MDS Alert

Use the Reality Comprehension Clock Test to promote optimal well-being.

Use the Reality Comprehension Clock Test to assess a resident's cognitive functioning--and count the ways your facility's quality-of-care and life outcomes improve.

A case in point: The interdisciplinary team at Holbrook on the Hill administers the test to identify cognitively impaired residents' "functional age" or   the amount of "brain power" the person has left expressed in years and months. The bottom line: "We want to know how well a person is thinking so we know how to design his or her care plan and address safety issues," says Nancy Henderson, RN, care plan coordinator for the Buckhannon, WV-based facility.

What CMS has to say: "It's important to remember that [dementing] illness changes a resident's cognitive age," emphasized Susan Harris, in a recent Centers for Medicare & Medicaid Services-sponsored surveyors training Webcast on the new survey guidance for activities.

To complete the screening test, the resident simply looks at a picture of a clock "and replicates it the best he or she can," says Barbara Brock, principal of Communication Art Inc., and one of the researchers who developed and validated the RCCT. (For details about the test, go to www.clocktestrcct.com.) The test calculates functional age (FA), global deterioration stage (GDS) and a visual spatial score (VSS). Nurses, therapists or other healthcare professionals who've received training in the RCCT can administer, score and interpret the test results.

Key take-home message: The Holbrook staff has found that "just because someone thinks well doesn't mean he or she speaks well," says Donna Gay, RN, the facility's director of nursing. Conversely, someone can speak well but not think well. In fact, the interdisciplinary staff has in several instances been "shocked" by the resident's results on the RCCT, Gay says.

In addition to telling a person's cognitive functional age, the clock can flag safety risks and other problems. For example, "a recent ... grant- funded research project confirmed the RCCT is also capable of predicting residents risk of falling based on their visual spatial abilities," says Brock.

Don't get blindsided: If the person draws the clock in a certain way, staff can identify that the person can't see out of his left or right side--or the top portion of the person's sight may be missing. Knowing a resident can't see on one side helps staff avoid approaching him from that side, which may startle the resident--and cause him to strike out in fear.

A person sometimes also conveys his pain in a clock test drawing. "If the person is having right leg pain, for example, the person may draw the clock as deformed on that side," says Gay. "One woman with a brain tumor drew a big bulge at the top of the clock. A person with headaches may flatten the top of the clock, showing that something is going on in that region."

The tool can also pick up cognitive changes caused by an acute condition, such as infection. "We have noted that ... a person's performance on the test will improve once the infection resolves," says Gay.

Tip: To track a resident's cognitive functioning, Brock suggests administering the test at admission, quarterly and when a resident has a significant change.

Tailoring the Care Plan

Identifying a resident's cognitive functional level helps staff know how to communicate with the person. For example, Holbrook staff finds the care team needs to ask simpler questions and use a more limited vocabulary for a person with a 5-year-old capacity. That way "the person feels successful in communicating," says Katina Louden, a restorative nurse at the nursing facility.

Even a resident who is cognitively 7 years old may require "task segmentation" where you break down instructions or cue someone to perform subtasks of an activity of daily living, says Brock. (For details on how to do task segmentation coded at G7 of the MDS, see the August 2006 MDS Alert.)

Other ways you can use the person's cognitive age to develop an individualized care plan include:

• Meeting dietary and dining needs. "If someone is 4 years old mentally, he or she may use their fingers to eat," observes Cindy Haney, the facility's dietitian. Thus, "we may offer more finger foods and then have the CNAs, as part of the care plan, remind the person to use utensils."

"If the person showed left-side neglect, that gives us information about where to place the meal so he can manage eating" more easily, adds Haney. The interdisciplinary team has also found that the dining-room experience may overwhelm some residents with cognitive impairment. "So we try to put people at the same cognitive level at a table so we can provide more assistance and supervision of that group. Some residents do better eating in their room or in a smaller group."

• Identifying incontinence caused by cognitive functional level. "The RCCT helps us in care planning incontinence issues," says Louden. "People aren't fully continent in all situations until they are 6.8 years mentally," she says. Thus, "if we know someone has a cognitive age of 4, and we can't figure out why they are incontinent, that information can help explain it.

Also, "if we know someone has a cognitive functional level of 4, we can offer assistance."

•  Spatially arranging the room to accommodate visual defects. For example, "if the person had a stroke and can't see out of one side, we put the call light on the side where he can see and use it," says Louden. 

•  Determining the amount of supervision a resident needs to keep the person safe. Once staff understands the concept of a person's cognitive age, they more readily understand the supervision needs of someone who is, for example, 7 years mentally. The test also identifies people with spatial perceptual problems who need more supervision to prevent falls.

• Improving care planning with families. The staff "has brought the test itself to the care plan meetings to discuss the findings with family members," reports Henderson.

"Use of the test also allows us to consult with people in the community who want to keep their loved one out of the nursing home as long as possible," adds facility administrator Bonnie Hitt.

Of course, testing is just one component of an overall evaluation of a person's ability to function, including observation of her ability to function in her environment, adds Pamela Toto, MS, OTR/L, BCG, chairperson of the American Occupational Therapy Associations gerontology special interest section.