Assessing Cognitive Function Breas, Milisen,Foreman
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CHAPTER 4
ASSESSING COGNITIVE FUNCTION
Tom Braes, Koen Milisen, and Marquis D. Foreman
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. Discuss the importance of assessing cognitive function.
2. Describe the goals of assessing cognitive function.
3. Compare and contrast the clinical features of delirium, dementia, and depression.
4. Incorporate the assessment of cognitive function into daily practice.
(for description of Evidence Levels cited in this chapter, see Chapter, Evaluating Clinical Practice Guidelines, page
??) [PUBLISHER PLEASE INSERT PAGE]
OVERVIEW
Cognitive functioning comprises perception, memory, and thinking--the processes
by which a person perceives, recognizes, registers, stores, and uses information (Foreman
& Vermeersch, 2004 [Level I]). Cognitive functioning can be affected, positively and
negatively, by illness and its treatment. Consequently, assessing an individual's cognitive
functioning is paramount for identifying the presence of specific pathological conditions,
such as dementia and delirium, for monitoring the effectiveness of various health
interventions, and for determining an individual's readiness to learn and ability to make
decisions (Foreman & Vermeersch, 2004 [Level I]). Despite the importance of assessing
cognitive functioning, physicians and nurses routinely fail to assess an individual's
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cognitive functioning (Foreman & Milisen, 2004 [Level I]). This failure to assess
cognitive functioning has profoundly serious consequences that include the failure to
detect a potentially correctable condition of cognitive impairment and death (Inouye et
al., 2001 [Level IV]), outcomes that could be prevented or minimized by early
recognition of their existence afforded by the routine assessment of cognitive functioning
(Foreman & Milisen, 2004 [Level I]). More importantly, given that nurses tend to have
the most frequent and longest duration of contact with individuals seeking health care,
they are instrumental for the early recognition of impairment, and monitoring of
cognitive functioning (Milisen et al., 2006 [Level VI]).
BACKGROUND/STATEMENT OF PROBLEM
Declines in cognitive functioning are a hallmark of aging (McEvoy, 2001 [Level
VI]); however, most declines in cognition with aging are not pathological. Examples of
nonpathological changes include a diminished ability to learn complex information, a
delayed response time, and minor loss of recent memory; declines are especially evident
with complex tasks or with those requiring multiple steps for completion (McEvoy, 2001
[Level VI]).
Pathological conditions of cognitive impairment that are prevalent with aging
include delirium, dementia, and depression (please see Table 1 for a comparison of the
clinical features among delirium, dementia, and depression. Please also refer to the
respective chapters, Delirium and Dementia in this text). There are protocols to prevent
and treat delirium, and protocols to slow the progression of decline with dementia;
however these opportunities exist only when and if these conditions are detected early,
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and the possibility of early detection exists only when cognitive function is assessed
systematically (Chow & MacLean, 2001 [Level I]; Registered Nurse Association of
Ontario (RNAO), 2003 [Level I]). Without systematic assessment, these pathological
conditions go unchecked, and the individuals with these conditions face much greater
accelerated and long-term cognitive and functional decline and death (Fick & Foreman,
2000 [Level IV]; Fick, Agostini, & Inouye, 2002 [Level I]; Hopkins & Jackson, 2006
[Level IV]; Lang et al., 2006 [Level IV]). Health care providers report greater frustration
and job stress in caring for these individuals (Milisen et al., 2004 [Level IV]), and the
cost of providing care to these individuals is much greater (Milbrandt et al., 2004 [Level
IV]).
Despite these profoundly negative consequences for the afflicted individuals and
their families, as well as for their care providers, nurses and physicians fail to access
cognitive function (Ely et al., 2004 [Level IV]; Foreman & Milisen, 2004 [Level I];
Inouye et al., 2001 [Level IV]). Yet, it is clear that the assessment of cognitive function
is the first and most crucial step in a cascade of strategies to prevent, reverse, halt, or
minimize cognitive decline (Chow & MacLean, 2001 [Level I]; RNAO, 2003 [Level I]).
Thus, the purpose of this chapter is to provide a best-practices protocol for the assessment
of cognitive function.
ASSESSMENT OF COGNITIVE FUNCTIONING
Reasons for Assessing Cognitive Functioning
As mentioned, there are several reasons or purposes for assessing an individual's
cognitive functioning:
Assessing Cognitive Function Breas, Milisen,Foreman
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Screening: is conducted to determine the presence or absence of impairment.
