- After a client suffers a cardiovascular accident and has experienced a temporary loss of oxygen to the brain, it is possible that damage to the brain occurred.
- The following standardized cognitive assessments are useful screening tools to determine if cognitive impairment is present, and what processing areas of the brain are most impacted.
- Information obtained from these assessments can be used to inform team members if follow-up evaluation is needed, guide therapeutic interventions, and to ensure that clients are able to complete tasks safely upon discharge from hospital.
- Depending on the patient's age, level of education, and pre-admission factors (living at home, driving, etc.), one assessment may be more appropriate that the other (also see Research below), thus clinical reasoning is important.
Montreal Cognitive Assessment (MoCA) (Nasreddine, 2014)
Summary:
- Purpose: Screening tool for cognitive dysfunction
- Cognitive Domains assessed: Attention and concentration, executive function, memory, language, visuospatial skills, conceptual thinking, calculations, and orientation.
- Time to Administer: Approximately 10 minutes
- Equipment: No specialized equipment is needed (assessment and pen)
- Training:
- Total Score: 30
- "Normal" Cutoff Score: 26
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Mini Mental State Exam (MMSE) (Folstein, Folstein, & McHugh, 1975).
Summary:
≥ 27 None
21-26 Mild
11-20 Moderate
≤ 10 Severe
- Purpose: Developed as a breif screening tool to provide a detect the presence of cognitive impairment (Folstein, Robins, & Helzer, 1983)
- Cognitive Domains Assessed: Orientation, registration, attention, calculation, immediate recall, short-term verbal memory, language, and construct ability.
- Time to Administer: Approximately 10 minutes
- Equipment: No specialized equipment required.
- Total Score: 30.
- Score Interpretation: Folstein, Folstein, McHugh, and Fanjiang (2001) recommended the following cutoff scores:
≥ 27 None
21-26 Mild
11-20 Moderate
≤ 10 Severe
Research Resources
1. The MoCA and MMSE as screeners for cognitive impairment in a heart failure population: A study with comprehensive neuropsychological testing.
Hawkins, M.A., Gathright, E.C., Gunstad, J., Dolansky, M.A., Redle, J.D., Josephson, R., Moore, S.M., Hughes, J.W.
Heart and Lung: The Journal of Acute and Critical Care, July 2014.
Available at: http://www.heartandlung.org/article/S0147-9563(14)00185-X/fulltext
Abstract
Objective. To examine the ability of the Mini Mental Status Examination (MMSE) and Montreal Cognitive Assessment (MoCA) to detect cognitive impairment in persons with heart failure (HF) (1).
Background. Although the MMSE and MoCA are commonly used screeners in HF, no research team has validated their performance against neuropsychological testing (1).
Methods. Participants were 106 patients with HF (49.1% male, 68.13 ± 9.82 years) who completed the MoCA, MMSE, and a full neuropsychological battery. Sensitivity and specificity were examined. Discriminant function analyses tested whether the screeners correctly detected cognitive impairment (1).
Results. A MoCA score <25 and MMSE score of <28 yielded optimal sensitivity/specificity (.64/.66 and .70/.66, respectively). The MoCA correctly classified 65% of patients, Wilk's lambda = .91, χ2(1) = 9.89, p < .01, and the MMSE correctly classified 68%, Wilk's lambda = .87, χ2(1) = 14.26, p < .001 (1).
Conclusions. In HF, both the MoCA and MMSE are useful in identifying the majority of patients with and without cognitive impairment. Both tests misclassified approximately one-third of patients, so continued monitoring and evaluation of patients is needed in conjunction with screening (1).
Keywords: Heart failure, Screening, Cognitive impairment, MMSE, MoCA (1)
2. Screening for mild cognitive impairment in patients with heart failure: Montreal cognitive assessment versus mini mental state exam.
Cameron J., Worrall-Carter, L., Page K., Stewart S., Ski C.F. (2013).
