Assessing Assessing Cognitive Function Cognitive Function in the Acute Care in the Acute Care

SettingSettingAnn Lund OTR/L, CHT, CLTAnn Lund OTR/L, CHT, CLT

MOTA Conference 2012MOTA Conference 2012

DisclosureDisclosure

I have no personal or professional I have no personal or professional relationships with any of the relationships with any of the products featured in this talk, nor products featured in this talk, nor have I received any type of have I received any type of renumeration from any of the renumeration from any of the featured product manufacturers.featured product manufacturers.

Course ObjectivesCourse Objectives

1. The attendee will be able to cite use 1. The attendee will be able to cite use of 3 different cognitive assessments of 3 different cognitive assessments appropriate for their patients in the appropriate for their patients in the hospital based acute care settinghospital based acute care setting

2. The attendee will be able to cite 2. The attendee will be able to cite basic strategy of assessing cognition basic strategy of assessing cognition in the setting of pain and diseasein the setting of pain and disease

3. The attendee will be able to cite the 3. The attendee will be able to cite the legal implications of reporting on legal implications of reporting on cognitive function of their patientscognitive function of their patients

I’m frustrated!I’m frustrated!

Can we truly assess cognition in the Can we truly assess cognition in the acute care?acute care?

What are the factors impacting What are the factors impacting patient performance?patient performance?

What can we contribute to this What can we contribute to this patient’s care with the tools and patient’s care with the tools and knowledge we have to draw from?knowledge we have to draw from?

Limitations of Cognitive Limitations of Cognitive TestingTesting

These tests are standardized, the score does These tests are standardized, the score does not necessarily represent true functional level not necessarily represent true functional level of the person testedof the person tested

Those normally very high functioning pts will Those normally very high functioning pts will test normal, but to them still have significant test normal, but to them still have significant limitationslimitations

Those lower functioning pts will do poorly, but Those lower functioning pts will do poorly, but their function may seem or be very near their function may seem or be very near normal to themnormal to them

You are getting a momentary snapshot of You are getting a momentary snapshot of performance with use of a formalized testperformance with use of a formalized test

Most consistently cited in Most consistently cited in the literature as effective the literature as effective and easy to administer:and easy to administer:

For ICU settings:For ICU settings: Intensive Care Delirium Screening ChecklistIntensive Care Delirium Screening Checklist Confusion Assessment Method for the ICUConfusion Assessment Method for the ICU( CAM-ICU) ( CAM-ICU) Mini Mental Status Exam Mini Mental Status Exam

Be consistent between other professionals if Be consistent between other professionals if at all possible, use what your institution at all possible, use what your institution recommendsrecommends

What causes age-related What causes age-related cognitive decline?cognitive decline?

Processing speed theoryProcessing speed theory Executive function theoryExecutive function theory

Processing SpeedProcessing Speed T. A. Salthouse, 1996T. A. Salthouse, 1996 The central hypothesis in the theory is that increased age The central hypothesis in the theory is that increased age

in adulthood is associated with a decrease in the speed in adulthood is associated with a decrease in the speed with which many processing operations can be executed with which many processing operations can be executed and that this reduction in speed leads to impairments in and that this reduction in speed leads to impairments in cognitive functioning because of what are termed the cognitive functioning because of what are termed the limited time mechanism and the simultaneity mechanism. limited time mechanism and the simultaneity mechanism. That is, cognitive performance is degraded when That is, cognitive performance is degraded when processing is slow because relevant operations processing is slow because relevant operations cannot be successfully executed (limited time) and cannot be successfully executed (limited time) and because the products of early processing may no because the products of early processing may no longer be available when later processing is complete longer be available when later processing is complete (simultaneity).(simultaneity). Several types of evidence, such as the Several types of evidence, such as the discovery of considerable shared age-related variance discovery of considerable shared age-related variance across various measures of speed and large attenuation of across various measures of speed and large attenuation of the age-related influences on cognitive measures after the age-related influences on cognitive measures after statistical control of measures of speed, are consistent statistical control of measures of speed, are consistent with this theorywith this theory. .

