Work Sheet
Gap Analysis: Screening for Delirium, Dementia and Depression in Older Adults
Revised Sept 2011
Work Sheet
Gap Analysis: Screening for Delirium, Dementia and Depression in Older Adults- Revised Sept 2011
MoHLTC
RNAO Best Practice Guideline
Recommendations
Notes
Priority
Yes
No
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.
1. Nurses should maintain a high index of
suspicion for delirium, dementia and
depression in the older adult.
2. Written strategies, including
techniques and interventions, to
prevent, minimize or respond to the
responsive behaviours.
3. Nurses must recognize that delirium,
dementia and depression present with
overlapping clinical features and may coexist in the older adult.
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
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.
3. Resident monitoring and internal
reporting protocols.
5. Nurses should objectively assess for
cognitive changes by using one or more
2
Work Sheet
Gap Analysis: Screening for Delirium, Dementia and Depression in Older Adults- Revised Sept 2011
MoHLTC
4. Protocols for the referral of
residents to specialized resources
where required
RNAO Best Practice Guideline
Recommendations
standardized tools in order to substantiate
clinical observations.
Notes
Priority
Yes
No
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.
(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;
1. Nurses should maintain a high index of
suspicion for delirium, dementia and
depression in the older adult.
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.
(b) based on the assessed
needs of residents with
responsive behaviours; and
3. Nurses must recognize that delirium,
dementia and depression present with
overlapping clinical features and may coexist in the older adult.
3
Work Sheet
Gap Analysis: Screening for Delirium, Dementia and Depression in Older Adults- Revised Sept 2011
MoHLTC
RNAO Best Practice Guideline
Recommendations
Notes
Priority
Yes
No
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.
6. Factors such as sensory impairment
and physical disability should be assessed
and considered in the selection of mental
status tests.
(c) co-ordinated and
implemented on an
interdisciplinary basis.
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.
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
4
Work Sheet
Gap Analysis: Screening for Delirium, Dementia and Depression in Older Adults- Revised Sept 2011
MoHLTC
RNAO Best Practice Guideline
Recommendations
model of care and practice setting.
Notes
Priority
Yes
No
(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 evidencebased 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
1. Nurses should maintain a high index of
suspicion for delirium, dementia and
depression in the older adult.
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.
3. Nurses must recognize that delirium,
dementia and depression present with
overlapping clinical features and may coexist in the older adult.
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.
5. Nurses should objectively assess for
cognitive changes by using one or more
standardized tools in order to substantiate
5
Work Sheet
Gap Analysis: Screening for Delirium, Dementia and Depression in Older Adults- Revised Sept 2011
MoHLTC
the changes made and the
date that those changes
were implemented.
RNAO Best Practice Guideline
Recommendations
clinical observations.
Notes
Priority
Yes
No
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.
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.
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:
6
Work Sheet
Gap Analysis: Screening for Delirium, Dementia and Depression in Older Adults- Revised Sept 2011
MoHLTC
RNAO Best Practice Guideline
Recommendations
 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.
 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
Notes
Priority
Yes
No
7
Work Sheet
Gap Analysis: Screening for Delirium, Dementia and Depression in Older Adults- Revised Sept 2011
MoHLTC
RNAO Best Practice Guideline
Recommendations
implementation of the best
practice guideline on
 “Screening for Delirium,
Dementia and Depression in
Older Adults”.
Notes
Priority
Yes
No
(4) The licensee shall ensure that,
for each resident demonstrating
responsive behaviours,
(a) the behavioural triggers for
the resident are identified,
where possible;
1. Nurses should maintain a high index of
suspicion for delirium, dementia and
depression in the older adult.
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.
(b) strategies are developed and
implemented to respond to
these behaviours, where
possible; and
6. Factors such as sensory impairment
and physical disability should be assessed
and considered in the selection of mental
status tests.
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,
8
Work Sheet
Gap Analysis: Screening for Delirium, Dementia and Depression in Older Adults- Revised Sept 2011
MoHLTC
(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.
RNAO Best Practice Guideline
Recommendations
should the nurse have a high index of
suspicion for delirium, an urgent medical
referral is recommended
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.
Notes
Priority
Yes
No
ALTERCATIONS AND OTHER
INTERACTIONS
Altercations and other interactions
between residents
54. Every licensee of a long-term care
home shall ensure that steps are taken
to minimize the risk of altercations and
potentially harmful interactions
between and among residents,
including,
(a) identifying factors, based
1. Nurses should maintain a high index of
on an interdisciplinary
suspicion for delirium, dementia and
assessment and on
depression in the older adult.
information provided to the
9
Work Sheet
Gap Analysis: Screening for Delirium, Dementia and Depression in Older Adults- Revised Sept 2011
MoHLTC
licensee or staff or through
observation, that could
potentially trigger such
altercations; and
RNAO Best Practice Guideline
Recommendations
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.
Notes
Priority
Yes
No
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.
5. Nurses should objectively assess for
cognitive changes by using one or more
standardized tools in order to substantiate
clinical observations.
6. Factors such as sensory impairment
and physical disability should be assessed
and considered in the selection of mental
status tests.
(b) identifying and
implementing interventions.
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.
10
Work Sheet
Gap Analysis: Screening for Delirium, Dementia and Depression in Older Adults- Revised Sept 2011
MoHLTC
RNAO Best Practice Guideline
Recommendations
Notes
Priority
Yes
No
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.
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.
Behaviours and altercations
55. Every licensee of a longterm care home shall ensure
that,
(a) procedures and
interventions are developed
and implemented to assist
residents and staff who are
at risk of harm or who are
1. Nurses should maintain a high index of
suspicion for delirium, dementia and
depression in the older adult.
2. Nurses should screen clients for
11
Work Sheet
Gap Analysis: Screening for Delirium, Dementia and Depression in Older Adults- Revised Sept 2011
MoHLTC
harmed as a result of a
resident’s behaviours,
including responsive
behaviours, and to
minimize the risk of
altercations and potentially
harmful interactions
between and among
residents; and
(b) all direct care staff are
advised at the beginning of
every shift of each resident
whose behaviours,
including responsive
behaviours, require
heightened monitoring
because those behaviours
pose a potential risk to the
resident or others.
RNAO Best Practice Guideline
Recommendations
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.
Notes
Priority
Yes
No
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.
5. Nurses should objectively assess for
cognitive changes by using one or more
standardized tools in order to substantiate
clinical observations.
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.
9. All entry-level nursing programs
should include specialized content about
12
Work Sheet
Gap Analysis: Screening for Delirium, Dementia and Depression in Older Adults- Revised Sept 2011
MoHLTC
RNAO Best Practice Guideline
Recommendations
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.
Notes
Priority
Yes
No
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.
13