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OASIS Alert

Assessment:

Boost Outcomes When You Evaluate Confused Patients

Published on Wed May 02, 2012

Begin your dementia screening with OASIS.

Are you too quick to assume a patient is being noncompliant? A client who doesn't follow instructions, has problems with medication, self-neglect and unsafe behavior could have early, unidentified dementia.

Looking for signs and identifying early cognitive impairment can not only significantly improve the quality of care you are able to provide, it can help prevent adverse events and enhance episode outcomes.

What to do: Several OASIS assessment items focus on aspects of the patient's neurological and mental status. Working with these items along with informally questioning the patient and caregiver can help you recognize early dementia.

Caregivers Are The Best Resource for Accurate Answers

Use the whole assessment process as a screening for dementia. But concentrate on these four OASIS assessment items which focus on cognitive and behavioral symptoms. These signs may show up in patients with early or undiagnosed dementia:

  • M1700 (Cognitive functioning). This question assesses the patient's level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands. Responses are on a five-point scale ranging from "0" for an alert and oriented patient to "4" for a patient who is in a coma, a persistent vegetative state, or constant disorientation or delirium.

Answers of "1" (Requires prompting [cuing, repetition, reminders] only under stressful or unfamiliar conditions) or "2" (Requires assistance and some direction in specific situations [e.g., on all tasks involving shifting of attention] or consistently requires low stimulus environment due to distractibility) indicate patients who have some memory problems.

Asking the patient about the current illness, past health history, and ability to perform activities of daily living is a way the clinician can assess the patient's cognitive functioning.

Try asking the patient to carry out a series of two or three simple instructions and observe her response, suggests Northampton Mass.-based home care consulting firm Fazzi Associates in its OASIS-C Best Practice Manual. Observing how the patient responds to questions regarding current health and past history, medications, names of family and friends, time of day, and his ability to stay focused on conversation also helps you answer this item, Fazzi says.

Tip: Observing activities of daily living provides you an opportunity to determine the patient's ability to comprehend and recall task directions and whether cues, reminders, or directions for specific tasks are needed in non-stressful situations, Fazzi says in the tips for answering M1700.

Caution: Avoid jumping to conclusions -- good social skills and grooming may or may not be indicative of appropriate cognitive function, Fazzi says. Remember to verify your findings with family.

  • M1710 (When confused [reported or observed within the last 14 days]). This question identifies the time of day or situations when the patient experienced confusion, if at all.

M1710 differs from many OASIS items because it allows you to look beyond the 24-hour period directly preceding the assessment. This item takes into account reports of confusion in the recent past. You should report any episodes of confusion or anxiety that meet the descriptions included in the item that occurred during the last 14 days, the Centers for Medicare & Medicaid Services says in OASIS Q&A Category 4 Q124.2.

"Anxiety can be an apprehension about an uncertain future, real or imagined, situations where there is a threat to personal safety and security or anything that makes life less predictable or causes one to feel less in control over the direction of one's life," Fazzi says.

  • M1740 (Cognitive, behavioral, and psychiatric symptoms that are demonstrated at least once a week [Reported or Observed]). This question addresses problematic behavior such as physical aggression, verbal disruption, and impaired decision-making, as well as delusional behavior. It requires you to mark any of the seven responses that apply.

Along with observing the patient, you should ask caregivers about the behaviors assessed in the question, CMS instructs. These behaviors may reflect alterations in the patient's cognitive status. And many of them are listed as early warning signs of dementia.

How to do it: In answers 1 through 4, focus on the two words before the colon in each answer when deciding if the answer applies, Fazzi suggests. These questions help identify behaviors that could impact the patient's safety or social environment and present serious implications for care and care planning.

For example: Response 3 describes "verbal disruption," and then goes on to list different types.

  • M1745 (Frequency of Disruptive Behavior Symptoms [Reported or Observed]). This assessment item addresses any problematic behavior including those not listed in M1740, such as the wandering often seen in patients with dementia. The frequency can help you decide how much the behaviors might interfere with the patient's ability to meet goals outlined in the care plan.

Experts warn: If the patient exhibits multiple behavior problems, you should answer based on the total frequency of all the behaviors, Fazzi says.

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