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    ACI Cognition Screening For Older Adults

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    Badrun Ibrahim
    This document contains screening tools for assessing cognition and delirium risk in older adults, including the Abbreviated Mental Test Scores (AMTS), Delirium Risk Assessment Tool (DRAT), and Confusion Assessment Method (CAM). The AMTS is a 10 question test to establish baseline cognition. The DRAT is used to assess pre-morbid risk factors and precipitating factors that increase delirium risk. The CAM is a validated tool to assist with diagnosing delirium and should be used if the patient appears confused or had any change in behavior or level of consciousness.

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    ACI Cognition Screening For Older Adults

    Uploaded by

    Badrun Ibrahim
    214 views2 pages
    This document contains screening tools for assessing cognition and delirium risk in older adults, including the Abbreviated Mental Test Scores (AMTS), Delirium Risk Assessment Tool (DRAT), and Confusion Assessment Method (CAM). The AMTS is a 10 question test to establish baseline cognition. The DRAT is used to assess pre-morbid risk factors and precipitating factors that increase delirium risk. The CAM is a validated tool to assist with diagnosing delirium and should be used if the patient appears confused or had any change in behavior or level of consciousness.

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    ACI Cognition Screening for Older Adults

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    This document contains screening tools for assessing cognition and delirium risk in older adults, including the Abbreviated Mental Test Scores (AMTS), Delirium Risk Assessment Tool (DRAT), and Confusion Assessment Method (CAM). The AMTS is a 10 question test to establish baseline cognition. The DRAT is used to assess pre-morbid risk factors and precipitating factors that increase delirium risk. The CAM is a validated tool to assist with diagnosing delirium and should be used if the patient appears confused or had any change in behavior or level of consciousness.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    214 views2 pages

    ACI Cognition Screening For Older Adults

    Uploaded by

    Badrun Ibrahim
    This document contains screening tools for assessing cognition and delirium risk in older adults, including the Abbreviated Mental Test Scores (AMTS), Delirium Risk Assessment Tool (DRAT), and Confusion Assessment Method (CAM). The AMTS is a 10 question test to establish baseline cognition. The DRAT is used to assess pre-morbid risk factors and precipitating factors that increase delirium risk. The CAM is a validated tool to assist with diagnosing delirium and should be used if the patient appears confused or had any change in behavior or level of consciousness.

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    © All Rights Reserved
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    of 2

    Cognition Screening for Patient Label

    Older Adults
    This form incorporates the Abbreviated Mental Test
    scores (AMTS), Delirium Risk Assessment Tool (DRAT)
    and Confusion Assessment Method (CAM).

    Abbreviated Mental Test Score (AMTS)


    Establish baseline cognition by completing the Abbreviated Mental Test OR SMMSE for all
    presentations 65 years + (45+ ATSI). Repeat with any change in cognition behaviour of LOC. Score 1
    for each correct answer.

    QUESTION Time
    Date __/__/__ __/___/__ __/__/__ __/__/___
    1. How old are you
    2. What is the time (nearest hour)
    Give the patient an address and ask them to repeat it at the end of the test
    E.g. 42 Market St Queanbeyan
    3. What year is it?
    4. What is the name of this place
    5. Can the patient recognise two
    relevant persons (eg. Nurse/doctor or
    relative)
    6. What is your date of birth?
    7. When did the second world war
    start? (1939)
    8. Who is the current Prime Minister?
    9. Count down backwards from 20 to 1
    10 Can you remember the address I
    gave you?
    TOTAL SCORE
    Signature
     A score of 7 or less indicates cognitive impairment
     All patients require a Delirium Risk Assessment using (DRAT ) over page

    Does the person have a history of any recent / sudden change in behaviour,
    cognition, loss of consciousness or functional abilities (inc Falls)?

    Yes - Please do CAM No - Please do DRAT


    Delirium Risk Assessment Tool (DRAT)
    Assessment to be completed on admission, pre & post op. and when there is a change in behaviour

    Pre morbid RISK factors


    Precipitating factors
    Tick & add score
      70 yrs WARNING: these factors increase risk

    PLUS  Mechanical restraint

     Visual impairment (unable to read large print on  Malnutrition


    newspaper with glasses)
     Severe illness (nurses’ opinion including mental  3 new medications added in 24hrs
    Illness/depression)
     Cognitive impairment AMTS <7/10 or MMSE < 25/30  IDC
    or past history of memory or cognitive deficit
     Dehydration (scanty, concentrated urine; fever, thirst,  Iatrogenic event (procedure,
    dry mucous membranes or raised creatinine/urea) infection, complication, fall etc)

    If your patient is  70 yrs and has at least one of the


    above risk factors =
    RISK of Delirium 
    IF CHANGE IN BEHAVIOUR -RECOMMENDED INVESTIGATIONS

    CAM Medical History Physical Medication Bloods MSU


    review (incl. family) Exam Review

    CONFUSION ASSESSMENT METHOD (CAM)


    The CAM is a validated tool to be used in assisting with the differential diagnosis of Delirium. It should be used for any older
    person who appears to be disorientated / confused or who has any change in behaviour or LOC. It is important that the CAM is
    used in conjunction with a formal cognitive assessment (eg AMT/ SMMSE), good clinical and medical assessment, together with
    baseline cognition information from carers/family or the community or residential aged care service

    Is there evidence of an acute


    change in mental status from
    Uncertain, the patient’s baseline? E.g. tend to come and go,
    Acute onset and
    1 fluctuating course
    No Yes Specify: ____________ or increase and decrease
    If so, did the abnormal in severity
    behaviour fluctuate during
    the day?
    E.g. being easily
    Uncertain, Did the patient have
    distracted, or having
    2 Inattention No Yes Specify: ____________ difficulty focussing attention
    difficulty keeping track
    during the interview?
    of what was being said?
    E.g. Rambling or
    irrelevant conversation,
    Uncertain,
    Disorganised Was the patient’s thinking unclear or illogical flow
    3 thinking
    No Yes Specify: ____________
    disorganised or organised? of ideas, or unpredictable
    switching from one
    subject to another?
    Uncertain, Overall, how would you rate Altered E.g. Vigilant,
    Altered level of
    4 No Yes Specify: ____________ the patient’s level of Lethargic, Stupor, Coma,
    consciousness
    consciousness? Uncertain.
    Delirium is present if features 1 and 2 AND either 3 or 4 are present
    Delirium symptoms: not present / present Date: / /
    Medical Officer notified? Yes / No

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