Levels of evidence (I – VI) are defined at the end of the "Major Recommendations" field.
Parameters of Assessment
No formal recommendations for cognitive screening are indicated in asymptomatic individuals. Clinicians are advised to be alert for cognitive and functional decline in older adults to detect dementia and dementia-like presentation in early stages. Assessment domains include cognitive, functional, behavioral, physical, caregiver, and environment.
- Cognitive Parameters
- Orientation: person, place, time
- Memory: ability to register, retain, recall information
- Attention: ability to attend and concentrate on stimuli
- Thinking: ability to organize and communicate ideas
- Language: ability to receive and express a message
- Praxis: ability to direct and coordinate movements
- Executive function: ability to abstract, plan, sequence, and use feedback to guide performance
- Mental Status Screening Tools
- Folstein Mini-Mental State Examination (MMSE) (Folstein, Folstein & McHugh, 1975 [Level IV]): the most commonly used test to assess serial cognitive change. On average, the MMSE declines 3 points per year in those with Alzheimer's disease (AD) (Han et al., 2000 [Level I]). It is composed of items assessing orientation, attention, concentration, memory, language, and construction ability. Age, education, cultural background, and perceptual and physical abilities can affect performance. The MMSE might not detect mild cognitive loss and, as well, it is not diagnostic of decision-making capacity (Parker & Philp, 2004 [Level VI]).
- Clock Drawing Test (CDT) (Royall et al., 1999 [Level IV]): a useful measure of cognitive function that correlates with executive-control functions (i.e., the cognitive process necessary to plan and carry out goal-directed behaviors). The patient is asked to draw a clock free-hand, put in all the numbers, and set a time asked for by the examiner. Physical ability and dexterity can influence performance.
- Mini-Cognitive (Mini-Cog) (Borson et al., 2003 [Level IV]) combines the Clock Drawing Test with the three-word recall. The patient is asked to remember three unrelated words and later is asked to recall the three words. This clinically useful tool, rapidly administered, has a high level of sensitivity and specificity and less bias than some other instruments (e.g., the MMSE) (Borson et al., 2003 [Level IV]). See Resources section in www.ConsultGeriRN.org Mini-Cog tool.
- When the diagnosis remains unclear, the patient may be referred for more extensive screening and neuropsychological testing, which might provide more direction and support for the patient and the caregivers.
- Functional Assessment
- Behavioral Assessment
- Assess and monitor for behavioral changes; in particular, the presence of agitation, aggression, anxiety, disinhibitions, delusions, and hallucinations.
- Evaluate for depression because it commonly coexists in individuals with dementia (Zubenko et al., 2003 [Level IV]). Symptoms and signs may include the presence of neurovegetative signs (e.g., hypersomnia, insomnia, increased or decreased appetite, decreased energy, weight loss or gain, psychomotor agitation or slowing) or mood changes (e.g., depressed mood, feelings of worthlessness or helplessness, suicidal ideation). Determine if there is a diminished level of interest in life. Is there a lack of motivation, decreased initiation, or a poor ability to sustain effort? See www.consultgeriRN.org for Depression assessment tools.
- Physical Assessment
- A comprehensive physical examination with a focus on the neurological and cardiovascular system is indicated in individuals with dementia to identify the potential cause and/or the existence of a reversible form of cognitive impairment.
- A thorough evaluation of all prescribed, over-the-counter, homeopathic, herbal, and nutritional products taken is done to determine the potential impact on cognitive status.
- Laboratory tests are valuable in differentiating irreversible from reversible forms of dementia. Structural neuroimaging with noncontrast computed tomography (CT) or magnetic resonance imaging (MRI) scans are appropriate in the routine initial evaluation of patients with dementia.
- Caregiver/Environment
- The caregiver of the patient with dementia often has as many needs as the patient with dementia; therefore, a detailed assessment of the caregiver and the caregiving environment is essential.
