Assessment Of Cognitive Functioning Flashcards
Why is it important to assess cognition?
- > 1/4 of medical inpatients have dementia
- 15-25% of medical inpatients have delirium
- Relevant to assessment of capacity/Mental Capacity Act (MCA)/Deprivation of Liberty Safeguards (DoLS)
What is cognition?
Of, relating to, or involving conscious mental activities such as thinking, understanding, learning and remembering (Webster dictionary) but its difficult to say and there are many different definitions
What are the different areas of cognition?
- MEMORY
- Reading
- Praxis
- ATTENTION/CONCENTRATION
- Calculation
- VISUOSPATIAL
- LANGUAGE
- EXECUTIVE FUNCTIONING
- Writing
What are the different types of memory?
Short-term:
- Working: immediate recall of small amounts of verbal/visual material
Long-term memory:
- Anterograde: acquisition of new info
- Retrograde: recall of previously learnt info
What is explicit and implicit memory?
Explicit: episode and semantic
Implicit: procedural
Is orientation an area of cognition?
No, it is not itself a separate area of cognition
How many items can you keep in your working/short-term memory and for how long?
7 items +/- 2 for about 30 seconds - can be improved by chunking the information into parts BUT new info will replace this
What is attention?
Ability to initiate it and persist with it i.e. concentration so includes:
- Persistence
- Vigilance
What are the different types of language?
Aphasia/dysphasia:
- Receptive vs expressive
- Language vs speech (dysphagia vs dysarthria)
What is dyspraxia?
Inability to carry out complex motor actions despite intact motor/sensory, coordination, comprehension and co-operation
What is executive functioning?
‘Higher order cognitive functioning’ involving the frontal lobe which is involved in executive, behaviour and personality inc. adaptation, abstraction, mental flexibility, problem-solving, planning, initiation, sequencing, judgement and goal-setting e.g. planning to go on holiday
What patients should be cognitively assessed?
ALL but degree will vary depending on presentation - can be screen through observation so cognitive assessments do not necessarily mean the use of assessment schedules
When should you carry out formal cognitive bedside testing?
If history of screening indicates poor memory, head injury or reduced attention at interview
Many cognitive tests are not ___.
Pure (i.e. cognitive aspects are not tested in isolation)
How do you assess working memory?
- Observation but not easily assessed
- Bedside testing:
- Digit span forwards (7)/backwards (5)
- Immediate recall of 10 item list/7 item name and addresses
(NOT 3 items like in MMSE)
How do you assess anterograde memory?
- Observation: forgetful of content of conversation and repetitive
- Bedside testing:
- Delayed recall of 10 item list/7 item name and address
- Delayed recall of 3 items
How do you assess retrograde memory?
- Observation: incoherent history and forgetting past events
- Bedside testing:
- Dates of wars
- Recall of prime ministers/presidents/monarchs
- Recall of personal info (need informant to confirm)
How do you assess attention/concentration?
- Observation: ability to establish/maintain conversation and distractibility
- Bedside testing:
- Orientation in time/place (also memory)
- Serial subtraction e.g. 100-7, 20-3/spelling backwards e.g. WORLD (check they can spell it forward 1st)
- Days of week or months of year backwards
How can you assess language through observation?
- Able to express fluently and appropriately
- Wordfinding difficulties (semantic dysphasia)
- Able to understand questions/instructions
How can you assess language through bedside testing?
- Naming objects + parts e.g. watch, strap, winder, pen, nib, naming of pictures
- Repetition of complex words e.g. Statistician, Hippopotamus or Constitutional
- Repetition of complex sentences e.g. “No ifs, ands or buts”
- Comprehension e.g. 3 stage command, pen-watch-keys test
How do you assess executive functioning by bedside testing?
- Verbal fluency e.g. 1 min - animals, supermarket, FAC
- Abstraction: proverb interpretation (e.g. people in glass houses), similarities/differences (apple/banana, coat/dress) or cognitive estimates (Camels in Holland/How fast horse gallops)
- Set shifting e.g. alternating sequence test, Luria, trail-making test
- Response inhibition e.g. go-no go test
How do you assess executive functioning by observation?
Not easily assessed
What is the alternating sequence test?
Draw out a shape pattern and ask patient to continue it
What is the trail-making test?
Connect letters and numbers
What is the Luria test?
Moving fists and hands in a certain sequence repeatedly
What is the go-no go test?
Give instructions to patient e.g. tell patient to bang hand against desk with 1 knock and not move hand with 2 knocks
How do you assess visuospatial functioning?
- Observation: position on chair and bumping into furniture (if severely impaired)
- Bedside testing: draw 2 intersecting pentagons (tend to struggle with intersection), cube or clock drawing (draw face, numbers and sets hand to 10 past 5)
How can you assess reading?
- Read aloud complex works (pint, tomb, dough) or a sentence
- Follow written instructions e.g. close your eyes
How do you assess writing?
Write a simple sentence
How do you assess calculation?
- Addition
- Subtraction
- Multiplication
- Division
How do you calculate praxis?
Mime a common action e.g. cleaning teeth
What is a quick method of assessing that a patients cognition is grossly intact?
Orientation to time, place and person
What is the MMSE?
Simple quick screen with wide breadth but it is not comprehensive, not covering executive or memory particularly well so if a problem is shown the patient needs further testing
What is the ACE-R?
More comprehensive test that takes approximately 30 minutes utilised for people shown to have a cognitive deficit
What is the DemTect test?
Brief and simple test for early cognitive changes detecting minor problems but not for moderate problems as they will just be scoring 0
What is the MoCA?
Longer test that is more widespread in use but also good for early cognitive changes
What is the CAMCOG?
Comprehensive test that is usually carried out by an OT
What are the different types of brief GP cognitive tests?
6-CIT
AMT
GPCOG
What other specialities will use specialised versions of cognitive assessments?
Neuropsychology
SALT
Psychology
CAMHS
What are the pros and cons of assessment schedules?
Pros: standardised, validated and transferable
Cons: don’t cover all areas fully, some require training
If you use an assessment schedule, what should you be aware of?
Shortcomings
Fill in deficits
Supplement depending on findings