Information obtaining in screening can be useful for determining if the individual is
cognitively impaired, however, bedside screening methods such as those described
below, e.g., MMSE and Mini-Cog, are not useful in and of themselves for diagnosing
specific pathological conditions of impairment such as delirium or dementia. Screening
is also an important element in determining an individual's: readiness to learn, and
capacity to consent (Assessing Care of Vulnerable Elders [ACOVE] Investigators, 2001
[Level I]). As a result, screening activities enable the early detection of impairment that
affords the opportunity to determine the nature of the impairment. That is, is the
impairment delirium, dementia or depression, or possibly one superimposed upon
another? Only through early detection can treatment be initiated promptly and accurately
to either reverse, halt, or slow the progression of impairment (Chow & MacLean, 2001
[Level I]; RNAO, 2003 [Level I])
Monitoring: is conducted to track cognitive function over time as a means for
following the progression or regression of impairment especially in response to treatment
(ACOVE Investigators, 2001 [Level I]; RNAO, 2003 [Level I]).
How to Assess Cognitive Functioning
For assessing cognitive functioning, Folstein's Mini-Mental State Examination
(MMSE) (Folstein, Folstein, & McHugh, 1975 [Level IV]) is the most frequently
recommended instrument (British Geriatrics Society, 2005 [Level I]; Brodaty et al., 2006
[Level I]; Michaud et al., 2007 [Level I]; Milisen et al., 2006 [Level VI]; O'Keefe et al.,
Assessing Cognitive Function Breas, Milisen,Foreman
5
2005 [Level IV]; RNAO, 2003 [Level I]; Scottish Intercollegiate Guidelines Network,
2006 [Level I]; Tullman et al., 2007 [Level VI]; and Fletcher, 2007 [Level VI]). The
MMSE has been the most commonly used screening instrument for cognitive
functioning for more than 25 years because it is brief, consisting of 11-items and taking
about 7-10 minutes to complete, and easy to use. It is composed of items assessing
orientation, attention, memory, concentration, language, and constructional ability
(Tombaugh & McIntyre, 1992 [Level I]). Each question is scored as either correct or
incorrect; the total score ranges from 0 to 30 and reflects the number of correct responses.
A score less than 24 is considered evidence of impaired cognition (Tombaugh &
McIntyre, 1992 [Level I]).
Although considered the best available method for screening for impairment, the
performance on the MMSE is significantly influenced by education (individuals with less
than an 8th grade education commit more errors), language (individuals for whom
English is not their primary language commit more errors), and verbal ability (the MMSE
can only be used with individuals who can respond verbally to questioning), and age
(older people do less well) (Tombaugh & McIntyre, 1992 [Level I]). Others contend that
the MMSE takes too long to administer (Borson et al., 2005 [Level IV]). Despite these
limitations, it remains the most frequently recommended and most commonly used tool
to assess cognitive functioning.
To minimize the limitations of the MMSE while maximizing practical aspects of
assessing cognitive function, the Mini-Cog was developed (Borson et al., 2000 [Level
IV]). The aim was to have a brief screening test that required no equipment and little
Assessing Cognitive Function Breas, Milisen,Foreman
6
training to use while not being negatively influenced by age, education, or language
(Borson et al., 2000 [Level IV]; Borson et al., 2005 [Level IV]). The Mini-Cog is a 4item screening test consists of 3-item recall similar to the MMSE, and a clock-drawing
item. For the 3-item recall, the person is asked to listen to 3 unrelated words, to repeat
them, and finally to remember them for later. The person is then asked to draw the face
of a clock, to number the clock face, and to place the hands on the clock face to indicate a
specific time such as 10:20. The person is then asked to recall the 3-items previously
instructed to remember. Each item correctly recalled received one point for a total of 3
points; a correctly drawn clock received 2 points for a total score of 5 (Borson et al., 2000
[Level IV]). If any errors is made in drawing the clock, zero points are assigned.
Since its initial development in 2000, the Mini-Cog has been used with various
samples of people from different cultural, educational, age, and language backgrounds.
In a recent Systematic Review, it was reported that the Mini-Cog was suitable for the
routine screening for cognitive impairment (Brodaty et al., 2006 [Level I]) and even more
recently, was found to predict the development of in-hospital delirium (Alagiakrishnan et
al., 2007 [Level IV]).
