Assessing Cognition

  • Detecting cognitive impairment in older patients is important because of the impairment’s association with adverse events (Bradshaw et al., 2013).
  • Assessing cognitive function is necessary for early detection and prompt treatment of impairment (McCarten et al., 2012).

 

BACKGROUND AND STATEMENT OF PROBLEM

A.  Definition of cognitive functioning includes the processes by which an individual perceives, registers, stores, retrieves, and uses information.

B.  The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) provides criteria for diagnosing declines from a previously attained level (see DSM-5 for specific criteria; APA, 2013; Sachdev et al., 2014).

  1. Delirium is a disturbance in attention and awareness that develops over a short period of time and tends to fluctuate in severity during the course of a day, combined with a disturbance in cognition (e.g., disorientation, memory deficit, etc.), neither of which are better explained by another neurocognitive disorder, but by one or multiple physiological effects (APA, 2013).
  2. Mild neurocognitive disorder (or mild cognitive impairment) is characterized by a modest cognitive decline from a previous level of performance in at least one cognitive domain (e.g., executive function, complex attention) that does not interfere with capacity for independence in everyday activities if the decline is not exclusively present in the context of a delirium or attributable to another mental disorder (APA, 2013).
  3. Major neurocognitive disorder (or dementia) is characterized by a significant cognitive decline from a previous level of performance in at least one cognitive domain (e.g., learning and memory, language) that interferes with independence in everyday activities if the decline is not exclusively present in the context of a delirium or attributable to another mental disorder (APA, 2013).
  4. Depression is a disorder represented by several symptoms. At the very least, one symptom needs to be the presence of a depressed mood or loss of interest or pleasure during a 2-week period, which causes clinically significant distress and leads to a decline from previous functioning; these symptoms cannot be attributed to direct physiological effects of a substance or a general medical condition (APA, 2013).

ASSESSMENT OF COGNITIVE FUNCTION

A.  Methods for assessing cognitive function

  1. Screening: to determine the absence or presence of impairment
  2. Full evaluation: to make a diagnosis if screening results indicate impairment
  3. Monitoring: to track cognitive status over time, especially in response to treatment

B.  Instruments to assess for cognitive impairment

  1. MMSE (Folstein et al., 1975) is the most well-known and best studied instrument. It can be used to screen for or monitor cognitive impairment. However, performance on the MMSE is adversely influenced by education, age, language, and verbal ability. The MMSE is not available for public use without cost.
  2. MoCA and SLUMS can both detect and monitor cognitive impairment. Its performance is reported to be equivalent or superior to that of the MMSE, especially in patients with mild cognitive impairment.
  3. Mini-Cog is a widely used and recommended instrument that is often preferred over MMSE, MoCA, and SLUMS for detecting impairment because MMSE, MoCA, and SLUMS administration time is quite long. Depending on the setting, many other tools are available to briefly screen for the presence or absence of cognitive impairment.
  4. Differential diagnosis: Parallel use of other short instruments, such as the CAM (Inouye et al., 1990), the UB-2 (Fick et al., 2015), or the GDS (Yesavage et al., 1982), can be useful to rule out issues of delirium or depression and determine the nature of impairment.
  5. Heteroanamnesis: Information from relatives assists in determining the duration and nature of impairment. IQCODE, AD8, NPI, and FAM-CAM can be used to obtain this information.
  6. Naturally occurring observations: NOSCA standardizes the reporting of observations and conversations during naturally occurring care interactions (Persoon et al., 2011). The use of NOSCA is especially relevant when a patient’s condition does not allow the use of other aforementioned instruments.
  7. When screening results indicate impairment: Referral to a specialist setting (e.g., memory clinic, neuropsychologist, psychiatrist, advanced practice nurse) is necessary for more diagnostic workup (i.e., extensive history taking, clinical and neurological examination, extended neuropsychological assessment, brain imaging, blood sampling, etc.).

