Assessing Cognitive

Function in Clinical Care

and Community Setting
Henni Kusuma
Keb. Aman dan Nyaman
2017
 Course Objectives
1. Students will be able to cite use of 2 different
cognitive assessments appropriate for their
patients in the hospital based acute care setting
2. Students will be able to cite basic strategy of
assessing cognition in the setting of pain and
disease
3. Students will be able to cite the legal
implications of reporting on cognitive function
of their patients
 Problem ...
 Can we truly assess cognition in the acute
care?
 What are the factors impacting patient
performance?
 What can we contribute to this patient’s care
with the tools and knowledge we have to draw
from?
 Limitations of Cognitive Testing

 These tests are standardized, the score does not

necessarily represent true functional level of the
person tested
 Those normally very high functioning will test
normal, but to them still have significant limitations
 Those lower functioning pts will do poorly, but their
function may seem or be very near normal to them
 You are getting a momentary snapshot of
performance with use of a formalized test
 Most consistently cited in the
literature as effective and easy to
administer:
 For clinical / community settings:
 Intensive Care Delirium Screening Checklist
 Confusion Assessment Method for the ICU

(CAM-ICU)
 Mini Mental Status Exam
 Short Portable Mental Status Questionary

Be consistent between other professionals if at all

possible, use what your institution recommends
 What causes age-related cognitive
decline?
 Processing speed theory
 Executive function theory
 Processing Speed
 T. A. Salthouse, 1996
 The central hypothesis in the theory is that increased age in
adulthood is associated with a decrease in the speed with
which many processing operations can be executed and that
this reduction in speed leads to impairments in cognitive
functioning because of what are termed the limited time
mechanism and the simultaneity mechanism. That is,
cognitive performance is degraded when processing is slow
because relevant operations cannot be successfully
executed (limited time) and because the products of early
processing may no longer be available when later
processing is complete (simultaneity). Several types of
evidence, such as the discovery of considerable shared age-
related variance across various measures of speed and large
attenuation of the age-related influences on cognitive
measures after statistical control of measures of speed, are
consistent with this theory.
 Executive Function Theory
 T. Salthouse, et al, 2003 J Exper. Psych
 “Executive functions are those control
processes responsible for planning,
assembling, coordinating, sequencing and
monitoring other cognitive operations”
 Lezak 1995: “The executive functions consist
of those capacities that enable a person to
engage successfully in independent,
purposeful, self serving behavior”
 Executive Functions
 Executive function is an umbrella term for cognitive processes
such as planning, working, memory attention, problem
solving, verbal reasoning, inhibition, mental flexibility, multi-
tasking, and initiation and monitoring of actions
 Carried out by the prefrontal areas of the frontal lobe; new
work proposes that their origins are more spread out around
the cortex
 Decline in cognition is found in conjunction with deterioration
of the associated area of the brain

 R. Chan at al, Arch. Clin. Neuropsychology, 2008

 Executive functions
(A more generous description)
 Allow us to handle new situations
 Allow us to plan and make decisions
 Allow us to make corrections or problem solve
 Allow us to handle dangerous or technically
difficult situations
 Allow “override” of automatic reactions for
the greater good
 D.Norman, T. Shallice, 2000
 Warning signals of cognitive
impairment in acute care
 Personality changes; increased apathy, loss of
social inhibition, irritability/paranoia,
outbursts of anger
 Memory: difficulty with new information,
word finding, cannot recall conversations with
medical staff or family visits, cannot recall
what or when they ate last

 S. Gordon et al, Intensive Care Medicine 2004

 Warning signals continued
 Executive dysfunction; cannot follow orders or MD,
RN, OT, etc, demonstrate difficulty with planning or
making dismissal decisions, confusion during multi-
tasking
 Functional deficits; difficulty looking up information
or operating the hospital equipment, decline in self
care not attributed to physical limitations, inability to
follow a conversation, inability to find one’s room,
inability to follow through with tasks

