Assessment of Cognitive Functions in Older Adults

Afza.Malik GDA

Cognitive Functions In Old Age and Nursing Management

Assessment of  Cognitive Functions in Older Adults
Assessment,methods of screening and cautions for cognitive functioning.Nursing care for cognitive dysfunction.

Assessing Cognitive Function

    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 an 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).

   Ooutcomes that could be prevented or minimized by early recognition of their existence afforded by the routine assessment of cognitive functioning (Foreman &Milisen , 2004).

Background And Statement Of Problem

    Declines in cognitive functioning are a hallmark of aging (McEvoy, 2001); 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.

    Minor loss of recent memory, declines are especially evident with complex tasks or with those requiring multiple steps for completion (McEvoy, 2001).

    Pathological conditions of cognitive impairment that are prevalent with aging include delirium, dementia, and depression. 

    There are protocols to prevent and treat delirium, and protocols to slow the progression of decline with dementia (Protocol 8.1; however, these opportunities exist only when and if these conditions are detected early, and the possibility of early detection exists only when cognitive function is assessed systematically (Chow & MacLean. 2001; Registered Nurse Association of Ontario, 2003).

    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 , Agostini, & Inouye, 2002; Fick & Foreman, 2000; Hopkins & Jackson, 2006; Lang et al., 2006).

    Despite these profoundly negative consequences, nurses and physicians fail to access cognitive function (Ely et al., 2004; Foreman &Milisen , 2004; Inouye et al., 2001). 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: Registered Nurse Association of Ontario, 2003).

Reasons for Assessing Cognitive Functioning

    There are several reasons for assessing an individual's cognitive functioning: Screening is conducted to determine the presence or absence of impairment. Bedside screening methods, however, 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 ( Shekelle , MacLean, Morton, & Wenger, 2001). 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; Registered Nurse Association of Ontario, 2003). 

    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 (Registered Nurse Association of Ontario, 2003; Shekelle et al. , 2001).

 How to Assess Cognitive Functioning

     For assessing cognitive functioning, Folstein's Mini-Mental State Examination (MMSE; Folstein , Folstein , & McHugh, 1975) is the most frequently recommended instrument (British Geriatrics Society Clinical Guidelines, 2005: Fletcher, 2007: Registered Nurse Association of Ontario, 2003 ) . 

    The MMSE is a brief instrument, consisting of 11 items and taking about 7-10 minutes to complete. It is composed of items assessing orientation, attention, memory, concentration, language, and constructional ability (Tombaugh &McIntyre, 1992). 

    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).

Method for Screening 

    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).

    Age (older people do less well: Tombaugh & McIntyre, 1992). Others contend that the MMSE takes too long to administer in hectic, fast-paced health care environments (eg, more than 10 minutes; Borson , Scanlan, Watanabe, Tu, & Lessig, 2005).

MMISE Limitations 

    To minimize the limitations of the MMSE while maximizing practical aspects of assessing cognitive function, the Mini-Cog was developed ( Borson , Scanlan, Brush, Vitaliano, &Dokmak , 2000). 

    The aim was to have a brief screening test that required no equipment and little training to use while not being negatively influenced by age, education, or language ( Borson , Scanlan, Brush, et al., 2000; Borson , Scanlan, Watanabe , et al., 2005). 

    The Mini-Cog is a four-item screening test consisting of three-item recall similar to the MMSE, and a clock-drawing item (eg, draw the face of a clock, number the dock face. and place the hands on the clock face to indicate a specific time such as 11:10).

    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 routine screening for cognitive impairment ( Brodary , Low, Gibson, & Burns, 2006) and, even more recently, was found to predict the development of in hospital delirium ( Alagiakrishnan et al., 2007).

The Sweet 16

    Another brief cognitive assessment tool (The Sweet 16) has recently been developed to address the aforementioned limitations of the MMSE. It is reported to be an easy-to-use instrument that can be completed in 2-3 minutes. 

    In contrast to MMSE and Mini-Cog, it requires no pen, paper, or props to administer. It may be, therefore, more appropriate in frail older patients admitted to an acute hospital setting in which ability to write and manipulate props may be limited for reasons other than cognitive impairment (IV tubing, positioning in bed, etc.). 

    Initial validation of the Sweet 16 indicates its performance to be equivalent or superior to that of the MMSE; however, much more research is needed to further validate the Sweet 16 (Fong et al., 2010).