Executive Function Executive Function TheoryTheory

T. Salthouse, et al, 2003 J Exper. PsychT. Salthouse, et al, 2003 J Exper. Psych ““Executive functions are those control Executive functions are those control

processes responsible for planning, processes responsible for planning, assembling, coordinating, sequencing assembling, coordinating, sequencing and monitoring other cognitive and monitoring other cognitive operations”operations”

Lezak 1995: “The executive functions Lezak 1995: “The executive functions consist of those capacities that enable a consist of those capacities that enable a person to engage successfully in person to engage successfully in independent, purposeful, self serving independent, purposeful, self serving behavior”behavior”

Executive FunctionsExecutive Functions Executive function is an umbrella term for Executive function is an umbrella term for

cognitive processes such as planning, working, cognitive processes such as planning, working, memory attention, problem solving, verbal memory attention, problem solving, verbal reasoning, inhibition, mental flexibility, multi-reasoning, inhibition, mental flexibility, multi-tasking, and initiation and monitoring of actionstasking, and initiation and monitoring of actions

Carried out by the prefrontal areas of the frontal Carried out by the prefrontal areas of the frontal lobe; new work proposes that their origins are lobe; new work proposes that their origins are more spread out around the cortexmore spread out around the cortex

Decline in cognition is found in conjunction with Decline in cognition is found in conjunction with deterioration of the associated area of the braindeterioration of the associated area of the brain

R. Chan at al, Arch. Clin. Neuropsychology, 2008 R. Chan at al, Arch. Clin. Neuropsychology, 2008

Executive functionsExecutive functions((A more generous description)A more generous description)

Allow us to handle new situationsAllow us to handle new situations Allow us to plan and make decisionsAllow us to plan and make decisions Allow us to make corrections or Allow us to make corrections or

problem solveproblem solve Allow us to handle dangerous or Allow us to handle dangerous or

technically difficult situationstechnically difficult situations Allow “override” of automatic reactions Allow “override” of automatic reactions

for the greater goodfor the greater good D.Norman, T. Shallice, 2000D.Norman, T. Shallice, 2000

Warning signals of Warning signals of cognitive impairment in cognitive impairment in

acute careacute care Personality changes; increased Personality changes; increased

apathy, loss of social inhibition, apathy, loss of social inhibition, irritability/paranoia, outbursts of angerirritability/paranoia, outbursts of anger

Memory: difficulty with new Memory: difficulty with new information, word finding, cannot information, word finding, cannot recall conversations with medical staff recall conversations with medical staff or family visits, cannot recall what or or family visits, cannot recall what or when they ate last when they ate last

S. Gordon et al, Intensive Care Medicine 2004S. Gordon et al, Intensive Care Medicine 2004

Warning signals Warning signals continuedcontinued

Executive dysfunction; cannot follow orders Executive dysfunction; cannot follow orders or MD, RN, OT, etc, demonstrate difficulty or MD, RN, OT, etc, demonstrate difficulty with planning or making dismissal decisions, with planning or making dismissal decisions, confusion during multi-taskingconfusion during multi-tasking

Functional deficits; difficulty looking up Functional deficits; difficulty looking up information or operating the hospital information or operating the hospital equipment, decline in self care not equipment, decline in self care not attributed to physical limitations, inability to attributed to physical limitations, inability to follow a conversation, inability to find one’s follow a conversation, inability to find one’s room, inability to follow through with tasksroom, inability to follow through with tasks

S. Gordon et al, Intensive Care Medicine 2004S. Gordon et al, Intensive Care Medicine 2004

Causes of Cognitive Causes of Cognitive Changes in Cancer PatientsChanges in Cancer Patients

Tumor located in the central nervous Tumor located in the central nervous system (CNS) which includes the brain system (CNS) which includes the brain and spinal cord and spinal cord

Treatments administered directly to the Treatments administered directly to the CNS CNS

Chemotherapy and radiation given to the Chemotherapy and radiation given to the brain at the same time brain at the same time

Treatments administered when extremely Treatments administered when extremely ill; be an advocate for your patient when ill; be an advocate for your patient when neededneeded

Cardiac Failure and Cardiac Failure and Cognitive IssuesCognitive Issues

Mary Jane Sauvé, D.N.Sc., R.N., of the University of Mary Jane Sauvé, D.N.Sc., R.N., of the University of California, Davis.California, Davis.

