The Cornell is found to be reliable, sensitive and valid in rating depression in a population of demented subjects with various degrees of depression. The scale is designed as screening tool and is not diagnostic. How to Administer the Cornell Scale for Depression?
Administration requires 2 separate interviews. The clinician/healthcare provider first interviews the person's carer and family: • During the carer and family interview, the clinician inquires about the signs and symptoms of depression as they appear on the scale. • Additional descriptions can be used to clarify the carer/family the meaning of an item. • The clinician assigns preliminary scores to each item of the scale on the basis of the carer's/family's report. Next, the clinician briefly examines the person using the Cornell scale items as a guide. • If there is disagreement between the clinician's impression and the carer's/family's report, the carer/family is interviewed again in order to clarify the source of discrepancy. • Finally, the clinician scores the Cornell scale based on his/her judgment formed during this Please note: Two items, "loss of interest" and "lack of energy" require both a disturbance occurring during the week prior to the interview and relatively acute changes in these areas occurring over less than one month. The Scale:
• 19 questions distributed within 5 major headings (mood-related signs, behavioural disturbance, physical signs, cyclic functions and ideational disturbance). • Each question is scored on a three-point scale: 0 1 = mild or intermittent n/a = unable to evaluate The item "suicide" is rated with a score of "1" if the person has passive suicidal ideation, e.g., feels like life is not worth living. • A score of "2" is given to subjects who have active suicidal wishes, or have made recent suicide • History of a suicide attempt in a subject with no passive or active suicidal ideation does not in itself justify a score. • The clinician is to mark an "n/a" when an item cannot be evaluated. Older persons often have disabilities or medical illnesses with symptoms and signs similar to those of depression. Scoring of the Cornell scale on such items as "multiple physical complaints", "appetite loss", "weight loss", "lack of energy" and possibly others may be confounded by disability or physical disorder. To minimize assignment of falsely high Cornell scale scores in disabled or medically ill individuals, raters are instructed to assign a score of "0" for symptoms and signs associated with these conditions. In many cases the relationship between symptomatology and physical disability or illness is obvious. In some individuals, however, the determination cannot be made reliably. There is a maximum score of 38. The ratings are based on behaviours observed or reported the previous week. The five categories (mood-related signs, behavioural disturbance, physical signs, cyclic functions, and ideational disturbance) provide a format to assist the interviewer in organizing his/her assessment interviews and observation. The total time for administration and rating of the Cornell Scale is approximately 30 minutes. How to interpret the results?
Caution must be used when interpreting the score. It is important for the clinician to note the exact responses. This will allow a more consistent interpretation of the scores in each area of the tool. Average Cornell Ratings
No psychiatric diagnosis Non-depressive psychiatric disorders Minor or probable major depressive disorder Definite major depressive disorder Decimal points found in ranges are due to mathematical act of averaging. Clinicians are not encouraged to assign partial scores during assessment. Addressograph with Resident's Name: Cornell Scale for Depression
Assessor: Date Administered (d/m/y): Mood-related Signs
Cyclic Functions
1. Anxiety……………………………
ation of mood symptoms, anxious expression, ruminations, worrying worse in the morning……………… _
13. Difficulty falling asleep sad expression, sad voice, tearfulness later than usual for resident…………
3. Lack of reactivity to pleasant events…
14. Multiple awakenings during sleep……. _
15. Early morning awakening easily annoyed, short tempered earlier than usual for this resident…… _
Behavioural Disturbance
Ideational Disturbance
5. Agitation………………………
restlessness, handwringing, hairpulling feels life is not worth living, has suicidal
wishes, or makes suicide attempt…. _
slow movements, slow speech, slow 17. Poor self-esteem self-blame, self-depreciation, feelings (score 0 if GI symptoms only)……
anticipation of the worst…………… _
8. Loss of interest less involved in usual activities (score only if change occurred acutely, 19. Mood-congruent delusions e.g., less than 1 month)…… delusions of poverty, illness, or loss… _
Physical Signs
Scoring System
Ratings should be based on symptoms and eating less than usual………… _
signs occurring during the week prior to interview. No score should be given if symptoms result from physical disability or (score 2 if greater than 5 lbs. in 1 month) 11. Lack of energy fatigues easily, unable to sustain 1 = mild or intermittent activities(score only if change occurred acutely, e.g., in less than 1 N/A = unable to evaluate month)……………………… _
SIG E CAPS
The acronym SIG E CAPS or a "prescription for energy capsules" can be used to screen for nervous problems or possible depressed mood. The scale is designed as screening tool and is not diagnostic. How to Administer the SIG E CAPS?
Assess for each of the presenting symptoms by checking "yes" or "no". Add the number of "yes" answers to obtain a total number. Interpretation of Scores:
If five symptoms are present, the person likely suffers from a major depressive episode which will likely require active treatment with antidepressants and other appropriate treatment, such as interventions, psychotherapy. Further investigation is required including referral to the appropriate interdisciplinary team member (e.g., attending physician) and services such as Geriatric Mental Health Outreach Team and Psychogeriatric Resource Consultant (PRC).
