MODULE 5.

COGNITIVE / MENTAL STATUS ASSESSMENT

Module 5. Cognitive/Mental Status Assessment

Maureen Matthews, RN, MSN, CS, PhD Editor: Conchita Rader, MA, RN

Staff Development Partners Edition Instructor Guide

THIS MODULE INCLUDES: 1. 2. 3. Expected Staff Cognitive Competencies Expected Staff Clinical Competencies Content Outline including Learning Activities a. REMINDER TO INSTRUCTOR: Read activities in Instructor Guide and prepare materials for activities in advance 4. Scripted PowerPoint Presentation 5. 10-item Post Test 6. Resources

EXPECTED STAFF (Cognitive) COMPETENCIES 1. Identify the importance of mental status assessment in older adults

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MODULE 5. COGNITIVE / MENTAL STATUS ASSESSMENT 2. 3. 4. Define and identify the components of mental status assessment. Assess mental status using validated tool Folstein Mini-Mental Status Examination (MMSE) identifying strengths and limitations of the tool. Assess mood using validated tool Yesavage Geriatric Depression Scale (GDS) and Cornell Depression Scale (CDS) identifying strengths and limitations of the tools.

EXPECTED STAFF (Clinical) COMPETENCIES

Behaviors How validated
Novice Advanced Beginner Competent Proficient Expert

1. Accurately assess cognitive function of an older adult client who is experiencing sensory loss, or has a limited English proficiency.

2. Accurately score a patients mental status using one of the validated tools: MiniMental Status Exam, Geriatric Depression Scale, and Cornell Scale for Depression in Dementia

Direct observation and accurate documentation Group or Individual Clinical Project: such as a Translation project for the Mini-Mental Status Examination (MMSE), Geriatric Depression Scale (GDS), or the Cornell Depression Scale (CDS) Direct observation and accurate documentation of findings

3. Initiates referrals and follow- up visits for older adult clients identified having a score of >5 using the Yesavage Geriatric Depression Scale (GDS), and those who scored 12 or above using the Cornell Scale for Depression in Dementia (CSDD)

Direct observation using cognitive and mental assessment tool

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MODULE 5. COGNITIVE / MENTAL STATUS ASSESSMENT Competency 1. Identify the importance of mental status assessment in older adults. A. Cognitive function encompasses the processes by which an individual perceives, registers, retrieves, and uses information. There are several categories of cognitive decline in older adults. These are: A.1. The dementias (e.g. Alzheimers, vascular). These are chronic, progressive, insidious, and permanent states of cognitive impairment; A.2. Delirium / acute confusion acute and sudden impairment of cognition considered temporary, but generally an identifiable, biophysical cause; and A.3. Impaired thought process B. Cognitive assessment can (1) identify the presence of and monitor the course of dementia, depression, or delirium; (2) determines the individuals readiness to learn, and (3) evaluate the effectiveness of a treatment regimen. The mental status of older adults upon admission to a hospital setting is predictive of behavioral problems during their hospitalization. Therefore, assessment of the older adults mental status is an effective way for staff to identify older patients who are more likely to develop behavioral problems during hospitalization.
C.

There is widespread debate about the value of cognitive screening of older adults. In general, cognitive screening could detect noncomplaining but impaired older adults whose deficits are not obvious. Up to 80% of all medical care for dementia occurs in primary care settings, including doctors offices, hospital settings and nursing homes. Among older adults who enter healthcare through outpatient services, dementia almost always are undiagnosed, and overall, only a few patients are screened unless the cognitive impairment is apparent. Studies have demonstrated that unrecognized delirium or cognitive deficits are present in 30 40% of older emergency department patients.1 Detecting cognitive dysfunction is important because it would change the work up, management, and the disposition of older patients.

D. Cognitive impairment and psychiatric symptoms are relatively common in the older adult, with an estimated 4 to 5 million older adults experiencing cognitive disorders. Of community-residing older adults, 5% aged 65 to 75 and 25 to 30% aged 85+ evidence dementia, most commonly Alzheimers disease. 60% of nursing home residents are demented.
E.