- Elicit the caregiver perspective of patient function and the level of support provided.
- Evaluate the impact that the patient's cognitive impairment and problem behaviors have on the caregiver (mastery, satisfaction, and burden). Two useful tools include the Zarit Burden Interview (ZBI) (Bedard et al., 2001 [Level IV]) and the Caregiver Strain Index (CSI) Tool (Robinson, 1983 [Level IV]). For CSI see www.ConsultGeriRN.org, Caregiving Topic.
- Evaluate the caregiver experience and patient–caregiver relationship. The caregiving experience is a stressful one and the potential for elder mistreatment and caregiver illness exists.
Nursing Care Strategies
Based on evidence provided under the Interventions and Care Strategies in the guideline document, specifically, use of the PLST that provides a framework for the nursing care of individuals with dementia (Smith et al., 2006 [Level V]).
- Monitor the effectiveness and potential side effects of medications given to improve cognitive function or delay cognitive decline.
- Provide appropriate cognitive-enhancement techniques and social engagement.
- Ensure adequate rest, sleep, fluid, nutrition, elimination, pain control, and comfort measures.
- Avoid the use of physical and pharmacologic restraints.
- Maximize functional capacity: Maintain mobility and encourage independence as long as possible, provide graded assistance as needed with ADLs and IADLs, provide scheduled toileting and prompted voiding to reduce urinary incontinence, encourage an exercise routine that expends energy and promotes fatigue at bedtime, establish bedtime routine and rituals.
- Address behavioral issues: Identify environmental triggers, medical conditions, caregiver–patient conflict that may be causing the behavior, define the target symptom (i.e., agitation, aggression, wandering) and pharmacological (psychotropics) and nonpharmacological (manage affect, limit stimuli, respect space, distract, redirect) approaches, provide reassurance; refer to appropriate mental-health care professionals as indicated.
- Ensure a therapeutic and safe environment: Provide an environment that is modestly stimulating, avoiding overstimulation that can cause agitation and increase confusion, and understimulation that can cause sensory deprivation and withdrawal. Utilize patient identifiers (name tags), medic alert systems and bracelets, locks, wander guard; eliminate any environmental hazards and modify the environment to enhance safety; provide environmental cues or sensory aides that facilitate cognition; maintain consistency in caregivers and approaches.
- Encourage and support advance-care planning: Explain trajectory of progressive dementia, treatment options, and advance directives.
- Provide appropriate end-of-life care in terminal phase: Provide comfort measures including adequate pain management; weigh the benefits/risks of the use of aggressive treatment (tube feeding, antibiotic therapy).
- Provide caregiver education and support: Respect family systems/dynamics and avoid making judgments, encourage open dialogue, emphasize the patient's residual strengths, provide access to experienced professionals, teach caregivers the skills of caregiving.
- Integrate community resources into the plan of care to meet the needs for patient and caregiver information; identify and facilitate both formal (i.e., Alzheimer's Association, Respite Care, Specialized Long Term Care) and informal (i.e., churches, neighbors, extended family/friends) support systems.
Follow-up to Monitor Condition
- Follow-up appointments are regularly scheduled; frequency depends on the patient's physical, mental, and emotional status and caregiver needs.
- Determine the continued efficacy of pharmacological/nonpharmacological approaches to the care plan and modify as appropriate.
- Identify and treat any underlying or contributing conditions.
- Community resources for education and support are accessed and utilized by the patient and/or caregivers.
Definitions:
Levels of Evidence
Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)
Level II: Single experimental study (randomized controlled trials [RCTs])
Level III: Quasi-experimental studies
Level IV: Non-experimental studies
Level V: Care report/program evaluation/narrative literature reviews
Level VI: Opinions of respected authorities/Consensus panels
Reprinted with permission from Springer Publishing Company: Capezuti, E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) Evidence Based Geriatric Nursing Protocols for Best Practice, (3rd ed). New York: Springer Publishing Company.
