Delirium, Dementia and Depression Responsive Behaviours

The case study and its accompanying discussion guide were developed for educational purposes in long-term care homes to promote use of the RNAO Delirium, Dementia, and Depression in Older Adults: Assessment and Care BPG. This resource provides the necessary instructions to hold a facilitated discussion with long-term care staff.  Overall goals of the case study and discussion guide are to:

• Actively engage participants in discussions about delirium, dementia, and depression
• Help long-term care staff identify the differences between delirium, dementia, and depression
• Help long-term care staff become familiar with key resources they can use at the point-of-care to support identification of delirium, dementia, and depression
• Reinforce best practices for the care of delirium, dementia, depression in older adults

Reference: Registered Nurses’ Association of Ontario. (2017). Delirium, Dementia, and Depression in Older Adults: Assessment and Care. Toronto, ON, Canada: Author. Retrieved from http://rnao.ca/bpg/guidelines/assessment-and-care-older-adults-delirium-dementia-and-depression

The Abbey Pain Scale is an instrument designed to assist in the assessment of pain in patients who are unable to clearly articulate their needs, for example, patients with dementia, cognition or communication issues. The scale does not differentiate between distress and pain, so measuring the effectiveness of pain-relieving interventions is essential.

Abbey, J; De Bellis, A; Piller, N; Esterman, A; Giles, L; Parker, D and Lowcay, B. Funded by the JH & JD Gunn Medical Research Foundation 1998 – 2002. This document may be reproduced with this acknowledgment retained.

Retrieved from: https://www1.health.gov.au/internet/publications/publishing.nsf/Content/triageqrg~triageqrg-pain~triageqrg-abbey

The ACE Website provides materials for public education on prevention of elder abuse. Materials include information on powers of attorney, consumer protection and legal issues affecting older persons.

Advocacy Centre for the Elderly (ACE) (2013) Retrieved from http://acelaw.ca

This Alzheimer Canada website section provides resources for health care professionals on the following topics: Ambiguous Grief and Loss, Pain, End of Life and Culture Change

Retrieved from http://www.alzheimer.ca/en/We-can-help/Resources/For-health-care-professionals

2017 Alzheimer Society of Canada. All rights reserved.

This table from Appendix K pages 152-153 of the BPG Delirium, Dementia and Depression in Older Adults: Assessment and Care (2016) helps us reflect on our own attitudes, skills and knowledge about dementia and provides tips for successful interpersonal skills with residents with dementia.

Registered Nurses’ Association of Ontario. (2016). Delirium, Dementia, and Depression in Older Adults: Assessment and Care. Toronto, ON, Canada: Author. Retrieved from http://rnao.ca/bpg/guidelines/assessment-and-care-older-adults-delirium-dementia-and-depression

The BSO-DOS^© is an observational tool that helps to identify patterns of behaviour for care planning purposes. It is based on the former DOS. Simple registration is required to access this free tool. A user guide and resource manual are available.

This intervention toolkit provides links to universally recognized behavioural assessment tools for common responsive behaviours. The toolkit describes possible behavioural causes and a range of strategies to help with care planning.

Reference:Central East Local Health Integration Network (LHIN) Behavioural Supports Ontario Education Committee (n.d.) Central East LHIN Behavioural Supports Ontario Intervention Tool Kit, retrieved from http://centraleast.behaviouralsupportsontario.ca/Uploads/ContentDocuments/Intervention%20Tool%20Kit_Version%201_May_2016.pdf  

Acknowledgements: This tool was created by the Central East Local Health Integration Network (LHIN) Behavioural Supports Ontario Education Committee. Acknowledgment to the Psychogeriatric Resource Consults of the Central East Region for developing this tool. Thank you to the Central East Long-Term Care Homes for contributing to the development of the tool.

Disclaimer: Permission to use, copy, modify, and distribute this material for educational, research, and not-for-profit purposes, without fee and without a signed licensing agreement, is hereby granted, provided that the above copyright notice, this paragraph and the following paragraphs appear in all copies, modifications, and distributions. Contact Terry Donaghue, Technology Transfer & Industrial Liaison, Mount Sinai Hospital, & The Samuel Lunenfeld Research Institute, 600 University Avenue, Toronto, ON Canada M5G 1X5, Tel. (416) 586-8225, Fax (416) 586-3110, E-mail: donaghue@mshri.on.ca for commercial licensing opportunities.

Canadian Dementia Resource and Knowledge Exchange (CDRAKE) and Alzheimer Knowledge Exchange (AKE) have amalgamated to create this new hub of dementia resources. Contained within are links to Behaviour Support Ontario (BSO), Psychogeriatric Resource Consultants (PRC) and many resources pertinent to dementia and responsive behaviours.

Confusion Assessment Method (CAM) helps identify individuals who may be suffering from delirium or an acute confusional state and is useful for distinguishing between delirium and dementia. There are choices such as the long or short version CAM or the 3D CAM.

