Assessing Cognitive Function in the Acute Care Setting

1. Assessing Cognitive Function in the Acute Care Setting Ann Lund OTR/L, CHT, CLT MOTA Conference 2012

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

3. Course Objectives 1. The attendee will be able to cite use of 3 different cognitive assessments appropriate for their patients in the hospital based acute care setting 2. The attendee will be able to cite basic strategy of assessing cognition in the setting of pain and disease 3. The attendee will be able to cite the legal implications of reporting on cognitive function of their patients

4. I’m frustrated! • Can we truly assess cognition in the acute care? • What are the factors impacting patient performance? • What can we contribute to this patient’s care with the tools and knowledge we have to draw from?

5. Limitations of Cognitive Testing • These tests are standardized, the score does not necessarily represent true functional level of the person tested • Those normally very high functioning pts will test normal, but to them still have significant limitations • Those lower functioning pts will do poorly, but their function may seem or be very near normal to them • You are getting a momentary snapshot of performance with use of a formalized test

6. Most consistently cited in the literature as effective and easy to administer: • For ICU settings: • Intensive Care Delirium Screening Checklist • Confusion Assessment Method for the ICU ( CAM-ICU) • Mini Mental Status Exam • Be consistent between other professionals if at all possible, use what your institution recommends

7. What causes age-related cognitive decline? • Processing speed theory • Executive function theory

8. Processing Speed • T. A. Salthouse, 1996 • The central hypothesis in the theory is that increased age in adulthood is associated with a decrease in the speed with which many processing operations can be executed and that this reduction in speed leads to impairments in cognitive functioning because of what are termed the limited time mechanism and the simultaneity mechanism. That is, cognitive performance is degraded when processing is slow because relevant operations cannot be successfully executed (limited time) and because the products of early processing may no longer be available when later processing is complete (simultaneity). Several types of evidence, such as the discovery of considerable shared age-related variance across various measures of speed and large attenuation of the age-related influences on cognitive measures after statistical control of measures of speed, are consistent with this theory.

9. Executive Function Theory • T. Salthouse, et al, 2003 J Exper. Psych • “Executive functions are those control processes responsible for planning, assembling, coordinating, sequencing and monitoring other cognitive operations” • Lezak 1995: “The executive functions consist of those capacities that enable a person to engage successfully in independent, purposeful, self serving behavior”

10. Executive Functions • Executive function is an umbrella term for cognitive processes such as planning, working, memory attention, problem solving, verbal reasoning, inhibition, mental flexibility, multi-tasking, and initiation and monitoring of actions • Carried out by the prefrontal areas of the frontal lobe; new work proposes that their origins are more spread out around the cortex • Decline in cognition is found in conjunction with deterioration of the associated area of the brain • R. Chan at al, Arch. Clin. Neuropsychology, 2008

11. Executive functions(A more generous description) • Allow us to handle new situations • Allow us to plan and make decisions • Allow us to make corrections or problem solve • Allow us to handle dangerous or technically difficult situations • Allow “override” of automatic reactions for the greater good • D.Norman, T. Shallice, 2000

12. Warning signals of cognitive impairment in acute care • Personality changes; increased apathy, loss of social inhibition, irritability/paranoia, outbursts of anger • Memory: difficulty with new information, word finding, cannot recall conversations with medical staff or family visits, cannot recall what or when they ate last • S. Gordon et al, Intensive Care Medicine 2004

13. Warning signals continued • Executive dysfunction; cannot follow orders or MD, RN, OT, etc, demonstrate difficulty with planning or making dismissal decisions, confusion during multi-tasking • Functional deficits; difficulty looking up information or operating the hospital equipment, decline in self care not attributed to physical limitations, inability to follow a conversation, inability to find one’s room, inability to follow through with tasks • S. Gordon et al, Intensive Care Medicine 2004

14. Causes of Cognitive Changes in Cancer Patients • Tumor located in the central nervous system (CNS) which includes the brain and spinal cord • Treatments administered directly to the CNS • Chemotherapy and radiation given to the brain at the same time • Treatments administered when extremely ill; be an advocate for your patient when needed

15. Cardiac Failure and Cognitive Issues • Mary Jane Sauvé, D.N.Sc., R.N., of the University of California, Davis. • The researchers administered tests of cognitive (intellectual) function to 50 patients with HF and 50 people without HF, matched for age and estimated intelligence.  Most of the patients had mild to moderate HF. Overall, patients with HF scored lower than controls on 14 of 19 cognitive tests.  46% percent of the HF patients were rated as having mild to severe cognitive impairment, compared to a 16 percent rate of mild impairment in controls.  Memory problems, especially short-term memory, were the most common type of cognitive deficit. • Most associated with left ventricular dysfunction

16. Liver failure and Cognitive Decline • A. Collie, 2005, Liver International • Studied HE (hepatic encephalopathy), SHE (subclinical HE) • 34-84% have SHE • Estimated 1.5-2 million pts in North America • Early diagnosis of liver disease=best results • McCrea et al; see issues with attention and motor skills, but intact visual-spatial, memory, general intellect and language skills • DRIVING SAFETY!!

