Introduction
- Wash hands (and don PPE if needed)
- Introduce yourself (name and role)
- Confirm patient’s name and DOB
- Explain what the examination involves
- Gain consent to continue
Before starting, think about why you are assessing the patient’s cognitive function – what is your differential diagnosis from the history and mental state examination? You will need to interpret the results of cognitive assessment in the context of the patient, the history and examination findings.
Prepare Patient
- Let the patient know that you are going to be asking them some questions to see how well their brain is working
- Some questions may seem strange, odd or obvious but we need your answers to all of them
Never ask a yes/no closed question - only questions where the patient must generate a response
Prepare Informant
- If this is the first time the assessment is done the correct answers to some of the questions may need to be verified by the informant
Domains
Orientation (Time, Place, Person):
- Time: time (to nearest hour) day, date, month, year, season
- Place: location (address, place, ward, building, room etc), city, county, country
- Person: name, age and date of birth (both should be asked), home address
- Need three for each orientation domain for adequate assessment
- Check answers for person orientation with informants
Attention/Concentration:
- 20-1 backwards, Months of the year backwards, serial sevens subtraction
Language:
- Talk with patient – look for confabulation, perseveration, dysphasia
- Ask patient to name common objects – watch, telephone, keys, pen etc.
Memory:
- Recall of three/five words/test address
- Apple, table, penny
- Lemon, key, ball
- Face, truck, church, daisy, green
- Random address: Mr Brown, 42 West Street
Construction/Praxis:
- Copy figures – cube, cylinder
- Clock Face
- Circular clock face with all the number and the hands at ten past five
Screening tests
- AMTS – MBChB Leeds screening test of choice – see Appendix 1.
- You should be able to use this from memory.
Also in use:
- GPCOG – widely used in primary care.
- 6-CIT – frequently used in primary care
- MoCA – free to use screening tool available on the internet.
- MMSE – previously free with widespread usage but now officially copyrighted.
*You should look at these tests, so that you understand what a score might indicate if you see it reported in a letter or case notes.
Results
ALWAYS interpret the results of cognitive assessment in the context of the patient, the history and examination findings.
Record results in notes. Include relevant MSE findings or confounders for poor performance (e.g. deaf, unable to draw due to stroke hemiplegia etc.)
Always say which test you have used when reporting screening test scores.
Screening test scores always out of maximum, even if they don’t complete all the questions.
Consider reasons for reduced performance: eyesight/visual problems, hearing problems, physical illness, mental illness, delirium, and dementia.
REMEMBER: Testing picks up deficits NOT diagnosis and you need to put any test result in context with rest of history and examination.
| QUESTIONS | SCORING RULES |
|---|---|
| How old are you? | Score for exact age only |
| What is your date of birth? | Only date and month needed |
| What is the year now? | Score for exact year only |
| What is the time of day? | Score if within 1 hr of correct time |
| Where are we? What is this building? | Score for exact place name (e.g. ‘hospital’ insufficient) |
| Who is the current monarch? | Score only for current monarch |
| What is the date of the 1st World War? | Score for year of start or finish |
| Can you count backwards from 20-1? | Score if no mistakes or any mistakes corrected spontaneously |
| Can you tell me what these 2 people do for a living? | Score if recognises role of 2 people correctly e.g. doctor and nurse |
| Can you remember the address I gave you? | Score for exact recall only |
To Complete the Exam
- Explain to the patient that the examination is now finished.
- Thank the patient for their time.
- Dispose of PPE appropriately and wash your hands.
- Summarise your findings.