1. LaReau, Rita MSN, APRN, BC, GNP

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Bronson Methodist Hospital, in Kalamazoo, Michigan, had been using the Mini-Mental State Exam to screen patients for cognitive impairment. When it became necessary to purchase this tool, a search for another evidence-based practice tool was initiated. The tool had to be easy to use, reliable, and available for free. The Mini-Cog, developed by Soo Borson, MD, and colleagues, was one such tool and was endorsed by the American Geriatrics Society. After reviewing the research, Bronson Methodist Hospital chose the Mini-Cog for use in screening older adult patients for dementia.


In addition to the usual assessment of orientation to person, place, and time, nurses can use the Mini-Cog to further assess an older adult patient's mental status. While the Mini-Cog is listed on the hospitalists' admission order form, enabling orders for screenings to be made on admission of new patients, nurses can also initiate screenings on their own; no physician's order is required. Administration of the screening tool can be triggered by patient risk factors such as age 70 years and older and a negative score on the Confusion Assessment Method tool, or by disorientation or other patient behaviors such as


* exhibiting signs of impaired working memory (being a "poor historian").


* deferring to a family member when questions are addressed to the patient.


* repeatedly and apparently unintentionally failing to follow instructions.


* having difficulty finding the right words or using inappropriate or incomprehensible words.


* having difficulty following conversations.



The completed Mini-Cog form is placed in the progress notes for physician review.


At Bronson Methodist Hospital, if the screening results indicate possible impairment, nurses take the following steps:


* "Confusion" is checked as a risk factor on the hospital's Fall Risk Pathway Interventions Addendum form.


* Associated interventions listed on the form are implemented (for example, using bed and chair alarms, reorienting patients, and evaluating the patient's medications).


* Possible cognitive impairment is documented in the neurologic assessment section of the hospital's electronic medical-nursing documentation system.


* Referrals to be handled by case managers following up with patients and family members are either conveyed verbally or entered in the electronic documentation system.



Patients whose Mini-Cog results are positive (indicating cognitive impairment) are at increased risk for delirium, falls, dehydration, inadequate nutrition, untreated pain, and medication-related problems. The following are some interventions nurses should consider initiating if a positive screen is obtained:


* Review medications for adverse effects.


* Assess for acute changes in mental status.


* Assess for depression.


* Assess for fall risk.


* Assess for malnutrition and dehydration.


* Encourage fluid intake unless contraindicated.


* Monitor for adequate nutritional intake.


* Assess for pain.


* Assess for constipation and fecal impaction.


* Assess for pressure ulcer risk.


* Collaborate with interdisciplinary team members.


* Monitor laboratory results.



Rita LaReau MSN, APRN, BC, GNP


Geriatric clinical nurse specialist, Bronson Methodist Hospital, Kalamazoo, MI.


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