Behavioural and Cognitive Neuroscience - Assessment of Cognitive Function Flashcards
what is cognition?
higher level intellectual functioning
Enables us to learn and remember, to concentrate, to communicate & understand the world, carry out everyday functions & solve problems
what domains does cognition include?
Memory
Executive Function
Arousal & Attention
Visual & Spatial Processing
Processing Speed
Motor Skills
Language
why do we assess cognition?
Most clinical investigations, including assessment of cognitive functioning, are directly or indirectly intended to answer one or more of the following questions:
What is going on? Nature of the Impairment
What is going to happen? Predict recovery, risk and adjustment
What will help? Type of intervention or adaptation
Has functioning changed? Recovery and effectiveness of intervention (aide at home?)
what are challenges of cognitive bedside assessment?
The ward environment (e.g. noise, privacy, light, competing requirements)
May need to consider differential diagnosis (e.g. Depression, Delerium and/or Dementia?)
Medical & Post surgical side effects
Significant sensory & Motor Impairments (pre and post surgery)
Communication issues
Building rapport can be difficult
Fatigue
Resource demand (e.g. bed shortage, staffing, COVID-19)
what do you look for when reveiwing a patient medical records?
Should always be done in advance but in reality can be difficult due to limited time and resource.
Look for red flags:
– Lengthy entries and correspondence
Particular disciplines (e.g. neurology, psychiatry, psychology)
Relevant laboratory findings and imaging
Medications
Are there co-morbid conditions or factors that may be impacting on presentation e.g. alcohol or substance misuse, neurodevelopmental disorders, seizure disorders, previous CNS insults or A&E
what makes up bedside assessment?
Observations
Stop, take and step back – what do you see?
Alert, orientated in time, person & place, awareness/insight into condition, affect
Interactions: Always reintroduce yourself and explain your role. Provide reassurance.
Organised history and awareness, appropriateness, recall, affect, concern, patient
interests and motivation, use of cues
Cognitive Screens: Brief, sensitive, specific, reliable & standardised and or use of other screening tools to assess mood or anxiety
e.g. GAD or PHQ-9
Collateral: Nursing staff, other team members, family, significant others
what are the functions of a cognitive screen?
Detect possible cognitive impairment
Stage & track the degree of impairment
Flag problem areas for future assessment and investigation
Assist with referral and management
Often have subscales to briefly explore domains
A time efficient, brief measure of cognitive functioning
what is a cognitive screen not?
Not a diagnostic tool
Does not replace observation & information gathering
Should not form the basis of planning decisions
Does not determine capacity
Scores do not directly relate to everyday functioning
It is not a neuropsychological assessment
when do you avoid using a cognitive screen?
if the patient has a known learning disability
If the patient appears sedated to the extent that it is likely they will not be able to attend properly.
If the patient is delirious or experiencing hallucinations
If the patient is distressed about completing the test or refuses to complete.
what factors do you consider when choosing your cognitive screen?
STANDARDISATION
VALIDITY
RELIABILITY
what are three common cognitive tests?
Mini Mental State Examination (MMSE)
Montreal Cognitive Assessment (MOCA)
Addenbrooke’s Cognitive Examination (ACE-III)
what is the mini mental state examination?
30-point scale
-Arguably an appropriate screening tool for dementia in a defined clinical setting
(acute geriatric medical units, over 75yrs, geriatric liaison teams)
when should you avoid Mini Mental State Examination (MMSE)?
Lack of diagnostic specificity
Poor sensitivity in distinguishing patients with mild cognitive impairment from normal older adults
Has both a poor ‘ceiling’ and ‘floor’ effect – a score of 0 does not imply the absence of cognition; similarly, a score of 30 does not necessarily indicate normal cognition.
Fails to take level of education, literacy levels or visual difficulties into account
Processing speed & executive functioning not assessed
Arguably using the time taken to administer to observe and interact with the patient is more useful
when do you use MONTREAL COGNITIVE ASSESSMENT (MOCA)?
Published in 2005 as a rapid screening tool (10 mins) covering many cognitive domains
Wide age range & culturally diverse populations
Alternate forms available plus iPad version
Improving norms and evidence to support use across clinical different populations
Score of 26/20 considered normal
Johns et al, 2010 adjusted for lower academic achievement
what are limitations of MONTREAL COGNITIVE ASSESSMENT (MOCA)?
Still only a brief screen
New restrictions on use from December 2020 – new one hour training & certification
Multiple linguistic and cultural variables may impact on norms across different countries and languages.
Several cut offs suggested across different languages to compensate for education level of the population, however most of these have not been validated.