Memory skills are important to general cognitive functioning, and declining scores on tests of memory are indicators of general cognitive loss for older adults. Low cognitive functioning (i.e., memory impairment) is a major risk factor for entering a nursing home.2 The prevalence of moderate or severe memory impairment is slightly lower among older

Birrer, R., Singh,U., & Kumar, D. N. (1999, May). Disability and dementia in the emergency department. Emergency Medicine Clinics of North America, 17(2), 505-517. 2 Wygaard, H.A. and Albreksten, G.(1992). Risk factors for admission to a nursing home. A study of elderly people receiving home nursing. Scandinavian Journal of Primary Health Care 10, 128133.

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MODULE 5. COGNITIVE / MENTAL STATUS ASSESSMENT women than among older men. In 1998, memory impairment occurred among 35 percent of women age 85 or older, compared with 37 percent of men in the same age group. F. Mental status assessment screens for changes in cognition and mood, but does not provide a diagnosis of dementia. G. Quantified versions of mental status examination can be used to screen for cognitive and emotional disorders in older persons across a variety of settings. Measures of cognition provide systematic, standardized assessment and can be used to monitor older adults with cognitive impairments over time.

Competency 2. Define and identify the components of mental status assessment. A. Mental status assessment is designed to elicit cognitive abilities and deficits, emotional functioning, and basic intellectual functioning.
B.

The Components of Mental Status Assessment are:3 B.1. Alertness / Level of Consciousness this is the level of arousal or responsiveness to stimuli determined by interaction with individuals best eye, verbal, and motor response to stimuli (alert, lethargy, obtunded, stupor, coma) B.2. Attention the ability to focus on stimuli (can follow directions, easily distracted) B.3. Comprehension B.4. Construction - ability to accurately reproduce simple objects B.5. Emotional status B.6. Higher Memory Function ability to interpret, calculate, write, and constructional ability B.7. Insight ability to see and understand connections between objects and situations B.8. Intelligence the ability to respond to unknown situation B.9. Judgment ability to compare or evaluate a situation (real or hypothetical) and determine an appropriate action B.10. Memory ability to register, retain, and recall information both new and old B.11. Orientation to time, place, and person B.12. Perception presence / absence of illusions, delusions, or visual / auditory hallucinations B.13. Physical appearance clothing, grooming B.14. Psychomotor behavior ability to comprehend and perform simple motor skills B.15. Speech and language

Foreman, M. D., Fletcher, K., Mion, L. C., Trygstad, L. J., & the NICHE Faculty. (1999). Assessing cognitive function. In Abraham, I., Bottrell, M. M., Fulmer, T., & Mezey, M. (Eds.). Geriatric nursing protocols for best practice (pp. 51-62). New York: Springer Publishing Company.
3

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MODULE 5. COGNITIVE / MENTAL STATUS ASSESSMENT B.16. Thinking ability to organize and communicate ideas; thoughts should be organized, coherent, and appropriate

Competency 3. Assess mental status using validated tool Folstein Mini-Mental Status Examination (MMSE) identifying strengths and limitations of the tool.
A.

Mini-Mental State Exam (MMSE). This is a brief mental status exam designed to quantify cognitive ability and is able to measure changes in cognitive status over time. It is also used to identify the presence of organic disease. While the MMSE has limited specificity with respect to individual clinical syndromes, it represents a brief, standardized method by which to grade cognitive mental status. It assesses orientation, attention, immediate and short-term recall, language, and the ability to follow simple verbal and written commands. Furthermore, it provides a total score that places the individual on a scale of cognitive function. This measure takes approximately 10 minutes to administer.

Assess the level of consciousness along a continuum: Alert

Drowsy

Stupor

Coma

Scoring 24 30 = No Cognitive Impairment 18 - 23 = Mild Cognitive Impairment 00 17 = Severe cognitive impairment Those who score below 23 should be referred for follow-up. B.

