Note from the National Guideline Clearinghouse (NGC): In this update of the guideline, the process previously used to develop the geriatric nursing protocols has been enhanced.
Levels of evidence (I – VI) are defined at the end of the "Major Recommendations" field.
Assessment of Cognitive Function
- Reasons/Purposes of Assessment
- Screening: to determine the absence or presence of impairment (Foreman et al., 2003 [Level VI]).
- Monitoring: to track cognitive status over time, especially response to treatment (Foreman et al., 2003 [Level VI]).
- How to Assess Cognitive Function
- Mini-Mental State Examination (MMSE) (Folstein, Folstein & McHugh, 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.
- 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 it takes about half as much time to administer and score as the MMSE.
- IQCDE (Informant Questionnaire on Cognitive Decline in the Elderly) 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 (Jorm, 1994 [Level IV]).
- 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]).
- When to Assess Cognitive Function
- On admission to and discharge from an institutional care setting (Shekelle et al., 2001 [Level I]; British Geriatric Society, 2005 [Level I]).
- On transfer from one care setting to another (Shekelle et al., 2001 [Level I]).
- 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 (Shekelle et al., 2001 [Level I]).
- Before making important health care decisions as an adjunct to determining an individual's capacity to consent (Shekelle et al., 2001 [Level I]).
- On the first visit to a new care provider (Shekelle et al., 2001 [Level I]).
- Following major changes in pharmacotherapy (Shekelle et al., 2001 [Level I]).
- With behavior that is unusual for the individual and/or inappropriate to the situation (Foreman & Vermeersch, 2004 [Level I]).
- Cautions for Assessing Cognitive Function
- Physical environment (Dellasega, 1998 [Level VI]).
- Comfortable ambient temperature.
- Adequate lighting (i.e., not glaring).
- Free of distractions (e.g., should be conducted in the absence of others and other activities).
- Position self to maximize individual's sensory abilities.
- Interpersonal environment (Engberg & McDowell, 1999 [Level VI])
- Prepare individual for assessment.
- Initiate assessment within nonthreatening conversation.
- Let individual set pace of assessment.
- Be emotionally nonthreatening.
- Timing of assessment (Foreman et al., 2003 [Level VI])
- Select time of assessment to reflect actual cognitive abilities of the individual.
- Avoid the following times:
- Immediately on awakening from sleep; wait at least 30 minutes.
- Immediately before and after meals.
- Immediately before and after medical diagnostic or therapeutic procedures.
- In the presence of pain or discomfort.
Follow-up Monitoring
- Provider competence in the assessment of cognitive function
- Consistent and appropriate documentation of cognitive assessments
- Consistent and appropriate care and follow-up in instances of impairment
- Timely and appropriate referral for diagnostic and treatment recommendations
Definitions:
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.