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Assessment Tool Reference Guide  

Tool	Description of Tool	Refer to…
Extensive Nursing Assessment/Mental Status Questions	Sample questions to be used for nurse-client interview.	Appendix D
Mini-Mental Status Exam (MMSE)	Most widely used mental status assessment; a good tool to substantiate clinical observations in nursing. Measures: memory, orientation, language, attention, visuospatial and constructional skills.	Appendix E
Clock Drawing Test	May assist in supporting a diagnosis of dementia or in indicating to a clinician areas of difficulty experienced by a client. Complements other tests which focus on memory/language.	Appendix F
Neecham Confusion Scale	Measures level of confusion in processing, behaviour and physiologic control.	Appendix G
Confusion Assessment Method (CAM) Instrument	To help identify individuals who may be suffering from delirium or an acute confusional state. Useful for differentiating delirium and dementia.	Appendix H
Establishing a Diagnosis of Depression in the Elderly [Sig: E Caps]	If there are nervous problems or a depressed mood, use the acronym Sig: E Caps to describe.	Appendix I
Cornell Scale for Depression	Provides a quantitative rating of depression in individuals with or without dementia. Utilizes information from the caregiver as well as the client.	Appendix J
Geriatric Depression Scale and Geriatric Depression Scale (GDS – 4 Short Form)	May assist in supporting a diagnosis of depression (an adjunct to clinical assessment). Provides a quantitative rating of depression.	Appendix K & L
Suicide Risk in the Older Adult	Helps identify suicidal risk in individuals with a depressed mood.	Appendix M

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Please refer to “Screening for Delirium, Dementia, and Depression” Best Practice Guideline for more details.

 

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