• Registered Nurses Association of Ontario (RNAO). Screening for delirium, dementia and depression in older adults. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2003 Nov. 88 p. [53 references]

This is the current release of the guideline.

Delirium, dementia, and depression

Screening

Family Practice
Geriatrics
Internal Medicine
Nursing

Advanced Practice Nurses
Nurses

To improve the screening assessment of older adult clients for delirium, dementia, and depression

Older adults

1. Screen for changes in cognition, function, behavior, and/or mood
2. Assess differences between delirium, dementia, and depression
3. Assess cognitive changes using Mini-Mental Status Exam, Clock Drawing Test, Neecham Confusion Scale, Confusion Assessment Method Instrument (CAM), Establishing a Diagnosis of Depression in the Elderly, Cornell Scale for Depression, Geriatric Depression Scale, or Suicide Risk in the Older Adult
4. Referral, as necessary

• Quality of life
• Morbidity and mortality

Searches of Electronic Databases
Searches of Unpublished Data

Following the appraisal process, the guideline development panel identified seven guidelines and related updates to develop the recommendations cited in the guideline.

Weighting According to a Rating Scheme (Scheme Given)

Strength of Evidence A: Requires at least two randomized controlled trials as part of the body of literature of overall quality and consistency addressing the specific recommendations.

Strength of Evidence B: Requires availability of well conducted clinical studies, but no randomized controlled trials on the topic of recommendations.

Strength of Evidence C: Requires evidence from expert committee reports or opinions and/or clinical experience of respected authorities. Indicates absence of directly applicable studies of good quality.

Review of Published Meta-Analyses
Systematic Review

Not stated

Expert Consensus

In February of 2001, a panel of nurses and researchers with expertise in practice, education, and research related to gerontology and geriatric mental healthcare was convened under the auspices of the Registered Nurses Association of Ontario (RNAO). At the onset the panel discussed and came to a consensus on the scope of the best practice guideline.

A critique of systematic review articles and pertinent literature was conducted to update the existing guidelines. Through a process of evidence gathering, synthesis, and consensus, a draft set of recommendations was established.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Clinical Validation-Pilot Testing
External Peer Review
Internal Peer Review

This draft document was submitted to a set of external stakeholders for review and feedback. Stakeholders represented various healthcare professional groups, clients and families, as well as professional associations. External stakeholders were provided with specific questions for comment, as well as the opportunity to give overall feedback and general impressions. The results were compiled and reviewed by the development panel; discussion and consensus resulted in revisions to the draft document prior to pilot testing.

A pilot implementation practice setting was identified through a "Request for Proposal" (RFP) process. Practice settings in Ontario were asked to submit a proposal if they were interested in pilot testing the recommendations of the guideline. These proposals were then subjected to a review process, from which a successful practice setting was identified. A nine-month pilot implementation was undertaken to test and evaluate the recommendations in three hospitals in Toronto, Ontario. The development panel reconvened after the pilot implementation in order to review the experiences of the pilot sites, consider the evaluation results, and review any new literature published since the initial development phase. All these sources of information were used to update/revise the document prior to publication.

The levels of evidence supporting the recommendations (A-C) are defined at the end of the "Major Recommendations" field.

Practice Recommendations

Recommendation 1

Nurses should maintain a high index of suspicion for delirium, dementia, and depression in the older adult. (Strength of Evidence B)

Recommendation 2

Nurses should screen clients for changes in cognition, function, behaviour, and/or mood, based on their ongoing observations of the client and/or concerns expressed by the client, family, and/or interdisciplinary team, including other specialty physicians. (Strength of Evidence C)

Recommendation 3

Nurses must recognize that delirium, dementia, and depression present with overlapping clinical features and may coexist in the older adult. (Strength of Evidence B)

Recommendation 4

Nurses should be aware of the differences in the clinical features of delirium, dementia, and depression and use a structured assessment method to facilitate this process. (Strength of Evidence C)

