Gap Analysis
Screening for Delirium, Dementia and Depression
in Older Adults, Revised 2010
Work Sheet
This guideline can be downloaded for free at:
http://rnao.ca/bpg/guidelines/screening-delirium-dementia-and-depression-older-adult
The RNAO Toolkit: Implementation of Best Practice Guidelines, Second Edition is also available at:
http://rnao.ca/bpg/resources/toolkit-implementation-best-practice-guidelines-second-edition
What is a Gap Analysis?
Uses of a Gap Analysis
A process comparing your organization’s current
practice with evidence-based best practice
recommendations to determine:
 Existing practices and processes that are currently
implemented and supported by best practices. This
information is useful to reinforce practice strengths.
 Recommendations that are currently partially
implemented in practice. These would be good first
targets for change efforts.
 Recommendations that are not currently being met.
 Recommendations that are not applicable to your
practice setting.
 Contributes to annual evaluation by allowing you to
compare practice from year to year and choose
which areas to focus on changing within the year.
 Focuses on needed practice change which prevents
a total overhaul of practice and builds on
established practices and processes.
 Informs next steps such as development of
infrastructure to support implementation,
stakeholder engagement, identification of barriers
and facilitators, resource requirements, selection of
implementation strategies and evaluation
approaches.
 Leads to sustained practice change by informing
plans related to process, staff and organization and
reinforces current evidence based practices.
Conducting a Gap Analysis
Engage the team, and internal and external stakeholders as needed in gathering information for the gap analysis.
Collect information on:
 Current practice – is it known and is it consistent?
 Are there any barriers to implementation? These
(met, unmet, partially met)
may include staffing, skill mix, budget, workload
issues, etc.
 Partially met recommendations may only be
implemented in some parts of the home, or you
 What are the time frames in relation to specific
may feel it is only half done.
actions and people or departments who can
support the change effort?
 Are there some recommendations that must be
implemented before others?
 Are there links with other practices and programs in
the LTC home?
 Can any recommendations be implemented
quickly? These are easy wins and build confidence
 Are there existing resources and education that
in the change.
your LTC home can access?
 Are there recommendations based on higher levels
 Are there any must-do recommendations that are
of evidence than others?
crucial to resident and staff safety?
Next Steps
What does Strength of Evidence mean?
1. Celebrate the recommendations you are
meeting.
2. Prioritize the areas you want to work on. Start
with practice changes that can be made easily
or are crucial to resident and staff safety. Start
by reinforcing success and focusing on quick
wins.
3. These priority areas become the foundation for
planning your program or implementing
practice change.
4. For more information on taking your gap
analysis to the next level see the RNAO Toolkit:
Implementation of Best Practice Guidelines
(Second edition).
After each guideline recommendation you will notice a
‘strength of evidence’. Strength of evidence is a
ranking system used to describe the strength of results
measured in clinical trials and other types of research
studies.
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.
Long-Term Care Homes:
Contact your Long-Term Care Best Practice
Co-ordinator to assist you in completing a gap
analysis. Visit RNAO.ca/ltc.
Gap Analysis – Updated September 2013
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
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Gap Analysis Work Sheet - Screening for Delirium, Dementia and Depression
in Older Adults, Revised 2010
Date Completed:
Team Members participating in the Gap Analysis:






Unmet
Partially
Met
RNAO Best Practice Guideline
Recommendations
Met
Completion of this gap analysis allows for the annual comparison of your current practice to evidence-based practices
as regulated by the MOHLTC. See Appendix A for this and other regulations that apply to a responsive behaviour
program in your home.
Notes
(Examples of what to include: is this a priority to our home,
information on current practice, possible overlap with
other programs or partners)
Practice Recommendations
1. Nurses should maintain a high index of suspicion
for delirium, dementia and depression in the
older adult.
(Strength of Evidence = B)
2. Nurses 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)
3. Nurses must recognize that delirium, dementia
and depression present with overlapping clinical
features and may co-exist in the older adult.
(Strength of Evidence = B)
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)
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)
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)
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
Gap Analysis – Updated September 2013
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Unmet
Partially
Met
Met
Gap Analysis Work Sheet - Screening for Delirium, Dementia and Depression
in Older Adults, Revised 2010
Notes
RNAO Best Practice Guideline
(Examples of what to include: is this a priority to our home,
information on current practice, possible overlap with
Recommendations
other programs or partners)
multidisciplinary team, as indicated by screening
findings.
(Strength of Evidence = C)
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
referral is recommended.
(Strength of Evidence = C)
Education Recommendations
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)
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
11. 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 implementation.
 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.
Gap Analysis – Updated September 2013
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Unmet
Partially
Met
Met
Gap Analysis Work Sheet - Screening for Delirium, Dementia and Depression
in Older Adults, Revised 2010
Notes
RNAO Best Practice Guideline
(Examples of what to include: is this a priority to our home,
information on current practice, possible overlap with
Recommendations
other programs or partners)
 Ongoing opportunities for discussion and
education to reinforce the importance of best
practices.
 Opportunities for reflection on personal and
organizational experience in implementing
guidelines.
In this regard, RNAO (through a panel of nurses,
researchers and administrators) has developed
the “Toolkit: Implementation of clinical practice
guidelines”, based on available evidence,
theoretical perspectives and consensus. The
RNAO strongly recommends the use of this
Toolkit for guiding the implementation of the
best practice guideline on Screening for
Delirium, Dementia and Depression in Older
Adults.
(Strength of Evidence = C)
Gap Analysis – Updated September 2013
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Gap Analysis Work Sheet - Screening for Delirium, Dementia and Depression
in Older Adults, Revised 2010
Appendix A
Applicable Ministry of Health and Long-Term Care Regulations for Responsive Behaviours
53. (1) Every licensee of a long-term care home shall ensure that the following are developed to meet the
needs of residents with responsive behaviours:
1. Written approaches to care, including screening protocols, assessment, reassessment and identification
of behavioural triggers that may result in responsive behaviours, whether cognitive, physical,
emotional, social, environmental or other.
2. Written strategies, including techniques and interventions, to prevent, minimize or respond to the
responsive behaviours.
3. Resident monitoring and internal reporting protocols.
4. Protocols for the referral of residents to specialized resources where required. O. Reg. 79/10, s. 53 (1).
(2) The licensee shall ensure that, for all programs and services, the matters referred to in subsection (1)
are,
(a) integrated into the care that is provided to all residents;
(b) based on the assessed needs of residents with responsive behaviours; and
(c) co-ordinated and implemented on an interdisciplinary basis. O. Reg. 79/10, s. 53 (2).
(3) The licensee shall ensure that,
(a) the matters referred to in subsection (1) are developed and implemented in accordance with
evidence-based practices and, if there are none, in accordance with prevailing practices;
(b) at least annually, the matters referred to in subsection (1) are evaluated and updated in accordance
with evidence-based practices and, if there are none, in accordance with prevailing practices; and
(c) a written record is kept relating to each evaluation under clause (b) that includes the date of the
evaluation, the names of the persons who participated in the evaluation, a summary of the changes
made and the date that those changes were implemented. O. Reg. 79/10, s. 53 (3).
(4) The licensee shall ensure that, for each resident demonstrating responsive behaviours,
(a) the behavioural triggers for the resident are identified, where possible;
(b) strategies are developed and implemented to respond to these behaviours, where possible; and
(c) actions are taken to respond to the needs of the resident, including assessments, reassessments and
interventions and that the resident’s responses to interventions are documented. O. Reg. 79/10,
s. 53 (4).
Gap Analysis – Updated September 2013
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