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

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 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

CPT 7 tasks

 Dress for the weather

 Shopping for belt

 Making toast

 Washing

 Phone use

 Travel

 Medication box
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

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

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

CAM 17 subtests evaluate:

 Attention span

 Memory orientation

 Visual neglect

 Temporal awareness
  Recall/recognition

 Auditory memory and sequencing

 Simple math skills

 Safety and judgement

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

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

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

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

Short Portable Mental Status Questionnaire; E Pfeiffer, 1975

 Rapid screening tool for cognitive impairments

 10 item test

 Easy to administer

 Verbal responses only

 Scoring: 0-3 errors = normal cognitive function ,4-5 errors = mild impairment, 6-8 errors =
moderate impairment, 9 or more severe impairment

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 Exam

 Developed in 1975 by M. Folstein

  11 questions, tests orientation, registration, attention/calculation, recall, language
Category Possible Description
points

Orientation to 5 From broadest to most narrow. Orientation to time has been

time correlated with future decline.

Orientation to 5 From broadest to most narrow. This is sometimes narrowed down to

place streets, and sometimes to floor.

Registration 3 Repeating named prompts

Attention and 5 Serial sevens, or spelling "world" backwards It has been suggested
calculation 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 6 Varies. Can involve drawing figure shown

commands

 Takes 5-10 minutes to administer

 Max score is 30, a score less or equal to 23 indicates impairment

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

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

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
that is sensitive to level of cognitive imcapabilities pairment and seems applicable in patients
with varying degrees of dementia.

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

Intensive Care Delirium Screening Checklist

 Administered consistently for 5 days

 Assesses first for altered level of consciousness, then goes on to rate inattention, disorientation,
hallucination, psychomotor agitation or retardation, inappropriate speech or mood, disturbance
in sleep/wake cycle, and symptom fluctuation

 Scoring: A=no response, E=exaggerated response

 Max score is 8, normal response scored as 0 (the patient needs to be able to demonstrate at
least response to mild or moderate stimulation to administer and score, if not the testing was
held until they could).

 Easy to administer with guidelines that make interpretation easy

Test Administration

 Choose time of day wisely

 Well lit room

 No distractions

 Consider timing of food, medication

 Glasses on, hearing aids in

The interview

 I’ve been asked by your primary care MDs to help determine where you are in your ability to
take care of yourself at this point in time and where you need to be to return home.
  Your care team has noted that it has been difficult for you to….(recall, process, problem solve).

 Have you noticed any of this?

 Reassure them that this is normal

After dismissal…

 Recommend recheck at 2 mos.

 Pts should be fully recovered from medications and delirium, but likely noting limitations

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

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

 Ask about depression and anxiety

Is there neurological involvement? Cranial Nerve Exam

 #1: Olfactory Nerve

 Rarely tested, need to test each nostril separately

 Can try toothpaste, alcohol wipe (noxious), “Quease Ease” product

 Bilateral loss of smell can come with smoking, aging, or chronic rhinitis

 Olfactory nerve loss can be a symptom of meningioma

Cranial Nerve Exam

 #II Optic Nerve

 Test eyes separately, have patient wear glasses

 Examiner wiggles their finger in each of the four quadrants, the patient indicates when it
is in the periphery of vision.

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

 Flashlight test, move light between both eyes

 Abnormal findings could be a symptom of optic neuritis

Cranial Nerve Exam

 # III Oculomotor Nerve

 #IV Trochlear Nerve

 #VI Abducens Nerve

 Look for ptosis, eye position and nystagmus

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

 #IV Trigeminal Nerve

 Light touch to the sides of the face, using a point stimulus, forehead, cheek, chin

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

 #VII Facial, motor and sensory

 Motor: raise both eyebrows, frown close eyes, smile, show upper and lower teeth, puff
out both cheeks

 Sensory: test for taste

 Symptom of Bell’s Palsy, Ramsay-Hunt Syndrome

 # VIII Vestibulocochlear

 Whisper numbers and ask patient to repeat

 Balance/vestibular function

 Symptom of acoustic neuroma

 #IX Glossopharyngeal Nerve

 #X Vagus Nerve

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

 #XI Accessory Nerve

 Shrug shoulders, turn head side to side

 #XII Hypoglossal Nerve

 Tongue strength, motion, symmetry

Consult with Mayo Legal

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

 Document the details

 Document that you spoke with the family/caregivers about the results, provide contact
information

Equally important as any test!

 Clinical judgment
  Patient observation

 Family member perception/interaction and report

Final Recommendations

 Based on what you see NOW

 Minimize predictions, support what you recommend with functional performance details noted
in therapy

 Recommend level of care required immediately on dismissal

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