The researchers administered tests of cognitive The researchers administered tests of cognitive (intellectual) function to 50 patients with HF and 50 (intellectual) function to 50 patients with HF and 50 people without HF, matched for age and estimated people without HF, matched for age and estimated intelligence.  Most of the patients had mild to intelligence.  Most of the patients had mild to moderate HF. moderate HF. Overall, patients with HF scored Overall, patients with HF scored lower than controls on 14 of 19 cognitive tests.  lower than controls on 14 of 19 cognitive tests.  46% percent of the HF patients were rated as 46% percent of the HF patients were rated as having mild to severe cognitive impairment, having mild to severe cognitive impairment, compared to a 16 percent rate of mild compared to a 16 percent rate of mild impairment in controls. impairment in controls.  Memory problems, Memory problems, especially short-term memory, were the most common especially short-term memory, were the most common type of cognitive deficit.type of cognitive deficit.

Most associated with left ventricular dysfunctionMost associated with left ventricular dysfunction

Liver failure and Cognitive Liver failure and Cognitive DeclineDecline

A. Collie, 2005, Liver InternationalA. Collie, 2005, Liver International Studied HE (hepatic encephalopathy), SHE Studied HE (hepatic encephalopathy), SHE

(subclinical HE)(subclinical HE) 34-84% have SHE34-84% have SHE Estimated 1.5-2 million pts in North AmericaEstimated 1.5-2 million pts in North America Early diagnosis of liver disease=best resultsEarly diagnosis of liver disease=best results McCrea et al; see issues with attention and McCrea et al; see issues with attention and

motor skills, but intact visual-spatial, memory, motor skills, but intact visual-spatial, memory, general intellect and language skillsgeneral intellect and language skills

DRIVING SAFETY!!DRIVING SAFETY!!

Cognitive Impairment in Cognitive Impairment in Trauma PatientsTrauma Patients

JC Jackson et al, prospective cohort study, JC Jackson et al, prospective cohort study, 173 pts fromVanderbilt Univ. TICU173 pts fromVanderbilt Univ. TICU

Moderately and severe trauma ptsModerately and severe trauma pts 108 evaluated at 1 yr f/u108 evaluated at 1 yr f/u 55% demonstrated cognitive impairment at 55% demonstrated cognitive impairment at

12 mos. 5.5% had pre-existing cog. 12 mos. 5.5% had pre-existing cog. conditioncondition

No significant difference in cog. No significant difference in cog. impairment between moderate vs. severe impairment between moderate vs. severe trauma ptstrauma pts

Jackson/Vanderbilt cont.Jackson/Vanderbilt cont.

The study found the clinically The study found the clinically significant symptoms of depression significant symptoms of depression occurred in 40% of ICU pts at 1 yr.occurred in 40% of ICU pts at 1 yr.

PTSD found in 26% of pts at 1 yearPTSD found in 26% of pts at 1 year No significant difference in numbers No significant difference in numbers

in moderate vs. severe injured pts.in moderate vs. severe injured pts.

Drugs that cause cognitive Drugs that cause cognitive changeschanges

Drug-induced cognitive impairment is Drug-induced cognitive impairment is most commonly linked to most commonly linked to benzodiazepines, (tranquilizers and benzodiazepines, (tranquilizers and sleeping aides), opiates, (narcotics/pain sleeping aides), opiates, (narcotics/pain relievers), tricyclic antidepressants, relievers), tricyclic antidepressants, (pain syndrome/neuropathy), and (pain syndrome/neuropathy), and anticonvulsants (drugs used to treat and anticonvulsants (drugs used to treat and prevent seizures). prevent seizures).

Corticosteroids (autoimmune disease Corticosteroids (autoimmune disease treatment), is also linked to cognitive treatment), is also linked to cognitive changeschanges

Older adults and drug Older adults and drug tolerancetolerance

The body’s ability to clear drugs decreases The body’s ability to clear drugs decreases with age, often because of a normal age-with age, often because of a normal age-related decrease in kidney and liver function. related decrease in kidney and liver function. This results in a greater accumulation of This results in a greater accumulation of drugs in the body.drugs in the body.

Older patients are often prescribed multiple Older patients are often prescribed multiple drugs at the same time. Due to complicated drugs at the same time. Due to complicated interactions between different drugs, side interactions between different drugs, side effects can become more prominent.effects can become more prominent.

Some research suggests that Some research suggests that neurotransmitters become naturally neurotransmitters become naturally imbalanced as people age, increasing the imbalanced as people age, increasing the brain’s sensitivity to drugs that have activity brain’s sensitivity to drugs that have activity in the central nervous system.in the central nervous system.

