Assessing Cognitive Impairment In Older Adults: Importance And Procedure

What is Cognitive Impairment?

Question:

Write an essay on "Mental health concerns in an old adult".
 

Cognitive abilities are the skills we use to do our daily tasks, be it simple or complex. With age this ability deteriorates. Cognitive changes or impairment was once considered an inevitable part of aging. But in severe conditions it can lead to an abnormal state, dementia. There is evidence that cognitive impairment is associated with poor social and work outcomes, and an early treatment has potential to change functional outcomes of illness. Older adults are always at a risk of cognitive changes which demands a prompt action so that their quality of life can be made better (Tatari et al, 2011). About 20.5 percent old adults experience mental health concerns but only two of three get proper treatment. Dementia is the most common such condition and about 5 million old adults (65 and older) suffer from Alzheimer. Nevertheless many other symptoms like depression and anxiety go unnoticed in old patients.

The older adult, whose age is 65+ suffers from fatigue and has lost interest in recreational activities. He is mostly sad and in depressive mood, sleeping pattern has also changed. He is confused and has a big time trouble taking decisions. Further he suffers from memory loss or short term memory. These are some of the warning signs which were brought into notice to the healthcare providers by his family. Fortunately there is a test which screens and assesses the mental state of an old adult who reflect any mental health concerns which is called MMSE (Mini Mental State Examination). The old adult has a strong educational background hence this test can be easily performed on him. It consists of 11 questions measure test in which the maximum point is 30. There are some advantages as well as disadvantages of the test. It doesn’t require any specialized training or equipment and can be performed very easily as it takes just 10 minutes to examine the patient. It is the most reliable and widely used test to rule out mental diseases in older adults. The disadvantage is that this test is considerably affected by the factors like age, education, culture. In severe dementia cases recording changes becomes difficult (Lancu & Olmar, 2006). 

The old adult is hence brought to continue with the test and accordingly consider the goal of treatment for him. This test evaluates five cognitive functional areas: Orientation, Registration, Attention and Calculation, Recall, Language. The procedure to conduct Mini Mental State Examination to assess the five areas on him is as follows:

Orientation (score-10): This area of the test assesses the memory of the old adult. Ask the older adult about the date, day, month, year followed by the season. For each correct answer award one point. Then ask him about the country, state, or anything related to the place and give him one point each for the correct answer

Registration (score-3): Call name of any three objects slowly. Tell the patient to repeat object names one by one. Give the score depending on the names recalled. Suppose the patient doesn’t name all the objects correctly then continue saying the object names until the patient gets it right. Make a note of how many trials patient took to recall the names.

Importance of Assessing Cognitive Impairment in Older Adults

Attention and Calculation (score-5): Starting with 100, tell patient to count backward by seven. After patient answers five tell him to stop. Give points depending on the correct answers. Alternatively, the older adult can be asked to spell ‘world’ backward. Score again depends on the letters spelled correctly (e.g., 5 points for dlrow, 3 points for dlorw).

Recall (score-3): Ask patient to recollect the names of the three objects stated above. Note down the scores.

Language (9 points): For this show the old adult a pencil and a wrist watch and ask him what he sees. Award one point each for correct naming. After that, give patient just one chance and tell him to repeat this sentence (“No ifs, and’s, or buts.”). Points are given. Give a command in three stages to the patient. “In your hand take a paper, fold it, and keep it on the floor.” For every command understood correctly give one point each. Write on a paper, “Close your eyes”. Big enough letters should be there. Ask patient to do what the paper says. Give the score if he does close his eyes. Tell patient to write a sentence on a paper. The sentence must be written promptly and shouldn’t be senseless. Grammatical mistakes or incorrect punctuation is negligible. Ask the patient to copy this figure as it is:  

As a result of the five areas test, the older adult shows cognitive impairment which means according to MMSE data the patient has mental illness. He shows traces of confusion, indecisive patterns. He is not able to think properly and can’t pay attention. At the same time older adult shows considerable low memory symptoms and recalling issues. In general, according to MMSE score, 24 or any score greater than that is considered as normal cognition, 9 score or less than that is considered severe, 10 to 18 points is moderate and 19 to 23 is mild cognitive impairment. As per the score, this patient may have some degree of dementia along with other mental diseases as well. Diagnosis of this cognitive impairment in a person indicates significance of the treatment that he should undergo and especially in these severe cases an early intervention is important (Brooker, 2004). This mental illness care treatment highlights three main perspectives i.e., management of challenging behaviors, maintenance of cognitive functions and reduced emotional disorders. Each and every area has potential to improve the quality of life which in turn also affects those providing care (The royal college of psychiatrists, 2007).