17. Cognitive Impairment in Trauma Patients • JC Jackson et al, prospective cohort study, 173 pts fromVanderbilt Univ. TICU • Moderately and severe trauma pts • 108 evaluated at 1 yr f/u • 55% demonstrated cognitive impairment at 12 mos. 5.5% had pre-existing cog. condition • No significant difference in cog. impairment between moderate vs. severe trauma pts

18. Jackson/Vanderbilt cont. • The study found the clinically significant symptoms of depression occurred in 40% of ICU pts at 1 yr. • PTSD found in 26% of pts at 1 year • No significant difference in numbers in moderate vs. severe injured pts.

19. Drugs that cause cognitive changes • Drug-induced cognitive impairment is most commonly linked to benzodiazepines, (tranquilizers and sleeping aides), opiates, (narcotics/pain relievers), tricyclic antidepressants, (pain syndrome/neuropathy), and anticonvulsants (drugs used to treat and prevent seizures). • Corticosteroids (autoimmune disease treatment), is also linked to cognitive changes

20. Older adults and drug tolerance • The body’s ability to clear drugs decreases with age, often because of a normal age-related decrease in kidney and liver function. This results in a greater accumulation of drugs in the body. • Older patients are often prescribed multiple drugs at the same time. Due to complicated interactions between different drugs, side effects can become more prominent. • Some research suggests that neurotransmitters become naturally imbalanced as people age, increasing the brain’s sensitivity to drugs that have activity in the central nervous system.

21. Confusion/Delirium • State that develops over hours or days • Involves changes in alertness that vary over the course of the day • Usually temporary and reversible • DSM III: changes in consciousness, cognition, occurs over a short period of time and these fluctuate, and they are determined to be, (via history/exam/lab finding), a direct cause of the current medical condition

22. Common reasons to see confusion in the acute care setting • New surroundings • Increase or change in medications • Exposure to anesthesia, especially if prolonged • Excessive blood loss • Change in wake/sleep cycle • Dehydration or malnutrition • Infection • Alcohol or drug withdrawl

23. Incidence of Delirium • Present in 10% of ER patients, 10-31% of medical units, 50% hip fracture pts, > 80% pts on mechanical ventilation • Most likely to have delirium: prior cognitive issues, visual impairments, severe illness, elevated blood urea nitrogen/creatinine ratio • Hospital contributors: use of restraints, catheterization, malnutrition, > 3 medication additions, sustaining an iatrogenic event • Presence of delirium associated with development of dementia in subjects followed for 4 years, with an increase from 8.1% to 62% • M. Rathier, W. Baker; A Review of Recent Clinical Trials and Guidelines on the Prevention and Management of Delerium in Hospitalized Older Patients, 2011

24. Treatment of confusion/delirium • Try to normalize the environment • Assure adequate sleep time/schedule • Write out the daily schedule • Bring in familiar objects • Ensure patient wears glasses/hearing aids • Explain to the patient that they appear confused at times and encourage them to ask questions

25. Does the duration of delirium indicate anything? • Morandi et al; Crit. Care Med 2012 • 47 pts, median age 50, studied is delirium duration predictive of long term cognitive impairment • Cognition tested at 3 and 12 months post • Delirium duration in the ICU was associated with white matter disruption, which in turn was associated with worse cognitive scores for up to 12 months. • M. Rather, Hospital Practice 2011; Delirium resolves in many patients by the time of discharge, but is an independent risk factor of for death, institutionalization and dementia

26. Physical Function and Cognition • Assessment of one without the other is worthless • At a minimum, dressing, bathing, toileting, from bed base, EOB, standing

27. Baseline Cognition Assessment(you start assessing these as soon as you walk in the room) • Orientation • Attention/concentration/focus • Memory • Initiation, sequencing, termination skills • L. Johnson, A. Parker, C. Johnson; Is My Patient Ready to Go Home? 2/2012

