Cognitive Assessment

Definition/Introduction

The cognitive assessment is useful to test for cognitive impairment—a deficiency in knowledge, thought process, or judgment. Psychiatrists often perform cognitive testing during the Mental Status Exam. However, when cognitive impairment is suspected, the cognitive assessment can obtain a more detailed analysis by surveying the neuropsychological domains. This detailed investigation of cognition can diagnose major cognitive impairment (ie, dementia) and mild cognitive impairment, evaluate traumatic brain injuries, help determine decision-making capacity, and survey intellectual dysfunction.[1][2][3][4]

There are many established tools used to conduct cognitive assessments. Each is carefully constructed to evaluate neuropsychological domains such as memory, language, executive function, abstract reasoning, attention, and visuospatial skills. Available assessment tools range from those designed to evaluate a single neuropsychological domain to mental status screens that survey multiple neuropsychological domains to the most extensive test. This complete neuropsychological exam assesses each neuropsychological domain.[5]

Most clinicians will use an established mental status screening tool such as the Mini-Mental Status Exam (MMSE) or Montreal Cognitive Assessment (MoCA) to determine if cognitive impairment is present. Mental status screens are short, efficient, and well-researched modalities for evaluating multiple cognitive domains. A cognitive assessment, along with a good history, physical exam, and appropriate labs and imaging, can establish a diagnosis or decide if further evaluation is necessary.[2][6]

A complete neuropsychological evaluation is an option if a screening test is inconclusive or more information is required. A full neuropsychological evaluation would ideally identify the patient’s specific deficits, differentiate between neurological and psychological etiologies, differentiate between Alzheimer’s dementia and other dementias, localize the deficits, and help formulate a personalized management plan. This exam is noninvasive and involves a battery of assessments a trained professional performs. This comprehensive evaluation can take up to a full day to complete. While a full neuropsychological evaluation is the most detailed assessment, it is unnecessary for all patients who have a diagnosis or suspicion of cognitive impairment. However, it can be a helpful resource if there are questions or concerns about a diagnosis or care.[7][8]

How to Performing a Cognitive Assessment

When performing a cognitive assessment, the clinician must take a good patient history and perform a physical exam; this ensures that the patients receive a thorough evaluation while strengthening the caregiver-patient relationship. Suppose the assumption is that the patient has cognitive impairment before considering other diagnoses. In that case, the patient may feel that the clinician has dismissed them due to their age, level of education, or other reasons. A thorough examination can also help identify any behavior or personality disorders potentially contributing to the patient’s chief complaints, as mild cognitive impairments or dementia often coexist with behavioral and personality disturbances. Cognitively impaired patients cannot express themselves fully, so it is very beneficial to have someone with a close relationship with the patient present to help establish baseline levels of functioning.

Before deciding upon a particular testing modality, one should compare all available tests to find the best suited for the administrator and the patient. One should be mindful that some institutions may have a preferred testing modality.[9]

Cognitive Assessment Screens

Various cognitive assessment screens exist, each with instructions, templates (if applicable), and often a website. Below is a short list of the more popular screening tools and their strengths and weaknesses.

MMSE

The MMSE usually takes less than ten minutes to administer, is easy to use, and has been thoroughly researched since 1975. However, what was once the gold standard in cognitive assessments is now used less frequently due to copyright laws and additional costs.

MoCA 

The MoCA is another popular screening tool that takes approximately ten minutes to complete. It evaluates visuospatial skills, attention, language, abstract reasoning, delayed recall, executive function, and orientation.[10] The MoCA covers more domains than the MMSE and, consequently, has greater sensitivity and specificity.[6] The associated website includes specific adaptations for different populations, many different languages, printable versions of the test, and training opportunities.

Mini-Cog™

The Mini-Cog is one of the faster cognitive assessment screens that is used. It consists of a 3-item recall and a clock-drawing test. The delayed 3-item recall tests memory, while the clock drawing test evaluates cognitive function, language, executive function, and visuospatial skills. The Mini-Cog website also gives detailed instructions for administrators. 