 S. Gordon et al, Intensive Care Medicine 2004

 Causes of Cognitive Changes in
Cancer Patients
 Tumor located in the central nervous system
(CNS) which includes the brain and spinal
cord
 Treatments administered directly to the CNS
 Chemotherapy and radiation given to the brain
at the same time
 Treatments administered when extremely ill;
be an advocate for your patient when needed
Cardiac Failure and Cognitive Issues
 Mary Jane Sauvé, D.N.Sc., R.N., of the University of
California, Davis.
 The researchers administered tests of cognitive (intellectual)
function to 50 patients with HF and 50 people without HF,
matched for age and estimated intelligence.  Most of the
patients had mild to moderate HF. Overall, patients with HF
scored lower than controls on 14 of 19 cognitive tests.  46%
percent of the HF patients were rated as having mild to
severe cognitive impairment, compared to a 16 percent
rate of mild impairment in controls.  Memory problems,
especially short-term memory, were the most common type of
cognitive deficit.
 Most associated with left ventricular dysfunction
 Liver failure and Cognitive Decline
 A. Collie, 2005, Liver International
 Studied HE (hepatic encephalopathy), SHE
(subclinical HE)
 34-84% have SHE
 Estimated 1.5-2 million pts in North America
 Early diagnosis of liver disease=best results
 McCrea et al; see issues with attention and motor
skills, but intact visual-spatial, memory, general
intellect and language skills
 DRIVING SAFETY!!
 Cognitive Impairment in Trauma
Patients
 JC Jackson et al, prospective cohort study, 173
pts fromVanderbilt Univ. TICU
 Moderately and severe trauma pts
 108 evaluated at 1 yr f/u
 55% demonstrated cognitive impairment at 12
mos. 5.5% had pre-existing cog. condition
 No significant difference in cog. impairment
between moderate vs. severe trauma pts
 Jackson/Vanderbilt cont.
 The study found the clinically significant
symptoms of depression occurred in 40% of
ICU pts at 1 yr.
 PTSD found in 26% of pts at 1 year
 No significant difference in numbers in
moderate vs. severe injured pts.
 Drugs that cause cognitive changes
 Drug-induced cognitive impairment is most
commonly linked to benzodiazepines,
(tranquilizers and sleeping aides), opiates,
(narcotics/pain relievers), tricyclic
antidepressants, (pain syndrome/neuropathy),
and anticonvulsants (drugs used to treat and
prevent seizures).
 Corticosteroids (autoimmune disease
treatment), is also linked to cognitive changes
 Older adults and drug tolerance
 The body’s ability to clear drugs decreases with age,
often because of a normal age-related decrease in
kidney and liver function. This results in a greater
accumulation of drugs in the body.
 Older patients are often prescribed multiple drugs at
the same time. Due to complicated interactions
between different drugs, side effects can become
more prominent.
 Some research suggests that neurotransmitters
become naturally imbalanced as people age,
increasing the brain’s sensitivity to drugs that have
activity in the central nervous system.
 Confusion/Delirium
 State that develops over hours or days
 Involves changes in alertness that vary over
the course of the day
 Usually temporary and reversible
 DSM III: changes in consciousness, cognition,
occurs over a short period of time and these
fluctuate, and they are determined to be, (via
history/exam/lab finding), a direct cause of the
current medical condition
Common reasons to see confusion in
the acute care setting
 New surroundings
 Increase or change in medications
 Exposure to anesthesia, especially if prolonged
 Excessive blood loss
 Change in wake/sleep cycle
 Dehydration or malnutrition
 Infection
 Alcohol or drug withdrawl
 Incidence of Delirium
 Present in 10% of ER patients, 10-31% of medical units, 50%
hip fracture pts, > 80% pts on mechanical ventilation
 Most likely to have delirium: prior cognitive issues, visual
impairments, severe illness, elevated blood urea
nitrogen/creatinine ratio
 Hospital contributors: use of restraints, catheterization,
malnutrition, > 3 medication additions, sustaining an
iatrogenic event
 Presence of delirium associated with development of dementia
in subjects followed for 4 years, with an increase from 8.1%
to 62%

