Cognitive Functions In Old Age and Nursing Management
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
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
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).