Abbreviated Mental Test (Amt) - And Delirium Screening Form

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SURNAME
UNIT NO/UAID
Southern NSW LHD
Murrumbidgee LHD
FIRST NAMES
Facility__________ Date: ___/___/______
DOB
SEX
WARD
MO
ABBREVIATED MENTAL TEST (AMT) -
AND DELIRIUM SCREENING FORM
Establish baseline cognition by completing Abbreviated Mental Test OR SMMSE
for on all presentations 65 years + (45+ ATSI)
Time of test___________ Name of person completing test___________________
QUESTION
Score
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
If score 7 or less screen for delirium using the CAM (see next page)
If score 8 or greater assess for delirium symptoms and risk
If unable to complete AMT or SMMSE AND/OR regardless of score
Does the person present with or have a history of any recent/sudden
change in behaviour, cognition, LOC or functional ability (including falls)?
YES
Screen for delirium with CAM (next page)
NO
Does the person have any of the high level risk factors for delirium?
Dementia or pre -existing cognitive impairment?
Severe medical illness
Dehydration
Visual and or hearing impairment
Depression
Chronic Alcohol use > 2 drinks/day
History of previous delirium
If yes to any of above insert delirium alert and prevention strategies into front
of health record & refer to ASET/AARC/discharge planner
Ref: Clinical practice guidelines for the management of delirium in older people (AHMAC, 2006) updated 2011

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