The fact that most practice guidelines and Systematic Reviews recommend the
use of the MMSE for systematic screening of cognitive functioning does not necessarily
mean it is the best instrument for this purpose. You won't go wrong in using it, but
studies in which the performance of the MMSE and the Mini-Cog are compared in the
same subjects have demonstrated the Mini-Cog to be more accurate while less influenced
by age, education, and language (Brodaty et al., 2006 [Level I]). Moreover, the Mini-
Assessing Cognitive Function Breas, Milisen,Foreman
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Cog takes about half the time to administer and score than the MMSE, making the
practical value of the Mini-Cog greater than the MMSE. However, more research is
needed on this topic (Brodaty et al., 2006 [Level I]).
With respect to both the MMSE and the Mini-Cog, they are classified as simple
bedside cognitive screens. This means that they are both qualified for determining the
presence or absence of cognitive impairment; however, neither is capable of indicating if
the impairment is delirium, dementia, or depression. If the results of this cognitive
assessment or screening indicate the individuals to be impaired, further evaluation is
necessary to confirm a diagnosis of dementia, depression, delirium, or some other health
problem (Brodaty et al., 2006 [Level I]). One example of a diagnostic instrument is the
Confusion Assessment Method (Inouye et al., 1990 [Level IV]) for diagnosing delirium;
other instruments useful for diagnosing dementia and delirium and these diagnostic
instruments are discussed in greater detail in the respective chapters in this text.
When to Assess Cognitive Functioning
When and how frequently to assess cognitive functioning, either using the MMSE
or Mini-Cog, is in part a function of the purpose for the assessment, the condition of the
patient, and the results of prior or current testing. Recommendations for the systematic
assessment of cognition using standardized and validated tools include:

On admission to and discharge from an institutional care setting (ACOVE
Investigators, 2001 [Level I]; British Geriatric Society, 2005 [Level I]);

Upon transfer from one care setting to another (ACOVE Investigators, 2001
[Level I]);
Assessing Cognitive Function Breas, Milisen,Foreman

8
During hospitalization, every 8 to 12 hours throughout hospitalization
(http://www.icudelirium.org/delirium);

As follow-up to hospital care, within 6 weeks of discharge (ACOVE
Investigators, 2001 [Level I]);

Before making important health care decisions as an adjunct to determining an
individual's capacity to consent (ACOVE Investigators, 2001 [Level I]);

On the first visit to a new care provider (ACOVE Investigators, 2001 [Level I]);

Following major changes in pharmacotherapy (ACOVE Investigators, 2001
[Level I]); and

With behavior that is unusual for the individual and/or inappropriate to the
situation (Foreman & Vermeersch, 2004 [Level I]).
It also is recommended that formal cognitive testing, with either the MMSE or
Mini-Cog, be supplemented with information from close intimate others (Cole et al.,
2002 [Level II]; RNAO, 2003 [Level I]), and from naturally occurring
observations/conversations (Foreman et al., 2003 [Level VI]). One method for obtaining
information from intimate others (Cole et al., 2002 [Level II]) is through the use of the
Informant Questionnaire on Cognitive Decline in the Elderly (IQCDE) (Jorm, 1994
[Level IV]). Obtaining information from intimate others about an individual's cognitive
functioning assists in determining the duration of impairment necessary for determining
whether the impairment is delirium or dementia (see chapters in this text). Whereas
naturally occurring observations/conversations during everyday nursing care activities in
which it becomes apparent that the individuals is inattentive, and responding unusually or
Assessing Cognitive Function Breas, Milisen,Foreman
9
inappropriately to conversation or questioning may be the first indication of the need to
assess the individual's cognitive functioning.
Cautions for Assessing Cognitive Functioning
When assessing cognitive functioning, various characteristics of the physical
assessment environment should be considered to ensure that the results of the assessment
accurately reflect the individual's abilities and not extraneous factors. Overall, the ideal
assessment environment should maximize the comfort and privacy of both the assessor
and the individual. With respect to the individual, the environment should enhance
performance by maximizing the individual’s ability to participate in the assessment
process (Dellasega, 1998 [Level VI). To accomplish this, the room should be well lit and
of comfortable ambient temperature, so that neither party is distracted from the cognitive
task. Lighting must be balanced to be sufficient for the individual to see adequately the
examination materials, while not being so bright as to create glare. Also, the assessment
environment should be free from distractions that can result from extraneous noise,
scattered assessment materials, or brightly colored and/or patterned clothing and flashy
jewelry on the assessor (Lezak, Howieson, & Loring, 2004 [Level VI]).