Strengths of MMSE. MMSE is a valid, reliable screen for delirium and dementia, requiring 5 10 minutes to administer. It can be administered by clinicians or lay persons specifically trained to conduct the assessment. Limitations of MMSE. This instrument relies heavily on verbal response and reading and writing. A patient who has a hearing and / or visual loss, is intubated, or has a low English proficiency, and with communication disorders may perform poorly. Subjects in studies tend to perform differently across education or racial / ethnic groups as related to language, such as repeating phrases, or following commands.4 Older persons may score lower due to advanced age. Areas of cognitive functioning that are not assessed are judgment, insight, remote memory, mood or perceptual disturbances. Although this is valuable for screening cognitive deficits, it does not provide a diagnosis.

C.

Learning Activity. Role Play. Use the MMSE with one another. This will not only help to familiarize you with the mental status tool but also allow you to understand the anxiety patients experience when tested. Ask two participants to role-play the testing and then allow for comments and discussion from
4

Teresi, J. A., et al. (2001). Performance of cognitive tests among different racial/ethnic and education groups: findings of differential item functioning and possible item bias. Journal of Mental Health and Aging. 7(1), 79 89.

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MODULE 5. COGNITIVE / MENTAL STATUS ASSESSMENT the group. Following this demonstration, divide into groups of three. One participant will be the observer and cue the participants. For example, the observer might notice that the tester is giving hints to the person being tested. It is important to provide time for each participant to play each role in the exercise.

Competency 4. Assess mood using validated tool Yesavage Geriatric Depression Scale (GDS)5 and Cornell Depression Scale (CDS) identifying strengths and limitations of each tool
A.

The Geriatric Depression Scale (GDS) is used to screen for depression in older adults. Significant depression has been reported in 5% of the population aged 65 and older, however the incidence may be considerably higher. Depression is frequently misdiagnosed as dementia, and up to 32% of those referred for dementia evaluation actually suffer from depression. This misdiagnosis tends to occur because of a failure to accurately assess cognitive functioning. A.1. Instruction for use of the Short Form Geriatric Depression Assessment Tool

1. The same caregiver should administer this test each time. 2. Choose a quiet place, preferably the same location each time the test is
administered. 3. The administration of this test should NOT be immediately after some mental trauma or unsteady period. 4. Speak in a soft pleasant tone. 5. Answer all questions by circling the answer (yes or no) to the question. 6. Add the total number of BOLD FACED answers circled and record that number in the SCORE box.

Yesavage, J. A. (1986). The use of rating depression series in the elderly. In Poon (Ed.): Clinical memory assessment of older adults. American Psychological Association.

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7. Scores totaling five (5) points or more indicate probable depression.

Geriatric Depression Scale MOOD SCALE (Short form) NAME Room Physician Age: Sex Date Assessor

Choose the best answer for how you have felt over the past week:

1. Are you basically satisfied with your life? YES / NO 2. Have you dropped many of your activities and interests? YES / NO 3. Do you feel that your life is empty? YES / NO 4. Do you often get bored? YES / NO 5. Are you in good spirits most of the time? YES / NO 6. Are you afraid that something bad is going to happen to you? YES / NO 7. Do you feel happy most of the time? YES / NO 8. Do you often feel helpless? YES / NO 9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO 10. Do you feel you have more problems with memory than most? YES / NO 11. Do you think it is wonderful to be alive now? YES / NO 12. Do you feel pretty worthless the way you are now? YES / NO 13. Do you feel full of energy? YES / NO 14. Do you feel that your situation is hopeless? YES / NO 15. Do you think that most people are better off than you are? YES / NO
A.2. Strengths

of the GDS. It a self-rated tool that permits the client to answer yes or no, thereby overcoming the need for the client to make subtle discriminations in answering. It can be completed by the client, and no training is required. Selfrated scales are generally thought to be very effective in screening minor depression. The short version (see next page) has 15 items and is available for use rather than the 30-item scale. The GDS can be used in screening the physically healthy as well as physically ill and cognitively impaired (MMSE >15. of the GDS. The GDS cannot be used if the client cannot selfreport. Self-report is limited in persons with severe depression and/or psychosis. In the presence of cognitive impairment (MMSE <15), the reliability of the scale is questionable. GDS is not able to differentiate between clinical diagnostic categories and is not sensitive to changes in symptomatology over time as are observer-rated scales.

