Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Practice Recommendations
  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 co-exist 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 clinical observations.
  6. Factors such as sensory impairment and physical disability should be assessed and considered in the selection of mental status tests.
  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.
  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.