Reference: Hospital Elder Life Program (2003). Confusion Assessment Method. Retrieved from http://www.hospitalelderlifeprogram.org/delirium-instruments/

This conversation sheet from Alzheimer Canada informs how dementia can affect intimacy and sexuality. Strategies are provided for caregivers. There is also a section to support LGBTQ persons with dementia.

The Alzheimer Society is Canada’s leading health charity for people living with Alzheimer’s disease and other dementias. For more information visit the home page www.alzheimer.ca  

Indigenous Cognitive and Aging Awareness Research Exchange (I-CAARE) offers a number of factsheets, a health wheel and pathway for persons with dementia and their caregivers. The indigenous perspective may provide added support and comfort to families as they journey through dementia.

Reference: Indigenous Cognitive and Aging Awareness Research Exchange (2023). Dementia Factsheets. Retrieved from: https://www.i-caare.ca/factsheets 

©  2023 ICARE

Les présentes lignes directrices sur les pratiques exemplaires, Développement et maintien des soins de santé interprofessionnels : optimisation des résultats pour le patient/client, l’organisme et le système sont conçues pour favoriser des milieux de travail sains. Les présentes lignes directrices déterminent les pratiques exemplaires pour faciliter, améliorer et maintenir le travail d’équipe ainsi que la collaboration interprofessionnelle, et pour accroître les résultats positifs pour les patients/clients, les systèmes et les organisations.

Ce travail est financé par le Ministère de la Santé et des Soins de longue durée d'Ontario.

This resource from pages 94-98 of Delirium, Dementia and Depression in Older Adults: Assessment and Care (2016) includes structure, process and outcome indicators helpful in evaluating the changes made by an organization.

Registered Nurses’ Association of Ontario. (2016). Delirium, Dementia, and Depression in Older Adults: Assessment and Care. Toronto, ON, Canada: Author. Retrieved from http://rnao.ca/bpg/guidelines/assessment-and-care-older-adults-delirium-dementia-and-depression

This flow chart from page 33 of the BPG Delirium, Dementia and Depression in Older Adults: Assessment and Care (2016) provides a concise and systematic overview of the best practice recommendations.

Registered Nurses’ Association of Ontario. (2016). Delirium, Dementia, and Depression in Older Adults: Assessment and Care. Toronto, ON, Canada: Author. Retrieved from http://rnao.ca/bpg/guidelines/assessment-and-care-older-adults-delirium-dementia-and-depression

The GDS is a screening tool to facilitate the assessment of depression in older adults. It is available in both long form and short form versions and also in multiple languages.

Reference: Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., Adey, M., & Leirer, V. O. (1983). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17(1), 37–49. Retrieved from https://web.stanford.edu/~yesavage/GDS.html

This e-resource offered by Baycrest provides six sections of learning including understanding depression, signs and symptoms, self-check, causes, types and treatments for late-life depression.

Reference: Baycrest Health Sciences (2016) Late-Life Depression. Retrieved from http://www.baycrest.org/educate/mental-health/depression/

© 2016 BAYCREST HEALTH SCIENCES - ALL RIGHTS RESERVED. UNAUTHORIZED COPYING, REPRODUCTION, REPUBLISHING, UPLOADING, DOWNLOADING, POSTING, TRANSMITTING OR DUPLICATING ANY OF THE MATERIAL FOUND ON THIS WEBSITE IS PROHIBITED. Your use of this site constitutes your agreement to abide by these Terms of Use. Baycrest reserves the right, in their sole discretion, to modify, alter or otherwise update these Terms of Use at any time and you agree to be bound by such modifications, alterations or updates. You agree to review these Terms of Use on an ongoing basis. Baycrest hereby grants you a personal, non-exclusive, non-assignable and non-transferable license to use and display, one copy of any Material and/or software that you may download from this site, including, but not limited to, any files, codes, audio or images incorporated in or generated by the software (collectively called the “Downloaded Material”) provided, however, that you must maintain all copyright and other notices contained in such Downloaded Material. You acknowledge and agree that you may not sublicense, assign or otherwise transfer this license or the Downloaded Material and that no title to the Downloaded Material has been or will be transferred to you from Baycrest or anyone else. You also agree that you will not alter, disassemble, decompile, reverse engineer or otherwise modify the Downloaded Material.

The Mini-Cog is a brief screening instrument to determine memory recall and clock drawing ability. A positive screen would suggest more in-depth assessment for cognitive impairment. Mini-Cog instrument, instructions and scoring are provided.

Reference: Borson, S. (n.d.). Mini-Co. Retrieved from https://mini-cog.com/

Mini-Cog™ © S. Borson. All rights reserved. Reprinted with permission of the author solely for clinical and educational purposes. May not be modified or used for commercial, marketing, or research purposes without permission of the author (soob@uw.edu). v. 01.19.16

Music and Memory looks at how music can enrich the lives of long-term care residents with cognitive impairment.