Addressograph with Resident's Name: SIG E CAPS
Initial Assessment Date:
Re-Assessment Date:
At least five (5) of the following symptoms* have been
present nearly every day, for most of the day, during
the same two-week period and represent a change
from previous functioning:
S – Sleep is disturbed.
I – Interest is decreased.
G – Guilt (feelings of guilt are common, having
regrets, etc.).
E – Energy is lower than usual.
C – Concentration is poor and memory problems
may be exacerbated. A – Appetite is disturbed, usually a loss of appetite
accompanied (or not) by weight loss. P – Psychomotor retardation or agitation (agitation
may be misconstrued as a result of anxiety only). S – Suicidal ideation, at least a passive wish to die,
is frequently present. Additional symptoms: At least one of the symptoms is either (1) Depressed Mood (2) Loss of interest in pleasure SIG E CAPS Score (Total number of "Yes" answers)
(Adapted from DSM-IV, American Psychiatric Association, 1994.) *Symptoms cause significant distress or impairment in daily activities, social life, or other important areas of functioning. *Symptoms are not due to the direct effects of a substance (e.g., drugs of abuse or medication) or a general medical condition. Suicide Risk in the Older Adult
The Suicide Risk in the Older Adult is a screening tool that can be used to assess for suicidal intent and behaviours, and risk factors. How to Administer the Suicide Risk Screening Tool?
Answer "yes" or "no" for every question in each of the 3 categories, suicidal intent, suicidal behaviour, and risk factors. Total the number of "yes" answers. Please take note: • Any concerns of suicidal risk, inform resident that you will be sharing your assessment with his/her Physician and healthcare team. • Document assessment, discuss with Attending Physician and team if medium to high risk and has Addressograph with Resident's Name: Suicide Risk in the Older Adult
Assess for:
Initial Assessment
Suicidal
Verbalizes suicidal thoughts (Flagging question: Do you
ever go to sleep and wish of
never waking up?)

Can outline a concrete realistic
plan
(Flagging question: Have you
ever thought of ending your
life? If so, what is your plan?

Physical ability to carry out threat Describes suicidal intent Methods are available Suicidal
Gives guarded answers to Behaviour questions
Increasing withdrawal Resolving depression Gives away possessions Drug/alcohol abuse Diverts interviewer off topic Depressed affect Sudden interest/disinterest in religion Put affairs in order Support systems: decreased or non-existent Decline in cognitive status History of suicide attempts or violence Family history of suicide Decline in physical status Recent loss or change in life Total number of "Yes" answers
Any concerns of suicidal risk, inform resident that you will be sharing your assessment with his/her
Physician and healthcare team.

Document assessment, discuss with Attending Physician and team if medium to high risk and has plan.
Decision Tree: Strategies for Depression
High Index of Suspicion
Rapid Screening:
1. Ask – Do you often feel sad or depressed?
2. Observe – For anhedonia (loss of interest in pleasurable things)
and lack of eye contact ssess for depre
tomatology & risk factors
1. Screen using SIG E CAPS (DSM IV Criteria) 2. Observe for depression related symptoms 3. Use other depression screens as appropriate (GDS, Cornell Scale for Ask about any previous history of depression Determine th
ure & severity
of the depression:
Mild Moderate Severe Severe Recurrent Without With Psychotic Psychotic Features Features Determine suicidal ideation or intent & urgency
Consultation/Referrals
Ɣ Specialized Geriatrics Prevention
Ɣ Geriatric Psychiatry, Ɣ Harm reduction Ɣ Least restraint use Ɣ Interdisciplinary Team Ɣ Tertiary Ɣ Prevent elder abuse
Non-Pharmacological Therapy
Ɣ Know the person Pharmacological
Ɣ Psychological therapies Ɣ Relate effectively
-cognitive-behavioural Ɣ Recognize retained -interpersonal/dynamic psychotherapy abilities Ɣ Counselling Ɣ Manipulate the -supportive listening environment -provide information Ɣ -stress management/exercise -balanced diet/sleep patterns -reducing drugs & alcohol -problem solving Ɣ Aromatherapy/Music/Art/Light/ Environment Client/Family/
Ɣ Electroconvulsive Therapy (ECT) Community Partnering
Adapted from: Registered Nurses' Association of Ontario (2004). Caregiving Strategies for Older Adults with Delirium, Dementia and Depression. Toronto, Canada: Registered Nurses' Association of Ontario.