Saint Louis University Mental Status Exam  

Initially developed for the veteran population, the Saint Louis University Mental Status Exam (SLUMS) is another tool with an online printable testing form. Its website has an instructional outline for administrators, training opportunities, and a wide range of language options.

Other modalities include but are not limited to the Blessed Orientation-Memory-Concentration Test, Kokmen Short Test of Mental Status, Memory Impairment Screen, Ottawa 3DY, Brief Alzheimer’s Screen, Caregiver-completed AD8, and many other dementia screening scales.[11]

The results of these assessments require review in the context of each patient. Each administrator should remember that a screening test is not a substitute for a diagnostic workup. Lastly, it mentions that no current data supports using cognitive assessments in asymptomatic patients. 

Neuropsychological Domains

Cognitive assessments evaluate for cognitive impairment by assessing the neuropsychological domains. A brief explanation of the frequently tested domains follows.

Language

The language domain involves naming, reading, writing, and repeating words. Some practitioners will evaluate the language by noting the patient’s communication skills throughout the interview. There are many ways to test for language. Two neurocognitive tests include the Boston Naming Test and the Controlled Oral Word Association.[12] It should be noted that a part of the language domain can become mildly impaired with normal aging. Expressive aphasia, which is the inability to find words, can become impaired with normal aging.

Executive function

This assessment encompasses organizing, planning, working memory, mental flexibility, list-making, and executing tasks. An example of executive function impairment might be a patient who cannot follow recipes or cook as well as they used to. Executive function testing is often done by naming as many categorical items as possible; for example, naming as many animals as possible in one minute. Other neuropsychological tests include the Trail Making Tests A and B and the Wisconsin Sorting Test.[12][6]

Abstract reasoning

Abstract reasoning refers to analyzing information, detecting patterns and relationships, or solving problems on an intangible, theoretical level. An example of abstract reasoning skills would be identifying patterns or relationships between things that do not appear to be similar. Another example would be the ability to solve problems without the knowledge it would normally take.[13][14] Abstract reasoning is often tested by having the patient describe similes, analogies, proverbs, or sayings. For example, recognizing the relationship between an airplane and a bicycle is that they are both modes of transportation. Some neuropsychological abstract reasoning tests include the Shipley-2 Abstract Test, Gorham’s Proverbs Test, Conceptual Level Analogy Test, and Verbal Concept Attainment Test.[15]

Memory

Memory is the mechanism that takes information encodes, stores it, and retrieves it for later use.[16] Different kinds of memory make this domain very complicated.

Memory is divided into short-term and long-term memory. Short-term memory can take small pieces of information and utilize them briefly. Long-term memory is subdivided into procedural and declarative, further divided into episodic and semantic. Procedural memory is storing information used to perform or complete tasks that are often done, like driving a car. Declarative memory is the storing and recall of facts and events, such as a family member’s birthday. Episodic memory is contextual information storing or remembering things from a specific experience. An example of episodic memory is the patient remembering what they did for their last birthday. Semantic memory is more general knowledge or factual-based memory, including learned subjects such as math.

Because memory is so complex, it is essential to recognize and document what is under evaluation during this assessment. Memory impairment can be easy to pinpoint from the patient’s history, but it can also masquerade as other things, such as having trouble learning new information.[9] It is also worth noting that normal aging can slightly impair memory. A normal aging patient’s activities of daily living will remain intact.

Attention/concentration

Testing for attention and concentration often takes place together. They are frequently tested by spelling words backward or serially subtracting numbers from a large starting point, such as the MoCA, where the examiner asks the patient to subtract seven from 100 in five increments. Some clinicians observe the patient and assess their level of attention throughout the interview.[9] The Connors Continuous Performance Test is an example of a neuropsychological test that acknowledges attention and concentration.[6]

Visuospatial skills

This concept is a person’s ability to conceptualize and manipulate 2- and 3-dimensional objects. Testing is often done by copying figures, block designs, or clock drawings.[17] This skill set may be difficult to assess while taking a history. Still, it could present as a patient suddenly having difficulty with parallel parking their car or getting into small accidents.[9] In neuropsychology, an example of a test used for these skills is the Rey-Osterrieth Complex Figure Copy Test.[12]

Issues of Concern