Cognitive Functions in Older Adults Cognitive Functions in Old Age and Nursing Management
Assessment Methods, Screening Techniques, and Precautions for Evaluating Cognitive Functioning; Nursing Care for Cognitive Dysfunction
Assessing Cognitive Function
Cognitive functioning encompasses perception, memory, and thinking—the processes through which an individual perceives, recognizes, registers, stores, and utilizes information (Foreman & Vermeersch, 2004). Cognitive abilities can be influenced both positively and negatively by illness and its treatment. Therefore, evaluating a person’s cognitive function is crucial for identifying specific pathological conditions such as dementia and delirium, monitoring the effectiveness of various health interventions, and determining an individual’s readiness to learn and ability to make decisions (Foreman & Vermeersch, 2004).
Despite the significance of assessing cognitive functioning, healthcare professionals often neglect this critical evaluation (Foreman & Milisen, 2004). This omission can lead to serious consequences, including the failure to detect potentially reversible cognitive impairments and even death (Inouye, Foreman, Mion, Katz, & Cooney, 2001). Early recognition through routine cognitive assessments can prevent or mitigate adverse outcomes associated with cognitive decline (Foreman & Milisen, 2004).
Background and Statement of the Problem
Declines in cognitive functioning are characteristic of aging (McEvoy, 2001); however, most age-related cognitive changes are not pathological. Examples of non-pathological changes include reduced ability to learn complex information, delayed response times, and minor recent memory loss. These declines are particularly evident in complex tasks or those requiring multiple steps to complete (McEvoy, 2001).
Pathological conditions of cognitive impairment that are prevalent among older adults include delirium, dementia, and depression. There are protocols to prevent and treat delirium and to slow the progression of dementia (Protocol 8.1). However, these interventions are only effective when these conditions are detected early, which is possible only through systematic assessment of cognitive function (Chow & MacLean, 2001; Registered Nurses’ Association of Ontario, 2003). Without systematic assessment, these pathological conditions may go unnoticed, leading to accelerated cognitive and functional decline and increased mortality (Fick, Agostini, & Inouye, 2002; Fick & Foreman, 2000; Hopkins & Jackson, 2006; Lang et al., 2006).
Despite these severe negative outcomes, healthcare providers often fail to assess cognitive function (Ely et al., 2004; Foreman & Milisen, 2004; Inouye et al., 2001). Yet, assessing cognitive function is the first and most crucial step in implementing strategies to prevent, reverse, halt, or minimize cognitive decline (Chow & MacLean, 2001; Registered Nurses’ Association of Ontario, 2003).
Reasons for Assessing Cognitive Functioning
There are several reasons for evaluating an individual’s cognitive functioning:
- Screening: To determine the presence or absence of cognitive impairment. While bedside screening methods are not sufficient on their own to diagnose specific pathological conditions like delirium or dementia, they are essential for early detection of impairment. Screening also helps assess an individual’s readiness to learn and capacity to consent (Shekelle, MacLean, Morton, & Wenger, 2001). Early detection allows for timely and accurate treatment initiation to reverse, halt, or slow the progression of impairment (Chow & MacLean, 2001; Registered Nurses’ Association of Ontario, 2003).
- Monitoring: To track cognitive function over time, especially in response to treatment, by observing the progression or regression of impairment (Registered Nurses’ Association of Ontario, 2003; Shekelle et al., 2001).
How to Assess Cognitive Functioning
For assessing cognitive functioning, the Mini-Mental State Examination (MMSE) developed by Folstein, Folstein, and McHugh (1975) is the most commonly recommended tool (British Geriatrics Society Clinical Guidelines, 2005; Fletcher, 2007; Registered Nurses’ Association of Ontario, 2003). The MMSE is a brief instrument consisting of 11 items and takes about 7–10 minutes to administer. It assesses orientation, attention, memory, concentration, language, and constructional ability (Tombaugh & McIntyre, 1992).
Each question is scored as either correct or incorrect, with a total score ranging from 0 to 30, reflecting the number of correct responses. A score below 24 is considered indicative of cognitive impairment (Tombaugh & McIntyre, 1992).
Methods for Screening
Although the MMSE is considered the best available screening method for impairment, performance on the MMSE can be significantly influenced by factors such as education level (individuals with less than an 8th-grade education may make more errors), language proficiency (those for whom English is not the primary language may commit more errors), and verbal ability (the MMSE requires verbal responses). Age is also a factor, as older individuals tend to score lower (Tombaugh & McIntyre, 1992). Additionally, some argue that the MMSE takes too long to administer in fast-paced healthcare environments (Borson, Scanlan, Watanabe, Tu, & Lessig, 2005).
Limitations of the MMSE
To address the limitations of the MMSE while maintaining practicality, the Mini-Cog was developed (Borson, Scanlan, Brush, Vitaliano, & Dokmak, 2000). The goal was to create a brief screening test that requires no special equipment or extensive training and is not adversely affected by age, education, or language (Borson et al., 2000; Borson, Scanlan, Watanabe, et al., 2005).
The Mini-Cog is a four-item screening test consisting of a three-item recall (similar to the MMSE) and a clock-drawing task (e.g., drawing a clock face, numbering it, and setting the hands to a specific time like 11:10). Since its development, the Mini-Cog has been used with diverse populations from different cultural, educational, age, and language backgrounds. A systematic review reported that the Mini-Cog is suitable for routine cognitive impairment screening (Brodaty, Low, Gibson, & Burns, 2006), and it has been 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 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. Unlike the MMSE and Mini-Cog, it requires no pen, paper, or props, making it potentially more appropriate for frail older patients in acute hospital settings where the ability to write or manipulate objects may be limited due to factors other than cognitive impairment (e.g., IV tubing, positioning in bed). Initial validation suggests that the Sweet 16 performs equivalently or superiorly to the MMSE; however, further research is needed to validate it fully (Fong et al., 2010).