C.  When to assess cognitive function

  1. Presence of signs, symptoms, and/or complaints of cognitive impairment
  2. With behavior that is inappropriate to a situation and/or unusual for the individual (including functional decline)
  3. Lack of an informant to confirm absence of signs or symptoms
  4. Before making important treatment decisions as an adjunct to determining an individual’s capacity to consent and capacity to adhere to treatment guidelines

D.  Cautions for assessing cognitive function

  1. Physical environment (Dellasega, 1998)
    • Comfortable ambient temperature
    • Adequate lighting (not glaring)
    • Free of distractions (e.g., should preferably be conducted in the absence of others and other activities)
    • Position self to maximize individual’s sensory abilities
  2. Interpersonal environment (Engberg & McDowell, 2000)
    • Prepare individual for assessment
    • Initiate assessment within nonthreatening conversation
    • Let individual set pace of assessment
    • Be emotionally nonthreatening
  3. 3.  Timing of assessment (Foreman et al., 2003)
    • Select time of assessment to reflect actual cognitive abilities of the individual
    • Avoid the following times:
      • Immediately on awakening from sleep (wait at least 30 minutes)
      • Immediately before and after meals
      • Immediately before and after medical diagnostic or therapeutic proceduresIn the presence of unstable and/or interfering medical conditions (e.g., fever, nausea)
  4. Reporting of assessment results (Shenkin et al., 2014)
    • Report screening results with the context in which they were obtained.

EVALUATION/EXPECTED OUTCOMES

A.  Patient

  1. Is assessed at recommended moments
  2. Any impairment detected early
  3. Care tailored to appropriately address cognitive status/impairment
  4. Satisfaction with care improved

B.  Healthcare provider

  1. Competent to assess cognitive function
  2. Able to differentiate among delirium, mild cognitive impairment, dementia, and depression
  3. Uses standardized cognitive assessment protocol
  4. Satisfaction with care improved

C.  Institution

  1. Improved documentation of cognitive assessments
  2. Impairments in cognitive function identified promptly and accurately
  3. Improved referral to appropriate advanced providers (e.g., geriatricians, geriatric nurse practitioners, neurologists, psychiatrists, memory clinics) for additional assessment and treatment recommendations
  4. Decreased overall costs of care

FOLLOW-UP MONITORING

A.  Provider competence in the assessment of cognitive function

B.  Consistent and appropriate documentation of cognitive assessment

C.  Consistent and appropriate care and follow-up in instances of impairment

D.  Timely and appropriate referral for diagnostic and treatment recommendations

RELEVANT PRACTICE GUIDELINES

A.  United States Preventive Services Task Force. Cognitive impairment in older adults: Screening. Retrieved from http://www.uspreventiveservicestaskforce.org/Page/Document/
UpdateSummaryFinal/cognitive-impairment-in-older-adults-screening?ds=1&s=cognitive

B.  Guidelines and Protocols Advisory Committee (GPAC) guideline. Cognitive impairment in the elderly—Recognition, diagnosis, management. Retrieved from http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/cognitive-impairment

C.  National Institute for Health and Clinical Excellence (NICE) guideline. Delirium: Diagnosis, prevention, and management. Retrieved from http://guidance.nice.org.uk/CG103

D.  The Registered Nurse Association of Ontario. Best practice guideline for screening for delirium, dementia, and depression in older adults. Retrieved from http://rnao.ca/bpg/guidelines/caregiving-strategies-older-adults-delirium-dementia-and-depression

E.  American Geriatrics Society. Clinical practice guideline for postoperative delirium in older adults. Retrieved from https://geriatricscareonline.org/ProductAbstract/american-geriatrics-society-clinical-practice-guideline-for-postoperative-delirium-in-older-adults/CL018

