2.4 Psychosocial, Nutritional, Cognitive & Mental Health Screening Instruments

Psychosocial, Nutritional, Cognitive & Mental Health Screening Instruments

The ANCC test content outline lists two separate skill statements under Patient Assessment Process that are easy to skim past: psychosocial assessment (health literacy, lifestyle, nutritional, caregiver/support, cultural, spiritual) and cognitive and mental health assessment using screening tools. Board items in this space are rarely "what is depression"; they are "which instrument, what cut score, and what do you do with a positive result."

A screening instrument is not a diagnosis. Every tool below identifies people who need further evaluation. Confusing a positive screen with a diagnosis is one of the most reliably tested errors on the examination.

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1. Cognitive Screening Instruments

+---------------------------------------------------------------------------------------------------+
|                            COGNITIVE SCREENING INSTRUMENT COMPARISON                              |
|                                                                                                   |
|   INSTRUMENT   TIME    MAX     POSITIVE SCREEN        BEST USE / CAVEAT                           |
|   ==========   ====    ===     ===============        ====================                        |
|   Mini-Cog     ~3 min   5      0 to 2                 Fastest validated screen. 3-item recall     |
|                                                       (0-3) + clock draw (0 or 2). Minimal        |
|                                                       education and language bias.                |
|   ---------------------------------------------------------------------------------------------   |
|   MoCA         ~10 min  30     < 26                   Most sensitive for MILD cognitive           |
|                                                       impairment. +1 point if <= 12 years of      |
|                                                       education. Requires certification to use.   |
|   ---------------------------------------------------------------------------------------------   |
|   MMSE         ~7 min   30     < 24                   Long-standing, but insensitive to mild      |
|                                                       impairment and to executive dysfunction;    |
|                                                       heavily education- and language-biased.     |
|   ---------------------------------------------------------------------------------------------   |
|   SLUMS        ~7 min   30     Educated: < 27         Detects mild neurocognitive disorder;       |
|                                Non-HS grad: < 25      free, developed by the VA.                  |
|   ---------------------------------------------------------------------------------------------   |
|   AD8          ~3 min   8      >= 2                   INFORMANT questionnaire. The tool of choice |
|                                                       when the patient minimizes or the history   |
|                                                       comes from a caregiver.                     |
+---------------------------------------------------------------------------------------------------+

Interpreting the clock draw. In the Mini-Cog, the patient draws a clock face with all numbers and sets the hands to a stated time. A normal clock scores 2; any abnormality scores 0 - there is no partial credit. The clock draw taps executive function, visuospatial construction and working memory simultaneously, which is why it survives as the shortest useful screen.

Which one to choose. For a Medicare Annual Wellness Visit, which requires detection of cognitive impairment, the Mini-Cog or AD8 is efficient. When a patient or family reports subtle word-finding difficulty, medication errors or getting lost while driving but the Mini-Cog is normal, escalate to the MoCA, which detects mild cognitive impairment the MMSE misses. When the patient is a poor historian or lacks insight, an informant tool such as the AD8 outperforms any patient-administered screen.

[!WARNING] Never screen cognition during delirium. A screening score obtained while a patient is acutely ill, hypoxic, in pain, febrile, or freshly dosed with an anticholinergic or an opioid measures the acute illness, not the baseline. Treat the acute problem, then rescreen.

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2. Mood, Anxiety, Trauma and Suicide Risk

USPSTF context. The Task Force recommends screening all adults for depression (Grade B) and adults aged 64 and younger for anxiety disorders (Grade B), each with adequate systems in place for accurate diagnosis, effective treatment and appropriate follow-up. The Task Force concluded that current evidence is insufficient to assess screening for suicide risk in asymptomatic adults - which is not permission to ignore risk in a patient with a positive depression screen.

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3. Substance Use Screening

• AUDIT-C (3 items, 0-12): positive at >= 4 in men and >= 3 in women. The single-item screener - "How many times in the past year have you had 5 or more drinks in a day (4 or more for women)?" - is positive at >= 1.
• CAGE (4 items): >= 2 is a positive screen. It detects lifetime dependence rather than current hazardous drinking and misses binge patterns, so it has largely been supplanted by AUDIT-C.
• TAPS and the NIDA Quick Screen cover tobacco, alcohol, prescription medication and other substance use in one instrument.
• DAST-10: >= 3 suggests a drug problem warranting further assessment.

Any positive substance screen should be followed by SBIRT: Screening, Brief Intervention, and Referral to Treatment.

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4. Nutritional Screening

Older adults, and particularly the frail elderly age band on the ANCC blueprint, are at high risk of protein-calorie malnutrition that is invisible on a routine visit.

Remember the reversible contributors before labeling weight loss idiopathic: ill-fitting dentures and oral pain, dysgeusia from medications, dysphagia, depression, food insecurity, alcohol, and the "Meals on Wheels" mnemonic of medication effects, emotional problems, anorexia tardive, paranoia, swallowing disorders, oral factors, no money, wandering, hyperthyroidism, enteric problems, eating problems, low-salt/low-cholesterol diets, and social/shopping problems.

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5. Health Literacy, Caregiver Strain, Spirituality and Social Risk

Health literacy. Roughly one in three US adults has basic or below-basic health literacy. Rather than trying to identify who is affected, apply universal precautions: plain language, no more than three key points per visit, and teach-back on every new medication or self-management task. Validated brief instruments include the Newest Vital Sign (6 questions about an ice-cream nutrition label; <= 3 suggests limited literacy), the REALM-SF (7 words to pronounce) and the Single Item Literacy Screener ("How often do you need to have someone help you when you read instructions or pamphlets from your doctor?").

Caregiver strain. The Zarit Burden Interview (short forms of 4, 12 or 22 items) and the Modified Caregiver Strain Index (13 items; >= 7 indicates high strain) quantify the burden carried by the family member sitting in your exam room. Screening the caregiver is a legitimate part of the patient's plan of care, because caregiver collapse is one of the most common precipitants of nursing-home placement.

Spiritual assessment. The FICA tool structures the conversation: Faith or belief, Importance and influence, Community, and Address in care. HOPE is an alternative. These are not conversion opportunities; they identify sources of meaning, coping and decision-making that will matter enormously in advance care planning.

Social risk. The PRAPARE tool and the CMS Accountable Health Communities Health-Related Social Needs screening tool cover housing instability, food insecurity, transportation, utility needs and interpersonal safety. The two-item Hunger Vital Sign is a rapid food-insecurity screen. Positive findings should be documented with ICD-10-CM Z codes (Z55-Z65) and linked to a concrete referral.

Elder mistreatment. The Elder Abuse Suspicion Index (EASI) is a 6-item tool for cognitively intact older adults; a "yes" to any of questions 2 through 6 is a positive screen. Interview the patient alone, away from the accompanying person, and know your state's mandatory reporting statute.