Purpose and scope
This best practice guideline (BPG) outlines recommendations for the assessment and care of delirium, dementia and depression in older adults. The focus is on the provision of effective, compassionate and dignified care, and on managing any presenting signs, symptoms or behaviours.
Nurses and other members of the interprofessional health-care team can use this BPG to enhance the quality of their practice pertaining to delirium, dementia and depression in older adults, and to optimize clinical outcomes by using evidence-based practices. The recommendations apply to foundational clinical care provided by nurses and other health-care providers in a range of community and health-care settings.
Registered Nurses’ Association of Ontario. (2016). Delirium, Dementia, and Depression in Older Adults: Assessment and Care (2nd ed.) Toronto, ON: Registered Nurses’ Association of Ontario.
Do you want to learn about and implement the most- up-to-date evidence-based recommendations on this topic with your colleagues? Download and share the full best practice guideline (BPG), Delirium, Dementia, and Depression in Older Adults: Assessment and Care.
See below for a snapshot of the recommendations from this BPG. We strongly suggest you review the full BPG before implementing the recommendations and good practice statements. The BPG also includes further resources to support implementation and evaluation.
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.
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.
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.
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.
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.
Recommendation 1.6: Use principles of least restraint/restraint as a last resort when caring for older adults.
Recommendation 2.1: Assess older adults for delirium risk factors on initial contact and if there is a change in the person’s condition.
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.
Recommendation 4.1: Implement the delirium prevention plan in collaboration with the person, his/her family/care partners, and the interprofessional team.
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.
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.
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.
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,
- non-pharmacological interventions, and
- appropriate use of medications to alleviate the symptoms of delirium and/or manage pain.
Recommendation 4.6: Educate persons who are at risk for or are experiencing delirium and their families/care partners about delirium prevention and care.
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.
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.
Recommendation 6.1b: Refer the person for further assessment/diagnosis if dementia is suspected.
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.
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.
Recommendation: 6.4: Assess older adults with dementia for pain using a population-specific pain assessment tool.
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.
Recommendation 8.1: Implement the plan of care in collaboration with the person, his/her family/care partners, and the interprofessional team.
Recommendation 8.2: Monitor older adults with dementia for pain, and implement pain-reduction measures to help manage behavioural and psychological symptoms of dementia.
Recommendation 8.3: Employ communication strategies and techniques that demonstrate compassion, validate emotions, support dignity, and promote comprehension when caring for people with dementia.
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:
- interventions that support cognitive function,
- advanced care planning, and
- other strategies to support living well with dementia.
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.
Recommendation 8.5b: Refer family members and care partners who are experiencing distress or depression to an appropriate health-care provider.
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.
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.
Recommendation 10.2: Assess for risk of suicide when depression is suspected or present.
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.
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.
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.
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.
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.
Recommendation 14.1: All entry-level health-care programs include content and practice education opportunities that are specific to caring for older adults who have or are suspected of having delirium, dementia, and/or depression, and that are tailored to the discipline’s scope of practice.
Recommendation 14.2: Organizations provide opportunities for nurses and other health-care providers to enhance their competency in caring for older adults with delirium, dementia, and depression. Pertinent educational content should be provided during the orientation of new staff and students, and continuously through refresher courses and professional development opportunities.
Recommendation 14.3: Design dynamic, evidence-based educational programs on delirium, dementia, and depression that support the transfer of knowledge and skills to the practice setting. Such programs should be:
- interactive and multimodal,
- tailored to address learners’ needs,
- reinforced at the point of care by strategies and tools, and
- supported by trained champions or clinical experts.
Recommendation 14.4: Evaluate educational programs on delirium, dementia, and depression to determine whether they meet desired outcomes, such as practice changes and improved health outcomes. Refine programs as required.
Recommendation 15.1: Organizations demonstrate leadership and maintain a commitment to foundational principles that support care for older adults with delirium, dementia, and depression, including:
- person- and family-centred care,
- collaborative, interprofessional care, and
- healthy work environments.
Recommendation 15.2: Organizations select validated screening and assessment tools for delirium, dementia, and depression that are appropriate to the population and health-care setting, and provide training and infrastructure to support their application.
Recommendation 15.3: Organizations implement comprehensive, multi-component programs, delivered by collaborative teams within organizations, to address delirium, dementia, and depression. These should be supported by:
- comprehensive educational programs,
- clinical experts and champions, and
- organizational processes that align with best practices.
Recommendation 15.4: Establish processes within organizations to ensure that relevant information and care planning for older adults with delirium, dementia, and depression is communicated and coordinated over the course of treatment and during care transitions.
Disclaimer: These guidelines are not binding for nurses, other health providers or the organizations that employ them. The use of these guidelines should be flexible and based on individual needs and local circumstances. They constitute neither a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses’ Association of Ontario (RNAO) gives any guarantee as to the accuracy of the information contained in them or accepts any liability with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work.
Current edition published 2016.
About the new edition
The Registered Nurses' Association of Ontario (RNAO) is developing a third edition of this best practice guideline (BPG), with the working title Delirium, Dementia, and Depression in Older Adults: Assessment and Care. The anticipated publication date is 2025.
This BPG is intended to replace the RNAO BPGs Screening for Delirium, Dementia and Depression in Older Adults (2010), Caregiving Strategies for Older Adults with Delirium, Dementia and Depression (2010), and Delirium, Dementia, and Depression in Older Adults: Assessment and Care (2016).