Confusion/DeliriumConfusion/Delirium

State that develops over hours or daysState that develops over hours or days Involves changes in alertness that vary Involves changes in alertness that vary

over the course of the dayover the course of the day Usually temporary and reversibleUsually temporary and reversible DSM III: changes in consciousness, DSM III: changes in consciousness,

cognition, occurs over a short period of cognition, occurs over a short period of time and these fluctuate, and they are time and these fluctuate, and they are determined to be, (via history/exam/lab determined to be, (via history/exam/lab finding), a direct cause of the current finding), a direct cause of the current medical conditionmedical condition

Common reasons to see Common reasons to see confusion in the acute care confusion in the acute care

settingsetting New surroundingsNew surroundings Increase or change in medicationsIncrease or change in medications Exposure to anesthesia, especially if Exposure to anesthesia, especially if

prolongedprolonged Excessive blood lossExcessive blood loss Change in wake/sleep cycleChange in wake/sleep cycle Dehydration or malnutritionDehydration or malnutrition Infection Infection Alcohol or drug withdrawlAlcohol or drug withdrawl

Incidence of DeliriumIncidence of Delirium Present in 10% of ER patients, 10-31% of medical units, 50% Present in 10% of ER patients, 10-31% of medical units, 50%

hip fracture pts, > 80% pts on mechanical ventilationhip fracture pts, > 80% pts on mechanical ventilation Most likely to have delirium: prior cognitive issues, visual Most likely to have delirium: prior cognitive issues, visual

impairments, severe illness, elevated blood urea impairments, severe illness, elevated blood urea nitrogen/creatinine rationitrogen/creatinine ratio

Hospital contributors: use of restraints, catheterization, Hospital contributors: use of restraints, catheterization, malnutrition, > 3 medication additions, sustaining an malnutrition, > 3 medication additions, sustaining an iatrogenic eventiatrogenic event

Presence of delirium associated with development of Presence of delirium associated with development of dementiadementia

in subjects followed for 4 years, with an increase from 8.1% in subjects followed for 4 years, with an increase from 8.1% to 62%to 62%

M. Rathier, W. Baker; A Review of Recent Clinical Trials and M. Rathier, W. Baker; A Review of Recent Clinical Trials and Guidelines on the Prevention and Management of Delerium in Guidelines on the Prevention and Management of Delerium in Hospitalized Older Patients, 2011Hospitalized Older Patients, 2011

Treatment of Treatment of confusion/deliriumconfusion/delirium

Try to normalize the environmentTry to normalize the environment Assure adequate sleep time/scheduleAssure adequate sleep time/schedule Write out the daily scheduleWrite out the daily schedule Bring in familiar objectsBring in familiar objects Ensure patient wears glasses/hearing Ensure patient wears glasses/hearing

aidsaids Explain to the patient that they appear Explain to the patient that they appear

confused at times and encourage them confused at times and encourage them to ask questionsto ask questions

Does the duration of Does the duration of delirium indicate anything?delirium indicate anything?

Morandi et al; Crit. Care Med 2012Morandi et al; Crit. Care Med 2012 47 pts, median age 50, studied is delirium duration 47 pts, median age 50, studied is delirium duration

predictive of long term cognitive impairmentpredictive of long term cognitive impairment Cognition tested at 3 and 12 months postCognition tested at 3 and 12 months post Delirium duration in the ICU was associated with Delirium duration in the ICU was associated with

white matter disruption, which in turn was white matter disruption, which in turn was associated with worse cognitive scores for up to 12 associated with worse cognitive scores for up to 12 months. months.

M. Rather, Hospital Practice 2011; Delirium M. Rather, Hospital Practice 2011; Delirium resolves in many patients by the time of discharge, resolves in many patients by the time of discharge, but is an independent risk factor of for death, but is an independent risk factor of for death, institutionalization and dementia institutionalization and dementia

Physical Function and Physical Function and CognitionCognition

Assessment of one without the other Assessment of one without the other is worthlessis worthless

At a minimum, dressing, bathing, At a minimum, dressing, bathing, toileting, from bed base, EOB, toileting, from bed base, EOB, standingstanding

Baseline Cognition Baseline Cognition AssessmentAssessment

(you start assessing these as soon as you walk (you start assessing these as soon as you walk in the room)in the room)

OrientationOrientation Attention/concentration/focusAttention/concentration/focus MemoryMemory Initiation, sequencing, termination Initiation, sequencing, termination

skillsskills

L. Johnson, A. Parker, C. Johnson; Is My Patient Ready to Go Home? 2/2012L. Johnson, A. Parker, C. Johnson; Is My Patient Ready to Go Home? 2/2012