Recommendation 5

Nurses should objectively assess for cognitive changes by using one or more standardized tools in order to substantiate clinical observations. (Strength of Evidence A)

Recommendation 6

Factors such as sensory impairment and physical disability should be assessed and considered in the selection of mental status tests. (Strength of Evidence B)

Recommendation 7

When the nurse determines the client is exhibiting features of delirium, dementia, and/or depression, 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. (Strength of Evidence C)

Recommendation 8

Nurses should screen for suicidal ideation and intent when a high index of suspicion for depression is present and seek an urgent medical referral. Further, should the nurse have a high index of suspicion for delirium, an urgent medical referral is recommended. (Strength of Evidence C)

Education Recommendations

Recommendation 9

All entry-level nursing programs should include specialized content about the older adult, such as normal aging, screening assessment, and caregiving strategies for delirium, dementia, and depression. Nursing students should be provided with opportunities to care for older adults. (Strength of Evidence C)

Recommendation 10

Organizations should consider screening assessments of the older adult’s mental health status as integral to nursing practice. Integration of a variety of professional development opportunities to support nurses in effectively developing skills in assessing the individual for delirium, dementia, and depression is recommended. These opportunities will vary depending on model of care and practice setting. (Strength of Evidence C)

Organization and Policy Recommendations

Recommendation 11 (Strength of Evidence C)

Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes:

• An assessment of organizational readiness and barriers to education
• Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process
• Dedication of a qualified individual to provide the support needed for the education and implementation process
• Ongoing opportunities for discussion and education to reinforce the importance of best practices
• Opportunities for reflection on personal and organizational experience in implementing guidelines

Refer to the "Description of the Implementation Strategy" field for more information.

Definitions:

Strength of Evidence A: Requires at least two randomized controlled trials as part of the body of literature of overall quality and consistency addressing the specific recommendations.

Strength of Evidence B: Requires availability of well conducted clinical studies, but no randomized controlled trials on the topic of recommendations.

Strength of Evidence C: Requires evidence from expert committee reports or opinions and/or clinical experience of respected authorities. Indicates absence of directly applicable studies of good quality.

An algorithm is provided in the original guideline document for the screening assessment for delirium, dementia, and depression.

The type of evidence is provided for each recommendation (see "Major Recommendations").

Enabling the nurse to recognize and provide timely screening for delirium, dementia, and depression may result in improved outcomes for the client.

Not stated

• Guidelines should not be applied in a "cookbook" fashion but used as a tool to assist in decision making for individualized client care, as well as ensuring that appropriate structures and supports are in place to provide the best possible care.
• These best practice guidelines are related only to nursing practice and not intended to take into account fiscal efficiencies. These guidelines are not binding for nurses, and their use should be flexible to accommodate client/family wishes and local circumstances. They neither constitute a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor Registered Nurses Association of Ontario (RNAO) give any guarantee as to the accuracy of the information contained in them, nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of this work. Any reference throughout the document to specific pharmaceutical products as examples does not imply endorsement of any of these products.

Best practice guidelines can only be successfully implemented if there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. In this light, the Registered Nurses Association of Ontario (RNAO), through a panel of nurses, researchers, and administrators, has developed a Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives, and consensus. The Toolkit is recommended for guiding the implementation of any clinical practice guideline in a healthcare organization.

The "Toolkit" provides step-by-step directions to individuals and groups involved in planning, coordinating, and facilitating guideline implementation. Specifically, the Toolkit addresses the following key steps in implementing a guideline:

1. Identifying a well-developed, evidence-based clinical practice guideline
2. Identification, assessment, and engagement of stakeholders
3. Assessment of environmental readiness for guideline implementation
4. Identifying and planning evidence-based implementation strategies
5. Planning and implementing an evaluation
6. Identifying and securing required resources for implementation and evaluation

Implementing practice guidelines that result in successful practice changes and positive clinical impact is a complex undertaking. The Toolkit is one key resource for managing this process.

