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


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

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


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.


Is the patient bed bound/able to turn themselves? Can they walk with/without use of aids i.e. Zimmer frame?


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.

Sampson et al. BMC Palliative Care 2008 7:8   doi:10.1186/1472-684X-7-8

Open Data