Confusion Assessment Method for Intensive Care Unit(77. Fabbri RM, Moreira MA, Garrido R, Almeida OP. Validity and reliability of the portuguese version of the confusion assessment method (CAM) for the detection of delirium in the elderly. Arq Neuropsiquiatr. 2001;59(2 A):175-9.)
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Delirium |
Nurse researcher |
Resident |
1. Acute onset and fluctuating course of delirium symptoms 2. Inattention 3. Altered level of consciousness 4. Disorganized thinking |
When features 1 and 2 are both present and either features 3 or 4 are present: Confusion Assessment Method for Intensive Care Unit is positive, delirium is present |
Mini Nutritional Assessment®(8)
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Nutritional status |
Nurse researcher |
Resident |
18 items encompassing anthropometry, dietary assessment, global clinical evaluation and self-perception of health and nutritional status |
24-30 points: normal nutritional status 17-23.5 points: at risk of malnutrition 17 points: malnourished |
Downton Fall Risk Index(99. Downton J. Falls in the Elderly. Great Britain: Edward Arnold; 1993.)
|
Fall risk |
Nurse researcher |
Resident, medical records and family members |
Past history of falls, medications, sensory deficits, mental state, and walking activities |
Each factor can obtain a score of 1 point, with scores ≥3 identifying patients at risk |
Braden scale(1010. de Souza DM, Santos VL, Iri HK, Sadasue Oguri MY. Predictive validity of the Braden Scale for Pressure Ulcer Risk in elderly residents of long-term care facilities. Geriatr Nurs. 2010;31(2):95-104.)
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Pressure injury risk |
Nurse researcher |
Resident |
6 subscales, namely: sensory perception, activity, mobility, moisture, nutrition, friction or shear |
Total score can vary from 6-23 points, and the patients are classified as follows: very high risk of pressure injury (≤9 points), high risk (10-12), moderate risk (13-14), low risk (15-18) and no risk (19-23) |
Clinical Dementia Rating(1111. Montaño MB, Ramos LR. Validity of the Portuguese version of Clinical Dementia Rating. Rev Saude Publica. 2005;39(6):912-7.)
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Cognitive and functional performance in dementia |
Researcher and a physician |
Resident and/or family member |
6 domains: memory, orientation, judgment & problem solving, community affairs, home & hobbies, and personal care |
Five-point scale. An overall score is calculated through the use of an algorithm – 0: normal – 0.5: very mild dementia – 1: mild dementia – 2: moderate dementia – 3: severe dementia |
Mini-Mental State Examination(1212. Lourenço RA, Veras RP. Mini-Mental State Examination: psychometric characteristics in elderly outpatients. Rev Saude Publica. 2006;40(4):712-9.)
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Cognitive impairment |
Nurse researcher |
Resident |
30-point questionnaire grouped into 7 categories, each representing a different cognitive domain/function: orientation to time (5 points), orientation to place (5 points), registration of 3 words (3 points), attention and calculation (5 points), recall of 3 words (3 points), language (8 points) and visual construction (1 point) |
The cutoff points for cognitive impairment vay according to the level of education: – 18: illiterate – 21: 1 to 3 years of education – 24: 4 to 7 years of education – 26: over 7 years of education |
Semantic Verbal Fluency(1313. Rodrigues AB, Yamashita ÉT, Chiappetta AL. Teste de fluência verbal no adulto e no idoso: verificação da aprendizagem verbal. Rev CEFAC. 2008;10(4):443-51.)
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Cognitive impairment |
Nurse researcher |
Resident |
Tracks the storage capacity of the semantic memory system, the ability to retrieve information stored in memory, and the processing of executive functions. This test includes reporting as many animal names as possible within a 1-minute period, and assigns 1 point per animal named |
Results are scored as follows: 9 points: illiterate; 12 points: 1 to 8 years of study; 13 points: 9 years or more of study. |
Clock Drawing Test(1414. Atalaia-Silva KC, Lourenço RA. Translation, adaptation and construct validation of the Clock Test among elderly in Brazil. Rev Saude Publica. 2008;42(5):930-7)
|
Cognitive impairment |
Nurse researcher |
Resident |
Residents were given a blank sheet of paper and a pen, and were then asked to follow the instructions: “First, draw a clock with all the numbers on it. Second, put hands on the clock to make it read 2:45” |
10-6 points: drawing of clock face with circle and numbers is generally intact 5-1 point: drawing of clock face with circle and numbers is not intact Scores <6 are classified as cognitive impairment |
Geriatric Depression Scale: Short Form(1515. Pereira KR. Adaptação transcultural e validação da Escala de Depressão Geriátrica GDS-15 [Dissertação]. Uberaba: Universidade Federal do Triângulo Mineiro; 2017.)
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Depression in elderly without dementia |
Nurse researcher |
Resident |
15-item scale, in which 10 items indicate the presence of depression when answered positively, whereas 5 items indicate depression when answered negatively |
− 0-5: absence of depression – 6-10: mild depression – 9-11: moderate depression – 11-15: severe depression |
Cornell Scale(1616. Carthery-Goulart MT, Areza-Fegyveres R, Schultz RR, Okamoto I, Caramelli P, Bertolucci PH, et al. Versão brasileira da escala cornell de depressão em demência (cornell depression scale in dementia). Arq Neuropsiquiatr. 2007;65(3 B):912-5.)
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Depression in elderly with dementia |
Nurse researcher |
Caregiver interview |
19 items, each of which is evaluated for severity, on a scale of 0-2: – 0: absent – 1: slight or intermittent – 2: severe |
Total score ≤9 equates to absence of depression; 10-17 indicates probable depression; 18 correlates to depression |
Katz Index(1717. Lino VT, Pereira SR, Camacho LA, Ribeiro Filho ST, Buksman S. Adaptação transcultural da Escala de Independência em Atividades da Vida Diária (Escala de Katz). Cad Saude Publica. 2008;24(1):103-12.)
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Autonomy in ADL |
Nurse researcher |
Resident, medical records and family member |
Assess by ranking adequacy of performance in bathing, dressing, toileting, transferring, continence, and feeding. In each activity, the residents were scored “yes” or “no” for independence |
Classified as totally dependent when ≤2 yes scores were obtained; partially dependent (3 or 4 points); totally dependent (5 or 6 points) |
Lawton & Brody Scale(1818. Santos RL, Virtuoso Júnior JS. Confiabilidade da versão brasileira da Escala de Atividades Instrumentais da Vida Diária. RBPS. 2008;21(4):290-6.)
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Independence in IADL |
Nurse researcher |
Resident and family member |
8 domains: ability to use telephone, shopping, food preparation, housekeeping, laundry, mode of transportation, responsibility for own medications and ability to handle finances |
- Score of 0-1: total dependence – 2-3: severe dependence – 4-5: moderate dependence – 6-7: mild dependence – 8: independent |