Tools for Cognitive Screening & Assessment in Nursing Home Residents (Part 1)

Comprehensive assessment is the first step in the GuideStar Eldercare LTC Antipsychotic Stewardship Program®, and it’s crucial, because diagnosis drives treatment. “Establishing an accurate picture of a resident’s cognitive functioning, along with a comprehensive neurobehavioral assessment, can develop a treatment plan and improve quality of life. Ongoing, standardized assessments help practitioners identify changes over time as well,” as noted in an earlier blog.

Domains of cognitive functioning

Cognitive functioning is “the performance of the mental processes of perception, learning, memory, understanding, awareness, reasoning, judgment, intuition, and language,” as defined by the American Psychological Association.

A diagnosis of dementia is based on “a significant decline” in an individual’s baseline of cognitive performance, according to the American Psychiatric Association. “In a person with dementia, the neurons in the regions of the brain that affect cognition progressively get damaged,” they explain.

This evolution in our understanding of dementia is reflected in the DSM-5 terminology change from “dementia” to “major neurocognitive disorder”. This concept underpins the neurology-forward approach to dementia care practiced by GuideStar Eldercare clinical teams.

According to the American Psychiatric Association, dementia may affect one or more domains of cognitive functioning, including:

• “Memory, including the ability to remember recent events and conversations.
• “Learning new information and applying it.
• “Ability to sustain attention on complex tasks.
• “Language, including naming, speaking without grammatical errors and with appropriate use of words.
• “Movement-related skills, including hand-eye coordination, body-eye coordination, and visual-auditory skills.
• “Ability to focus attention, plan, organize and coordinate multiple tasks.
• “Ability to perceive, understand, and judge others and one’s social behavior.”

Memory problems are often among the first symptoms of Alzheimer’s. However, “the symptoms of dementia vary between individuals and types of dementia,” explains the American Psychiatric Association.

Cognitive screening: BIMS

The Brief Interview for Mental Status (BIMS) measures two of the cognitive domains, memory and orientation. The simple test uses recall of three words and questions about temporal orientation (year, month, and day of the week). It is a required component of the MDS 3 because, in the words of CMS, “A structured cognitive test is more accurate and reliable than observation alone for observing cognitive performance.” Capturing data that is objective and replicable also allows caregivers to screen for changes over time.

The test takes about three minutes to administer, and scoring for a total possible 15 points is as follows:

• 13-15: cognitive functioning intact
• 8-12: cognitive functioning moderately impaired
• 0-7: cognitive functioning severely impaired

Results of this initial and quarterly screening can also help caregivers define needs for assistance and conduct “direct nursing interventions to facilitate greater independence such as posting or providing reminders for self-care activities,” says CMS.

Tips for conducting a BIMS

CMS states that nearly every nursing home resident can complete the BIMS. How you introduce it can help put residents at ease. Advises CMS, “If the resident expresses concern that you are testing his or her memory, he or she may be more comfortable if you reply: ‘We ask these questions of everyone so we can make sure that our care will meet your needs.’”

Other tips from CMS:

• Be sure to use an interpreter or American Sign Language if needed.
• Be sure the resident has any needed communication devices, e.g., hearing aid.
• Minimize background noise.

Limitations of a BIMS

The BIMS is a screening tool only. The Cleveland Clinic emphasizes that “cognitive screening tests don’t reveal any information about: why there might be cognitive impairment, the location in the brain of the cognitive impairment, the condition that might be causing the cognitive impairment, or the severity of the cognitive impairment.”

In addition, “Cognitive decline or complaints often co-occur with mental health conditions, such as depression and anxiety,” according to the American Psychological Association. A qualified psychologist can evaluate distinctions between neurodegenerative illness vs. psychiatric symptoms, says the Association. Holistic neuropsychiatric assessment is vital to building a complete clinical picture.

Learn about the MMSE and MoCA in Part 2 of this blog series.