DEMENTIA
Dementia Definition
Dementia is a gradual and progressive decline in mental processing ability that affects short-term memory, communication, language, judgment, reasoning, and abstract thinking. Dementia eventually affects long-term memory and the ability to perform familiar tasks. Sometimes there are changes in mood and behaviour. Predisposing Factors May Include:
• Memory impairment (impaired ability to learn new information or to recall previously learned
Apraxia (impaired ability to carry out motor activities despite intact motor function) Agnosia (failure to recognize or identify objects despite intact sensory function) Disturbance in executive functioning (e.g., planning, organizing, sequencing, abstracting) • Decline in social, occupational or day-to-day functioning Best Practice Recommendations addressed in this section
• Nurses should maintain a high index of suspicion for 3D's in the older adult. • Nurses should be aware of the differences in the clinical features of 3D's and use a structured assessment method to facilitate this process. • Nurses should objectively assess for cognitive changes by using one or more standardized tools in order to substantiate clinical observations. • Nurses should have knowledge of the most common presenting symptoms of: Alzheimer Disease, Vascular Dementia, Frontotemporal Lobe Dementia, Lewy Body Dementia and be aware that there are mixed dementias. • Nurses should know their clients, recognize their retained abilities, understand the impact of the environment, and relate effectively when tailoring and implementing their caregiving strategies. • Nurses caring for clients with dementia should be knowledgeable about non-pharmacological interventions for managing behaviour to promote physical and psychological well-being. • Nurses caring for clients with dementia should be knowledgeable about pharmacological interventions and should advocate for medications that have fewer side effects. What you will find in this section
Common Types of Dementia
Early recognition of dementia is essential since timely assessment and treatment are key to preventing excessive caregiver burden and improving the quality of life for persons with this condition. There are over 60 causes of dementia. The four most common types of dementia are Alzheimer Disease (60%), Vascular Dementia (15%), Frontotemporal Lobe Dementia (15%) and Lewy Body Dementia (20-25%). It is very important to distinguish the type of dementia in order to maximize functional capacity and independence. Care strategies should be tailored to the person's remaining abilities (which will vary depending on the type of dementia) rather than focusing only on their lost abilities. In so doing, nurses can minimize excess disability and promote well-being. Dementia Assessment Tools
The assessment tools listed below are not inclusive but have been selected by the Toronto Best Practice Implementation Steering Committee to screen for dementia. The evidence does not support a specific tool and one tool is not considered superior to another. It is stressed that screening tools can augment, but not replace a comprehensive "head to toe" nursing assessment. Thus, it is recommended that LTC Homes should use the screening tools in combination with the "head to toe" nursing assessment on admission. Folstein Mini Mental Status Exam (MMSE)
Clock Drawing Test (CDT)
Mini-Cog
Cohen-Mansfield Agitation Inventory (CMAI)
Decision Tree: Strategies for Dementia
Care Strategies for Dementia
Common Types of Dementia
Alzheimer's Disease (AD)
Diffuse Lewy Body
Vascular Dementia (VaD)
FrontoTemporal Dementia
Disease (DLBD)
Abrupt but may be insidious (small vessel disease) Gradually Progressive Step wise or gradual Gradually Progressive Symptoms
1. Functional decline Functional decline Cognitive problems depends on where the Personality change Plus, a triad of symptoms: Early neuropsychiatric • Lack of insight Signs of Parkinsonism Right Parietal lobe: denial, • Memory deficits loss of sense of time, loss Early loss of social graces • Inability to carry out Fluctuating cognitive of language, intonation Early signs of disinhibition purposeful movements impairment over weeks Frontal Lobe = impulsive, • Speech disturbance & months; also day-to- pseudobulbar, crying or • Impaired comprehension day and intraday laughing, disinhibited, • Inability to recognize (pronounced variations amotivated, patchy Emotional unconcern objects for what they are in attention and Somatic preoccupation Disturbance in planning, Focal neurologic signs Recurrent vivid visual Early lack of judgment problem solving, • Gait abnormalities Severe loss of abstract organizing, abstracting, • Weakness of extremity delusions or non-visual Personality & mood hallucinations may be Memory may improve with Poor verbal fluency symptoms: depression, Poor set shifting a history of falls or gait 2. Early speech problems difficulty, or sleep 3. Neurological: Late akinesia, rigidity Comments
Rule out Delirium – Rule out Delirium & 1. Rule out Delirium & Rule out Delirium & underlying treatable illness / drugs / alcohol 2. Memory problems maybe Memory problems maybe Rule out Depression maybe relatively mild or relatively mild or not relatively mild or not not present in early present in early stages.
present in early stages.
stages. High mini High Mini Mental Status High Mini Mental Status Visual hallucinations 3. High incidence of Prominent Behavioral and are colourful, complex depression associated with Personality changes early emotional incontinence in the course of the illness Neuroleptic sensitivity 4. Apathy can be a major Presents in relatively even with low doses younger people (usually Specific
Early / moderate stages: Cholinesterase inhibitors (CI) - Cholinesterase inhibitors Cholinesterase inhibitors - Monitor for safety issues Aricept, Reminyl, Exelon (CI) - Aricept, Reminyl, Aricept, Reminyl, Exelon because of poor judgment & problem solving ability Moderate / severe stages: Reduce vascular risk factors: NMDA receptor antagonist - Avoid neuroleptics weight, smoking, lower Serotinergic not cholinergic Ebixa (Memantine) cholesterol, alter lifestyle; deficit; therefore CI's not ?ASA as prophylaxis indicated.
SSRI are used for symptomatic *Risk factor treatment *Risk factor treatment Note: Mixed Dementia (AD and VaD) commonly co-exist. Two presentations: a) Clinical - gradual progression punctuated by episode(s) of
stepwise decline (TIA/CVA) usually with focal neurological symptoms/signs. (2) Radiological - gradual, slow progression without
stepwise
decline/neurological symptoms or signs but brain neuroimaging positive (CT/MRI).