While the MMSE, Mini-Cog, and Sweet 16 are useful as simple bedside cognitive screens, they are only qualified to determine the presence or absence of cognitive impairment. They cannot diagnose whether the impairment is due to delirium, dementia, or depression. If the results indicate impairment, further in-depth evaluation is necessary to confirm a diagnosis and identify any underlying health problems.
When to Assess Cognitive Functioning
Deciding when and how frequently to assess cognitive functioning depends on the purpose of the assessment, the patient’s condition, and prior or current test results. Recommendations for systematic cognitive assessments using standardized and validated tools include:
- On Admission and Discharge: Evaluate cognitive function upon admission to and discharge from an institutional care setting (British Geriatrics Society Clinical Guidelines, 2005; Shekelle et al., 2001).
- During Transitions: Assess when transferring from one care setting to another (Shekelle et al., 2001).
- Regular Intervals: During hospitalization, assess every 8–12 hours throughout the stay to monitor changes.
- Follow-Up Care: Conduct assessments within six weeks of discharge as part of follow-up care (Shekelle et al., 2001).
- Before Critical Decisions: Evaluate cognitive function before making important healthcare decisions to assist in determining an individual’s capacity to consent.
- Medication Changes: Assess following major changes in pharmacotherapy (Shekelle et al., 2001).
- Behavioral Changes: Evaluate when the individual exhibits behavior that is unusual or inappropriate for them (Foreman & Vermeersch, 2004).
It is also recommended that formal cognitive testing be supplemented with information from close relatives or intimate others (Cole et al., 2002; Registered Nurses’ Association of Ontario, 2003) and from observations made during routine interactions (Foreman, Fletcher, Mion, & Trygstad, 2003). One method for obtaining information from intimate others is through the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE; Jorm, 1994). Information from close associates assists in determining the duration of impairment, which is crucial for differentiating between delirium and dementia.
Observations during daily care activities (e.g., bathing, feeding, transferring) may reveal inattentiveness or unusual responses, indicating the need for formal assessment using one of the aforementioned instruments. However, formal assessment may not always be possible (e.g., if the patient is too ill). In such cases, naturally occurring observations are based on routine contacts in a natural setting rather than a formal test environment.
One criticism of naturally occurring observations is the lack of standardization (Persoon et al., 2010). To address this, Persoon and colleagues developed and validated the Nurses’ Observation Scale for Cognitive Abilities (NOSCA; Persoon et al., 2010). Using this instrument, nurses can comprehensively and non-threateningly evaluate cognitive functioning, including consciousness, attention, perception, orientation, memory, thoughts, higher cognitive functions, language, and praxis.
Cautions for Assessing Cognitive Functioning
Several environmental factors should be considered to ensure that the assessment results accurately reflect the individual’s abilities and are not influenced by external factors. The ideal assessment environment should maximize comfort and privacy for both the assessor and the individual, enhancing performance by optimizing the individual’s ability to participate in the assessment process (Dellasega, 1998).
To achieve this, the room should be well-lit with comfortable ambient temperature. Lighting must be balanced to be sufficient for the individual to see the examination materials without causing glare. The environment should be free from distractions such as extraneous noise, scattered materials, or visually distracting clothing and jewelry worn by the assessor (Lezak, Howieson, & Loring, 2004).
Preparing the individual for the assessment by explaining what will take place and how long it will take can reduce anxiety and create a non-threatening environment, fostering a safe assessor-individual relationship (Engberg & McDowell, 2000). Performing the assessment in the presence of others should be avoided when possible, as others may be distracting or may inadvertently influence the individual’s responses. For instance, significant others may provide answers or make comments that heighten anxiety.
Older adults may be particularly sensitive to any suggestion that they have a “memory problem,” so it is important to stress the importance of the assessment without increasing anxiety. Describing the assessment as consisting of “simple,” “silly,” or “stupid” questions can be counterproductive, decreasing motivation and increasing anxiety when errors are made.
The assessment can be perceived as intrusive, intimidating, fatiguing, and offensive, which can negatively affect performance. Therefore, Lezak et al. (2004) recommend an initial period to establish rapport with the individual. This period allows the assessor to determine the individual’s capacity for assessment and identify any conditions that could alter performance or interpretation of results, such as sensory impairments.
The assessor can then adjust the testing environment accordingly, such as positioning themselves appropriately to facilitate communication and reduce glare. Additionally, assessments should be scheduled appropriately, avoiding times immediately upon awakening, before and after meals, during medical procedures, or when the individual is in pain or discomfort (Foreman et al., 2003).
Nursing Care for Cognitive Dysfunction
Nurses play a critical role in assessing cognitive function and implementing interventions to manage cognitive dysfunction. Key nursing care strategies include:
- Early Detection: Regular cognitive assessments to identify impairments promptly.
- Individualized Care Plans: Developing care plans tailored to the individual’s cognitive abilities and needs.
- Environmental Modifications: Creating a safe and supportive environment that minimizes distractions and reduces anxiety.
- Education and Support: Providing education to patients and their families about cognitive impairment and available interventions.
- Interdisciplinary Collaboration: Working with other healthcare professionals to coordinate care and optimize outcomes.
- Monitoring and Evaluation: Continuously monitoring cognitive function and adjusting care plans as needed based on the individual’s response to interventions.
By adhering to these strategies, nurses can effectively manage cognitive dysfunction in older adults, improving their quality of life and potentially slowing the progression of cognitive decline.