ACFI 7 Behaviour Record for Wandering Record the behaviour code(s) of the behaviour(s) that occur every hour W1 Interfering while wandering W2 Trying to get to inappropriate places Further description: Initial Code Initial Code Initial Code Initial Code Initial Facility ID ACFI Appraiser identification details Appraiser name Profession Signature Date Code Initial Resident name / ID Code Initial Code
4. Irritability, easily annoyed, short tempered Interviewing staff or other informant: Has X/ she/ he been irritable – short-tempered, easily annoyed or unusually impatient – in the last week? Can you give me an example? Does this happen occasionally or often? How much does it interfere with her/ his everyday life? Interviewing the care recipient or observation: Observe care recipient during interview Have you been feeling irritable, easily annoyed or short-tempered in the last week? Can you give me an example? Does this happen occasionally or often? How much does it interfere with your everyday life? Staff: Interview Other: Observation Notes: Score unable to score = a absent = 0 minor interference with everyday life and/ or symptoms occur occasionally = mild = 1 major interference with everyday life and symptoms occur often = severe = 2 Q’s 5-8: behavioural disturbance 5. Agitation (physical restlessness, hand wringing, hair pulling) Interviewing staff or other informant: Has X/ she/ he been so restless in the last week that they’ve been unable to sit still for even an hour? Has she/ he done things like pacing up and down, wringing their hands or sighing? Can you give me an example? Does this happen occasionally or often? How much does it interfere with her/ his everyday life? Interviewing the care recipient or observation: Observe the care recipient Have you been so restless in the last week that you have been unable to sit still for an hour? Can you give me an example? Does this happen occasionally or often? How much does it interfere with your everyday life? Staff: Interview Other: Observation Notes: Score unable to score = a absent = 0 minor interference with everyday life and/ or symptoms occur occasionally = mild = 1 major interference with everyday life and symptoms occur often = severe = 2
and gets out of bed for the day (i.e. cannot fall back asleep). Notes: Score unable to score = a absent = 0 wakes up on own but goes back to sleep = mild = 1 wakes earlier than usual and gets out of bed for the day = severe = 2 Q’s 16-19: ideational disturbance 16. Suicide (feels life is not worth living, suicide attempt or wishes) Interviewing staff or other informant: In the last week, has X/ she/ he said that life isn’t worth living or that she would rather be dead? (rate 0 for a history of, but without current thoughts) If yes, has she/ he spoken of wanting to harm herself? If yes, has she/ he spoken of how she would do that? (rate 1 for passive thoughts - has no plan ) Can you give me an example? (rate 2 for active suicidal wishes and/ or any recent attempts, gestures or plans) Interviewing the care recipient or Observation: A. In the last week, have you had any thoughts that life isn’t worth living? B. In the last week, have you had any thoughts that you would rather be dead? If yes to either A or B have you had any thoughts of wanting to harm or kill yourself? If yes, have you thought about how you would do that? Can you give me an example? Staff: Interview Other: Observation Guideline: Rate 1 for passive thoughts (feels life isn’t worth living or would rather be dead but has no plan to end their life). Rate 2 for active suicidal wishes and/or any recent attempts, gestures or plans. A history of one or more suicide attempts without current passive or active thoughts is not scored. Notes: Score unable to score = a history of one or more suicide attempts without current passive or active thoughts = absent = 0 passive thoughts = mild = 1 active suicidal wishes and/ or any recent attempts, gestures or plans = severe = 2