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Cognition

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Cognition refers to mental processes including memory, attention, concentration, intelligence, learning, judgement, orientation and psychomotor abilities (Baumgartner, 2004; Hjermstad, Loge & Kaasa, 2004). Impairment in any of these domains may result from a range of diseases or conditions (Robinson, 1999).

Cognitive Impairment in Palliative Care
Assessment
Implications of Cognitive Assessment Results
Intervention
References

Cognitive Impairment in Palliative Care

Clients receiving palliative care may show signs of cognitive impairment due to various conditions that may be experienced towards the end of life (Robinson, 1999).

Such conditions may include the following:

Progressive neurological diseases*
Advanced cancers and tumors and metasteses (Hjermstad, Loge & Kassa, 2004; Robinson, 1999; Pereira, Hanson & Breura, 1997)
Cognitive decline associated with ageing (Baumgartner, 2004)
Infections (Baumgartner, 2004; Robinson, 1999)
Metabolic disturbances (Baumgartner, 2004; Robinson, 1999)
Drug interactions (Robinson, 1999)
Dementia (Baumgartner, 2004; Robinson, 1999)
Cancer interventions, such as radiation and chemotherapy may result in temporary delirium (Baumgartner, 2004; Robinson, 1999)

Definitions of types of cognitive impairments:

Dementia:
Dementia is characterized by several cognitive deficits including impaired memory (both new learning and recall of previously learnt information) and one or more of the following: aphasia, apraxia, agnosia or a disturbance in executive functioning (planning and organization) (Baumgartner, 2004; Robinson, 1999).

Delirium:
Delirium is a disturbance in consciousness which often occurs in clients who have advanced cancers (Baumgartner, 2004). Delirium is an acute event involving a reduced ability to focus or shift attention. It may also impact on memory, language and orientation or the development of a perceptual disturbance, where a diagnosis of dementia is unlikely (Robinson, 1999).

Amnestic disorder:
Amnestic disorders are characterized by memory disturbance, primarily by the inability to learn new information or recall previously learnt information. This is a condition which impacts significantly on the client's occupational and social functioning, and causes a marked change in the person's level of cognitive functioning, which cannot be explained by a delirium episode or dementia (Robinson, 1999).

Delirium is reported more frequently in palliative care than either dementia or an amnestic disorder (Hjermstad, Loge & Kaasa, 2004).

Prevalence
The prevalence of cognitive impairment among palliative care clients ranges from 33%-80% (Robinson, 1999). With the combination of spontaneous recovery and effective intervention for infections, cognitive impairment may be successfully resolved in 25% of palliative care clients (Periera, Hanson & Breura, 1997).

Assessment

Cognitive failure is often underdiagnosed or misdiagnosed as depression (Hjermstad, Loge & Kaasa, 2004). Conversely, depression may be incorrectly diagnosed as dementia, which is known as pseudo-dementia (Bayles & Kaszniak, 1987).

A speech pathologist may be involved in the assessment and diagnosis of cognitive impairments with palliative clients (Robinson, 1999).

Assessment Tools:
Assessment tools used in palliative care by speech pathologists may include the following*:

Cognitive screening (orientation to person, place and time)
Mt Wilga High Level Language Test (Christie, Clark & Mortensen, 1986)
Caulfield Language For Cognition*
Arizona Battery for Communication Disorders (ABCD; Bayles & Tomoeda, 1993)

A neuropsychology referral may be appropriate for further cognitive assessment, particularly to assess cognitive capacity*. These assessments reflect client capabilities and needs, such as those in relation to decision making, supervision requirements and finance management.

There are several benefits and disadvantages of assessing palliative clients' cognitive function which must be considered before proceeding with a cognitive assessment.

Reasons for conducting a cognitive assessment:

Palliative clients' self-report of cognitive function may be unreliable (Klepstad et al., 2002) and staff often fail to detect cognitive impairments unless formal assessment is conducted (Robinson, 1999).
Cognitive performance can be used to predict an individual's likelihood of discharge. For example, those with cognitive failure have a poorer prognosis of discharge (Peirera, Hanson & Breura, 1997).
Assessment can provide an evaluation of a client's capacity to make decisions that may influence case management (Robinson, 1999).
Cognitive impairment may affect relationships with family and carers. Assessment can provide an answer as to why a deterioration in the client's cognitive functions may be occurring (Hermjstad, Loge & Kassa, 2004).
In the DSM-IV Cognitive impairment is can be a feature indicating delirium, dementia and amnestic disorders (Robinson, 1999). Thus, cognitive assessment can assist in the accurate diagnosis of these conditions and consequently appropriate strategies can be applied.

Reasons why a cognitive assessment may not be appropriate:

The formal cognitive assessment procedure and the realisation of impaired cognitive functioning can be distressing for a client and their family (Peirera, Hanson & Breura, 1997). This contradicts the idea of maximizing client's quality of life in palliative care (Peirera et al., 1997).
Many cognitive assessment tools are unreliable because they do not take into account pre-morbid abilities, culture and intelligence levels, therefore cannot be used in assessing competence in decision-making (Peirera et al., 1997).

