Implementing and sustaining evidence-based practices in long-term care.

Delirium, Dementia and Depression Responsive Behaviours

Click on the titles to display the resource.

  • 4AT Rapid Assessment Test for Delirium
    Show description [+]

    The 4AT is a validated rapid assessment test for delirium and cognitive impairment. It is widely used in routine clinical practice in the UK and internationally. It is free for download and use.

    Reference: MacLullich, A., Ryan, T. and Cash, H. (2014). 4AT Rapid Assessment Test for Delirium. Retrieved from http://www.the4at.com/

  • Abbey Pain Scale
    Show description [+]

    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.

    https://www.apsoc.org.au/PDF/Publications/Abbey_Pain_Scale.pdf

     

     

     

     

     

     

     

     

     

  • ABC (Antecedent, Behaviour, Consequences) Charting Template - RNAO Appendix L
    Show description [+]

    This template is helpful in identifying and altering the antecedent and consequences to change behaviour.

    Registered Nurses’ Association of Ontario. (2012). Appendix L of Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, Canada: Author.  (p. 113). Retrieved from https://rnao.ca/sites/rnao-ca/files/Promoting_Safety_-_Alternative_Approaches_to_the_Use_of_Restraints_0.pdf

    Source: Omelan, C. (2006). CME: Approach to Managing Behavioural Disturbances in Dementia. Canadian Family Physician, February, 52, p. 193 Reprinted with permission from the Canadian Family Physician

  • Attitudes, Skills, and Knowledge that are Beneficial for Communication in Dementia Care – RNAO
    Show description [+]

    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

  • Behavioural Supports Ontario - (DOS) Dementia Observation System©
    Show description [+]

    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.

    Behavioural Supports Ontario. (2019). Behavioural Supports Ontario - Dementia Observation System. Retrieved from https://brainxchange.ca/BSODOS

     

  • Behavioural Supports Ontario: Intervention Tool Kit - Central East LHIN
    Show description [+]

    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.

  • Comparison of the Clinical Features of Delirium, Dementia, and Depression – RNAO Appendix D
    Show description [+]

    This helpful table from Appendix D (page 127) of the BPG Delirium, Dementia and Depression in Older Adults: Assessment and Care (2016) helps to distinguish among delirium, dementia and depression where features are often similar or overlapping.

    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

  • Delirium Risk Factors and Interventions – RNAO Appendix G
    Show description [+]

    Appendix G from pages 133-134 of Delirium, Dementia and Depression in Older Adults: Assessment and Care (2016) identifies risk factors and related interventions for delirium.

    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

  • Flow Chart for Delirium, Dementia, and Depression – RNAO
    Show description [+]

    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

  • Geriatric Depression Scale (GDS) Long Form
    Show description [+]

    The Geriatric Depression Scale, is a screening tool used to assessment depression in older adults. It is available in both long form and short form versions and also in multiple languages. The link below is for the long form.

    Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 1983; 17:37-49

    Retrieved from: https://integrationacademy.ahrq.gov/sites/default/files/2020-07/Update%20Geriatric%20Depression%20Scale-30.pdf

     

     

  • Geriatric Depression Scale (GDS) Short Form
    Show description [+]

    The Geriatric Depression Scale, is a screening tool used to assessment depression in older adults. It is available in both long form and short form versions and also in multiple languages. The link below is for the short form.

    Reference: Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 1983; 17:37-49.

    Retrieved from:  https://integrationacademy.ahrq.gov/sites/default/files/2020-07/Update_Geriatric_Depression_Scale-15.pdf

     

     

  • Interventions for Depression – RNAO Table 5
    Show description [+]

    This table from page 76-77 of the Delirium, Dementia, Depression in Older Adults: Assessment and Care BPG (2016) reviews interventions for depression, including psychotherapy, psychological/social and antidepressants.

    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

  • Mini-Cog™ - Instructions for Administration and Scoring
    Show description [+]

    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

  • Montreal Cognitive Assessment (MoCA)©
    Show description [+]

    A useful tool for assessing early stage dementia.  For more information or feedback on MoCA© contact Dr Z. Nasreddine at info@mocatest.org.

    Nasreddine, Z.  (2003). Welcome to the Montreal Cognitive Assessment.   Quebec, QC, Canada: Center for Diagnosis & Research on Alzheimer’s disease.  Retrieved from www.mocatest.org.  Copyright Dr Z. Nasreddine 2003 to 2013 - The Montreal Cognitive Assessment - MoCA© - All rights reserved.

  • Non-pharmacological Approaches to Management of the Behavioural and Psychological Symptoms of
    Show description [+]

    This Table from page 61 of Delirium, Dementia and Depression in Older Adults: Assessment and Care (2016) describes non- pharmacological approaches to use to minimize behavioural and psychological symptoms of 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

  • Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC)
    Show description [+]

    PACSLAC is a tool to observe and assess both common and subtle pain behaviours. Copyright © Shannon Fuchs-Lacelle and Thomas Hadjistavropoulos. The PACSLAC may not be reproduced without permission. For permission to reproduce the PACSLAC, please contact the copyright holders (Thomas.Hadjistavropoulos@uregina.ca).

    Retrieved from: https://gerocentral.org/wp-content/uploads/2013/12/Pain-Assessment-Checklist-for-Seniors-with-Limited-Ability-to-Communicate-PASLAC.pdf

  • Pain Assessment in Advanced Dementia (PAINAD) Scale
    Show description [+]

    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.

     

  • RAI-MDS© and P.I.E.C.E.S.™ Integration Job Aid
    Show description [+]

    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

  • Risk Factors and Signs of Depression – RNAO Table 4
    Show description [+]

    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
    Show description [+]

    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).

     

     

     

  • Suggested Topics for Educational Programs for Nurses and Other Health-Care Providers – RNAO
    Show description [+]

    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

  • The Confusion Assessment Method (CAM)
    Show description [+]

    The Confusion Assessment Method (CAM) is a standardized evidence-based tool that enables non-psychiatrically trained clinicians to identify and recognize delirium quickly and accurately in both clinical and research settings. The CAM includes four features found to have the greatest ability to distinguish delirium from other types of cognitive impairment.

    https://geriatrictoolkit.missouri.edu/cog/Confusion-Assessment-Method-delirium.pdf

    The Hartford Institute for Geriatric Nursing, 2019. Donna McCabe, DNP, APRN-BC, GNP

    © 2003 Sharon K. Inouye, MD, MPH Inouye, S., van Dyck, C., Alessi, C., Balkin, S., Siegal, A. & Horwitz, R. (1990).

  • Types of Dementia – RNAO Appendix E
    Show description [+]

    Appendix E pages 128-130 of the BPG Delirium, Dementia and Depression in Older Adults: Assessment and Care (2016) identifies the major types of dementia and a description of each.

    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

  • Urinary Tract Infections and Dementia
    Show description [+]

    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.