M. Rathier, W. Baker; A Review of Recent Clinical Trials and

Guidelines on the Prevention and Management of Delerium in
Hospitalized Older Patients, 2011
Treatment of confusion /delirium
 Try to normalize the environment
 Assure adequate sleep time/schedule
 Write out the daily schedule
 Bring in familiar objects
 Ensure patient wears glasses/hearing aids
 Explain to the patient that they appear
confused at times and encourage them to ask
questions
 Does the duration of delirium
indicate anything?
 Morandi et al; Crit. Care Med 2012
 47 pts, median age 50, studied is delirium duration predictive
of long term cognitive impairment
 Cognition tested at 3 and 12 months post
 Delirium duration in the ICU was associated with white matter
disruption, which in turn was associated with worse cognitive
scores for up to 12 months.

 M. Rather, Hospital Practice 2011; Delirium resolves in many

patients by the time of discharge, but is an independent risk
factor of for death, institutionalization and dementia
Physical Function and Cognition
 Assessment of one without the other is
worthless
 At a minimum, dressing, bathing, toileting,
from bed base, EOB, standing
 Baseline Cognition Assessment
(you start assessing these as soon as you walk in the room)

 Orientation
 Attention/concentration/focus
 Memory
 Initiation, sequencing, termination skills

 L. Johnson, A. Parker, C. Johnson; Is My Patient Ready to Go Home? 2/2012

 Choices
 Allen
 CPT
 CAM (Confusion Assessment Method)
 MOCA
 Short Blessed Test
 Short Portable Mental Status Questionnaire
 MMST Mini Mental Status
 Texas Functional Living Scales
 Intensive Care Delirium Screening Checklist
 Allen Cognitive Level Screen
 Task/performance based assessment
 Leather lacing, 3 visual motor tasks
 Designed to provide a quick measure of
cognitive processing capacities, learning
potential and performance abilities
 Scoring: 3.0-5.8
 Each score provides description of functional
performance abilities
 Allen’s cognitive levels
 Level 1: total care
 Level 2: total care, may do very basic adls
such as self feed or ambulate
 Level 3: 24 hr. care on site, uses familiar
objects, needs help and cues, poor safety
 Level 4: daily on site supervision, learns with
repetition
 Level 5: needs daily/weekly supervision
 Level 6: lives independently
 Cognitive Performance Test
 Standardized assessment that evaluates
information processing skills via ADL tasks
 Measures memory, executive functioning and
processing capacities that support functional
performance
 Can track changes over time
 Alzheimers, CVA, TBI, dementia populations
 Author Teressa Burns, OTR/L, Mpls VA
 CPT 7 tasks
 Dress for the weather
 Shopping for belt
 Making toast
 Washing
 Phone use
 Travel
 Medication box
 Confusion Assessment Method
(CAM)
 Inouye et al, 1990
 Two parts; part 1 screens for overall cognitive
impairment. Part II includes the 4 features that
had the greatest ability to distinguish between
reversible delirium and other types of
cognitive impairment
 Administered in less than 5 minutes
 Scoring via yes/no answers to questions
 Confusion Assessment Method:
Part 1
 Acute onset
 Inattention, behavior fluctuation
 Disorganized thinking
 Altered level of consciousness
 Disorientation
 Memory impairment
 Perceptual disturbances
 Psychomotor agitation
 Psychomotor retardation
 Altered sleep-wake cycles
Cognitive Assessment of Minnesota
(CAM)
 Standardized, measures cognitive abilities of
adults with neurological impairments
 Administration in 60 minutes or less
 Can be used to establish baseline or validate
treatment effectiveness
 Developed by R. Rustad OTR, T. DeGroot
OTR, M. Jungkunz OTR, K. Freeberg OTR, L
Borowick OTR, Ann Wanttie, OTR
 CAM 17 subtests evaluate:
 Attention span
 Memory orientation
 Visual neglect
 Temporal awareness
 Recall/recognition
 Auditory memory and sequencing
 Simple math skills
 Safety and judgement
 Montreal Cognitive Assessment
(MOCA)
 Developed by neurologist Ziad Nasreddine
1996
 Detects mild cognitive impairment and
Alzheimer’s Disease
 30 pt. test involving several cognitive domains
 15-20 minute administration time
 Available in several languages
 Available via internet
 MOCA Subtests
 Short term memory recall
 5 item recall
 Visual spatial tasks
 Clock drawing
 3 D cube drawing
 Executive function
 Trail making tasks
 Phonemic fluency task
 Verbal abstraction task
 MOCA Subtests
 Attention, concentration, working memory
 sustained attention task
 Serial subtraction task
 Counting backward/forward

