Overview

Cognitive functioning comprises perception, memory, and thinking--the processes by which a person perceives, recognizes, registers, stores, and uses information (Foreman & Vermeersch, 2004).  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 and individual's readiness to learn and ability to make decisions (Foreman & Vermeersch, 2004).  Despite the importance of assessing cognitive functioning, physicians and nurses routinely fail to assess an individual's cognitive functioning (Foreman & Milisen, 2004).  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, Foreman, Mion, Katz, & Cooney, 2001) and outcomes that could be prevented or minimized by early recognition of their existence afforded by the routine assessment of cognitive functioning (Foreman & Milisen, 2004).   

Nursing Standard of Practice Protocol: Assessing Cognitive Function 

Tom Braes RN, MSN, PhDCan, Koen Milisen, RN, PhD, Marquis D. Foreman, PhD, RN, FAAN

Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. These protocols were revised and tested in NICHE hospitals. The text is available here.

Goal

Overview

Background and Statement of Problem

Assessment of Cognitive Functioning

Evaluation/Expected Outcomes

Follow-up Monitoring

Relevant Practice Guidelines

References

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.

Overview

A. Undetected impairment in cognition is associated with greater morbidity and mortality.1

B. Assessing cognitive function is the foundation for early detection and prompt treatment of impairment (Shekelle et al., 2001).

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. Conditions in which cognitive functioning is impaired:

1. Dementia (e.g., Alzheimer’s or vascular) is a syndrome of cognitive deterioration that involves memory impairment and a disturbance in at least one other cognitive function (e.g., aphasia, apraxia, or agnosia that result in changes in function and behavior).3

2. Delirium is a disturbance of consciousness with impaired attention and disorganized thinking that develops rapidly. Evidence of an underlying physiologic or medical condition is generally present.3

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.3

Assessment of Cognitive Functioning

A. Reasons/Purposes of Assessment

1. Screening: to determine the absence or presence of impairment.4

2. Monitoring: to track cognitive status over time, especially response to treatment.4

B. How to Assess Cognitive Function

1. Mini-Mental State Examination (MMSE)5 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, Scanlan, Watanabe, et al., 2005) or Sweet 16 (Fong et al., 2010) can also be used to screen and monitor cognitive function; is not adversely influenced by age, language, and education; and it takes about half as much time to administer and score as the MMSE.

3. Informant Questionnaire on Cognitive Decline in the Elderly (IQCDE) is useful to supplement testing with the MMSE or Mini-Cog because it is useful to determine onset, duration, and functional impact of the cognitive impairment. Information from intimate others can be obtained by using the IQCDE.7

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.4 Furthermore, observations should be standardized by using a formal observation instrument such as the Nurses' Observation Scale for Cognitive Abilities (NOSCA) (Persoon, 2010).

C. When to Assess Cognitive Function

1. On admission to and discharge from an institutional care setting (Ref 8; Shekelle et al., 2001).8

2. Upon transfer from one care setting to another (Shekelle et al., 2001).

3. During hospitalization, every 8 to 12 hours throughout hospitalization (http://www.mc.vanderbilt.edu/icudelirium/).

4. As follow-up to hospital care, within 6 weeks of discharge (Shekelle et al., 2001).

5. Before making important health care decisions as an adjunct to determining an individual’s capacity to consent (Shekelle et al., 2001).

6. On the first visit to a new care provider (Shekelle et al., 2001)

7. Following major changes in pharmacotherapy (Shekelle et al., 2001).

8. With behavior that is unusual for the individual and/or inappropriate to the situation.9

D. Cautions for Assessing Cognitive Function

1. Physical environment:10

a. Comfortable ambient temperature.

b. Adequate lighting (not glaring).

c. Free of distractions (e.g., should be conducted in the absence of others and other activities).

d. Position self to maximize individual’s sensory abilities.

2. Interpersonal environment11

a. Prepare individual for assessment.

b. Initiate assessment within nonthreatening conversation.

c. Let individual set pace of assessment.

d. Be emotionally nonthreatening.

3. Timing of assessment4

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 procedures.

iv. In the presence of pain or discomfort.

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.

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. The Registered Nurse Association of Ontario Best Practice Guideline for Screening for Delirium, Dementia and Depression in Older Adults. Retrieved from http://rnao.org/Page.asp?PageID=924&ContentID=818

B. Guidelines and Protocols Advisory Committee (GPAC) guideline. Cognitive impairment in the elderly--recognition, diagnosis, management. Retrieved from http://www.bcguidelines.ca/gpac/guideline_cognitive.html

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 National Guideline Clearinghouse. Delirium, dementia, amnestic, cognitive disorders. Retrieved from http://www.guideline.gov/by-topic-detail.aspx?id=13949

References

1. Inouye, S. K., Foreman, M. D., Mion, L. C., Katz, K. H., & Cooney, L. M., Jr. (2001). Nurses’ recognition of delirium and its symptoms: Comparison of nurse and researcher ratings. Archives of Internal Medicine, 161, 2467–2473. Evidence Level IV: Nonexperimental Study.

3. (APA). American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.

4. Foreman, M. D., Fletcher, K., Mion, L. C., & Trygstad, 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: Springer Publishing Company. Evidence Level VI: Expert Opinion.

5. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). “Mini-MentalState”: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189–198. Evidence Level IV: Nonexperimental Study.

7. Jorm, A. (1994). A short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): Development and cross-validation. Psychological Medicine, 24, 145–153.Evidence Level IV: Nonexperimental Study.

8. British Geriatrics Society Guidelines. (2005). Guidelines for the prevention, diagnosis, and management of delirium in older people in hospital. Retrieved from http://www.bgs.org.uk/publications/Publications%20Downloads/Delirium-200... Level I.

9. Foreman, M. D., & Vermeersch, P. E. H. (2004). Measuring cognitive status. In M. Frank-Stromborg & S. J. Olsen (Eds.), Instruments of clinical health-care research (3rd ed., pp. 100–127). Sudbury, MA: Jones and Bartlett. Evidence Level I: Systematic Review.

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

11. 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.

Shekelle, P.G., MacLean, C.H., Morton, S.C., & Wenger, N.S. (2001). ACOVE quality indicators. Annals of Internal Medicine, 135(8 Pt 2) 653-667. Evidence Level I.

Borson, S., Scanlan, J.M., Watanabe, J., Tu, S.P., & Lessiq, M. (2005). Simplifying detection of cognitive impairment: Comparison of the Mini-Cog and Mini-Mental state examination in a multiethnic sample. Journal of the American Geriatrics Society, 53(3), 871-874. Evidence Level IV.

Fong, T.G., Jones, R.N., Rudolph, J.L., Yang, F.M., Tommet, D., Habtemariam, D.,...Inouye, S.K. (2010). Development and validation of a brief cognitive assessment tool: The Sweet 16. Archives of Internal Medicine, 171(5), 432-437. Evidence Level IV.

Persoon, A. (2010). Development and validation of the Nurse Observation Scale for Cognitive Abilities - NOSCA (Doctoral thesis, Radbound University, Nijmegen, The Netherlands). Evidence Level IV.

Last updated - July 2012

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