Table 2 Patient assessment
Dementia Severity Functional Assessment Staging (FAST) Score [8] | An observational scale describing a continuum of 7 successive stages from normal to the most severe dementia |
Delirium Confusion Assessment Measure (CAM) [18] | The most widely used instrument for the detection of delirium. It has a sensitivity of 94–100% and a specificity of 90–95%. |
Pain and discomfort | Â |
Abbey Pain Scale [19]. | A brief 6-item scale to measure the intensity/severity of acute and chronic pain in late stage dementia |
Pain Assessment Checklist for Seniors with Severe Dementia (PACSLAC) [20] | Measures the number of pain symptoms present |
Doloplus-2 [21] | A 10-item observational scale for use in non-verbal adults. Addresses a wide range of pain indicators |
Communication | Clinical assessment of patient's ability to communicate their needs including non-verbal communication and comprehension. |
Pressure sores and skin condition Waterlow Scale [22] Stirling Scale [23] | The Waterlow scale is routinely used for the assessment of risk for developing pressure sores. The Stirling Scale measures the extent of damage from 1, Non-blanching erythema of intact skin to 4, full-thickness wound, which involving subcutaneous tissue and the deep fascia. |
Mobility | Is the patient bed bound/able to turn themselves? Can they walk with/without use of aids i.e. Zimmer frame? |
Elimination | Continence is routinely assessed as part of the FAST scale. Patients will also be assessed for the presence of urinary tract infection and constipation. |
Food and fluid intake | As routinely documented on food and fluid chart |
Swallowing and feeding | Formal assessment by speech and language therapy will be requested if there is clinical suspicion of difficulty. |