Reference: Blanchard, Laurie (2016). Music and Memory. Retrieved from http://libguides.lib.umanitoba.ca/ld.php?content_id=25047510

Neuropsychiatric Inventory (NPI) is used to assess behavioural and psychological symptoms in clients with dementia. It evaluates the frequency and severity of the following symptoms: delusion, hallucinations, agitation, depression/dysphoria, anxiety, euphoria/jubilation, and apathy/indifference, disinhibition, irritability/lability, motor behaviour without a purpose, sleep alteration, and eating disorder. It is used to assess behavioural and psychological symptoms in patients

Reference: Wood S, Cummings JL, Hsu M-A, Barclay T, Wheatley MV, Yarema KT, Schnelle JF. The use of the Neuropsychiatric Inventory in nursing home residents, characterization and measurement. Am J Geriatr Psychiatry 2000; 8: 75-83. http://www.dementia-assessment.com.au/behavioural/NPI.pdf

The Office of the Public Guardian and Trustee (“OPGT”) delivers a unique and diverse range of services that safeguard the legal, personal and financial interests of certain private individuals and estates. Services are provided by multi-disciplinary teams of dedicated staff with experience in the health care, social work and financial planning fields. They receive professional support from lawyers, accountants and investigators. A brief description of many of the services offered by the OPGT is set out in the website.

Reference: Office of the Public Guardian and Trustee (OPGT)

Website: https://www.attorneygeneral.jus.gov.on.ca/english/family/pgt/overview.php

This website provides information and resources about the P.I.E.C.E.S.™ program. "Putting the P.I.E.C.E.S.™ Together" represents Physical, Intellectual, Emotional, Capabilities, Environment, Social, and are the cornerstones of the philosophy and care of the P.I.E.C.E.S.™ approach.

This resource from Interior Health, is a pain assessment tool useful for scoring pain levels of people with dementia who are unable to verbally express their pain. It focuses on assessing behaviours and provides a score rating of mild, moderate or severe pain levels.

Retrieved from: https://www.interiorhealth.ca/sites/default/files/PDFS/810310-pain-assessment-advance-dementia-scale.pdf

Warden, V., Hurley, A. & Volicer. L. (2003). Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. JAMDA, 4(1), 9 -15. Horgas, A., & Miller, L. (2008). Pain assessment in people with dementia. American Journal of Nursing, 108(7), 62-70.

Partnerships in Dementia Care Alliance (PiDC) helps to change culture in long-term care and community settings to enhance dementia care. Examples of culture change in LTC homes is included.

Reference: Partnerships in Dementia Care Alliance Website: https://uwaterloo.ca/partnerships-in-dementia-care/

The provincial RAI-MDS© and P.I.E.C.E.S.™ Integration Working Group have developed a Job Aid that allows for the streamlining of the RAI assessment and the P.I.E.C.E.S. 3-Question Assessment and Care Planning Framework.

Retrieved from: http://piecescanada.com/index.php?option=com_content&view=article&id=27&Itemid=30

This table from page 71 of the Delirium, Dementia, and Depression in Older Adults: Assessment and Care BPG (2016) looks at predisposing and precipitating risk factors as well as signs of depression.

Registered Nurses’ Association of Ontario. (2016). Delirium, Dementia, and Depression in Older Adults: Assessment and Care. Toronto, ON, Canada: Author. Retrieved from http://rnao.ca/bpg/guidelines/assessment-and-care-older-adults-delirium-dementia-and-depression

SIGECAPS is a mnemonic used to recall the most frequent symptoms of depression (prescription for energy capsules).

Reference: adapted from "The patient who is depressed" in Psychiatry in Primary Care by Raymond W. Lam, (CAMH, 2019).

Cette affiche du Regional Geriatric Program de Toronto nous donne 6 stratégies pour prévenir et soutener le délire.

© 2019 Regional Geriatric Program of Toronto. All Rights Reserved.

This table from pages 83-84 of the Delirium, Dementia, and Depression in Older Adults: Assessment and Care BPG (2016) informs nurse educators of relevant content for designing education sessions for those caring for clients with delirium, dementia and depression.

Registered Nurses’ Association of Ontario. (2016). Delirium, Dementia, and Depression in Older Adults: Assessment and Care. Toronto, ON, Canada: Author. Retrieved from http://rnao.ca/bpg/guidelines/assessment-and-care-older-adults-delirium-dementia-and-depression

This site from Capital District health Authority, Halifax, Nova Scotia includes a vignette showing a daughter recognizing that her mother's behaviour has changed suddenly and therefore is not just related to her dementia. Delirium is described in the video and the site includes other information and resources for delirium.

Reference: This is not My Mom Website: http://thisisnotmymom.ca/

U-FIRST! Is a proven and effective approach to working with people with dementia. Through dialogue and a case-based approach, learners will have more confidence in working with people with responsive behaviours. Training is especially designed for people working in community care, acute care and long-term care. For more information visit www.u-first.ca.  Permission to post obtained from Cathy Conway.

This resource highlights a treatment plan for an elderly person with a diagnosis of memory impairment who develops a urinary tract infection that results in delirium. 

© 2022 Alzheimer's Society.