Nursing Home Assessment of Cognitive Impairment: Development and Testing of a Brief Instrument of Mental Status

Authors

  • Joshua Chodosh MD, MSHS,

    1. From the aGeriatric Research, Education and Clinical Center, bHealth Services Research and Development Service Center of Excellence, Department of Veterans Affairs Greater Los Angeles, Sepulveda, CaliforniacDepartment of Medicine, Division of Geriatrics, Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CaliforniadRand Health, Santa Monica, CaliforniaeDepartment of Health Care Policy, Harvard Medical School, Boston, MassachusettsfAtlanta Department of Veterans Affairs Medical Center, Atlanta, GeorgiagWesley Woods Geriatric Hospital, Emory University, Atlanta, GeorgiahCenter for Health Quality, Outcomes and Economic Research, Veterans Affairs Medical Center, Bedford, MassachusettsiDepartment of Internal Medicine, Schools of Public Health and Medicine, Boston University, Boston, MassachusettsjMental Illness Research, Education, and Clinical Care Centers, Philadelphia Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania; and kDepartment of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania.
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  • abc Maria Orlando Edelen PhD,

    1. From the aGeriatric Research, Education and Clinical Center, bHealth Services Research and Development Service Center of Excellence, Department of Veterans Affairs Greater Los Angeles, Sepulveda, CaliforniacDepartment of Medicine, Division of Geriatrics, Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CaliforniadRand Health, Santa Monica, CaliforniaeDepartment of Health Care Policy, Harvard Medical School, Boston, MassachusettsfAtlanta Department of Veterans Affairs Medical Center, Atlanta, GeorgiagWesley Woods Geriatric Hospital, Emory University, Atlanta, GeorgiahCenter for Health Quality, Outcomes and Economic Research, Veterans Affairs Medical Center, Bedford, MassachusettsiDepartment of Internal Medicine, Schools of Public Health and Medicine, Boston University, Boston, MassachusettsjMental Illness Research, Education, and Clinical Care Centers, Philadelphia Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania; and kDepartment of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania.
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  • d Joan L. Buchanan PhD,

    1. From the aGeriatric Research, Education and Clinical Center, bHealth Services Research and Development Service Center of Excellence, Department of Veterans Affairs Greater Los Angeles, Sepulveda, CaliforniacDepartment of Medicine, Division of Geriatrics, Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CaliforniadRand Health, Santa Monica, CaliforniaeDepartment of Health Care Policy, Harvard Medical School, Boston, MassachusettsfAtlanta Department of Veterans Affairs Medical Center, Atlanta, GeorgiagWesley Woods Geriatric Hospital, Emory University, Atlanta, GeorgiahCenter for Health Quality, Outcomes and Economic Research, Veterans Affairs Medical Center, Bedford, MassachusettsiDepartment of Internal Medicine, Schools of Public Health and Medicine, Boston University, Boston, MassachusettsjMental Illness Research, Education, and Clinical Care Centers, Philadelphia Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania; and kDepartment of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania.
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  • e Julia Ann Yosef MS,

    1. From the aGeriatric Research, Education and Clinical Center, bHealth Services Research and Development Service Center of Excellence, Department of Veterans Affairs Greater Los Angeles, Sepulveda, CaliforniacDepartment of Medicine, Division of Geriatrics, Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CaliforniadRand Health, Santa Monica, CaliforniaeDepartment of Health Care Policy, Harvard Medical School, Boston, MassachusettsfAtlanta Department of Veterans Affairs Medical Center, Atlanta, GeorgiagWesley Woods Geriatric Hospital, Emory University, Atlanta, GeorgiahCenter for Health Quality, Outcomes and Economic Research, Veterans Affairs Medical Center, Bedford, MassachusettsiDepartment of Internal Medicine, Schools of Public Health and Medicine, Boston University, Boston, MassachusettsjMental Illness Research, Education, and Clinical Care Centers, Philadelphia Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania; and kDepartment of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania.
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  • b Joseph G. Ouslander MD,

    1. From the aGeriatric Research, Education and Clinical Center, bHealth Services Research and Development Service Center of Excellence, Department of Veterans Affairs Greater Los Angeles, Sepulveda, CaliforniacDepartment of Medicine, Division of Geriatrics, Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CaliforniadRand Health, Santa Monica, CaliforniaeDepartment of Health Care Policy, Harvard Medical School, Boston, MassachusettsfAtlanta Department of Veterans Affairs Medical Center, Atlanta, GeorgiagWesley Woods Geriatric Hospital, Emory University, Atlanta, GeorgiahCenter for Health Quality, Outcomes and Economic Research, Veterans Affairs Medical Center, Bedford, MassachusettsiDepartment of Internal Medicine, Schools of Public Health and Medicine, Boston University, Boston, MassachusettsjMental Illness Research, Education, and Clinical Care Centers, Philadelphia Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania; and kDepartment of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania.
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  • fg Dan R. Berlowitz MD, MPH,