Staying Healthy

Effectiveness
Patient-centeredness

• Registered Nurses Association of Ontario (RNAO). Screening for delirium, dementia and depression in older adults. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2003 Nov. 88 p. [53 references]

2003 Nov

Registered Nurses Association of Ontario - Professional Association

Funding was provided by the Ontario Ministry of Health and Long Term Care.

Not stated

Guideline Development Panel Members:

Nancy Bol, RN, BScN, MScN
Team Leader
Clinical Nurse Specialist
Geriatric Psychiatry
Regional Mental Healthcare London
St. Joseph’s Healthcare London
London, Ontario

Madeline Edwards, RN, BA(Sociology),
Certificate in Dispute Resolution
Canada Pension Plan Disability Tribunal
Toronto, Ontario

Marielle Heuvelmans, RN, HBScN, GNC(C)
Client Services Leader
Community Care Access Centre for Eastern Counties
Cornwall, Ontario

Nadine Janes, RN, BScN, MSc, ACNP, GNC(C)
Doctoral Student
Faculty of Nursing
University of Toronto
Toronto, Ontario

Linda Kessler, RN, BScN, MHSc
Administrative Director
Geriatric Psychiatry Service
PCCC-Mental Health Services
Kingston, Ontario

Elizabeth Phoenix, RN, MScN, CPMHN(C)
Nurse Practitioner/Clinical Nurse Specialist
Child and Adolescent Centre
Mental Healthcare Program
London, Ontario

Tiziana Rivera, RN, BScN, MSc, ACNP, GNC(C)
Clinical Nurse Specialist/Nurse Practitioner
Baycrest Centre for Geriatric Care
Toronto, Ontario

Dianne Rossy, RN, BN, MScN, GNC(C)
Advanced Practice Nurse, Geriatrics
The Ottawa Hospital & The Regional
Geriatric Assessment Program
Ottawa, Ontario

Josephine Santos, RN, MN
Facilitator, Project Coordinator
Nursing Best Practice Guidelines Project
Registered Nurses Association of Ontario
Toronto, Ontario

Kathleen Sayle, RPN
Registered Practical Nurses Association of Ontario
Supervisor, Occupational Health and Safety Programs
Centre for Addiction and Mental Health
Toronto, Ontario

Agnes Scott, RN, CPMHN(C), BSN, MA
Community Nurse Clinician
Whitby Mental Health Centre
Seniors Mental Health Program
Whitby, Ontario

Selinah Sogbein, RN, BScN, BA, MHA, MEd, CHE, CPMNH(C)
Assistant Administrator/Chief Nursing Officer
North Bay Psychiatric Hospital
North Bay, Ontario

Anne Stephens, RN, BScN, MEd, GNC(C)
Coordinator, Geriatric Outreach Services
North York General Hospital
Toronto, Ontario

Ann Tassonyi, RN, BScN
Psychogeriatric Resource Consultant
Alzheimer Society and Niagara Geriatric
Mental Health Outreach
St. Catharines, Ontario

Catherine Wallis-Smith, RN, CPMNH(C)
Supervisor of Nursing and Home Support
Paramed Home Healthcare
Instructor – Palliative Care, Georgian College
Barrie, Ontario

Kevin Woo, RN, BScN, MSc, PhD(cand), ACNP, GNC(C)
Nurse Practitioner/Clinical Nurse Specialist
Mount Sinai Hospital
Toronto, Ontario

Not stated

This is the current release of the guideline.

This NGC summary was completed by ECRI on September 20, 2004. The information was verified by the guideline developer on October 14, 2004.

With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced, and published in its entirety only, in any form, including in electronic form, for educational or non-commercial purposes, without requiring the consent or permission of the Registered Nurses Association of Ontario, provided that an appropriate credit or citation appears in the copied work as follows:

Registered Nurses Association of Ontario (2003). Screening for delirium, dementia and depression in older adults. Toronto, Canada: Registered Nurses Association of Ontario.