*Reduce vascular risk factors: weight, atrial fib, high BP, DM, smoking, lower cholesterol, alter lifestyle, ECASA unless contraindicated
Reprinted with permission from the O 46 ntario Psychogeriatric Association (OPGA). To obtain copies of OPGA laminates, visit www.opga.on.ca.
Folstein Mini Mental Status Exam (MMSE)
Folstein MMSE is quick and easy test to administer and is considered reliable and valid as a cognitive screening tool for older persons. It measures the main areas of mental status or cognitive function: memory, orientation, language, attention, visuospatial, and constructional skills. It is to be used as a screening test for cognitive impairment and is the first line of mental assessment only. This screening tool should be used in conjunction with other assessments such as functional and physical examination. How to Administer the Folstein MMSE?
• Explain the nature of the Folstein MMSE and why you are using it; keep the explanations simple: "This is a general test of memory that will help identify problems you may be experiencing with your memory." • Obtain the person's permission to begin the test and provide reassurance by telling the person, "Some questions may be very simple and others more tricky. Try not to worry; if you do not know an answer, just try your best." • Ask each question up to three times; if no response is given, score 0. • Any incorrect answer is scored 0. Do not provide any hints, prompts, or cues. If a person asks, "Was that right" say, "You are doing fine," and move on to the next question. If you wish to examine an area further and provide prompts, note that on your worksheet. Interpretation of Scores:
• The entire score is out of 30. Alter the total score accordingly, if there are questions omitted (i.e., orientation to place may be altered if the individual is not familiar with the area; the sentence and diagram may be omitted if the individual is physically unable to attempt to answer). • The individual receives points for each correct answer as indicated on the tool. • The results will help the clinician determine whether or not there may be cognitive impairment. One must be careful to consider all reasons, i.e., education status, language and cultural background, hearing/vision/speech. • The Folstein MMSE should be used in conjunction with other assessments and is a screening tool only (not diagnostic). Normal cognitive functioning Please Note: There is more than one version of the MMSE; however, the committee has chosen the Folstein MMSE which is the most common tool. How to differentiate the 3D's using the Folstein MMSE?
Orientation Questions
• Delirium fluctuates; may not be orientated. • Depressed people are fully orientated; may say, "I'm not sure," initially and take longer to answer; however, typically will be correct. • People with dementia will not be fully orientated, likely wrong about season and year yet not be aware of this, or may look for external cues such as the date on a newspaper; may say things like "I don't pay attention to those things anymore." Recall Questions
• Delirium – fluctuations in attention, distractible, act startled, poor memory. • Depressed – may get obvious apathy, lack of concentration – "I don't know" answers. • Dementia – 0/3 recall; information is typically gone from memory in Alzheimer Disease; if the dementia is due to multiple infarcts, often the information can be retrieved with cueing; individuals try attending; often make an effort to conceal or deny. More likely misinformation that fits their reality. Three-stage Command
• Delirium – have trouble; can't remember or attend to instructions. • Depressed – can usually do this; may not have the energy. • Dementia – have trouble; can't remember all the instructions. Design Copy
• Delirium – cannot attend to task. • Depressed – no problems; may complain and say this is too hard or just refuses to try. • Dementia – cannot do; may separate two figures; draw only one, produce figures with too few sides, or neglect to close the figures; impacts on ability to drive car. Addressograph with Resident's Name: Folstein Mini Mental Status Exam (MMSE)
Assessor: Date Administered (d/m/y): _ Questions Point
Resident
What is the (year) (season) (month) (date) (day) Where are we? (country) (province) (city) (floor in building, room number) or (name of building, address) Registration Name 3 words (apple, table, penny). Ask the Resident to
repeat all three after you have said them. One point for each correct word. Then repeat them until he/she learns them. Count trials and record Attention &
Ask resident to spell "WORLD" forward and then backwards. Calculation
One point for each letter in the correct order for a total of 5. If language is a problem use serial 7's backwards (i.e.,100 take away 7 equals ?). Correct answers are: 93, 86, 79, 72, 65. One point for each correct answer. Ask for the 3 words (apple, table, penny). One point for each correct word. Language
Name: pencil, watch Repeat after me: "no ifs, ands, or buts" Follow a three-stage command: "Take the paper in your right/left hand (ask resident to use non-dominant hand), fold it in half, and put it on the floor". Read and obey the following: Close your eyes. (Show command on separate sheet of paper. Three repetitions allowed; score only if the resident actually closes his/her eyes in response to the command.) Write a sentence spontaneously. The sentence should have a noun and verb and make sense. Ignore spelling mistakes. (Provide separate sheet of paper.) Copy the design. (Show design on separate sheet of paper and ask Resident to copy. Allow multiple tries).
Total Score
Scoring:
25-30:
normal cognitive functioning
20-24: mild cognitive impairment
10-20: moderate cognitive impairment
< 10: severe cognitive impairment
CLOSE YOUR EYES
Write a sentence. Copy the picture. Clock Drawing Test (CDT)
CDT is easily administered, valid, and economical; it correlates with other clinical measures of dementia severity. This test is complementary to other tests that focus on memory/language and can be used in detection and diagnosis; monitoring a course of an illness; useful for education of family and others in terms of capacity of the person; can be administered to hearing impaired (with written instructions). It measures abstraction, attention, concentration, and visuospatial capabilities. It also measures impairment in geriatric depression (fronto-temporal dysfunction). CDT requires executive control and it therefore correlates with IADL. How to Administer the CDT?
