Practice Recommendations

Recommendations Related to Delirium, Dementia, and Depression

1.0 General Recommendations

Recommendation 1.1:

Establish therapeutic relationships and provide culturally sensitive person- and family-centred care when caring for and providing education to people with delirium, dementia, and depression and their families and care partners.

Ia & V

Recommendation 1.2:

Identify and differentiate among signs and symptoms of delirium, dementia, and/or depression during assessments, observations, and interactions with older persons, paying close attention to concerns about changes expressed by the person, his/her family/care partners, and the interprofessional team.

V

Recommendation 1.3:

Refer older adults suspected of delirium, dementia, and/or depression to the appropriate clinicians, teams, or services for further assessment, diagnosis, and/or follow-up care.

Ia

Recommendation 1.4a:

Assess the person’s ability to understand and appreciate information relevant to making decisions and, if concerns arise regarding the person’s mental capacity, collaborate with other members of the health-care team as necessary.

Recommendation 1.4b:

Support the older person’s ability to make decisions in full or in part. If the older person is incapable of making certain decisions, engage the appropriate substitute decision-maker in decision-making, consent, and care planning.

V

Recommendation 1.5:

Exercise caution in prescribing and administering medication to older adults (within the health-care provider's scope of practice), and diligently monitor and document medication use and effects, paying particular attention to medications with increased risk for older adults and polypharmacy.

Ia

Recommendation 1.6:

Use principles of least restraint/restraint as a last resort when caring for older adults.

V

Recommendations Related to Delirium

2.0

Assessment

Recommendation 2.1:
Assess older adults for delirium risk factors on initial contact and if there is a change in the person’s condition.

Ia & V

3.0

Planning

Recommendation 3.1:
Develop a tailored, non-pharmacological, multi-component delirium prevention plan for persons at risk for delirium in collaboration with the person, his/her family/care partners, and the interprofessional team.

Ia

4.0

Implementation

Recommendation 4.1:
Implement the delirium prevention plan in collaboration with the person, his/her family/care partners, and the interprofessional team.

Ia

Recommendation 4.2:

Use clinical assessments and validated tools to assess older adults at risk for delirium at least daily (where appropriate) and whenever changes in the person’s cognitive function, perception, physical function, or social behaviour are observed or reported.

1a & V

Recommendation 4.3:

Continue to employ prevention strategies when caring for older adults at risk for delirium who have not been identified as having delirium.

1a & V

Recommendation 4.4:
For older adults whose assessments indicate delirium, identify the underlying causes and contributing factors using clinical assessments and collaboration with the interprofessional team.

Ia

Recommendation 4.5:
Implement tailored, multi-component interventions to actively manage the person’s delirium in collaboration with the person, the person’s family/care partners, and the interprofessional team.

These interventions should include:

• treatment of the underlying causes (level of evidence = Ia),
• non-pharmacological interventions (level of evidence = V), and
• appropriate use of medications to alleviate the symptoms of delirium and/or manage pain (level of evidence = Ia).

Ia & V

Recommendation 4.6:
Educate persons who are at risk for or are experiencing delirium and their families/care partners about delirium prevention and care.

V

5.0.0Evaluation

Recommendation 5.1:
Monitor older adults who are experiencing delirium for changes in symptoms at least daily using clinical assessments/observations and validated tools, and document the effectiveness of interventions.

V

Recommendations Related to Dementia

6.0

Assessment

Recommendation 6.1a:

Assess older adults for possible dementia when changes in cognition, behaviour, mood, or function are observed or reported. Use validated, context-specific screening or assessment tools, and collaborate with the person, his/her family/care partners, and the interprofessional team for a comprehensive assessment.

Ia & V

Recommendation 6.1b:

Refer the person for further assessment/diagnosis if dementia is suspected.

Ia

Recommendation 6.2:
Assess the physical, functional, and psychological status of older adults with dementia or suspected dementia, and determine its impact on the person and his/her family/care partners using comprehensive assessments and/or standardized tools.

V

Recommendation 6.3:

Systematically explore the underlying causes of any behavioural and psychological symptoms of dementia that are present, including identifying the person’s unmet needs and potential “triggers.” Use an appropriate tool and collaborate with the person, his/her family/care partners, and the interprofessional team.

Ia

Recommendation: 6.4:

Assess older adults with dementia for pain using a population-specific pain assessment tool.

Ia

7.0 Planning

Recommendation 7.1:

Develop an individualized plan of care that addresses the behavioural and psychological symptoms of dementia (BPSD) and/or the person’s personal care needs. Incorporate a range of non-pharmacological approaches, selected according to:

• the person’s preferences,
• the assessment of the BPSD,
• the stage of dementia,
• the person’s needs during personal care and bathing,
• consultations with the person’s family/care partners and the interprofessional team, and
• ongoing observations of the person.

Ia

8.0

Implementation

Recommendation 8.1:
Implement the plan of care in collaboration with the person, his/her family/care partners, and the interprofessional team.

V

Recommendation 8.2:
Monitor older adults with dementia for pain, and implement pain-reduction measures to help manage behavioural and psychological symptoms of dementia.

Ia & V

Recommendation 8.3:

Employ communication strategies and techniques that demonstrate compassion, validate emotions, support dignity, and promote comprehension when caring for people with dementia.

Ia

Recommendation 8.4:
Promote strategies for people living with dementia that will preserve their abilities and optimize their quality of life, including but not limited to:

• exercise (level of evidence = Ia),
• interventions that support cognitive function (level of evidence = Ia),
• advanced care planning (level of evidence = Ia), and
• other strategies to support living well with dementia (level of evidence = V).

Ia & V

Recommendation 8.5a:

Provide education and psychosocial support to family members and care partners of people with dementia that align with the person’s unique needs and the stage of dementia.

Ia

Recommendation 8.5b:

Refer family members and care partners who are experiencing distress or depression to an appropriate health-care provider.

V

9.0.0Evaluation

Recommendation 9.1:

Evaluate the plan of care in collaboration with the person with dementia (as appropriate), his/her family/care partners, and the interprofessional team, and revise accordingly.

V

Recommendations Related to Depression

10.0

Assessment

Recommendation 10.1:

Assess for depression during assessments and ongoing observations when risk factors or signs and symptoms of depression are present. Use validated, context-specific screening or assessment tools, and collaborate with the older adult, his/her family/care partners, and the interprofessional team.

Ia & V

Recommendation 10.2:
Assess for risk of suicide when depression is suspected or present.

V

Recommendation 10.3:
Refer older adults suspected of depression for an in-depth assessment by a qualified health-care professional. Seek urgent medical attention for those at risk for suicide and ensure their immediate safety.

V

11.0

Planning

Recommendation 11.1:
Develop an individualized plan of care for older adults with depression using a collaborative approach. Where applicable, consider the impact of co-morbid dementia.

Ia & V

12.0

Implementation

Recommendation 12.1:

Administer evidence-based pharmacological and/or non-pharmacological therapeutic interventions for depression that are tailored to the person’s clinical profile and preferences.

Ia & V

Recommendation 12.2:

Educate older adults with depression (and their families/care partners, if appropriate) about depression, self-management, therapeutic interventions, safety, and follow-up care.

V

13.0.0Evaluation

Recommendation 13.1:

Monitor older adults who are experiencing depression for changes in symptoms and response to treatment using a collaborative approach. Document the effectiveness of interventions and changes in suicidal risk.

V