ABBREVIATIONS

AD8                  Eight-Item Interview to Differentiate Aging and Dementia

CAM                 Confusion Assessment Method

DOSS               Delirium Observation Screening Scale

DSM-5              Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

FAM-CAM       Family Confusion Assessment Method

GDS                  Geriatric Depression Scale

GPA                  Guidelines and Protocols Advisory Committee

IQCODE          Informant Questionnaire on Cognitive Decline in the Elderly

MMSE              Mini-Mental State Examination

MoCA               Montreal Cognitive Assessment

NICE                National Institute for Health and Clinical Excellence

NOSCA            Nurses’ Observation Scale for Cognitive Abilities

NPI                   Neuropsychiatric Inventory

SLUMS            St. Louis University Mental Status

UB-2-Item        Ultra-Brief Delirium Screen

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Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

REFERENCES

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Bradshaw, L. E., Goldberg, S. E., Lewis, S. A., Whittamore, K., Gladman, J. R., Jones, R. G., & Harwood, R. H. (2013). Six-month outcomes following an emergency hospital admission for older adults with co-morbid mental health problems indicate complexity of care needs. Age and Ageing, 42(5), 582–588. doi:10.1093/ageing/aft074. Evidence Level IV.

Dellasega, C. (1998). Assessment of cognition in the elderly: Pieces of a complex puzzle. Nursing Clinics of North America, 33(3), 395–405. Evidence Level VI.

Engberg, S. J., & McDowell, J. (2000). Comprehensive geriatric assessment. In J. T. Stone, J. F. Wyman, & S. A. Salisbury (Eds.). Clinical gerontological nursing: A guide to advanced practice (2nd ed., pp. 63–85). Philadelphia, PA: Saunders. Evidence Level VI.

Fick, D. M., Inouye, S. K., Guess, J., Ngo, L. H., Jones, R. N., Saczynski, J. S., & Marcantonio, E. R. (2015). Preliminary development of an ultrabrief two-item bedside test for delirium. Journal of Hospital Medicine, 10(10), 645–650. doi:10.1002/jhm.2418. Evidence Level IV.

Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). “Mini-Mental State.” A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3), 189–198. doi:10.1016/0022-3956(75)90026-6. Evidence Level IV.

Foreman, M. D., Fletcher, K., Mion, L. C., & Trygslad, L. (2003). Assessing cognitive function. In M. Mezey, T. Fulmer, & I. Abraham (Eds.), D. Zwicker (Managing ed.), Geriatric nursing protocols for best practice (2nd ed., pp. 99–115). New York, NY: Springer Publishing Company. Evidence Level VI.

Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., & Horwitz, R. I. (1990). Clarifying confusion: The confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine, 113(12), 941–948. doi:10.7326/0003-4819-113-12-941. Evidence Level IV.

McCarten, J. R., Anderson, P., Kuskowski, M. A., McPherson, S. E., Borson, S., & Dysken, M. W. (2012). Finding dementia in primary care: The results of a clinical demonstration project. Journal of the American Geriatrics Society, 60(2), 210–217. doi:10.1111/j.1532-5415.2011.03841.x. Evidence Level V.

Persoon, A., Banningh, L. J., van de Vrie, W., Rikkert, M. G., & van Achterberg, T. (2011). Development of the Nurses’ Observation Scale for Cognitive Abilities (NOSCA). ISRN Nursing, 2011, 895082. doi:10.5402/2011/895082. Evidence Level IV.

Sachdev, P. S., Blacker, D., Blazer, D. G., Ganguli, M., Jeste, D. V., Paulsen, J. S., & Petersen, R. C. (2014). Classifying neurocognitive disorders: The DSM-5 approach. Nature Reviews Neurology, 10(11), 634–642. doi:10.1038/nrneurol.2014.181. Evidence Level VI.

Shenkin, S. D., Russ, T. C., Ryan, T. M., & MacLullich, A. M. (2014). Screening for dementia and other causes of cognitive impairment in general hospital in-patients. Age and Ageing, 43(2), 166–168. doi:10.1093/ageing/aft184. Evidence Level VI.

Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., Adey, M., & Leirer, V. O. (1982). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17(1), 37–49. doi:10.1016/0022-3956(82)90033-4. Evidence Level IV.