The older adult, along with the diagnosed mental illness, also has a history of OCD (Obsessive Compulsive Disorder) and bipolar disease. He experience obsessive thoughts which are often sadistic, creates anxiety and uneasiness. For this to counter he gets into compulsive behavior. He may have at times depressive mood and sometimes may feel super energetic. The older adult who demonstrated cognitive impairment from the MMSE data may have delirium as well which is also known as an acute state of confusion and frequently occurs in people with dementia (Gagliardi, 2008). It causes emotional breakdown at times and the patient may have poor memory, trouble sleeping, difficulty recalling or uttering words and severe disorientation. Further the diagnosis depends on symptoms observation e.g.,

• Onset: Delirium starts showing in a short time while dementia begins with small symptoms which slowly worsens.
• Attention: Being non-attentive in delirium is quite significant while a person with dementia is generally alert during the first stages.
• Fluctuation: Symptoms of delirium fluctuate throughout the day whereas in dementia thinking skills and memory remains constant throughout the day. MMSE results for patients with delirium are different. It very soon accompanies acute mental illness in the older adult. The decrease of two or more points in MMSE determined the development of delirium (Nayeem et al, 2005).

Mini Mental State Examination (MMSE) for Assessing Cognitive Impairment in Older Adults

The older adult having delirium may undergo examinations to assess their mental thinking ability, attention etc., which can be done with screening or tests as mentioned above. There can be tests related to neurology (e.g., vision, coordination, balance and many reflexes check) as well as physical exams (urine or blood tests). Many other physical conditions such as pneumonia, asthma can interfere with normal brain functioning. Medications like blood pressure medicines and abusive drugs can further worsen the cognitive abilities. The older adult who is suffering from mental illness according to MMSE data may score low grades because of the delirium condition since low vision may impact the complex commands given. Similarly poor coordination and reflexes can get low scoring in registration, attention and calculation areas of test.

The very first goal of treatment in delirium and mental illness is to identify, control or reverse any symptom. The treatment basically depends on the reason causing delirium after which the focus is solely on providing the best environment for the patient to benefit physically and mentally. Stopping unnecessary medication to end confusion can improve cognitive function (The New York times, 2016). Also, patient should be taught to stay away from substances which can worsen confusion e.g., alcohol, drugs, narcotics (such as morphine, codeine), central nervous system depressants. The patient’s treatment includes component like support therapy and medicinal management. Fluid and nutrients intake should be taken care of as the patient might not be able to maintain a balance. Such older adults if diagnosed at an early stage for any sort of mental illness or chronic disease, they can be benefited with the course of treatment and their quality of life can be made far better. 

Conclusion

Older adults after a certain age are at a risk of developing many physical and mental problems which can affect their cognitive abilities. Many factors like psychological, biological decide the level of mental health of a person. Dementia affects a person’s ability of memory and thinking capacity. It states a confused state of a person. According to WHO, around 47.5 million people are affected with dementia worldwide. Early diagnosis is very crucial to set goals of treatment. Both medicinal and psychological intervention is influential to counter this mental health. MMSE test consists of 30 points questions. It is an effective tool to rule out dementia, Alzheimer’s disease in a patient. It assesses five areas i.e., orientation, registration, attention, and calculation, recall, language. The older adult diagnosed with dementia can have some traces of delirium as well and differentiating them becomes sometimes difficult and necessary. The old adult having mental illness as per the MMSE data may have delirium because this state may demonstrate many physical weaknesses adding to low score in the test. Providing social care in long run to the old adults should be a priority and also to provide them mental health education at the same time.  

References: 

A practical method for grading the cognitive state of patients for the clinician (1975). Journal of psychiatric research, 12(3), 189-198. 

Brooker, D. (2004). What is person-centered care in dementia?. Reviews in clinical gerontology, (13), 215-22. 

Gagliardi, J. (2008). Differentiate among delirium and dementia in elderly patients. Journal of ethics, 10(6), 383-388. 

Lancu, I., Olmar, A. (2006). The mini mental state examination. Harefuah, 145(9), 687-90. 

Nayeem, K. et al. (2005). Use of serial Mini-Mental State Examinations to diagnose and monitor delirium in elderly hospital patients. J Am Geriatr, (53), 867–70.

Tatari. et al. (2011). Mini mental state examination in first episode of psychosis. Journal of psychiatry, 6(4), 158-160. 

The royal college of psychiatrists. (2007). The nice-scie guideline on supporting people with dementia and their carers in health and social care. The British psychological society, UK.