A.3. Limitations

B. Cornell Depression Scale (CDS). This is a 20-question scale used to screen for depression in older adults with dementia.

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B.1. Strength

of the CDS. This depression scale is able to assess for depression in clients with advanced dementia (MMSE <15). of the CDS. This tool requires clinicians to rate the items. It is not self administered but can be administered by a nurse assistant. It also takes slightly longer to assess than the GDS.

B.2. Limitation

B.3. Instruction for use of the Cornell Dementia Depression Assessment Tool (Tool available for viewing at http://www.aafp.org/afp/20020915/1001.html) 1. The same caregiver should conduct the interview each time to assure consistency in response. 2. The assessment should be based on the patients normal weekly routine. 3. If uncertain of answers, questioning other caregivers may further define the answer. 4. Answer all questions by placing a check in the column under the appropriately numbered answer: a = unable to evaluate 0 = absent 1 = mild to intermittent 2 = severe 5. Add the total score for all numbers checked for each question. 6. Place the total score in the SCORE box and record any subjective observation notes in the NOTES/CURRENT MEDICATION section. Scores totaling twelve (12) points or more indicate probable depression.

7.

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MODULE 5. COGNITIVE / MENTAL STATUS ASSESSMENT

Learning Activities. 1. Case Study Ms. P is a 69-year-old woman who has been known in the community as a leader in nursing care and executive director of a successful home care agency. Following her surprise retirement, Ms. P is seen in the hospitals Geriatric Assessment Clinic with her two daughters for an evaluation. Ms. P lives alone and has been widowed for 23 years. Ms. P denies having any problems aside from some arthritis. When asked about her early retirement, she says that she was tired from all the stress related to the changing health care system. It was getting to be too much for me! Ms. Ps two daughters ask if they could speak with you about their mother. Ms. P agreed, commenting that her daughters were worried about nothing. The daughters said that they were concerned that their mother wasnt like her old self. She took less interest in her work during the six months prior to her retirement. They recalled that only a year ago, their mother had said that she would never retire and now she seemed relieved. At home, she wasnt interested in keeping the house organized, something she always took pride in. She even missed a lunch date with her granddaughter last week, saying she forgot. Questions: Based on Ms. Ps case, a physical exam was done with no abnormal findings. 1. What other tests would you suggest and why? 2. How would it feel to evaluate someone who has been a role model in the community? Another nurse? Someone who thinks nothing is wrong?

2.

VIDEO. Cognitive Assessment from the series Caring for the Cognitively Impaired Patient by the University of Kentucky Alzheimers Disease Center

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MODULE 5. COGNITIVE / MENTAL STATUS ASSESSMENT RESOURCES Agency for Health Care Policy and Research. (1996). Early recognition of Alzheimers disease and related dementias. Author. Beers, M., & Berkow, R. (2000). The merck manual of geriatrics (3rd ed.). Whitehouse Station, NJ: Merck and Com. Birrer, R., Singh,U., & Kumar, D. N. (1999, May). Disability and dementia in the emergency department. Emergency Medicine Clinics of North America, 17(2), 505-517. Danner, G., Beck, C., Heacock, P., & Modlin, T. (1993). Cognitively impaired elders: Using research findings to improve nursing care. Journal of Gerontological Nursing, 19(4), 5 11. Dellasega, C. (1998, September). Assessment of cognition in the elderly: Pieces of a complex puzzle. Nursing Clinics of North America, 33(3), 395 405. Folstein, M., Folstein, S. E., & McHugh, P. R. (1975). Mini-Mental State a practical method for grading the cognitive state of patients for the clinician. Psychiatric Research, 12, 189198. Foreman, M. D., & Gabrowski, R. (1992). Diagnostic dilemma: Cognitive impairment in the elderly. Journal of Gerontological Nursing, 18, 5-12. Foreman, M. D., Fletcher, K., Mion, L. C., Trygstad, L. J., & the NICHE Faculty. (1999). Assessing cognitive function. In Abraham, I., Bottrell, M. M., Fulmer, T., & Mezey, M. (Eds.). Geriatric nursing protocols for best practice (pp. 51-62). New York: Springer Publishing Company. Kurlowicz, L., & Wallace, M. (1999, January). The mini-mental state examination. Try this: Best practices in nursing care to older adults, 1(3). New York: Hartford Institute for Geriatric Nursing, New York University, Division of Nursing. Luggen, A. S. (1996). Core curriculum for gerontological nursing. St. Louis, MO: Mosby-Year Book. Maddox, G., et al (Eds.). (2001). The encyclopedia of aging (3rd ed.). New York: Springer Publishing Company. Mezey, M., et al. (Eds.). (2001). The encyclopedia of elder care. New York: Springer Publishing Company. Mezey, M., Rauckhorst, L., & Stokes, S. (1993). Health assessment of the older individual. New York: Springer. OHara, R., Mumenthaler, M. S., Davies, H., Cassidy, E. L., Buffum, M., Namburi, S., et al. (2002). Cognitive status and behavioral problems in older hospitalized patients [Electronic version]. Annals of General Hospital Psychiatry, 1(1).

