Assessing Cognitive
Function in the Acute
Care Setting
Ann Lund OTR/L, CHT, CLT
MOTA Conference 2012
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.
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
I’m frustrated!
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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?
Limitations of Cognitive Testing
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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
Most consistently cited in the
literature as effective and easy to
administer:
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For ICU settings:
Intensive Care Delirium Screening Checklist
 Confusion Assessment Method for the ICU
( CAM-ICU)
 Mini Mental Status Exam
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Be consistent between other professionals if at all
possible, use what your institution recommends
What causes age-related cognitive
decline?
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Processing speed theory
Executive function theory
Processing Speed
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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.
Executive Function Theory
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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”
Executive Functions
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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
Executive functions
(A more generous description)
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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
Warning signals of cognitive
impairment in acute care
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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
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S. Gordon et al, Intensive Care Medicine 2004
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Warning signals continued
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Executive dysfunction; cannot follow orders or MD,
RN, OT, etc, demonstrate difficulty with planning or
making dismissal decisions, confusion during multitasking
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
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S. Gordon et al, Intensive Care Medicine 2004
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Causes of Cognitive Changes in
Cancer Patients
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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
Cardiac Failure and Cognitive Issues
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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
Liver failure and Cognitive Decline
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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!!
Cognitive Impairment in Trauma
Patients
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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
Jackson/Vanderbilt cont.
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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.
Drugs that cause cognitive changes
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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
Older adults and drug tolerance
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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.
Confusion/Delirium
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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
Common reasons to see confusion in
the acute care setting
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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
Incidence of Delirium
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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
Treatment of confusion/delirium
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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
Does the duration of delirium
indicate anything?
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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
Physical Function and Cognition
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Assessment of one without the other is
worthless
At a minimum, dressing, bathing, toileting, from
bed base, EOB, standing
Baseline Cognition Assessment
(you start assessing these as soon as you walk in the room)
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Orientation
Attention/concentration/focus
Memory
Initiation, sequencing, termination skills
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L. Johnson, A. Parker, C. Johnson; Is My Patient Ready to Go Home? 2/2012
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Choices
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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
Allen Cognitive Level Screen
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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
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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
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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
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Dress for the weather
Shopping for belt
Making toast
Washing
Phone use
Travel
Medication box
Confusion Assessment Method
(CAM)
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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
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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)
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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:
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Attention span
Memory orientation
Visual neglect
Temporal awareness
Recall/recognition
Auditory memory and sequencing
Simple math skills
Safety and judgement
Montreal Cognitive Assessment
(MOCA)
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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
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Short term memory recall
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Visual spatial tasks
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5 item recall
Clock drawing
3 D cube drawing
Executive function
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Trail making tasks
Phonemic fluency task
Verbal abstraction task
MOCA Subtests
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Attention, concentration, working memory
sustained attention task
 Serial subtraction task
 Counting backward/forward
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Language
3 item naming (non-familiar animals)
 Complex sentence repetition
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Orientation
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Time and place
Short Blessed Test; G. Blessed, 1968
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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: 0-2 errors, normal cognitive function
3-4 errors, mild impairment, 5-7 errors, moderate
impairment, 8 or more severe impairment
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Short Portable questions
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Today’s date
Day of the week
Patient’s personal phone
number
Patient’s address
Patient’s age
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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
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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
Category
Possible
points
Description
Orientation to
time
5
From broadest to most narrow. Orientation to time has been
correlated with future decline.
Orientation to
place
5
From broadest to most narrow. This is sometimes narrowed down
to streets, and sometimes to floor.
Registration
3
Repeating named prompts
Attention and
calculation
5
Serial sevens, or spelling "world" backwards It has been suggested
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
commands
6
Varies. Can involve drawing figure shown
Texas Functional Living Scale
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“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”
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Pearson Assessments quote
TFLS continued
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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
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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.
Intensive Care Delirium Screening
Checklist
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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
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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
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Choose time of day wisely
Well lit room
No distractions
Consider timing of food, medication
Glasses on, hearing aids in
The interview
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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…
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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
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#1: Olfactory Nerve
Rarely tested, need to test each nostril separately
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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
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#II Optic Nerve
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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
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# 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
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Cranial Nerve Exam
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#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).
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Cranial Nerve Exam
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#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
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Symptom of Bell’s Palsy, Ramsay-Hunt
Syndrome
Cranial Nerve Exam
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# VIII Vestibulocochlear
Whisper numbers and ask patient to repeat
 Balance/vestibular function
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Symptom of acoustic neuroma
Cranial Nerve Exam
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#IX Glossopharyngeal Nerve
#X Vagus Nerve
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#XI Accessory Nerve
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Gag response, articulation of “ka, ga”, “go”
Shrug shoulders, turn head side to side
#XII Hypoglossal Nerve
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Tongue strength, motion, symmetry
Consult with Mayo Legal
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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
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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
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Assessing Cognitive Function in the Acute Care Setting