 Language
 3 item naming (non-familiar animals)
 Complex sentence repetition

 Orientation
 Time and place
Short Blessed Test; G. Blessed, 1968
 Used to determine cognitively impaired from normal
 6 item test-Patients are asked to answer the items year
and month, time of day, count backward 20-1, recite
months backwards, and the memory phrase.
 Easily administered
 Verbal responses only
 Scoring: 0-4= Normal cognition, 5-9 = questionable
impairment, > 10 = impairment consistent with
dementia
 Short Portable Mental Status
Questionnaire; E Pfeiffer, 1975
 Rapid screening tool for cognitive
impairments
 10 item test
 Easy to administer
 Verbal responses only
 Scoring: 0-3 errors = normal cognitive
function
4-5 errors = mild impairment, 6-8 errors =
moderate impairment, 9 or more severe
impairment
 Short Portable questions
 Date anddate
Today’s year patient was born
 Day of
Who is the
the week
current President
 Patient’s
Who waspersonal
the preceding
phonePresident
number
 Patient’s address
Mother’s maiden name
 Patient’s 3age
Subtract from 20, keep calculating down until you can no
longer properly divide
 Mini Mental Status Exam
 Developed in 1975 by M. Folstein
 11 questions, tests orientation, registration,
attention/calculation, recall, language
 Takes 5-10 minutes to administer
 Max score is 30, a score less or equal to 23
indicates impairment
 Category Possible Description
points
Orientation to 5 From broadest to most narrow. Orientation to time has been
time correlated with future decline.
Orientation to 5 From broadest to most narrow. This is sometimes narrowed down
place to streets, and sometimes to floor.
Registration 3 Repeating named prompts
Attention and 5 Serial sevens, or spelling "world" backwards It has been
calculation suggested that serial sevens may be more appropriate in a
population where English is not the first language.
Recall 3 Registration recall
Language 2 Naming a pencil and a watch
Repetition 1 Speaking back a phrase
Complex 6 Varies. Can involve drawing figure shown
commands
 Texas Functional Living Scale
 “TFLS provides an ecologically valid,
performance-based screening tool to help
identify the level of care an individual
requires. Brief and easy to use, the TFLS is
especially well-suited for use in assisted living
and nursing home settings”

