Geriatric Examination Tool Kit

Dementia, Delirium, & Depression Assessment

Cognitive Assessment

1. Mini-Cog Brief screening tool for cognitive impairment.

2. The Blessed Orientation-Memory-Concentration (BOMC) Test

3. Saint Louis University Mental status Examination (SLUMS)
Tariq SH, Tumosa N, Chibnall JT, Perry MH 3rd, Morley JE. (2006). Comparison of the Saint Louis University mental status examination and the mini-mental state examination for detecting dementia and mild neurocognitive disorder--a pilot study. Am J Geriatr Psychiatry. 14(11):900-10.

4. Mini Mental State Exam (MMSE) is not in the public domain.
Scoring: 25-30=Normal, 21-24=Mild Cognitive Impairment (MCI), 16-20=Moderate, <16=Severe

5. Montreal Cognitive Assessment (MoCA)  Free online with registration: Instructions, Test (English) 
Scoring: 26 -30=Normal, 19-25=Mild cognitive impairment (MCI), 11-21: Alzheimer’s Disease

6. Global Deterioration Scale (assessed by healthcare provider)


Delirum Screening

7. Delirium assessment: "CAM" Confusion Assessment Method (assessed by healthcare provider)

Training video for using the CAM - (watch up to 5'12")
Clinical Skills - Delirium Assessment. University of Dundee Medical School. Dundee Scotland. Accessed 8-5-2020. 


Pain Assessment in the presence of dementia

8. Pain Thermometer - self reporting scale
 Uses no words or numbers.
Note: this clinical method that has not been validated by research.

9. Pain Assessment in Advance Dementia (PAINAD) (assessed by healthcare provider)

10. Horgas (2008). Pain Assessment in People with Dementia.
Horgas A., Miller L. (2008). AJN 108(7), 63-70.


Depression

11. Two-Question Depression Screen  

  1. "During the past month have you often been bothered by feeling little interest or pleasure in doing things?"

  2. “During the past month have you often been bothered by feeling down, depressed, or hopeless?"

A positive resonse to both questions has a specificity of 57%

Whooley MA, Avins AL, Miranda J, Browner WS. (1997). Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med. 12(7):439-45.


12. Geriatric Depression Scale

  •  0-9: Normal
  •  10-19: Mild Depression
  •  20-30: Severe Depression

13. Groningen Meander Walking Test: A Dynamic Walking Test for Older Adults With Dementia.
Bossers WJR, van der Woude LHV, Boersma F, Scherder EJA, van Heuvelen MJG. (2014). The Groningen Meander Walking Test: A Dynamic Walking Test for Older Adults With Dementia. PHYS THER. 94(2):262-272.

 

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Prost E, Willis BW. (2020). Examination Tool Kit. University of Missouri,
School of Health Professions, Department of Physical Therapy

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Updated: Aug. 5, 2020