    With respect to MMSE, Mini-Cog, and Sweet 16, they are classified as simple bedside cognitive screens. This means that they are all qualified for determining the presence or absence of cognitive impairment; however, none are capable of determining if the impairment is delirium, dementia, or depression. 

    If the results of this cognitive assessment or screening indicate the individuals to be impaired, further in-depth evaluation is necessary to confirm a diagnosis of dementia, depression, delirium, or some other health problem.

Assess Cognitive Functioning

     When and how frequently to assess cognitive functioning, either using the MMSE, Mini-Cog, or Sweet 16, 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 (British Geriatrics Society Clinical Guidelines, 2005; Shekelle et al., 2001)

    On transfer from one care setting to another ( Shekelle et al., 2001); during hospitalization, every 8-12 hours throughout hospitalization as follow-up to hospital care, within 6 weeks of discharge ( Shekelle et al., 2001)

    Before making important health care decisions as an adjunct to determining an individual's capacity to consent: on the first visit to a new care provider; following major changes in pharmacotherapy ( Shekelle et al., 2001); and with behavior that is unusual for the individual and/or inappropriate to the situation (Foreman & Vermeersch, 2004).

    It is also recommended that formal cognitive testing be supplemented with information from close intimate others (Cole et al., 2002; Registered Nurse Association of Ontario, 2003) and from naturally occurring observations and conversations (Foreman, Fletcher, Mion, &Trygslad , 2003 ). 

    One method for obtaining information from intimate others (Cole et al., 2002) is through the use of the Informant Questionnaire on Cognitive Decline in the Elderly (1QCDE: Jorm , 1994), 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. 

    Whereas naturally occurring observations and conversations during everyday nursing care activities in which it becomes apparent that the individual is inattentive, and responding unusually or inappropriately to conversation or questioning may be the first indication of the need to formally assess the individual's cognitive functioning by using one of the aforementioned instruments. 

    However, formal assessment is not always possible (eg, patient is too sick for formal testing). In contrast with formal testing, naturally occurring observations are based on daily and routine contacts with the patient (eg, during bathing, feeding, transferring the patient) in a natural setting (eg, not in a formal test setting). 

    One criticism of naturally occurring observations ( Persoon , 2010) is that they lack standardization. Since well-validated observation scales are scarce and cognitive functioning is often assessed in a limited way by these instruments, Person and colleagues recently developed and validated the new Nurses' Observation Scale for Cognitive Abilities (NOSCA; Person , 2010). 

    By using this instrument, nurses can easily and in a nonthreatening way-evaluate the patients cognitive functioning in a comprehensive way (eg, consciousness, attention, perception, orientation, memory, thoughts, higher cognitive functioning, language, and praxis). 

Cautions for Assessing Cognitive Functioning 

    Various characteristics of the physical environment should be considered to ensure that the results of the cognitive 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. The environment should enhance performance by maximizing the individual's ability to participate in the assessment process ( Dellasega , 1998). 

    To accomplish this, the room should be well lit and of comfortable able ambient temperature. Lighting must be balanced to be sufficient for the individual to adequately see the examination materials, while not being so bright that it creates glare. 

    Additionally, the 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 ). 

    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 emotion-ally nonthreatening environment and a safe individual-assessor relationship (Engberg & McDowell, 2000). 

    Performing the assessment in the presence of others should be avoided when possible because the other individual may be distracting. If the other is a significant intimate relative, additional problems may 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 height ens anxiety. 

    Rarely does the presence of another facilitate the performance of an individual on cognitive assessment. Older adults are especially sensitive to any hint 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. 

    Furthermore, it can be counterproductive to describe the assessment as consisting of “simple,” “silly,” or “stupid” questions. Such explanations tend to decrease motivation to perform and only heighten anxiety when errors are committed.

    The assessment can be perceived by the individual as intrusive, intimidating, fatigued, and offensive characteristics that can seriously and negatively affect performance.

     Consequently, Lezak et al., 2004 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, do conditions exist that could alter the performance of the individual or interpretation of results such as sensory decreases? As a consequence, the assessor can alter the testing environment through simple methods (eg, by taking a position across from the individual or a little to the side). 

    In this position, the individual can readily use the assessor's nonverbal communication as well as read the assessor's lips. Positioning is also important relative to lighting and glare.

    Finally, avoid assessment periods immediately upon awakening from sleep (wait at least 30 minutes); immediately before and after meals, medical diagnostic, or therapeutic procedures; and when the individual is in pain or is uncomfortable (Foreman et al., 2003).

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