Regarding the interpersonal environment it will be vital to prepare the individual
for the assessment; explaining what will take place and how long it will take, this way
reducing anxiety and creating an emotionally non-threatening environment and a safe
individual-assessor relationship (Engberg & McDowell, 1999 [Level VI]). Performing
the assessment in the presence of others should be avoided when possible, as the other
individual may be distracting. If the other is a significant intimate relative, additional
Assessing Cognitive Function Breas, Milisen,Foreman
10
problems arise. For example, when the individual fails to respond or responds in error,
significant others have been known to provide the answer, or to say such things as “Now,
you know the answer to that,” or “Now, you know that’s wrong.” In most instances, the
presence of another only heightens anxiety. Rarely does the presence of another facilitate
the performance of an individual on cognitive assessment. Older adults are especially
sensitive to any insinuation that they may have some “memory problem,” therefore, the
dilemma for the assessor is to stress the importance of the assessment while taking care
not to increase the individual’s anxiety. It is important to create an environment in which
the individual is motivated to perform and to perform well while not being overly anxious
and therefore perform poorly. Similarly, it can be counterproductive to describe the
assessment as consisting of “simple,” “silly,” or “stupid” questions. Such explanations
tend to diminish motivation to perform and only heighten anxiety when errors are
committed. Anxiety also is heightened following a series of failures on assessment.
Various characteristics of the assessor and individual should also be considered.
The assessment of cognitive functioning can be perceived by the individual as intrusive,
intimidating, fatiguing, and offensive, characteristics that can seriously and negatively
affect performance. Consequently, Lezak et al. (2004 [Level VI]) recommends an initial
period to establish rapport with the individual. This period also allows a determination of
the individual’s capacity for assessment. For example, this period can be used to
establish if the individual has any special problems that could influence testing or its
interpretation (e.g., sensory decrements). With elderly individuals who may have some
decrements in sensory abilities, the assessor can improve the examinee’s ability to
Assessing Cognitive Function Breas, Milisen,Foreman
11
perform through simple methods. For example, if the individual has any degree of
hearing impairment, taking a position across from the assessor or a little to the side may
enhance hearing. In this position, the individual can readily use the assessor’s nonverbal
communication as well as read the assessor’s lips. Both strategies improve
communication and thus assessment. Sitting or standing a little to the side of the ear with
the better auditory function of the individual also improves better hearing. Positioning
also is important relative to lighting and glare.
When selecting the most suitable moment for assessing an individual's cognitive
status, one should generally avoid periods immediately upon awakening from sleep (wait
at least 30 min.), immediately before and after meals, immediately before and after
medical diagnostic or therapeutic procedures and when the individual is in pain or is
uncomfortable. By avoiding these periods, performance is more likely to reflect the
individual's cognitive abilities (Foreman et al., 2003 [Level VI]).
CASE STUDY WITH DISCUSSION
Mrs. O is a 79-year-old retired nurse who lives at home with her husband who is
physically frail. Mrs. O was diagnosed with probable Alzheimer’s disease approximately
3 years ago. In addition, she has Type II diabetes that is generally well controlled on
Actoplus (pioglitazone hydrochloride and metformin hydrochloride). She and her
husband are able to remain living in their own home because of help from their children,
neighbors, friends, and a monthly visit from a home health nurse. Mrs. O. is quite mobile
but recently has begun to wander at times. Her husband reports that she seems more
confused in the past few days and has fallen twice since yesterday. There is evidence of
Assessing Cognitive Function Breas, Milisen,Foreman
12
minor physical injury which Mrs. O insists is "nothing." Her husband also is concerned
that she has not been taking her Actoplus as prescribed; although she has been eating
okay, he is concerned that she has not been drinking enough. Because of these concerns,
he calls the home health nurse to come and evaluate the situation as he is concerned that
his wife may need urgent attention. [Mr. O's concerns are real and the call to the home
health nurse is appropriate].
When the nurse arrives, she assesses Mrs. O, including her cognitive functioning.
