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