Implications of Cognitive Assessment Results

If assessment reveals impaired cognitive status:

The client may have a decreased ability to contribute to making end-of-life decisions regarding their care
Client report of symptoms may be unreliable
The client may not understand or wish to comply with intervention plans
The client may be at risk of injury, for example falling

Intervention

Cognitive intervention may be conducted as a multi-disciplinary approach involving physiotherapists, occupational therapists and speech pathologists (Myers, 1999).

It is important to ensure cognitive therapy has functional meaning for the client (Myers, 1999; Deelman, Sann & van Zomeren, 1990), which is particularly relevant in palliative care given quality of life policies (O'Boyle & Waldren, 1997).

Some cognitive impairments may not respond to therapy and therefore compensatory strategies may be more appropriate (Deelman, Saan & van Zomeren, 1990).

Speech pathologists working in palliative care* have reported that their role in intervention may incorporate the following:

Providing strategies to enhance memory or to compensate for memory decline.
Discussing the client's cognitive status with staff and family, and helping to develop and explain appropriate communication strategies.
Educating staff and family on appropriate environmental modifications to minimise cognitive impairments (e.g. deficits in attention).

The following table demonstrates some cognitive strategies that speech pathologists may suggest for enhancing communication.

Cognitive Deficit	Communication strategies
Memory	Keep sentences short and simple Give information in one 'chunk' at a time Use visual aids, such as a diary or calendar to record visitors and daily events. Visual memory aids may also include phone number lists, photos of staff/family/friends with their names written on them.
Attention	Speak face to face with the client (so they have something to focus on) Reduce visual distractions and background noise to maximise communicative success
Neglect	Use visual, tactile and auditory cues to remind the client to attend to their neglected side (Myers, 1999). Encourage and teach the client to scan and attend to their side of neglect during tasks such as telling the time, grooming and walking (Deelman, Saan & van Zomeren, 1990).

References:

Baumgartner, K. (2004). Neurocognitive changes in cancer clients. Seminars in Oncology Nursing, 20(4), 284-290.

Bayles, K., & Tomoeda, C. (1993). Arizona Battery for Communication Disorders of Dementia. Texas: Pro-Ed.

Bayles, K., & Kaszniak, J. (1987). Communication and cognition in normal ageing and dementia. Massachussetts: Little, Brown & Company.

Christie, J., Clark, W., & Mortensen, L. (1986). Mount Wilga High Level Language Test (1st Ed.). Sydney: Mt Wilga Rehabilitation Centre. Unpublished manuscript.

Deelman, B., Saan, R., & van Zomeren. A. (1990). Traumatic brain injury: Clinical, social and rehabilitational aspects. Netherlands: Swets & Zeitlinger.

Hjermstad, M., Loge, J., & Kaasa, S. (2004). Methods for assessment of cognitive failure and delirium in palliative care clients: Implications for practice and research. Palliative medicine, 18, 494-505.

Klepstad, P., Hilton, P., Moen, J., Fougner, B., Bourchgrevink, P., & Kassa, S. (2002). Self-reports are not related to objective assessment of cognitive function and sedation in clients with cancer pain admitted to a palliative care unit. Palliative medicine, 16(6), 513-9.

Myers, P. (1999). Right hemisphere damage: Disorders of communication and cognition. London: Singular.

O'boyle, C., & Waldren D. (1997). Quality of life issues in palliative medicine. Journal of Neurology, 244, 18-24.

Pereira, J., Hanson, J., & Bruera, E. (1997). The frequency and clinical course of cognitive impairment in clients with terminal cancer. Cancer, 79(4), 835-42.

Robinson, J. (1999). Cognitive assessment of palliative care clients. Progress in Palliative Care, 7(6), 291-298.

Please note: Asterisk (*) indicates that information is based on the survey responses of 13 experienced speech pathologists working in palliative care in Victoria.

Disclaimer: The purpose of this website is to provide speech pathologists with a summary of the available evidence-base and current practice when dealing with patients in palliative care. The guidelines provided may be used as a guide for providing palliative care; however, cases will undoubtedly arise for which our findings may not be readily applied. The information contained in the website is not intended to prescribe specific procedures to use with palliative patients referred to speech pathology, but rather aims to assist speech pathologists by outlining the available evidence base and current practice methods used in the area. Information regarding current practice in palliative care was obtained from surveying thirteen speech pathologists with experience working in palliative care. It must be noted that not all speech pathologists surveyed contributed equally to all sections of this website.

© Copyright 2005.
Website developed by forth year speech pathology students Jane-Frances Gooden, Courtney Jones, Alyssa Mann, Marita McDowall and Jo Shugg. Supervised by Louise Brown.
School of Human Communication Sciences, La Trobe University, Melbourne, Australia.