ASSESSING COGNITIVE FUNCTION
Tom Braes RN, MSN, PhDCan, Koen Milisen, RN, PhD, Marquis D. Foreman, PhD, RN, FAAN
I.Goals
The goals of cognitive assessment include:
A. To determine an individual’s cognitive abilities.
B. To recognize early the presence of an impairment in cognitive functioning.
C. To monitor an individual’s cognitive response to various treatments.
II.Overview
A. Undetected impairment in cognition is associated with greater morbidity and mortality.1
B. Assessing cognitive function is the foundation for early detection and prompt treatment of impairment.2
III.Background and Statement of Problem
A. Definition of cognitive functioning includes the processes by which an individual perceives, registers, stores, retrieves, and uses information.
B. Conditions in which cognitive functioning is impaired:
1. The Dementias (e.g., Alzheimer’s or vascular) are a syndrome of cognitive deterioration that involves memory impairment and a disturbance in at least one other cognitive function (e.g., aphasia, apraxia, or agnosia) that results in changes in function and behavior. 3
2. Delirium is a disturbance of consciousness with impaired attention and disorganized thinking that develops rapidly. Evidence of an underlying physiologic or medical condition is generally present.3
3. Depression is a syndrome of either depressed mood or loss of interest or pleasure in most activities of the day. These symptoms represent a change from usual functioning for the individual and have been present for at least 2 weeks. 3
IV.Assessment of Cognitive Functioning
A. Reasons/Purposes of Assessment
1. Screening: to determine the absence or presence of impairment.4
2. Monitoring: to track cognitive status over time, especially response to treatment. 4.
B. How to Assess Cognitive Function
1. Mini-Mental State Examination5 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.
2. Mini-Cog 6 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.
3. IQCDE 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 Informant Questionnaire on Cognitive Decline in the Elderly (IQCDE). 7
4. 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. 4.
C. When to Assess Cognitive Function
1. On admission to and discharge from an institutional care setting. 2, 8
2. On transfer from one care setting to another. 2
3. During hospitalization, every 8 to 12 hours throughout hospitalization (http://www.icudelirium.org/delirium).
4. As follow-up to hospital care, within 6 weeks of discharge. 2
5. Before making important health care decisions as an adjunct to determining an individual’s capacity to consent. 2
6. On the first visit to a new care provider.2
7. Following major changes in pharmacotherapy. 2
8. With behavior that is unusual for the individual and/or inappropriate to the situation. 9
D. Cautions for Assessing Cognitive Function
1. Physical environment: 10
a. Comfortable ambient temperature.
b. Adequate lighting (i.e., not glaring).
c. Free of distractions (e.g., should be conducted in the absence of others and other activities).
d. Position self to maximize individual’s sensory abilities.
2. Interpersonal environment: 11
a. Prepare individual for assessment.
b. Initiate assessment within nonthreatening conversation.
c. Let individual set pace of assessment.
d. Be emotionally nonthreatening.
3. Timing of assessment: 4
a. Select time of assessment to reflect actual cognitive abilities of the individual.
b. Avoid the following times:
i. Immediately on awakening from sleep; wait at least 30 minutes.
ii. Immediately before and after meals.
iii. Immediately before and after medical diagnostic or therapeutic procedures.
iv. In the presence of pain or discomfort.
V. Evaluation/Expected Outcomes
A. Patient
1. Is assessed at recommended time points.
2. Any impairment detected early.
3. Care tailored to appropriately address cognitive status/impairment.
4. Satisfaction with care improved.
B. Health Care Provider
1. Competent to assess cognitive function.
2. Able to differentiate among delirium, dementia, and depression.
3. Uses standardized cognitive assessment protocol.
4. Satisfaction with care improved.
C. Institution
1. Improved documentation of cognitive assessments.
2. Impairments in cognitive function identified promptly and accurately.
3. Improved referral to appropriate advanced providers (e.g., geriatricians, geriatric nurse practitioners) for additional assessment and treatment recommendations.
4. Decreased overall costs of care.
VI. Follow-up Monitoring
A. Provider competence in the assessment of cognitive function.
B. Consistent and appropriate documentation of cognitive assessment.
C. Consistent and appropriate care and follow-up in instances of impairment.
D. Timely and appropriate referral for diagnostic and treatment recommendations.
VII. Relevant Practice Guidelines
A. The Registered Nurse Association of
B. The U.S. Preventive Services Task Force recommendations for Screening for Dementia. Retrieved
C. Recommendations for the early detection of dementia from The American Academy of Neurology. Retrieved
D. The National Guideline Clearinghouse. http://www.guideline.gov.
1. Inouye, S. K., Foreman, M. D., Mion, L. C., Katz, K. H., & Cooney, L. M., Jr. (2001). Nurses’ recognition of delirium and its symptoms: Comparison of nurse and researcher ratings. Archives of Internal Medicine, 161, 2467–2473. Evidence Level IV: Nonexperimental Study.
2. ACOVE Investigators (2001). ACOVE quality indicators. Annals of Internal Medicine, 135, 653–667. Evidence Level I: Systematic Review.
3. (APA). American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision).
4. Foreman, M. D., Fletcher, K., Mion, L. C., & Trygstad, L. (2003). Assessing cognitive function. In M. Mezey, T. Fulmer, & I. Abraham (Eds.), & D. Zwicker (Managing Ed.), Geriatric nursing protocols for best practice (2nd ed., pp. 99–115).
5. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). “
6. Borson, S., Scanlan, J. M., Brush, M., Vitaliano, P., & Dokmak, A. (2000). The Mini-Cog: A cognitive ‘vital signs’ measure for dementia screening in multi-lingual elderly. International Journal of Geriatric Psychiatry, 15, 1021–1027. Evidence Level IV: Nonexperimental Study.
7. Jorm, A. (1994). A short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): Development and cross-validation. Psychological Medicine, 24, 145–153.Evidence Level IV: Nonexperimental Study.
8. British Geriatrics Society Guidelines for the prevention, diagnosis, and management of delirium in older people in hospital. Retrieved
9. Foreman, M. D., & Vermeersch, P. E. H. (2004). Measuring cognitive status. In M. Frank-Stromborg & S. J. Olsen (Eds.), Instruments of clinical health-care research (3rd ed., pp. 100–127).
10. Dellasega, C. (1998). Assessment of cognition in the elderly: Pieces of a complex puzzle. Nursing Clinics of
11. Engberg, S. J., & McDowell, J. (1999). Comprehensive geriatric assessment. In J. T. Stone, J. F. Wyman, & S. A. Salisbury (Eds.), Clinical gerontological nursing: A guide to advanced practice (2nd ed., pp. 63–85).
Last updated - March 2009
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