• Provide the individual with a large pre-drawn circle on a plain piece of paper. • Ask the individual to "make the circle look like a clock". • If the individual does not understand the instructions, give more direction such as placing "numbers" on the circle to make it look like a clock. Be sure to note that you have given this exra prompt. • If the completed clock looks abnormal, ask the individual if the clock looks right to them. If they indicate that it does not, attempt to re-administer with another circle. Encourage the individual to take his/her time and try his/her best. • Ask the individual to "make the clock say 10 after 11". If further prompting is required, i.e., use of the word "hands"; note this on your worksheet. If the drawn clock is not drawn well enough to place a correct time on it, draw your own for the individual to use. Note: The request of "10 after 11" is important as this produces hands that are in both spheres, are asymmetrical, and it is not as common a time reference as for example, 5 o'clock. There are a variety of suggestions on applying a scoring system to the CDT. Such scoring procedures may be viewed as confusing and time-consuming. A brief description of the results provides consistent, understandable and meaningful information. Clock Drawing Test (CDT): Interpretation of Results
Significant impairment, perseverating, stimulus bound. Significant impairment: perseverating; dividing into pie-like shapes; individual knows that numbers belong on clock but gets side tracked by numbering sections. Severe to moderate impairment; perseverative with Difficult to assess degree of impairment numbering; individual knows numbers belong on based on clock alone; numbers may occur clock but is unable to space properly; seeks on either side and may suggest neglect. closure by numbering until clock is filled. Look for other indicators of neglect. It is important to ask the individual if he/she feels this clock is incorrect and in what way. An individual with a significant depression finds it The individual may be mild to moderately difficult to concentrate when completing the clock impaired; important to note that the and often misplaces the numbers. If asked, the individual attempted to use markers in person will admit that the numbers are not in the placing the numbers; the use of hands correct spaces and may even be able to self-correct. indicates that he/she is able to think in Could suggest neglect. an abstract fashion. This is a typical clock for mild to moderate This is a typical clock for mild impairment; it impairment; the individual is unable to think abstractly is important to ask the individual if he/she and place hands on the clock. feels the hands are in the correct places. The inability to place the hands in the correct place indicates difficulty in abstraction. How to differentiate the 3D's using CDT?
• Highly distractible, unable to sustain attention • High degree of variability in performance over time • Clock becomes more normal as person comes out of delirium • Important to administer test over time Depression
• Often requires encouragement to initiate and carry out the task but usually able to correctly place numbers on clock and set clock. Dementia and Neurological Illness
• Performance on clock test correlates with severity of dementia. • Those individuals who have had a stroke may show neglect i.e., clock done only on one half. • Individuals may do a clock with small numbers or number concentrated in one corner. • Person makes genuine attempt to complete test. • Performance deteriorates gradually with dementia progression; no acute fluctuations except for multi-infarct dementia. • Persons with dementia tend to produce clocks with: poor contour, omission of numbers numbers in the incorrect order failure to draw two hands poor placement of minute hand poor placement of centre writing minutes next to hour target number writing the time across clock face perseveration of numbers numbers outside clock drawing spokes of a wheel Addressograph with Resident's Name: Clock Drawing Test (CDT)
Assessor: Date Administered (d/m/y): _ Mini-Cog Dementia Screen
The Mini-Cog is a 3-minute cognitive screen. It was developed in a purposively ethnolinguistically diverse sample. It is a validated tool and it detects clinically significant cognitive impairment as well as or better than the MMSE in multiethnic elderly individuals. This tool is easier to administer to non-English speakers, and less biased by low education and literacy. How to Administer the Mini-Cog?
• Ensure the resident has his/her hearing aids, glasses before administering any cognitive screen. • Provide a quiet, undistracted environment if possible. • Introduce the Mini-Cog by a statement such as, "I am going to ask you a few questions just to see how clear your thinking is today." • Obtain the person's permission to begin the test (will need pen/pencil for clock drawing test). Features of the Mini-Cog:
The Mini-Cog combines a three-item word-learning and recall task (0-3 points; each correctly recalled word = 1 point), with a simple clock drawing task (abnormal clock = 0 points; normal clock = 2 points) used as distraction task before word recall. Scoring:
Mini-Cog total possible scores range from 0 to 5. 0 to 2 = high likelihood of cognitive impairment 3 to 5 = low likelihood of cognitive impairment. Addressograph with Resident's Name: Mini-Cog Dementia Screen
Date Administered (d/m/y): _ The Mini-Cog is a 3 question validated tool to screen for dementia. A. Immediate registration (3 words) _ _ B. Clock Drawing Test (CDT) [see attached] Ƒ Normal Ƒ Abnormal C. Recent recall (3 words) _ _ Reference: Borson, S., Scanlan, J., Brush, M. et al. (2000). The Mini-Cog: A Cognitive Vital Signs Measure for Dementia Screening in Multi-
Lingual Elderly. International Journal of Geriatric Psychiatry 15, 1021-1027
Scoring:
The Mini-Cog combines a three-item word-learning and recall task (0-3 points; each correctly recalled
word = 1 point), with a simple clock drawing task (abnormal clock = 0 points; normal clock = 2 points)
used as distraction task before word recall.