The results of her assessment with the MMSE indicate that Mrs. O's cognitive
functioning has deteriorated significantly since the nurse's visit two weeks ago. Mrs. O is
more disoriented to time and place, more easily distracted, her conversation is
disorganized, and she has greater difficulty following commands and remembering
simple objects. She scored 18 out of 30 on the MMSE 2 weeks ago which is usual for
her, but now scores 12/30. In talking with the husband, the nurse learns that these
changes occurred in the past 2 days. The nurse suspects delirium as evidenced by the
sudden and dramatic decline in Mrs. O's cognitive abilities. The nurse thinks that Mrs. O
may be severely dehydrated since her diabetes is no longer controlled, and is concerned
about impending hyperosmolar, nonketotic coma. The nurse seeks an emergency
admission to the local hospital for further diagnostic work to determine the cause for her
suspected delirium; is she hyperglycemic and dehydrated? [The nurse's suspected
diagnosis is certainly a health emergency warranting further diagnostic workup to
confirm a diagnosis of delirium and the identification of the underlying causes].
Assessing Cognitive Function Breas, Milisen,Foreman
13
Mrs. O is admitted with a diagnosis of mental status changes. On admission to
the hospital, the nurse describes Mrs. O as "cooperative, lying quietly in bed, but being
slow to respond." Being short staffed that day and given Mrs. O's history of dementia,
the nurse decides that the husband is being overprotective and that these changes are
merely a worsening of her dementia and nothing new. The nurse moves on to other
patients and more "important" patient care concerns. A couple of hours later, the nurse
goes back to check on Mrs. O only to find her obtunded, unresponsive to physical stimuli,
hypotensive, and tachycardic. The nurse calls a code, but Mrs. O fails to respond and
dies. [What went wrong here? It is likely that the assessment performed by the home
health nurse was not transmitted to the nurse in the hospital. Thus, vital information was
missing, and the nurse in the hospital was working at a disadvantage]. In addition, it is
not uncommon for health care providers to assume because an older person is "confused,"
that this confused is either a result of their age or an exacerbation of their underlying
dementia or both (Fick & Foreman, 2000 [Level IV]). However, this is an erroneous
assumption, and in this case dangerous as the undetected worsening of Mrs. O's cognitive
impairment resulted in lack of treatment of the underlying hyperglycemia and severe
dehydration leading to her eventual death. The cascade of mortal events could have been
prevented with detection of the impairment, diagnosis of delirium, and prompt treatment
of the underlying cause
SUMMARY/CONCLUSIONS
The determination of an individual's cognitive status is critical in the process and
outcomes of illness and its treatment. Being competent in the assessment of cognitive
Assessing Cognitive Function Breas, Milisen,Foreman
14
functioning requires (1) knowledge and skill as they relate to the performance of the
assessment of cognitive functioning, (2) sensitivity to the issues that can negatively bias
the results and interpretation of this assessment, (3) accurate and comprehensive
documentation of the assessment, and (4) the incorporation of the results of the
assessment in the development of the individual's plan of care.
Assessing Cognitive Function Breas, Milisen,Foreman
15
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cognitive impairment (an evidence-based review). Report of the Quality Standards
Subcommittee of the American Academy of Neurology. Neurology, 56, 1133-1142.
Evidence Level I: Systematic Review.
Registered Nurse Association of Ontario (RNAO). (2003). Screening for Delirium,
Dementia and Depression in Older Adults. Retrieved March 9, 2007 from:
http://rnao.org/Page.asp?PageID=924&ContentID=818.
Scottish Intercollegiate Guidelines Network, (2005). Management of patients with
dementia: A national clinical guideline. Retreived March 9, 2007 from:
http://www.guideline.gov/summary/summary.aspx?doc_id=8809&nbr=4855.
Evidence Level I: Systematic Review.
Tombaugh, T. N., & McIntyre, N. J. (1992). The Mini-Mental State Examination: A
comprehensive review. Journal of the American Geriatrics Society, 40, 922-935.
Evidence Level I: Systematic Review.
Tullman, D. F., Mion, L. C., Fletcher, K., & Foreman, M. D. (2007). Delirium:
Prevention, early recognition, and treatment. In E. Capezuti, D. Zwicker, M. Mezey,
T. Fulmer, (Eds.), Evidence-based geriatric nursing protocols (3rd ed.) (pp. XXXXXX). NY: Springer Publishing Co. Evidence Level VI: Expert Opinion.
[PUBLISHER PLEASE INSERT PAGE #]
Assessing Cognitive Function Breas, Milisen,Foreman
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U.S. Preventive Services Task Force. (2003). Screening for dementia: Recommendation
and rationale. Annals of Internal Medicine, 138, 925-926. Evidence Level I:
Systematic Review.