ChoicesChoices AllenAllen CPTCPT CAM (Confusion Assessment Method)CAM (Confusion Assessment Method) MOCAMOCA Short Blessed TestShort Blessed Test Short Portable Mental Status QuestionnaireShort Portable Mental Status Questionnaire MMST Mini Mental StatusMMST Mini Mental Status Texas Functional Living ScalesTexas Functional Living Scales Intensive Care Delirium Screening ChecklistIntensive Care Delirium Screening Checklist

Allen Cognitive Level Allen Cognitive Level ScreenScreen

Task/performance based assessmentTask/performance based assessment Leather lacing, 3 visual motor tasksLeather lacing, 3 visual motor tasks Designed to provide a quick measure Designed to provide a quick measure

of cognitive processing capacities, of cognitive processing capacities, learning potential and performance learning potential and performance abilitiesabilities

Scoring: 3.0-5.8Scoring: 3.0-5.8 Each score provides description of Each score provides description of

functional performance abilitiesfunctional performance abilities

Allen’s cognitive levels

Level 1: total care Level 2: total care, may do very basic

adls such as self feed or ambulate Level 3: 24 hr. care on site, uses

familiar objects, needs help and cues, poor safety

Level 4: daily on site supervision, learns with repetition

Level 5: needs daily/weekly supervision Level 6: lives independently

Cognitive Performance Cognitive Performance TestTest

Standardized assessment that evaluates Standardized assessment that evaluates information processing skills via ADL tasksinformation processing skills via ADL tasks

Measures memory, executive functioning Measures memory, executive functioning and processing capacities that support and processing capacities that support functional performancefunctional performance

Can track changes over timeCan track changes over time Alzheimers, CVA, TBI, dementia Alzheimers, CVA, TBI, dementia

populationspopulations Author Teressa Burns, OTR/L, Mpls VAAuthor Teressa Burns, OTR/L, Mpls VA

CPT 7 tasksCPT 7 tasks

Dress for the weatherDress for the weather Shopping for beltShopping for belt Making toastMaking toast Washing Washing Phone usePhone use TravelTravel Medication box Medication box

Confusion Assessment Confusion Assessment Method (CAM)Method (CAM)

Inouye et al, 1990Inouye et al, 1990 Two parts; part 1 screens for overall Two parts; part 1 screens for overall

cognitive impairment. Part II includes cognitive impairment. Part II includes the 4 features that had the greatest the 4 features that had the greatest ability to distinguish between ability to distinguish between reversible delirium and other types of reversible delirium and other types of cognitive impairmentcognitive impairment

Administered in less than 5 minutesAdministered in less than 5 minutes Scoring via yes/no answers to questionsScoring via yes/no answers to questions

Confusion Assessment Confusion Assessment Method: Method:

Part 1Part 1 Acute onsetAcute onset Inattention, behavior fluctuationInattention, behavior fluctuation Disorganized thinkingDisorganized thinking Altered level of consciousnessAltered level of consciousness DisorientationDisorientation Memory impairmentMemory impairment Perceptual disturbancesPerceptual disturbances Psychomotor agitationPsychomotor agitation Psychomotor retardationPsychomotor retardation Altered sleep-wake cyclesAltered sleep-wake cycles

Cognitive Assessment of Cognitive Assessment of Minnesota (CAM)Minnesota (CAM)

Standardized, measures cognitive Standardized, measures cognitive abilities of adults with neurological abilities of adults with neurological impairmentsimpairments

Administration in 60 minutes or lessAdministration in 60 minutes or less Can be used to establish baseline or Can be used to establish baseline or

validate treatment effectivenessvalidate treatment effectiveness Developed by R. Rustad OTR, T. DeGroot Developed by R. Rustad OTR, T. DeGroot

OTR, M. Jungkunz OTR, K. Freeberg OTR, OTR, M. Jungkunz OTR, K. Freeberg OTR, L Borowick OTR, Ann Wanttie, OTRL Borowick OTR, Ann Wanttie, OTR

CAM 17 subtests CAM 17 subtests evaluate:evaluate:

Attention spanAttention span Memory orientationMemory orientation Visual neglectVisual neglect Temporal awarenessTemporal awareness Recall/recognitionRecall/recognition Auditory memory and sequencingAuditory memory and sequencing Simple math skillsSimple math skills Safety and judgementSafety and judgement