European Journal of Cardiovascular Nursing
doi: 10.1177/1474515111435606
Abstract
BACKGROUND: Cognitive impairments occur frequently in patients with chronic heart failure (CHF), resulting in worse health outcomes than expected. These impairments can remain undetected unless specifically screened. There are limited sensitive screening measures available in nursing practice to identify mild cognitive impairment (MCI). AIM: To compare the Montreal Cognitive Assessment (MoCA) with the Mini Mental State Exam (MMSE) in screening for MCI in CHF patients. (2)
METHODS: The MMSE and MoCA were administered to 93 hospitalized CHF patients (70±11 years), without a history of neurocognitive problems. Patients with low MoCA scores (<26) were compared to those with low MMSE scores (<27). Two different parameters were examined between the MoCA and the MMSE: level of MCI agreement (Kappa coefficient) and task errors on assessed cognitive domains (χ2 test). (2)
RESULTS: Statistically more patients had low MoCA scores compared with low MMSE scores (66 vs. 30, p=0.02). The MoCA classified 38 (41%) patients as cognitively impaired that were not classified by the MMSE. A significantly low level of agreement was found (κ=0.25, p=0.001) between the MMSE and MoCA in identifying patients with scores suggestive of MCI. More task errors were observed on the MoCA cognitive domains compared with the MMSE cognitive domains. In 68% of patients with low cognitive scores, visuospatial task errors were observed on tasks from the MoCA compared with 22% on a similar task of the MMSE. (2)
CONCLUSION: The MoCA, a screening tool for MCI, identified subtle but potentially clinically relevant cognitive dysfunctions with greater frequency than MMSE. (2)
KEYWORDS: Chronic heart failure; MMSE; Montreal Cognitive Assessment; cognitive impairment; screening tools (2)
Interventions
MEMORY
Providing memory strategies to patients is a useful way to help them improve. It is important to remember that each person may develop their own strategies over time, and build on strategies as works for them. In an acute care environment formal intervention for cognition it not often feasible, but the following strategies can assist individuals with tasks until rehabilitation programs begin or their cognitive status improves.
1. Develop a Daily Routine and follow it
2. Be organized by making various lists
3. Write down directions
4. Develop organizational systems
5. Use external memory aids
6. Use cross-references
7. Use repetitions
8. Focus on one activity or task at a time
9. Use many senses
10. Mnemonics
11. Visualize
12. Use a journal
13. Use a system of reminders
14. Learn to trust your instincts
15. Simplify the information you obtain
16. Rehearse new information immediately
17. Restate the information in your own words
18. Jog your memory
19. Use a cue or a symbolic reminder
(The Ottawa Hospital, 2013)
References
(2) Cameron J., Worrall-Carter, L., Page K., Stewart S., Ski C.F. (2013). Screening for mild cognitive impairment in patients with heart failure: Montreal cognitive assessment versus mini mental state exam. European Journal of Cardiovascular Nursing, 12 (3):252-60. doi: 10.1177/1474515111435606.
Folstein MF, Folstein SE, McHugh PR (1975). ""Mini-mental state". A practical method for grading the cognitive state of patients for the clinician". Journal of Psychiatric Research, 12 (3): 189–98. doi:10.1016/0022-3956(75)90026-6.
Folstein, Robins,Hezler (1983). In depth Review of MMSE. Retrieved from http://strokengine.ca/assess/module_mmse_indepth-en.html
Folstein, Folstein, McHugh, and Fanjiang (2001). In depth Review of MMSE. Retrieved from http://strokengine.ca/assess/module_mmse_indepth-en.html
(1) Hawkins, M.A., Gathright, E.C., Gunstad, J., Dolansky, M.A., Redle, J.D., Josephson, R., Moore, S.M., Hughes, J.W. (2014). The MoCA and MMSE as screeners for cognitive impairment in a heart failure population: A study with comprehensive neuropsychological testing. Heart and Lung: The Journal of Acute and Critical Care. doi: 10.1016/j.hrtlng.2014.05.011.
Nasreddine, Z. (2014). The Montreal Cognitive Assessment. Retrieved from http://www.mocatest.org/
The Ottawa Hospital (2013). Memory Guide. The Ottawa Hospital.