The CDT is considered normal if all numbers are present in the correct sequence and position and the hands readably display the requested time of ten past eleven. Results:
Mini-Cog total possible scores range from 0 to 5.
0 to 2 = high likelihood of cognitive impairment
3 to 5 = low likelihood of cognitive impairment.
Resident Score: _ /5
Cohen-Mansfield Agitation Inventory (CMAI)
CMAI is used to assess the frequency of manifestations of agitated behaviour in older persons ranging from vocal disruption to overt physical aggression. It can track the occurrence of behaviour of interest (target behaviour) as frequently as "several times an hour". It is a useful tool because it provides descriptive data so that clinical decisions are based on evidence, not impressions alone. It replaces opinion with measurable data by: • Establishing the occurrence of distinct behavioural entities • Establishing the frequency of the target behaviours • Categorizing behavioural events so the team is clear about those behaviours that represent RISKS and those behaviours that should be accommodated • Serving as a baseline measure to track change CMAI is used when: • there is a change of concern in the person's typical behaviour profile • attempting to evaluate the impact of a specific interventions on the behaviour profile • the clinical team needs an outcome measure to determine if the target behaviour has changed in How to Administer the CMAI?
• Complete the CMAI by summarizing data that is available in the behavioural monitoring records in the person's chart. • Education is required to be able to collect the data using information from direct care providers by interviewing them. The best clinical application is to have a discussion with a group of direct care providers using the tool as a focus. • If the data is to be used as an outcome it must truly reflect where the person is, behaviourally. Therefore, co-ordinate the completion of the CMAI using the following process: 1. Read the progress notes.
2. Analyze the person's observation record or ABC documentation. (Antecedent – What
happened just before behavioural problem? Behaviour – What did the person do?
Consequence – What happened immediately after the behaviour?)
3. Fill out the form as a "draft". 4. Discuss the frequency/disruptiveness categories with staff familiar with the person, coming to consensus about the responses. 5. Direct evening and night shift staff to complete the CMAI for their shift, using the steps 6. Complete the 30th item (other) if there is a distinct behavioural entity that the direct care providers agree is a challenge for them and that they need to monitor more closely. Principles to keep in mind:
• When interviewing direct care providers or the carer and family, they know more about the person than you do. • Completing the CMAI together will ensure that the data is the most accurate reflection of the person's behavioural profile as possible; explain this to the family/carer. • Reassure staff that assigning a "high" frequency score is not a personal criticism of the • Reassure staff that you are trying to get them to focus on a very specific time period; you require the most recent behavioural events rather than what happened six weeks ago. • Encourage staff to consult with other informants, if the carer and family are unsure about certain behaviour. Remember the goal is to achieve the most accurate reflection of the frequency at which these behaviours occurred. Interpretation of Results:
• Results can assist the team to estimate risk that a particular set of behaviours represents, as well as the resources needed to assist with management. SEVERITY or RISKS associated with the behavioural profile can be based on how many of the 29 behaviours are present (i.e., the person who displays "hitting, kicking, biting, pushing, throwing" at a level of "several times a day" represents a greater risk than the person who displays only "hitting" at a level of "less than once a week"). • Results can assist with the identification of criteria for transfer/discharge. • Results can assist with evaluating the impact of titrating psychopharmacological interventions up • Results should NEVER be considered in isolation of other data; use as a supportive piece to clinical observations. • Results are a method of quantifying behavioural data; results tell us something about the • Results can help focus on those behaviours that represent a RISK and those behaviours that can be accommodated. Addressograph with Resident's Name: Cohen-Mansfield Agitation Inventory (CMAI)
Assessor: Date Administered (d/m/y): Frequency
2 = Less than once a week 3 = Once or twice a week 4 = Several times a week 5 = Once or twice a day 6 = Several times a day 7 = Several times an hour 9 = Don't know Please read each of the 30 agitated behaviours, and circle the frequency and disruptiveness of each during the past two weeks. (Level of disruptiveness: How disturbing it is to staff, other residents, or family members. If disruptive to anyone, rate the highest it is for those for whom it disrupts). Frequency Disruptiveness
1. Pace, aimless wandering 2. Inappropriate dress, disrobing 3. Spitting (include at meals) 4. Cursing or verbal aggression 5. Constant unwarranted request attention for help 6. Repetitive sentences/questions 7. Hitting (including self) 9. Grabbing onto people 11. Throwing things 12. Strange noises (weird laughter or crying) 16. Trying to get to a different place (e.g., out of the room or building) 17. Intentional falling 20. Eating/drinking/inappropriate substances 21. Hurt self of others (with cigarette, hot water, etc.) 22. Handling things inappropriately 23. Hiding things 24. Hoarding things 25. Tearing things or destroying property 26. Performing repetitious mannerisms 27. Making verbal sexual advances 28. Making physical sexual advances 29. General restlessness 30. Other inappropriate behaviour. Specify: _ Cohen-Mansfield, 1986. All rights reserved. Reference: Cohen-Mansfield, J. (1986). Agitated behaviours in the elderly II: Preliminary results in the cognitively deteriorated. Journal of the American Geriatrics Society, 34(10), 722-727. Cohen-Mansfield, J., Marx, M. S., & Rosenthal, A. S. (1989). A description of agitation in a nursing home. Journal of Gerontology, 44, M77-M84. Decision Tree: Strategies for Dementia
Common Dementias
Alzheimer Disease Vascular Dementia Frontotemporal Lobe Lewy Body Dementia Ɣ Know the person Ɣ Relate effectively Ɣ Recognize retained abilities Ɣ Manipulate the Promote emotional Enhance ADL/IADL Enhance or stabilize Develop partnerships with Reduce caregiver stress Prevent or minimize dysfunctional behaviour Adapted from: Registered Nurses' Association of Ontario (2004). Caregiving Strategies for Older Adults with Delirium, Dementia and Depression. Toronto, Canada: Registered Nurses' Association of Ontario.