Montreal Cognitive Montreal Cognitive Assessment (MOCA)Assessment (MOCA)

Developed by neurologist Ziad Developed by neurologist Ziad Nasreddine 1996Nasreddine 1996

Detects mild cognitive impairment and Detects mild cognitive impairment and Alzheimer’s DiseaseAlzheimer’s Disease

30 pt. test involving several cognitive 30 pt. test involving several cognitive domainsdomains

15-20 minute administration time15-20 minute administration time Available in several languagesAvailable in several languages Available via internetAvailable via internet

MOCA SubtestsMOCA Subtests

Short term memory recallShort term memory recall 5 item recall 5 item recall

Visual spatial tasksVisual spatial tasks Clock drawingClock drawing 3 D cube drawing3 D cube drawing

Executive functionExecutive function Trail making tasksTrail making tasks Phonemic fluency taskPhonemic fluency task Verbal abstraction taskVerbal abstraction task

MOCA SubtestsMOCA Subtests

Attention, concentration, working Attention, concentration, working memorymemory sustained attention tasksustained attention task Serial subtraction taskSerial subtraction task Counting backward/forwardCounting backward/forward

LanguageLanguage 3 item naming (non-familiar animals)3 item naming (non-familiar animals) Complex sentence repetitionComplex sentence repetition

OrientationOrientation Time and placeTime and place

Short Blessed Test; G. Short Blessed Test; G. Blessed, 1968Blessed, 1968

Used to determine cognitively impaired from Used to determine cognitively impaired from normalnormal

6 item test-Patients are asked to answer the 6 item test-Patients are asked to answer the items year and month, time of day, count items year and month, time of day, count backward 20-1, recite months backwards, and backward 20-1, recite months backwards, and the memory phrase.the memory phrase.

Easily administeredEasily administered Verbal responses onlyVerbal responses only Scoring: 0-4= Normal cognition, 5-9 = Scoring: 0-4= Normal cognition, 5-9 =

questionable impairment, > 10 = impairment questionable impairment, > 10 = impairment consistent with dementiaconsistent with dementia

Short Portable Mental Short Portable Mental Status Questionnaire; Status Questionnaire; E E

Pfeiffer, 1975Pfeiffer, 1975 Rapid screening tool for cognitive Rapid screening tool for cognitive

impairmentsimpairments 10 item test10 item test Easy to administerEasy to administer Verbal responses onlyVerbal responses only Scoring: 0-2 errors, normal cognitive Scoring: 0-2 errors, normal cognitive

functionfunction

3-4 errors, mild impairment, 5-7 errors, 3-4 errors, mild impairment, 5-7 errors, moderate impairment, 8 or more severe moderate impairment, 8 or more severe impairmentimpairment

Short Portable questions Today’s date Day of the week Patient’s personal

phone number Patient’s address Patient’s age

Date and year patient was born

Who is the current President

Who was the preceding President

Mother’s maiden name Subtract 3 from 20,

keep calculating down until you can no longer properly divide

Mini Mental Status ExamMini Mental Status Exam

Developed in 1975 by M. FolsteinDeveloped in 1975 by M. Folstein 11 questions, tests orientation, 11 questions, tests orientation,

registration, attention/calculation, registration, attention/calculation, recall, languagerecall, language

Takes 5-10 minutes to administerTakes 5-10 minutes to administer Max score is 30, a score less or Max score is 30, a score less or

equal to 23 indicates impairmentequal to 23 indicates impairment

Category Possible

points

Description

Orientation to time

5 From broadest to most narrow. Orientation to time has been correlated with future decline.

Orientation to place

5 From broadest to most narrow. This is sometimes narrowed down to streets, and sometimes to floor.

Registration 3 Repeating named prompts

Attention and

calculation

5 Serial sevens, or spelling "world" backwards It has been suggested that serial sevens may be more appropriate in a population where English is not

the first language.

