“Mental Status Assessment of Older Adults: The Mini-Cog.” (2007) AJN

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Table 1. Comparison of Other Brief Tools Used to
Screen for Cognitive Impairment
By Deirdre Mary Carolan Doerflinger, PhD, CRNP
Instrument Descriptor Scoring Time to administer
Blessed Dementia
Scale 1
Twenty-two items measuring change in activities
of daily living, self-care, personality, and
drive
0 (normal) to 28 (severe impairment) 20 minutes
Clinical Dementia
Rating 2
Semi-structured interview; impairment rated on
a five-point scale in each of six domains of
cognitive function: memory, orientation, judgment
and problem solving, community affairs;
home and hobbies, and personal care
Impairment ratings: 0 = none;
0.5 = questionable; 1 = mild;
2 = moderate; 3 = severe
20 minutes
FROMAJE 3
Seven items relating to mental function, reasoning,
orientation, memory, arithmetic, judgment,
and emotional state
Each item rated on a three-point scale; total
score ranges from 7 (mild to no impairment)
to 21 (13 or higher is indicative of severe
dementia or depression)
10 to 20 minutes
Set Test 4
Verbalized recollection of as many items as
possible (up to 10) in each of four categories:
colors, animals, fruits, and towns
10 is a perfect score in each category; 40 is
a perfect total score; few subjects have total
scores lower than 15
2 to 5 minutes
Clock Drawing Test 5 Drawing of clock with time at 11:10 No universal scoring 2 to 5 minutes
6-Item Cognitive
Impairment Test
(6CIT) 6
A six-item abbreviation of the Blessed
Information–Memory–Concentration Scale
0 (perfect score) to 28 (maximum impairment);
a score of 8 or more is indicative of
cognitive impairment
1 to 2 minutes
Mini-Mental State
Examination
(MMSE) 7
Eleven items measuring orientation, registration,
attention and calculation, recall, and
language
0 (poor) to 30 (normal) 10 minutes
7 Minute Screen 8 Four tests: orientation, memory, clock drawing,
and verbal fluency
0 (perfect score) to 113 (maximum error); 0
(maximum impairment) to 16 (perfect score);
0 to 7 (perfect score); and the number of animals
named in a one-minute period
7 to 10 minutes
REFERENCES
1. Blessed G, et al. The association between quantitative measures of dementia and of senile change in the cerebral grey matter of
elderly subjects. Br J Psychiatry 1968;114(512):797-811.
2. Morris JC. The Clinical Dementia Rating (CDR): current version and scoring rules. Neurology 1993;43(11):2412-4.
3. Libow LS. A readily administered, easily remembered mental status evaluation: FROMAJE. In: Libow LS, Sherman FT, editors.
The core of geriatric medicine: a guide for students and practitioners. St. Louis: Mosby; 1981.
4. Isaacs B, Akhtar AJ. The Set Test: a rapid test of mental function in old people. Age Ageing 1972;1(4):222-6.
5. Borson S, et al. The Clock Drawing Test: utility for dementia detection in multiethnic elders. J Gerontol A Biol Sci Med Sci
1999;54(11):M534-M540.
6. Brooke P, Bullock R. Validation of a 6 item cognitive impairment test with a view to primary care usage. Int J Geriatr Psychiatry
1999;14(11):936-40.
7. Folstein MF, et al. “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr
Res 1975;12(3):189-98.
8. Solomon PR, Pendlebury WW. Recognition of Alzheimer’s disease: the 7 Minute Screen. Fam Med 1998;30(4):265-71.
ajn@wolterskluwer.com AJN ▼ December 2007 ▼ Vol. 107, No. 12

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One Hospital’s Use of the Mini-Cog
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. Contact author: lareaur@
bronsonhg.org
ajn@wolterskluwer.com AJN ▼ December 2007 ▼ Vol. 107, No. 12

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How to Use the Try This Series for Assessing
Delirium and Dementia
Change in Mental Status or Other Behaviors That Would Trigger Assessment
Agitation or lethargy
Fluctuating or altered LOC
Memory impairment or disorganized thinking
Wandering
Uncooperativeness or failure to follow instructions
Change in behavior or function
Inattentiveness
Stupor
Assess for delirium
CAM + facility’s mental status evaluation
Possible delirium
with dementia
Possible delirium
without dementia
Probably
not delirium
Use the
Delirium
Superimposed
on Dementia
Algorithm
Contact primary
care provider
to investigate
the cause of
behavior change
Treat and manage: use facility protocol
to determine cause, modify risk factors,
protect patient, and perform ongoing
assessments to monitor response.
Assess for dementia using the
Mini-Cog or Recognition
of Dementia in Hospitalized
Older Adults
LOC = level of consciousness; CAM = Confusion Assessment Method
Note: bold text indicates instrument is part of the Try This series.
Probably
not dementia
Possible
dementia
Further assess
patients using
Try This best
practices for
dementia series
ajn@wolterskluwer.com AJN ▼ December 2007 ▼ Vol. 107, No. 12