NCM 114 RLE

Care of Older Adults

ANNE MARGARET CALLANG BOTOR, RN

PREPARED BY:
Comprehensive Geriatric
Assessment
Psychological/ Psychiatric
Assessment
GLASGOW COMA SCALE
ORIENTATION & MEMORY
Orientation
Person:
Place:
Time:
Memory
Immediate:
Recent:
Remote:
HEALTH ATTITUDE & NON- VERBAL
BEHAVIORS
Health attitude:

Non- verbal Behaviors:

 MINI- MENTAL STATE EXAMINATION
Maximum Score Patient’s Score Questions
5 “What is the year? Season? Date? Day? Month?”
5 “Where are we now? State? County? Town/city? Hospital? Floor?”
The examiner names three unrelated objects clearly and slowly, then the
instructor asks the patient to name all three of them. The patient’s response is
3 used for scoring. The examiner repeats them until patient learns all of them, if
possible.

“I would like you to count backward from 100 by sevens.” (93, 86, 79, 72, 65, …)
5 Alternative: “Spell WORLD backwards.” (D-L-R-O-W)

3 “Earlier I told you the names of three things. Can you tell me what those were?”
Show the patient two simple objects, such as a wristwatch and a pencil, and ask
2 the patient to name them.
 MINI- MENTAL STATE EXAMINATION
Maximum Patient’s Questions
Score Score
1 “Repeat the phrase: ‘No ifs, ands, or buts.’”
“Take the paper in your right hand, fold it in half, and put it on the floor.”
3 (The examiner gives the patient a piece of blank paper.)
“Please read this and do what it says.” (Written instruction is “Close your
1 eyes.”)
“Make up and write a sentence about anything.” (This sentence must
1 contain a noun and a verb.)
Please copy this picture.” (The examiner gives the patient a blank piece of
1 paper and asks him/her to draw the symbol below. All 10 angles must be
present and two must intersect.)
30 TOTAL
MINI- MENTAL STATE EXAMINATION
Score Degree of Impairment
25-30 No Impairment
20-24 Mild
10-19 Moderate
0-9 Severe
 GERIATRIC DEPRESSION SCALE
Directions to patient: Please choose the best answer for how you have felt over the past week.
Directions to examiner: Present questions verbally. Circle answer given by patient. Do not show to
patient.
1. Are you basically satisfied with your life? Yes No (1)
2. Have you dropped many of your activities and interests? Yes (1) No
3. Do You feel that your life is empty? Yes (1) No
4. Do you often get bored? Yes (1) No
5. Are you hopeful about the future? Yes No (1)
6. Are You bothered by thoughts you can't get out of your head? Yes (1) No
7. Are you in good spirits most of the time? Yes No (1)
8. Are you afraid that something bad is going to happen to you? Yes (1) No
9. Do you feel happy most of the time? Yes No (1)
10. Do you often feel helpless? Yes (1) No
 GERIATRIC DEPRESSION SCALE
Directions to patient: Please choose the best answer for how you have felt over the past week.
Directions to examiner: Present questions verbally. Circle answer given by patient. Do not show to patient.
11. Do you often get restless and fidgety? Yes (1) No
12. Do you prefer to stay at home rather than go out and do things? Yes (1) No
13. Do you frequently worry about the future? Yes (1) No
14. Do you feel you have more problems with memory than most? Yes (1) No
15. Do you think it is wonderful to be alive now? Yes No (1)
16. Do you feel downhearted and blue? Yes (1) No
17. Do you feel worthless the way you are now? Yes (1) No
18. Do you worry a lot about the past? Yes (1) No
19. Do you find life very exciting? Yes No (1)
20. Is it hard for you to get started on new projects? Yes (1) No
 GERIATRIC DEPRESSION SCALE
Directions to patient: Please choose the best answer for how you have felt over the past week.
Directions to examiner: Present questions verbally. Circle answer given by patient. Do not show to patient.
21. Do you feel full of energy? Yes No (1)
22. Do you feel that your situation is hopeless? Yes (1) No
23. Do you think that most people are better off than you are? Yes (1) No
24. Do you frequently get upset over little things? Yes (1) No
25. Do you frequently feel like crying? Yes (1) No
26. Do you have trouble concentrating? Yes (1) No
27. Do you enjoy getting up in the morning? Yes No (1)
28. Do you prefer to avoid social occasions? Yes (1) No
29. Is it easy for you to make decisions? Yes No (1)
30. Is your mind as clear as it used to be? Yes No (1)
Total: Please stun all bolded answers (worth one point) for a total score.
Scores: 0-10 Normal 11-20 Moderate depression 21-30 Severe depression
 Comprehensive Geriatric
Assessment

Social- Environmental Assessment

SOCIAL- ENVIRONMENTAL ASSESSMENT
Name of Caregiver:
Caregiver relationship:
Caregiver stress:
Significant others:
Social engagement
Occupation:
Current activities indoor:
Current activities outdoor:
Pets:
SOCIAL- ENVIRONMENTAL ASSESSMENT
Personal safety concerns:
Home safety concerns:
History of Abuse
Emotional: Alcohol Abuse
Sexual: Type:
Physical: Frequency:
Smoking Habit Hobbies and Favorite Activities:
Age started:
Age stopped:
Number of cigars a day:
Thank you!