 Pearson Assessments quote

 TFLS continued
 TFLS helps measure an individual’s ability in four
functional domains:
 Time—Ability to use clocks and calendars
 Money and Calculation—Ability to count money
and calculate change
 Communication; use phones and phone books,
emergency contacts
 Memory—Ability to remember simple information
from prior tasks and to correctly take medications
 CM Cullem et al;
Neuropsychiatry/Psychology/Behavioral Medicine
2001 Apr-Jun
 CONCLUSIONS:
 The TFLS showed evidence of good reliability,
internal consistency, and convergent and discriminant
validity with several popular measures of global
cognitive status and behavioral functioning. It is a
brief and easily administered performance-based
measure of daily functional capabilities that is
sensitive to level of cognitive impairment and seems
applicable in patients with varying degrees of
dementia.
 Intensive Care Delirium Screening
Checklist
 Developed by N. Bergeron et al; U of
Montreal Dept. of Psychiatry
 Screening tool
 Checklist based on 8 DSM criteria for delirium
 Intensive Care Delirium Screening
Checklist
 Administered consistently for 5 days
 Assesses first for altered level of consciousness, then goes on
to rate inattention, disorientation, hallucination, psychomotor
agitation or retardation, inappropriate speech or mood,
disturbance in sleep/wake cycle, and symptom fluctuation
 Scoring: A=no response, E=exaggerated response
 Max score is 8, normal response scored as 0 (the patient needs
to be able to demonstrate at least response to mild or moderate
stimulation to administer and score, if not the testing was held
until they could).
 Easy to administer with guidelines that make interpretation
easy
 Test Administration
 Choose time of day wisely
 Well lit room
 No distractions
 Consider timing of food, medication
 Glasses on, hearing aids in
 The interview
 I’ve been asked by your primary care MDs to
help determine where you are in your ability
to take care of yourself at this point in time
and where you need to be to return home.
 Your care team has noted that it has been
difficult for you to….(recall, process, problem
solve).
 Have you noticed any of this?
 Reassure them that this is normal
 After dismissal…
 Recommend recheck at 2 mos.
 Pts should be fully recovered from
medications and delirium, but likely noting
limitations
 Repeat MMSE, if they score worse by 3 or
more points, need further formal evaluation
 Ask questions: how are you at operating a
phone, remote, recipe, grocery list, managing
money and medications
 Ask about depression and anxiety
 Is there neurological involvement?
Cranial Nerve Exam
 #1: Olfactory Nerve
 Rarely tested, need to test each nostril
separately
 Can try toothpaste, alcohol wipe (noxious),
“Quease Ease” product
 Bilateral loss of smell can come with smoking,
aging, or chronic rhinitis
 Olfactory nerve loss can be a symptom of
meningioma
 Cranial Nerve Exam
 #II Optic Nerve
 Test eyes separately, have patient wear glasses
 Examiner wiggles their finger in each of the four
quadrants, the patient indicates when it is in the periphery
of vision.
 Pupillary right reflex test, shine a penlight obliquely into
each pupil, watch for constriction in both eyes
 Flashlight test, move light between both eyes
 Abnormal findings could be a symptom of optic
neuritis
 Cranial Nerve Exam
 # III Oculomotor Nerve
 #IV Trochlear Nerve
 #VI Abducens Nerve
 Look for ptosis, eye position and nystagmus
 Stand 1 meter from pt, move target object in a H,
then hold in a lateral field, -> nystagmus; watch
for diplopia
 Cranial Nerve Exam
 #IV Trigeminal Nerve
 Light touch to the sides of the face, using a point
stimulus, forehead, cheek, chin
 Check for muscle strength and bulk in the masseter
(clench jaw) and pterygoids (open mouth against
resistance).
 Cranial Nerve Exam
 #VII Facial, motor and sensory
 Motor: raise both eyebrows, frown close eyes,
smile, show upper and lower teeth, puff out both
cheeks
 Sensory: test for taste

 Symptom of Bell’s Palsy, Ramsay-Hunt

Syndrome
 Cranial Nerve Exam
 # VIII Vestibulocochlear
 Whisper numbers and ask patient to repeat
 Balance/vestibular function

 Symptom of acoustic neuroma

 Cranial Nerve Exam
 #IX Glossopharyngeal Nerve
 #X Vagus Nerve
 Gag response, articulation of “ka, ga”, “go”
 #XI Accessory Nerve
 Shrug shoulders, turn head side to side
 #XII Hypoglossal Nerve
 Tongue strength, motion, symmetry
 Consult with Mayo Legal
 Choose a standardized test that gives the best
definition of how much care they will need,
i.e. 24 hour supervision and assistance….
 Document the details
 Document that you spoke with the
family/caregivers about the results, provide
contact information
 Equally important as any test!
 Clinical judgment
 Patient observation
 Family member
perception/interaction and report
 Final Recommendations
 Based on what you see NOW
 Minimize predictions, support what you
recommend with functional performance
details noted in therapy
 Recommend level of care required
immediately on dismissal
 Patient should demonstrate to their caregivers
consistent (2-3 days) performance before
decreasing level of care