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MODULE 5. COGNITIVE / MENTAL STATUS ASSESSMENT Pritchard, E., & Dewing, J. (2000, July). Memory and cognitive assessment. Elderly Care, 12(5), 25-27. Teresi, J. A., et al. (2001). Performance of cognitive tests among different racial/ethnic and education groups: findings of differential item functioning and possible item bias. Journal of Mental Health and Aging. 7(1), 7989. Valle, R. (1998). Caregiving across cultures. Washington, DC: Taylor & Francis. Yazdanfar, D. J. (1990). Assessing the mental status of the cognitively impaired elderly. Journal of gerontological Nursing, 16(9), 32-36. Yeo, G., & Gallagher-Thompson, D. (Eds.). (1996). Ethnicity and the dementias. Washington, DC: Taylor & Francis. Yesavage, J. A. (1986). The use of rating depression series in the elderly. In Poon (Ed.): Clinical memory assessment of older adults. American Psychological Association. Yoshikawa, T. T., Dobbs, E. L., & Brummel-Smith, K. (1998). Practical ambulatory geriatrics (2nd ed.). New York: Mosby. Web Sites

1. www.minimental.com/MSRS.htm This site provides information about the Mental

Status Reporting Software (MSRS) provides unlimited scoring, interpretation, and report generation for the Mini-Mental State Examination (MMSE) and the 30-item MSRS Checklist. The MSRS was developed to help the clinician organize and record information about an individual's mental status. The information from the checklist can be completed on-screen, or a copy of the checklist items can be printed from the software and completed during the evaluation. Results from the MMSE Test Form can be manually entered into the software along with the item responses from the MSRS Checklist. The software scores and interprets the MMSE only, the MSRS only, or both instruments combined, and then generates the MSRS Evaluation Report. The report includes a Longitudinal Profile Record (LPR). The LPR is especially useful for clinicians who are monitoring individuals over time because it presents the scores and item responses for the current report as well as the scores and item responses for up to four previous administrations. The Evaluation Report also includes the item responses from the current MMSE and/or the MSRS Checklist. The demographic information for an individual Client File can be edited as needed.

2. http://www.medafile.com/mmses.htm This is the electronic version of the Mini-Mental

Status Exam, which can be completed online. This must be completed by a trained clinician.

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3. http://arcc.stanford.edu/videos.html This site provides streaming video: Assessing the

Cognitively Impaired Geriatric Patient in a Time-Dependent Practice Rita Hargrave, M.D. The presentation provides an overview of challenges in assessing cognitively impaired older adults and how to use the MMSE, and GDS. Differential diagnoses of cognitive impairment are discussed: depression, dementia, delirium, and substance abuse. Dr. Hargrave talks about the factors to consider in cognitive impairment. The speaker emphasizes language, education and other factors that influence cognitive assessment of older adults. A Question and Answer session follows.

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