Cognitive Screening and Functional Assessment OSCE ...



Cognitive Screening and Functional Assessment OSCE: Standardized Patient Guide

You are Ms. Yates, an 80-year-old widow with osteoarthritis of the L knee and knee pain with no apparent deficits in Activities of Daily Living (ADLs: Feeding, Transfers, Toileting, Dressing, Grooming, Bathing), Instrumental Activities of Daily Living (IADLS: Telephone, Traveling, Shopping, Preparing meals, Housework, Medication, Money) or complaints of difficulty with memory. However, you got your medications confused when your physician changed the doses and your daughter sends a note stating that mom has problems with memory and has had a recent fall.

The Note: Dear Doctor, Mom was found on the floor two days ago. She had no injury and has been her usual self. Can you evaluate her memory? Mom has not been sad or depressed and is otherwise in good health. Thanks, Kimberly

When asked about your medical problems, you report a history of arthritis in your L knee, and no other issues. You become somewhat anxious when the physician states that he/she is going to perform a test of your memory. You are sitting in a chair when the student arrives.

Results of Mini-Cog

• First you will be asked to repeat three words (Apple, Penny, Table) You should do this.

• You will be asked to draw the face of a clock within a circle: You should struggle to place the numbers correctly on the clock but eventually succeed after approximately 1 minute.

• You will be asked to place the time 11:10. Instead of doing this, you should place the hands of the clock to read ten before eleven instead of ten after eleven as instructed.

(This may suggest that you have a problem with your memory)

• Finally, the student will ask you to recall the three words you originally repeated: You are able to recall 2/3 objects: apple and penny. You do not recall table. If student attempts to cue you regarding furniture you state “chair.”

• You are defensive if the student suggests that you may have a problem with your memory.

•

Results of Gait Assessment

-You admit to a recent fall while walking in the house without your cane and when your knee pain was moderate to severe (7-9).

-You will be asked to rise from a chair without using your hand, walk ten feet, turn around and return to your seat. The student should be timing you as you perform this task. A normal test is done in less than 20 seconds.

• If the student suggests that you NOT use your cane, explain that you prefer to.

• As you walk, you should hold the cane that is too short in the wrong (Left) hand. You should not use it consistently. Just carry it while you limp at times.

• Limp and avoid bearing weight on left leg.

• Your Get-Up-Go test over 25 seconds. (This is abnormal. Normal is less than 20 seconds)

You may be asked by the preceptor to demonstrate the use of the cane at end of session

• Use cane in opposite hand of affected lower extremity

• Demonstrate walking with the cane as described by the preceptor

Measuring the Height of a Cane

Patient should stand in an upright position

Arms hang to the side with a normal bend at the elbow (15-20 degrees)

Place the cane on the ground on the opposite side to the affected lower extremity

Handle of the cane should reach the middle crease of the patient’s wrist

Increase or decrease the height for appropriate fit.

Cane touches the ground at the same time as the opposite (affected) foot

Cognitive Screening and Functional Assessment OSCE:

Case Description for Students

You have 15 minutes to read the instructions and perform the tasks

You are a medical student working with Dr. Smith. Dr. Smith has asked you to see one of his patients (Ms.Yates) and perform a cognitive evaluation and a gait assessment. .

Ms. Yates, an 80-year-old widow presenting to the office after a fall. Her BP is 160/90 and HR 60 on multiple anti HTN medications. Medications include Nifedipine XL 60 mg daily, Atenolol 100 mg daily, and HCTZ 25 mg daily. She states that she is independent with all ADLs and IADLs and denies any problems with her memory. Dr. Smith provided you with a note that the patient’s daughter wrote.

The Note: Dear Doctor, Mom was found on the floor two days ago. She had no injury and has been her usual self. Can you evaluate her memory? Mom has not been sad or depressed and is otherwise in good health. Thanks, Kimberly

Enter the room and see the patient. Perform the following tasks

Student Tasks

1) Introduce the subject of cognitive screening

2) Perform a Mini-Cog

3) Interpret the results of the Mini-Cog to the patient

4) Evaluate the patient’s gait with the Timed Get-up-Go Test

5) Explain the plan to Mrs. Yates

6) In the adjacent room, create a written plan for Mrs. Yates to discuss within the larger group.

You will be provided up to15 minutes to complete the interaction with the patient, and then will be guided to a separate room to compete your plan. Last student has 10 minutes

Cognitive Screening and Functional Assessment OSCE:

Instructions for preceptor

• The student is allowed 15 minutes to perform the tasks

• Observe the interaction between the student and patient

• Use the checklist to document items that the student has completed during the interaction.

• Keep track of the time, and inform the student when there are only 5 minutes left.