Assessing Cognitive Function Breas, Milisen,Foreman
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RESOURCES
Recommended Instruments for Assessing Cognitive Functioning
Mini-Mental State (Tombaugh & McIntyre, 1992 [Level I]), Retrieved March 9, 2007
from: http://www.minimental.com
Mini-Cog (Borson et al., 2000 [Level IV]; Borodaty et al., 2006 [Level I]).
Additional Online Information about Cognition in Older Persons
http://www.geronnurseonline.org/index.cfm?section_id=31&geriatric_topic_id=11&subs
ection_id=77&page_id=166&tab=2. Anonymous, last updated, January 2005. Normal
aging changes. Normal changes with aging of the various body systems, including
cognitive functioning, are reviewed in this document.
Additional Online Information about Assessing Cognitive Functioning
The Iowa Index of Geriatric Assessment Tools (IIGAT) retrieved March 9, 2007 from:
http://fm.iowa.uiowa.edu/fmi/xsl/iigat/index.xsl
"Try This," a series of tips on various aspects of assessing and caring for older adults
sponsored by the Hartford Institute for Geriatric Nursing at New York University College
of Nursing, retrieved March 9, 2007 from:
http://www.hartfordign.org/publications/trythis/
Assessing Cognitive Function Breas, Milisen,Foreman
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The Registered Nurse Association of Ontario Best Practice Guideline for Screening for
Delirium, Dementia and Depression in Older Adults retrieved March 9, 2007 from:
http://rnao.org/Page.asp?PageID=924&ContentID=818
The U.S. Preventive Services task Force recommendations for Screening for Dementia
retrieved March 9, 2007 from: http:www.ahrq.gov/clinic/cps3dix.htm
Recommendations for the early detection of dementia from The American Academy of
Neurology retrieved March 9, 2007 from:
http://aan.com/professionals/practice/guideline/index.cfm?a=0&fc=1
Geriatric Toolkits retrieved March 9, 2007 from:
http://www.gericareonline.net/tools/index.html
An Interactive Software Toolkit for the Comprehensive Geriatric Assessment retrieved
March 9, 2007 from:http://www.contexio.com/englishversion.htm
The Health Service/technology Assess Text service of the National Library of Medicine
provides full text documents of information for making health decisions, retrieved March
9, 2007 from: http://hstat.nlm.nih.gov/hg/Hquest
Assessing Cognitive Function Breas, Milisen,Foreman
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The National Guideline Clearinghouse: http://www.guideline.gov
Treating delirium: A quick reference guide by the American Psychiatric Association,
retrieved March 9, 2007 from:
http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm
British Geriatrics Society Guidelines for the prevention , diagnosis, and management of
delirium in older people in hospital retrieved March 9, 2007 from:
http://www.bgs.org.uk/publications/Publications%20Downloads/Delirium-2006.DOC
Delirium & Cognitive Impairment Study Group. (2006). Brain dysfunction in critically ill
patients. Retrieved March 9, 2007 from: http://www.icudelirium.org/delirium/
European Delirium Association website retrieved March 9, 2007 from:
http://www.europeandeliriumassociation.com
Assessing care of vulnerable elders (ACOVE) retrieved March 9, 2007 from:
http://www.rand.org or: http://www.acove.com
Assessing Cognitive Function Breas, Milisen,Foreman
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Box 4.1 NURSING STANDARD OF PRACTICE PROTOCOL:
ASSESSING COGNTIIVE FUNCTIONING
I. GOAL The goals of cognitive assessment include:
A. To determine an individual's cognitive abilities.
B. To recognize early the presence of an impairment in cognitive functioning.
C. To monitor an individual's cognitive response to various treatments.
II. OVERVIEW
A. Undetected impairment in cognition is associated with greater morbidity and
mortality (Inouye et al., 2001 [Level IV]).
B. Assessing cognitive function is the foundation for early detection and prompt
treatment of impairment (ACOVE Investigators, 2001[Level I]).
III. BACKGROUND/STATEMENT OF PROBLEM
A. Definition Cognitive functioning includes the processes by which an individual
perceives, registers, sores, retrieves, and uses information.
B. Conditions in which cognitive functioning is impaired
1. The Dementias, e.g., Alzheimer's or vascular, is a syndrome of cognitive
deterioration that involves memory impairment and a disturbance in at least
one (1) other cognitive function, e.g., aphasia, apraxia, or agnosia, that result
in changes in function and behavior (APA, 2000).