28. Choices • Allen • CPT • CAM (Confusion Assessment Method) • MOCA • Short Blessed Test • Short Portable Mental Status Questionnaire • MMST Mini Mental Status • Texas Functional Living Scales • Intensive Care Delirium Screening Checklist

29. Allen Cognitive Level Screen • Task/performance based assessment • Leather lacing, 3 visual motor tasks • Designed to provide a quick measure of cognitive processing capacities, learning potential and performance abilities • Scoring: 3.0-5.8 • Each score provides description of functional performance abilities

31. 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

32. Cognitive Performance Test • Standardized assessment that evaluates information processing skills via ADL tasks • Measures memory, executive functioning and processing capacities that support functional performance • Can track changes over time • Alzheimers, CVA, TBI, dementia populations • Author Teressa Burns, OTR/L, Mpls VA

33. CPT 7 tasks • Dress for the weather • Shopping for belt • Making toast • Washing • Phone use • Travel • Medication box

34. Confusion Assessment Method (CAM) • Inouye et al, 1990 • Two parts; part 1 screens for overall cognitive impairment. Part II includes the 4 features that had the greatest ability to distinguish between reversible delirium and other types of cognitive impairment • Administered in less than 5 minutes • Scoring via yes/no answers to questions

35. Confusion Assessment Method: Part 1 • Acute onset • Inattention, behavior fluctuation • Disorganized thinking • Altered level of consciousness • Disorientation • Memory impairment • Perceptual disturbances • Psychomotor agitation • Psychomotor retardation • Altered sleep-wake cycles

36. Cognitive Assessment of Minnesota (CAM) • Standardized, measures cognitive abilities of adults with neurological impairments • Administration in 60 minutes or less • Can be used to establish baseline or validate treatment effectiveness • Developed by R. Rustad OTR, T. DeGroot OTR, M. Jungkunz OTR, K. Freeberg OTR, L Borowick OTR, Ann Wanttie, OTR

37. CAM 17 subtests evaluate: • Attention span • Memory orientation • Visual neglect • Temporal awareness • Recall/recognition • Auditory memory and sequencing • Simple math skills • Safety and judgement

38. Montreal Cognitive Assessment (MOCA) • Developed by neurologist Ziad Nasreddine 1996 • Detects mild cognitive impairment and Alzheimer’s Disease • 30 pt. test involving several cognitive domains • 15-20 minute administration time • Available in several languages • Available via internet

39. MOCA Subtests • Short term memory recall • 5 item recall • Visual spatial tasks • Clock drawing • 3 D cube drawing • Executive function • Trail making tasks • Phonemic fluency task • Verbal abstraction task

40. MOCA Subtests • Attention, concentration, working memory • sustained attention task • Serial subtraction task • Counting backward/forward • Language • 3 item naming (non-familiar animals) • Complex sentence repetition • Orientation • Time and place

42. Short Blessed Test; G. Blessed, 1968 • Used to determine cognitively impaired from normal • 6 item test-Patients are asked to answer the items year and month, time of day, count backward 20-1, recite months backwards, and the memory phrase. • Easily administered • Verbal responses only • Scoring: 0-4= Normal cognition, 5-9 = questionable impairment, > 10 = impairment consistent with dementia

43. Short Portable Mental Status Questionnaire; E Pfeiffer, 1975 • Rapid screening tool for cognitive impairments • 10 item test • Easy to administer • Verbal responses only • Scoring: 0-2 errors, normal cognitive function 3-4 errors, mild impairment, 5-7 errors, moderate impairment, 8 or more severe impairment

44. 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 Short Portable questions

45. Mini Mental Status Exam • Developed in 1975 by M. Folstein • 11 questions, tests orientation, registration, attention/calculation, recall, language • Takes 5-10 minutes to administer • Max score is 30, a score less or equal to 23 indicates impairment

47. Texas Functional Living Scale • “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

48. TFLS 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

49. CM Cullem et al; Neuropsychiatry/Psychology/Behavioral Medicine 2001 Apr-Jun CONCLUSIONS: The TFLS showed evidence of good reliability, internal consistency, and convergent and discriminant validity with several popular measures of global cognitive status and behavioral functioning. It is a brief and easily administered performance-based measure of daily functional capabilities that is sensitive to level of cognitive impairment and seems applicable in patients with varying degrees of dementia.

50. Intensive Care Delirium Screening Checklist • Developed by N. Bergeron et al; U of Montreal Dept. of Psychiatry • Screening tool • Checklist based on 8 DSM criteria for delirium