Recall 3 Registration recall

Language 2 Naming a pencil and a watch

Repetition 1 Speaking back a phrase

Complex commands

6 Varies. Can involve drawing figure shown

Texas Functional Living Texas Functional Living ScaleScale

“TFLS provides an ecologically valid, performance-based screening tool to help identify the level of care an individual requires. Brief and easy to use, the TFLS is especially well-suited for use in assisted living and nursing home settings”

Pearson Assessments quote

TFLS continuedTFLS continued

TFLS helps measure an individual’s ability in four functional domains:

Time—Ability to use clocks and calendars Money and Calculation—Ability to count

money and calculate change Communication; use phones and phone

books, emergency contacts Memory—Ability to remember simple

information from prior tasks and to correctly take medications

CM Cullem et al; CM Cullem et al; Neuropsychiatry/Psychology/Behavioral Neuropsychiatry/Psychology/Behavioral

Medicine Medicine 2001 Apr-Jun2001 Apr-Jun CONCLUSIONS: CONCLUSIONS: The TFLS showed evidence of good The TFLS showed evidence of good

reliability, internal consistency, and reliability, internal consistency, and convergent and discriminant validity with convergent and discriminant validity with several popular measures of global cognitive several popular measures of global cognitive status and behavioral functioning. It is a brief status and behavioral functioning. It is a brief and easily administered performance-based and easily administered performance-based measure of daily functional capabilities that measure of daily functional capabilities that is sensitive to level of cognitive impairment is sensitive to level of cognitive impairment and seems applicable in patients with varying and seems applicable in patients with varying degrees of dementia.degrees of dementia.

Intensive Care Delirium Intensive Care Delirium Screening ChecklistScreening Checklist

Developed by N. Bergeron et al; U of Developed by N. Bergeron et al; U of Montreal Dept. of PsychiatryMontreal Dept. of Psychiatry

Screening tool Screening tool Checklist based on 8 DSM criteria Checklist based on 8 DSM criteria

for deliriumfor delirium

Intensive Care Delirium Intensive Care Delirium Screening ChecklistScreening Checklist

Administered consistently for 5 daysAdministered consistently for 5 days Assesses first for altered level of consciousness, then Assesses first for altered level of consciousness, then

goes on to rate inattention, disorientation, goes on to rate inattention, disorientation, hallucination, psychomotor agitation or retardation, hallucination, psychomotor agitation or retardation, inappropriate speech or mood, disturbance in inappropriate speech or mood, disturbance in sleep/wake cycle, and symptom fluctuationsleep/wake cycle, and symptom fluctuation

Scoring: A=no response, E=exaggerated responseScoring: A=no response, E=exaggerated response Max score is 8, normal response scored as 0 (the Max score is 8, normal response scored as 0 (the

patient needs to be able to demonstrate at least patient needs to be able to demonstrate at least response to mild or moderate stimulation to response to mild or moderate stimulation to administer and score, if not the testing was held until administer and score, if not the testing was held until they could).they could).

Easy to administer with guidelines that make Easy to administer with guidelines that make interpretation easyinterpretation easy

Test AdministrationTest Administration

Choose time of day wiselyChoose time of day wisely Well lit roomWell lit room No distractionsNo distractions Consider timing of food, medicationConsider timing of food, medication Glasses on, hearing aids inGlasses on, hearing aids in

The interviewThe interview

I’ve been asked by your primary care I’ve been asked by your primary care MDs to help determine where you are MDs to help determine where you are in your ability to take care of yourself in your ability to take care of yourself at this point in time and where you at this point in time and where you need to be to return home. need to be to return home.

Your care team has noted that it has Your care team has noted that it has been difficult for you to….(recall, been difficult for you to….(recall, process, problem solve). process, problem solve).

Have you noticed any of this?Have you noticed any of this? Reassure them that this is normalReassure them that this is normal

After dismissal…After dismissal… Recommend recheck at 2 mos.Recommend recheck at 2 mos. Pts should be fully recovered from Pts should be fully recovered from

medications and delirium, but likely noting medications and delirium, but likely noting limitationslimitations

Repeat MMSE, if they score worse by 3 or Repeat MMSE, if they score worse by 3 or more points, need further formal more points, need further formal evaluationevaluation

Ask questions: how are you at operating a Ask questions: how are you at operating a phone, remote, recipe, grocery list, phone, remote, recipe, grocery list, managing money and medicationsmanaging money and medications

Ask about depression and anxietyAsk about depression and anxiety

Is there neurological Is there neurological involvement? Cranial involvement? Cranial

Nerve ExamNerve Exam #1: Olfactory Nerve#1: Olfactory Nerve Rarely tested, need to test each Rarely tested, need to test each

nostril separatelynostril separately Can try toothpaste, alcohol wipe Can try toothpaste, alcohol wipe

(noxious), “Quease Ease” product(noxious), “Quease Ease” product Bilateral loss of smell can come with Bilateral loss of smell can come with

smoking, aging, or chronic rhinitissmoking, aging, or chronic rhinitis Olfactory nerve loss can be a Olfactory nerve loss can be a

symptom of meningiomasymptom of meningioma

Cranial Nerve ExamCranial Nerve Exam

#II Optic Nerve#II Optic Nerve Test eyes separately, have patient wear glassesTest eyes separately, have patient wear glasses Examiner wiggles their finger in each of the four Examiner wiggles their finger in each of the four

quadrants, the patient indicates when it is in the quadrants, the patient indicates when it is in the periphery of vision. periphery of vision.