2. Delirium is a disturbance of consciousness with impaired attention and
disorganized thinking that develops rapidly. Evidence of an underlying
Assessing Cognitive Function Breas, Milisen,Foreman
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physiologic or medical condition is generally present (APA, 2000).
3. Depression is a syndrome of either depressed mood or loss of interest or
pleasure in most activities of the day, these symptoms represent a change from
usual functioning for the individual and have been present for at least 2 weeks
(APA, 2000).
IV. ASSESSMENT OF COGNITIVE FUNCTION
A. Reasons/Purposes of Assessment
1. Screening: to determine the absence or presence of impairment (Foreman et
al., 2003 [Level VI]).
2. Monitoring: to track cognitive status over time, especially response to
treatment (Foreman et al., 2003 [Level VI]).
B. How to Assess Cognitive Function
1. Mini-Mental State Examination (MMSE) (Folstein et al.,1975 [Level IV]) can
be used to screen for or monitor cognitive function instrument; however
performance on the MMSE is adversely influenced by education, age,
language and verbal ability. The MMSE also is criticized for taking too long
to administer and score.
2. Mini-Cog (Borson et al., 2000 [Level IV]) also can be used to screen and
monitor cognitive function; is not adversely influenced by age, language, and
education; and takes about half as much time to administer and score as the
MMSE.
3. IQCDE is useful to supplement testing with the MMSE or Mini-Cog as it is
Assessing Cognitive Function Breas, Milisen,Foreman
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useful to determining onset, duration and functional impact of the cognitive
impairment. Information from intimate others can be obtained by using the
Informant Questionnaire on Cognitive Decline in the Elderly (IQCDE) (Jorm,
1994 [Level IV]).
4. Naturally occurring interactions: observations and conversations during
naturally occurring care interactions can be the impetus for additional
screening/monitoring of cognitive function with the MMSE or Mini-Cog
(Foreman et al., 2003 [Level VI]).
C. When to Assess Cognitive Function
1. On admission to and discharge from an institutional care setting (ACOVE
Investigators, 2001 [Level I]; British Geriatric Society, 2005 [Level I]).
2. Upon transfer from one care setting to another (ACOVE Investigators, 2001
[Level I]).
3. During hospitalization, every 8 to 12 hours throughout hospitalization
(http://www.icudelirium.org/delirium).
4. As follow-up to hospital care, within 6 weeks of discharge (ACOVE
Investigators, 2001 [Level I]).
5. Before making important health care decisions as an adjunct to determining an
individual's capacity to consent (ACOVE Investigators, 2001 [Level I]).
6. On the first visit to a new care provider (ACOVE Investigators, 2001 [Level
I]).
7. Following major changes in pharmacotherapy (ACOVE Investigators, 2001
Assessing Cognitive Function Breas, Milisen,Foreman
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[Level I]).
8. With behavior that is unusual for the individual and/or inappropriate to the
situation (Foreman & Vermeersch, 2004 [Level I]).
D. Cautions for Assessing Cognitive Function
1. Physical environment (Dellasega, 1998 [Level VI]).
a. Comfortable ambient temperature.
b. Adequate lighting (not glaring).
c. Free of distractions (e.g., should be conducted in the absence of other and
other activities).
d. Position self to maximize individual's sensory abilities.
2. Interpersonal environment (Engberg & McDowell, 1999 [Level VI]).
a. Prepare individual for assessment.
b. Initiate assessment within non-threatening conversation.
c. Let individual set pace of assessment.
d. Be emotionally non-threatening.
3. Timing of assessment (Foreman et al., 2003 [Level VI]).
a. Select time of assessment to reflect actual cognitive abilities of the
individual.
b. Avoid the following times.
i. Immediately upon awakening from sleep, wait at least 30 minutes.
ii. Immediately before and after meals.
iii. Immediately before and after medical diagnostic or therapeutic
Assessing Cognitive Function Breas, Milisen,Foreman
procedures
iv. In the presence of pain or discomfort.
V. EVALUATION/EXPECTED OUTCOMES
A. Patient
1. Is assessed at recommended time points.
2. Any impairment detected early.
3. Care tailored to appropriately address cognitive status/impairment.
4. Satisfaction with care improved.
B. Health Care Provider
1. Competent to assess cognitive function.
2. Able to differentiate among delirium, 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) for additional assessment and treatment
recommendations.