Care Strategies for Dementia
Early-Stage Manifestations and Behavioural Interventions
Manifestations Behavioural
• Impaired recall of recent • Use reminders (notes, single-day calendars, cues) • Talk with the resident about recent events • Avoid stressful situations especially complex tasks • Do not ask for more than the resident can do • Keep the environment, schedule, routine the same • Lowered tolerance of new • Have items in the same place and in view ideas and changes in routine • Anticipate what the resident is trying to say • Provide word or respond to thought/feeling • Be tolerant and respond like it is the first time stated or heard • Decreased judgment and • Assess safety of driving and other desired activities • Allow performance of skills as long as safe • Provide safe and secure walking area • Inconsistency tasks of daily living • Help to maintain consistency by keeping needed items in view and maintaining routines • Increasing tendency to • Keep items in the same place and in view • Find things and replace or hand to the resident without focusing on the forgetfulness • Narrowing of interest • Maintain familiar social, physical, mental, and work activities • Living in the past • Self-centred • Focus on the resident and listen restlessness or apathy • Allow pacing or sleeping • Preoccupation with physical • Assist in maintaining normal physical functions (basic and instrumental activities of daily living) Sparks, M. (2001). Assessment and management of Alzheimer's disease. Medscape [On-line] Available: http://www.medscape.com/viewarticle/408 II. Intermediate-Stage Manifestations and Environmental Interventions
Behavioural Interventions
• Place food where resident can see and reach it (meals, medications, people, • Hand medications to resident • Put things away as desired; do not expect resident to put them • Provide a chest of drawers for hoarding or rummaging • Difficulty with basic activities • Keep needed objects in sight/reach • Do for the resident what he or she cannot, but allow the resident to do as much as possible • Provide assistive equipment; shower stool, elevated seat • Close and perhaps lock doors on stairways and rooms that the resident should not access • Place cues to help recognize rooms or objects • Avoid physical and chemical restraints while providing areas for wandering and resting • Uncoordinated motor skills, • Have a non-shiny floors without contrasting colours or patterns • Provide soft environment • Repetition of words or • Provide environment where repetitive activities can occur safely • Reversed sleep-wake cycles • Provide activities in daytime • Provide room where the resident can safely be up alone for a • Put back to bed with usual bedtime routine • Loss of contact with reality; • Make available materials for activities that the resident enjoyed hallucinations, confusion • Keep picture albums with old pictures • Keep the resident's room location and layout unchanged • Remove confusing stimuli • Ignore hallucinations unless they are distressing to the resident; remain calm; act normally • Provide meaningful stimuli • Provide place for quiet time • Remove objects that could be damaging • Provide safe environment • Keep unsafe objects out of sight sensory-perceptual • Provide • Have non-shiny floors without contrasting colours or patterns Sparks, M. (2001). Assessment and management of Alzheimer's disease. Medscape [On-line] Available: http://www.medscape.com/viewarticle/408 EDUCATION
RESOURCES
Website List of Available Resources
The following resources are intended to assist in supporting education on delirium, depression and dementia. These are sample resources only, and are not intended to be a comprehensive listing. Websites
Alzheimer Knowledge Exchange Alzheimer's Research Exchange Alzheimer Society of Canada Alzheimer Society of Ontario (for a listing of Canadian Coalition for Seniors' Mental Health Canadian Mental Health Association Canadian Nurses Association (CNA) College of Nurses of Ontario (CNO) Continuing Gerontological Education Ontario Psychogeriatric Association (OPGA) Regional Geriatric Programs of Ontario Registered Nurses' Association of Ontario Seniors' Health and Research Transfer Network Toronto Dementia Network Vancouver Island Health Authority Yale-New Haven Hospital Teaching Resources for Families and Friends of Residents
Below are some teaching resources for families and friends of residents who may have delirium, depression, and/or dementia. These teaching resources are not intended to be a comprehensive listing and there may be others available that have not been included. For information on other teaching resources, visit the website of the organizations/networks as listed in the previous page. RNAO Health Education Fact Sheets
• Recognizing Delirium, Dementia and Depression • Caring for Persons with Delirium, Dementia and Depression The two health education fact sheets are available through the Registered Nurses' Association of Ontario. For more information, an order form or to download the health education fact sheets, visit www.rnao.org/bestpractices.