• Provide immediate feedback about how the student performed the assigned tasks (5 minutes)

• Inform the student of additional or missing components of the interaction

• Demonstrate the appropriate use of the cane.

• Direct the student to another room to write their plan when their interaction has been completed.

• Direct the next student to the OSCE room.

Large group session:

• Provide the students with the self assessment sheet. Allow time for completion.

• Review student’s plan for gait abnormality and cognitive impairment during the large group/wrap-up interaction.

• Provide OSCE evaluation sheet and collect.

Instructions to Student about appropriate use of the cane

• Use cane in opposite hand of affected lower extremity

• Show student how to evaluate the appropriate height of the cane, adjust the height, and demonstrate walking

Measuring the Height of a Cane

Patient should stand in an upright position

Arms hang to the side with a normal bend at the elbow (15-20 degrees)

Place the cane on the ground on the opposite side to the affected lower extremity

Handle of the cane should reach the middle crease of the patient’s wrist

Increase or decrease the height for appropriate fit.

Cane touches the ground at the same time as the opposite (affected) foot

Geriatrics Clerkship OSCE Evaluation Sheet

Student Name: ______________________ Level of Training ____3rd ____4th

Date: ______________

Cognitive Evaluation Checklist

 Introduced the subject of cognitive screening

 Patient given clear instructions for completion of Mini-Cog

 Patient asked to repeat 3 words “Apple, Penny, Table” in sequence

 Patient instructed to draw the face of a clock as it would normally appear

 Patient instructed to place the time 11:10

 Patient asked to recall the 3 words

 Clock scored correctly: Screen: Demented

(Preceptor: Ask student if screen is positive or negative)

Gait Assessment

 Asked the patient questions about the nature of the fall

 Examined the patient’s L knee

 Patient given clear instructions about performing the Timed Get Up and Go Test

 Scored the test appropriately, noting that the time is above 20 seconds and abnormal

(Preceptor: Ask the student if the patient’s screen was positive or negative)

Closing remarks to patient

 Provided a plan to the patient

Comments:___________________________________________________________

____________________________________________________________________

____________________________________________________________________

Student Mini-Cog Sheet

Patient: Ms. Yates

[pic]

Name:____________________

Student Plan for Ms. Yates

Instructions: Consider the clinical information provided in the case and the information you obtained after interviewing the patient. List problems and corresponding plans

Problem Plan

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Date___________

Student Self-Assessment: Do Not write your name

Please check off the items below that were part of your written plan.

 I addressed the following problems

 Hypertension

 Pain

 Recent fall

 Gait abnormality/ risk for falls

 Cognitive impairment

 I addressed the following in my plan

 Prescribe medication for pain i.e. acetaminophen

 Home safety evaluation

 Rehab/PT evaluation

 Confirm that patient has been compliant with medications

 Consider changing the dose of one of the medications if compliance has been confirmed. i.e.Nifedipine to 90mg XL daily

 Consider a method for patient to remember to taking medications i.e. Weekly pill box, daughter calls to remind, etc.

 Plan for further evaluation of memory i.e. MMSE

 Others ___________________________________________________________

____________________________________________________________________

____________________________________________________________________

Date: ____________

Student Evaluation of OSCE

1. This OSCE has increased my knowledge of the management of older adults

Strongly Disagree Disagree Neither agree nor disagree Agree Strongly Agree

2. I feel more confident in performing a brief cognitive screen in an older adult with memory impairment

Strongly Disagree Disagree Neither agree nor disagree Agree Strongly Agree

3. I feel more confident in performing a brief gait assessment in an older adult

Strongly Disagree Disagree Neither agree nor disagree Agree Strongly Agree

4. The overall quality of the session was excellent

Strongly Disagree Disagree Neither agree nor disagree Agree Strongly Agree

Comments:___________________________________________________________

____________________________________________________________________

____________________________________________________________________

Cognitive Screening and Functional Assessment OSCE:

Overview/Timing

Format of OSCE

Debriefing of Standardized Patients (SPs) 15 minutes

Introduction (All students): 15 min

Two simultaneous rooms with 1 faculty and 1 SP in each room

OSCE: 20 min/ student (10-15 OSCE, 5-10 min feedback by SP):

Student creates a plan alone: At least10 min for last 2 students

Group wrap-up: 90 min

Extra time for flow of session: 30 min

Personnel required:

2 faculty (1 Fellow, 1 Attending)

1 administrative staff member to oversee the flow of the day’s events

References:

Borson S, Scanlan J, et al. The Mini-Cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry. 2000;15(11):1021

Podsiadlo D, Richardson S. The timed “Up and Go”: a test of basic functional mobility for frail elderly persons. J A Geriatr Soc. 1991;39(2):142

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