4. Decreased overall costs of care.
VI. FOLLOW-UP MONITORING
A. Provider competence in the assessment of cognitive function.
29
Assessing Cognitive Function Breas, Milisen,Foreman
30
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.
VII. RELEVANT PRACTICE GUIDELINES
A. The Registered Nurse Association of Ontario Best Practice Guideline for
Screening for Delirium, Dementia and Depression in Older Adults. Retrieved
March 9, 2007 from: http://rnao.org/Page.asp?PageID=924&ContentID=818
B. The U.S. Preventive Services task Force recommendations for Screening for
Dementia. Retrieved March 9, 2007 from: http:www.ahrq.gov/clinic/cps3dix.htm
C. Recommendations for the early detection of dementia from The American
Academy of Neurology. Retrieved March 9, 2007 from:
http://aan.com/professionals/practice/guideline/index.cfm?a=0&fc=1.
D. The National Guideline Clearinghouse: http://www.guideline.gov.
Assessing Cognitive Function Breas, Milisen,Foreman
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Table1: A Comparison of the Clinical features of Delirium, Dementia, and
Depression
Clinical
Feature
Delirium
Dementia
Depression
Onset
Sudden/abrupt;
depends on cause;
often at twilight
Insidious/slow and
often unrecognized;
depends on cause
Course
Short; diurnal
fluctuations in
symptoms; worse at
night, in darkness,
and on awakening
Progression
Abrupt
Long, no diurnal
effects, symptoms
progressive yet
relatively stable over
time, may see deficits
with increased stress
Slow but uneven
Duration
Hours to less than 1
month; longer if
unrecognized and
untreated
Disturbed
Fluctuates from
stuporous to
hypervigilant
Inattentive, easily
distractible and may
have difficulty
shifting attention
from one focus to
another
Generally impaired;
disoriented to time
and place, should
not be disoriented
to person
Recent and
immediate
impaired; unable to
recall events of
hospitalization and
current illness,
Coincides with major
life changes; often
abrupt, but can be
gradual
Diurnal effects,
typically worse in the
morning; situational
fluctuations in
symptoms, but less
than with delirium
Variable; rapid or slow
but generally even
At least 6 weeks, can
be several months to
years
Consciousness
Alertness
Attention
Orientation
Memory
Months to years
Clear
Generally normal
Clear
Normal
Generally normal
Minimal impairment,
but is distractible
Generally normal
Selective disorientation
Recent and remote
impaired
Selective or "patchy"
impairment , "islands"
of intact memory,
evaluation often
difficult due to low
motivation
Assessing Cognitive Function Breas, Milisen,Foreman
Thinking
Perception
Psychomotor
behavior
forgetful, unable to
recall instructions
Disorganized;
rambling, irrelevant
and incoherent
conversation;
unclear or illogical
flow of ideas
Perceptual
disturbances such as
illusions and visual
and auditory
hallucinations;
misperceptions of
common people and
objects common
Variable;
hypoactive,
hyperactive, and
mixed
Variable affective
changes; symptoms
of autonomic hypohyperarousal
Difficulty with
abstraction, thoughts
impoverished;
judgment impaired;
words difficult to find
32
Intact but with themes
of hopelessness,
helplessness, or selfdeprecation
Misperceptions usually Intact; delusions and
absent
hallucinations absent
except in severe cases
Normal, may have
apraxia
Variable; psychomotor
retardation or agitation
Affect depressed;
dysphoric mood,
exaggerated and
detailed complaints;
preoccupied with
personal thoughts;
insight present; verbal
elaboration; somatic
complaints, poor
hygiene, and neglect of
self
Distracted from
Failings highlighted by Failings highlighted by
Assessment
task; fails to
family, frequent "near individual; frequent
remember
miss" answers,
"don't know" answers,
instructions,
struggles with test,
little effort; frequently
frequent errors
great effort to find an
gives up; indifferent
without notice
appropriate reply,
toward test: does not
frequent requests for
care or attempt to find
feedback on
answer
performance
Adapted from: Foreman et al. (2003). Assessing cognitive functioning. In M. Mezey et
Associated
features
Affect tends to be
superficial,
inappropriate, and
labile; attempts to
conceal deficits in
intellect; personality
changes, aphasia,
agnosia may be
present; lacks insight
al., Geriatric Nursing Protocols for Best Practice, 2nd edition. (102-103). Springer
Assessing Cognitive Function Breas, Milisen,Foreman
Publishing Company: New York.
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