Vancouver Island Health Authority (VIHA)
• DVD on Delirium in the Older Person: A Medical Emergency • Teaching tools including pamphlet on delirium for families and healthcare To order the DVD, email MediaSales@viha.ca or visit www.viha.ca/ppo/learning, print the order form (PDF) and mail in. The teaching tools are available for free download from their website. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Borson, S., Scanlan, J., Brush, M. et al. (2000). The Mini-Cog: A Cognitive Vital Signs Measure for Dementia
Screening in Multi-Lingual Elderly. International Journal of Geriatric Psychiatry 15, 1021-1027.
Borson, S., Scanlan, J. M., Watanabe, J., Tu, S.-P. & Lessig, M. (2005). Simplifying detection of cognitive impairment: Comparison of the Mini-Cog and Mini-Mental State Examination in a multiethnic sample. Journal of the American Geriatrics Society, 53(5), 871-874. Canadian Coalition for Seniors' Mental Health (CCSMH) (2006). National Guidelines for Seniors' Mental Health: The Assessment and Treatment of Mental Health Issues in Long Term Care Homes (Focus on Mood and Behaviour Symptoms). Toronto, Canada: Canadian Coalition for Seniors' Mental Health. [On-line]. Available: www.ccsmh.ca Cohen-Mansfield, J. (1986). Agitated behaviours in the elderly II: Preliminary results in the cognitively deteriorated. Journal of the American Geriatrics Society, 34(10), 722-727. Cohen-Mansfield, J., Marx, M. S., & Rosenthal, A. S. (1989). A description of agitation in a nursing home. Journal of Gerontology, 44, M77-M84. Drance, E. (2005). Brief to the Senate Standing Committee on Social Affairs, Science and Technology. Vancouver, British Columbia, 2. Health Canada (1999). Canada's Seniors. Ottawa, Canada: Division of Health and Aging [On-line]. Available: http://www.phac-aspc.gc.ca/senors-aines/pubs/factoids/1999/pdf/entire_e.pdf Inouye, S. K., van Dyck, CH., Alessi, C. A., Balkin, S., Siegal, A. P., & Horowitz, R. I. (1990). Clarifying Confusion: The Confusion Assessment Method. A new method for detection of delirium. Annals of Internal Medicine, 113(12), 941-948 Ontario Psychogeriatric Association (OPGA) (2005). Basics of the 3D's. PIECES Consultation Team (2005-2006). Putting the PIECES Together. Fifth Edition. Rapp, C. G., & The Iowa Veterans Affairs Nursing Research Consortium (1998). Research-Based Protocol: Acute confusion/delirium. In M. G. Titler (Series Ed.). Series on Evidence-Based Practice for Older Adults (pp. 10-13). Iowa City, IA: The University of Iowa College of Nursing Gerontology Nursing Interventions Research Center, Research Dissemination Core. Registered Nurses' Association of Ontario (2004). Caregiving Strategies for Older Adults with Delirium, Dementia and Depression. Toronto, Canada: Registered Nurses' Association of Ontario. Registered Nurses' Association of Ontario (2003). Screening for Delirium, Dementia and Depression in Older Adults. Toronto, Canada: Registered Nurses' Association of Ontario. Rovner, B. W., German, P. S., Broadhead, J., Morriss, R. K., Brant, L. J., Blaustein, J. et al. (1990). The prevalence and management of dementia and other psychiatric disorders in nursing homes. International Psychogeriatric, 2(1),13-24.
Smith, M. (2004). Commitment to Care: A Plan for Long-Term Care in Ontario. Toronto, Canada: Ministry of Health and Long-Term Care [On-line]. Available: http://www.health.gov.on.ca/english/public/pub/ministry_reports/ltc_04/mohltc_report04.pdf Sparks, M. (2001). Assessment and management of Alzheimer's disease. Medscape [On-line] Available: http://www.medscape.com/viewarticle/408 Vancouver Island Health Authority (2006). The 3D's. Comparison of Depression, Delirium, and Dementia.

Source: http://www.opadd.on.ca/Local%20Projects/documents/LocalProject-Educ.Training-3Dsresourceguide.pdf

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Critical Reviews in Toxicology, 2010; 40(4): 287–304 Critical Reviews in Toxicology Pharmaceuticals in the aquatic environment: A critical review of the evidence for health effects in fish Jenna Corcoran1, Matthew J� Winter2, and Charles R� Tyler1 1Environmental and Molecular Fish Biology, School of Biosciences, The Hatherly Laboratories, University of Exeter, Exeter, Devon, UK, and 2AstraZeneca Safety, Health and Environment, Brixham Environmental Laboratory, Freshwater Quarry, Brixham, UK

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RN PRESCRIBING AND ORDERING DIAGNOSTIC TESTS: REQUIREMENTS AND STANDARDS This document has not been approved by CARNA Provincial Council, it is a draft only for review and not for use. Once this document has been finalized and approved by Provincial Council, it can be found on College and Association of Registered Nurses of Alberta 11620 – 168 Street Edmonton, AB T5M 4A6 Phone: