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Dementia Discomfort Scale (short) Cheat Sheet by

Detecting discomfort in Dementia Patients
medical     scale     healthcare     dementia     discomfrot     ds-dat


Discomfort Scale for Dementia of the Alzheimer Type (DS-DAT) was developed based on interviews with experi­enced dementia care nurses . Discomfort was defined as a negative emotional and/or physical state in response to internal or enviro­nmental condit­ions.

DS-DAT has nine items that are made operat­ional by 40 defining charac­ter­istics. Items are scored 0, 1, 2, or 3 depending on the number of defining charac­ter­istics present, their intensity and duration during a 5-minute observ­ation period. When items cannot be observed; for example, a patient with shut eyes could not be rated for a sad facial expres­sion, the item is scored as NA (not applic­able) and recoded to “0.” The two positively worded items are reverse coded. Then item’s scores are summed to provide a total score. High scores mean high levels of discomfort observed .
Adapted from Hurley AC, Volicer BJ, Hanrahan PA, et al. Assessment of discomfort in advanced Alzheimer patients. Res Nurs Health 1992; 15:369­-377.

Discomfort Scale

Noisy Breathing
Negative sounding noise on inspir­ation or expira­tion: breathing looks strenuous, labored, or wearing: respir­ations sound loud, harsh, or gasping: difficulty breathing or trying hard at attempting to achieve a good gas exchange; episodic bursts of rapid breaths or hyperv­ent­ila­tion.
Negative Vocali­zation
Noise or speech with a negative or disapp­roving quality: hushed low sounds such as constant muttering with a guttural tone: monotone, subdued, or varying pitched noise with a definite unpleasant sound: faster rate than a conver­sation or drawn out as in a moan or groan: repeating the same words with a mournful tone: expressing hurt or pain.
Content Facial Expression
Pleasant, calm looking face, tranquil, at ease, or serene: relaxed facial expression with a slack unclenched jaw: overall look is one of peace.
Sad Facial Expression
Troubl­ed-­looking face, looking hurt, worried, lost, or lonesome: distressed appear­ance: sunken “hang dog” look with lackluster eyes: tears: crying.
Frightened Facial Expression
Scared, concer­ned­-lo­oking face: looking bothered, fearful, or troubled: alarmed appearance with open eyes and pleading face.
Face looks strained: or scowling looks: displeased expression with a wrinkled brow and creases in the forehead: corners of mouth turned down.
Relaxed Body Language
Easy openhanded position: look of being in a restful position: may be cuddled up or stretched out: muscles look of normal firmness and joints are without stress: look of being idle/lazy or “laid back”: appearance of “ just killing the day” casual.
Tense Body Language
Extrem­ities show tension: wringing of hands: clenched fists, or knees pulled up tightly: look of being in a strained and inflexible position.
Restless inpatient motion, acting squirmy or jittery appearance of trying to get away from hurt area, forceful touching, tugging or rubbing of body parts.
Scores: 0=None 1=Slight 2= Moderate 3=Inte­nse

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