Pupillary right reflex test, shine a penlight Pupillary right reflex test, shine a penlight obliquely into each pupil, watch for constriction obliquely into each pupil, watch for constriction in both eyesin both eyes

Flashlight test, move light between both eyesFlashlight test, move light between both eyes Abnormal findings could be a symptom of Abnormal findings could be a symptom of

optic neuritisoptic neuritis

Cranial Nerve ExamCranial Nerve Exam

# III Oculomotor Nerve # III Oculomotor Nerve #IV Trochlear Nerve#IV Trochlear Nerve #VI Abducens Nerve#VI Abducens Nerve

Look for ptosis, eye position and Look for ptosis, eye position and nystagmusnystagmus

Stand 1 meter from pt, move target Stand 1 meter from pt, move target object in a H, then hold in a lateral object in a H, then hold in a lateral field, -> nystagmus; watch for diplopiafield, -> nystagmus; watch for diplopia

Cranial Nerve ExamCranial Nerve Exam

#IV Trigeminal Nerve#IV Trigeminal Nerve Light touch to the sides of the face, Light touch to the sides of the face,

using a point stimulus, forehead, cheek, using a point stimulus, forehead, cheek, chinchin

Check for muscle strength and bulk in Check for muscle strength and bulk in the masseter (clench jaw) and the masseter (clench jaw) and pterygoids (open mouth against pterygoids (open mouth against resistance).resistance).

Cranial Nerve ExamCranial Nerve Exam

#VII Facial, motor and sensory#VII Facial, motor and sensory Motor: raise both eyebrows, frown Motor: raise both eyebrows, frown

close eyes, smile, show upper and lower close eyes, smile, show upper and lower teeth, puff out both cheeksteeth, puff out both cheeks

Sensory: test for tasteSensory: test for taste Symptom of Bell’s Palsy, Ramsay-Symptom of Bell’s Palsy, Ramsay-

Hunt SyndromeHunt Syndrome

Cranial Nerve ExamCranial Nerve Exam

# VIII Vestibulocochlear# VIII Vestibulocochlear Whisper numbers and ask patient to Whisper numbers and ask patient to

repeatrepeat Balance/vestibular functionBalance/vestibular function

Symptom of acoustic neuromaSymptom of acoustic neuroma

Cranial Nerve ExamCranial Nerve Exam

#IX Glossopharyngeal Nerve#IX Glossopharyngeal Nerve #X Vagus Nerve#X Vagus Nerve

Gag response, articulation of “ka, ga”, Gag response, articulation of “ka, ga”, “go”“go”

#XI Accessory Nerve#XI Accessory Nerve Shrug shoulders, turn head side to sideShrug shoulders, turn head side to side

#XII Hypoglossal Nerve#XII Hypoglossal Nerve Tongue strength, motion, symmetryTongue strength, motion, symmetry

Consult with Mayo LegalConsult with Mayo Legal

Choose a standardized test that Choose a standardized test that gives the best definition of how gives the best definition of how much care they will need, i.e. 24 much care they will need, i.e. 24 hour supervision and assistance….hour supervision and assistance….

Document the detailsDocument the details Document that you spoke with the Document that you spoke with the

family/caregivers about the results, family/caregivers about the results, provide contact informationprovide contact information

Equally important as any Equally important as any test!test!

Clinical judgmentClinical judgmentPatient observationPatient observationFamily member Family member

perception/interaction and perception/interaction and reportreport

Final RecommendationsFinal Recommendations

Based on what you see NOWBased on what you see NOW Minimize predictions, support what Minimize predictions, support what

you recommend with functional you recommend with functional performance details noted in therapyperformance details noted in therapy

Recommend level of care required Recommend level of care required immediately on dismissalimmediately on dismissal

Patient should demonstrate to their Patient should demonstrate to their caregivers consistent (2-3 days) caregivers consistent (2-3 days) performance before decreasing level performance before decreasing level of care of care