Assessing Cognitive Function

 

OVERVIEW

  • 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, as well as reversible causes (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 of functioning (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), neither of which is 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. The decline is not exclusively present in the context of 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. The decline is not exclusively present in the context of 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. 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

B. 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

C. Instruments to assess for cognitive impairment

  1. MMSE (Tombaugh & MacIntyre, 1992) 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. MMSE is not available for public use without cost.
  2. MoCA and SLUMS can both detect and monitor cognitive impairment. Their 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 administration time for MMSE, MoCA, and SLUMS 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 (Marcantonio et al., 2022), the UB-CAM (Marcantonio et al., 2022), or the GDS (Yesavage et al., 1982), can be useful to rule out delirium or depression.
  5. Patients with preexisting dementia: Use of delirium assessment tools that have been validated in patients with dementia, such as the UB-CAM, is recommended (Fong et al., 2022; Shrestha & Fick, 2023).
  6. 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.
  7. Remote cognitive assessment: The TICS (Seo et al., 2011) and the T-MoCA/MoCA BLIND (Katz et al., 2021) are among the most well-studied, telephone-based cognitive assessment tools, although this is an area in need of further research. The T-MoCA/MoCA BLIND may be superior to the TICS for assessing mild cognitive impairment. Instructions are available for administering the standard MoCA via videoconference.
  8. When screening results indicate impairment: Testing should be initiated in the primary care setting to determine the etiology of the impairment, assess its severity, and rule out reversible physiological causes. In complex cases, or when initial test results are inconclusive, referral to a specialist setting (e.g., memory clinic, neuropsychologist, psychiatrist, advanced practice nurse) may be necessary for further diagnostic workup.

D. Cautions when assessing cognitive function

  1. Physical environment
    • Comfortable ambient temperature
    • Adequate lighting (not glaring)
    • Free of distractions (e.g., should preferably be conducted in the absence of others and other activities)
    • Positioning self to maximize the individual’s sensory abilities
  2. Interpersonal environment (Engberg & McDowell, 2000)
    • Prepare the individual for assessment.
    • Initiate assessment within nonthreatening conversation.
    • Let the individual set the pace of the assessment.
    • Be emotionally nonthreatening.
  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 procedures
      • In 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 intervals
  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

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. U.S. Preventive Services Task Force. Cognitive impairment in older adults: Screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cognitive-impairment-in-older-adults-screening

B. Registered Nurses’ Association of Ontario. Delirium, dementia, and depression in older adults: Assessment and care. https://rnao.ca/bpg/guidelines/assessment-and-care-older-adults-delirium-dementia-and-depression

C. National Institute for Health and Care Excellence (NICE) guideline. Delirium: Diagnosis, prevention, and management in hospital and long-term care. http://guidance.nice.org.uk/CG103

D. National Dementia Office Guidelines. Integrated care pathways and delirium algorithms. https://dementiapathways.ie/care-pathways/acute-hospital-care/integrated-care-pathways-and-delirium-algorithms

E. American Geriatrics Society. Clinical practice guideline for postoperative delirium in older adults. 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

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

FAM-CAM     Family Confusion Assessment Method

GDS               Geriatric Depression Scale

IQCODE         Informant Questionnaire on Cognitive Decline in the Elderly

MMSE            Mini-Mental State Examination

MoCA             Montreal Cognitive Assessment

NICE               National Institute for Health and Care Excellence

NPI                  Neuropsychiatric Inventory

SLUMS          St. Louis University Mental Status

TICS              Telephone Interview for Cognitive Status

T-MoCA        Telephone-Montreal Cognitive Assessment (also called MoCA BLIND)

UB-CAM         Ultra-Brief Confusion Assessment Method

 

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Updated: January 2025

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti, PhD, RN, FAAN, E.A., & Fulmer PhD, RN, FAAN, T. T. (2025). Evidence-Based Geriatric Nursing Protocols for Best Practice (7th ed.). Springer Publishing. Retrieved December 17, 2024, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826152763.html#tableofcontents

Chapter 10, Inloes, J.B. & Fick, Donna M. (2025) Assessing Cognitive Function in the Older Adult

 

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