    1. From the aGeriatric Research, Education and Clinical Center, bHealth Services Research and Development Service Center of Excellence, Department of Veterans Affairs Greater Los Angeles, Sepulveda, CaliforniacDepartment of Medicine, Division of Geriatrics, Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CaliforniadRand Health, Santa Monica, CaliforniaeDepartment of Health Care Policy, Harvard Medical School, Boston, MassachusettsfAtlanta Department of Veterans Affairs Medical Center, Atlanta, GeorgiagWesley Woods Geriatric Hospital, Emory University, Atlanta, GeorgiahCenter for Health Quality, Outcomes and Economic Research, Veterans Affairs Medical Center, Bedford, MassachusettsiDepartment of Internal Medicine, Schools of Public Health and Medicine, Boston University, Boston, MassachusettsjMental Illness Research, Education, and Clinical Care Centers, Philadelphia Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania; and kDepartment of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania.
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  • hi Joel E. Streim MD,

    1. From the aGeriatric Research, Education and Clinical Center, bHealth Services Research and Development Service Center of Excellence, Department of Veterans Affairs Greater Los Angeles, Sepulveda, CaliforniacDepartment of Medicine, Division of Geriatrics, Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CaliforniadRand Health, Santa Monica, CaliforniaeDepartment of Health Care Policy, Harvard Medical School, Boston, MassachusettsfAtlanta Department of Veterans Affairs Medical Center, Atlanta, GeorgiagWesley Woods Geriatric Hospital, Emory University, Atlanta, GeorgiahCenter for Health Quality, Outcomes and Economic Research, Veterans Affairs Medical Center, Bedford, MassachusettsiDepartment of Internal Medicine, Schools of Public Health and Medicine, Boston University, Boston, MassachusettsjMental Illness Research, Education, and Clinical Care Centers, Philadelphia Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania; and kDepartment of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania.
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  • and jk Debra Saliba MD, MPH abcd

    1. From the aGeriatric Research, Education and Clinical Center, bHealth Services Research and Development Service Center of Excellence, Department of Veterans Affairs Greater Los Angeles, Sepulveda, CaliforniacDepartment of Medicine, Division of Geriatrics, Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CaliforniadRand Health, Santa Monica, CaliforniaeDepartment of Health Care Policy, Harvard Medical School, Boston, MassachusettsfAtlanta Department of Veterans Affairs Medical Center, Atlanta, GeorgiagWesley Woods Geriatric Hospital, Emory University, Atlanta, GeorgiahCenter for Health Quality, Outcomes and Economic Research, Veterans Affairs Medical Center, Bedford, MassachusettsiDepartment of Internal Medicine, Schools of Public Health and Medicine, Boston University, Boston, MassachusettsjMental Illness Research, Education, and Clinical Care Centers, Philadelphia Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania; and kDepartment of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania.
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  • The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

Address correspondence to Joshua Chodosh, MD, MSHS, 11301 Wilshire Blvd/GRECC (11G), Los Angeles, CA 90073. E-mail: JChodosh@mednet.ucla.edu

Abstract

OBJECTIVES: To test the accuracy of a brief cognitive assessment of nursing home (NH) residents and to determine whether facility nurses can reliably perform this assessment.

DESIGN: Cross-sectional, independent cognitive screening tests with NH residents.

SETTING: Six Department of Veteran Affairs nursing facilities.

PARTICIPANTS: Three hundred seventy-four residents from six regionally distributed Veteran Affairs NHs.

MEASUREMENTS: Three cognitive assessment instruments: the Brief Interview of Mental Status (BIMS), created for this study; the Minimum Data Set (MDS) 2.0 Cognitive Performance Scale (CPS), and the Modified Mini-Mental State Examination (3MS) as the criterion standard. The 15-point BIMS tests memory and orientation and includes free and cued recall items. Research assistants administered the 3MS and BIMS to all subjects. Facility nurses administered the same BIMS to a subsample.

RESULTS: Three hundred seventy-four of 417 (89.7%) residents approached completed the 3MS and research assistant–administered BIMS (BIMS-R); 212 residents also received a facility nurse–administered BIMS (BIMS-N). The BIMS-R was more highly correlated with the 3MS than was the CPS (Pearson correlation coefficient (r)=0.79 vs 0.62; P<.01 for difference). For the subset who received facility assessments, the BIMS-N was also more highly correlated with the 3MS (Pearson r=0.74 vs 0.65; P<.01 for difference). For any impairment (3MS<78), the area under the receiver operator characteristic curve (AUC) was 0.86 for the BIMS, versus 0.77 for the CPS. For severe impairment (3MS<48) the AUC was 0.94, versus 0.85 for the CPS.

CONCLUSION: In this population, a brief cognitive test is a more accurate approach to cognitive assessment than the current observational methods employed using the MDS 2.0.

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