Entrustable Professional Activities

EPA 13: Cognitive assessment and management

EPA 13

Cognitive assessment and management

Assess cognitive function, and manage patients with disorders of cognition

This activity requires the ability to:

  • identify changes in cognitive function from baseline
  • recognise delirium
  • evaluate the patient’s mental state and cognitive function, including conducting a cognitive function assessment and the use and limitations of standardised assessment tools
  • identify the impact on the patient’s independence and functioning
  • assess the patient’s functional decision-making capacity across domains including medical, financial and lifestyle
  • interpret neuropsychological reports
  • discuss findings with patients, families and/or carers
  • develop and implement tailored, holistic management plans in partnership with patients, their family/carers, and medical team

Professional practice framework domain

Medical expertise

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • establish an understanding of patients’ baseline cognitive function
  • determine whether a reported or observed change in cognition is of recent onset or a more long-standing condition
  • differentiate dementia, delirium, depression, anxiety and learning disorders
  • assess, investigate, diagnose, and manage established cognitive impairment
  • consult with family or carers in the identification of patients’ cognitive function and cognitive deterioration
  • use screening tools and recognised cognitive assessment batteries / neuropsychological reports in the characterisation of deficits in cognition
  • identify and document behaviours of concern
  • diagnose causes of underlying cognitive change
  • perform a capacity assessment, screening for medical health, physical, and psychological functioning
  • assess the needs of the family or carers
  • balance patients’ wishes in determining medical, financial, and lifestyle decisions
  • develop management plans that integrate the impact of cognitive impairment with patients’ other conditions and independence goals, as well as the needs of the family or carers
  • demonstrate understanding of pharmacotherapy in treatment of dementia / delirium, including balancing risks versus benefits
  • identify the need for a consultant of psychiatrist of old age in managing patients with sequalae of cognitive disorders

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • use a haphazard or non-systematic approach to determining patients’ cognitive baseline and current function
  • omit clinically significant history, examination findings, investigation results, or management plans
  • inadequately identify and manage symptomatic behaviours, including sleep disturbance or using antipsychotic or sedative medications
  • be unable to synthesise the risk factors that may have contributed to behaviours of concern

Communication

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • explain cognitive impairment to patients, families, and carers, recognising the distress it could cause
  • establish with the referrer what events led to concerns about capacity
  • recognise the fluidity of capacity and factors that may impact the patient’s decision-making ability
  • communicate with other health professionals who are involved in the care of the patients
  • tailor approaches to patients’ capacity assessment, considering culture, education, sensory impairment, and language
  • use sensitive language when introducing tests / assessment processes to patients and their family or carers
  • support patients with cognitive impairment in decision making, including using an interpreter or speaking in simpler language, using pictures or photos, and writing things down
  • determine what further information might be required for patients and their family and carers at the time, and facilitate access to the resources

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • inadequately communicate and consult with patients, and seek assistance to develop communication strategies
  • disregard advice from family or carers on safety and management issues related to patients
  • dismiss or interrupt patients’ comments
  • defer or avoid difficult or ambiguous conversations
  • ignore or avoid patients’ questions or concerns
  • inadequately assess patients and family information needs
  • provide supplementary information packages or resources indiscriminately, without assessing needs of patients and their family or carers

Quality and safety

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • develop risk prevention strategies after identifying high risk patients
  • collect, monitor, report, and review organisation-wide data on the identification and assessment of patients with cognitive impairment, e.g. data on safety and quality risks, the use of restraints and/or psychotropic drugs
  • demonstrate awareness that antipsychotic and other sedative medications may cause adverse effects, and use should align with goals of care
  • recognise the preventative environmental and clinical practice strategies that should be incorporated into the care plan of all older people across all health care settings
  • recognise cognitive impairment as an independent risk factor for falls and delirium, addressing these in patients’ management plans

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • fail to recognise the implications for care that patients’ behaviour may cause
  • fail to consider the adverse effects of antipsychotic and other sedative medications
  • inadequately advocate for appropriate setting of care for patients based on current state
  • fail to identify if the medical treatment is unsafe for patients with cognitive impairment
  • fail to address risks such as falls and delirium in patients’ management plans

Teaching and learning

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • educate patients, families, and health professionals to increase knowledge and awareness about cognitive impairment and strategies to promote healthy cognition
  • maintain current knowledge of developments in the field in assessing and managing cognitive impairment
  • advocate for learning for medical staff and junior medical students in relation to cognitive impairment

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • make best practice changes to patients’ environments without explaining actions or reasons why to health care providers
  • fail to address education of patients and their family or carers as part of cognitive assessment
  • fail to seek out latest, best practice research
  • demonstrate a lack of confidence teaching medical staff and junior medical students

Research

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • identify appropriate patients for clinical trials
  • understand the challenges and ethical dilemmas in recruiting patients with cognitive impairment into clinical trials
  • advocate for research funding into cognitive impairment

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • recommend patients who do not suit criteria for clinical trials
  • not consider patients for clinical trials
  • be unaware of the impact research funding has on finding new ways to manage and treat cognitive impairment

Cultural safety

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • demonstrate awareness of the importance of flexibility, and impact of social factors, culture, and language diversity, when performing capacity assessments
  • recognise the need for use of interpreters for assessments, and culturally appropriate cognitive screening tools
  • recognise how cultural belief impacts on manifestations of cognitive impairment

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • have an inflexible approach when performing capacity assessments
  • not recognise when interpreters should be used
  • use cognitive assessment screening tools without considering their appropriateness to patients

Ethics and professional behaviour

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • synthesise assessment into legal documentation for a court or tribunal
  • apply laws governing practice on consent, capacity, and elder abuse and neglect
  • discuss the risks and benefits and gain consent for the use of antipsychotics and physical and/or chemical restraints with patients and family or carers
  • balance the rights of patients with the wishes and expectations of the family or carers
  • assess frail older peoples’ capacity to assign proxy decision makers, and to decide about personal care and health care in the context of medicolegal legislation
  • refer to plans of care and limitations on medical treatments, e.g. resuscitation plans, during patients’ assessment and treatment
  • recognise and manage the impact of managing patients with challenging behaviours upon the clinician and the wider health care team, including debriefing
  • establish open disclosure processes that are accessible and understandable to patients with cognitive impairment and their family or carers
  • treat patients and carers with respect and dignity, encouraging open communication, their participation, and ensuring their privacy

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • show a lack of respect for patients and other health professionals
  • fail to recognise the impact challenging patient behaviours can have on self and health care teams
  • inadequately seek consent for use of antipsychotics and physical and/or chemical restraints from patients and family or carers

Judgement and decision making

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • assess the urgency, complexity, and related risk of situations
  • demonstrate effective clinical problem solving and judgment to address patients’ capacity to make decisions
  • consider financial and independent living capacity as required, relevant to patients’ presentation
  • assess the capacity of patients to give informed consent for medical decisions
  • determine which management strategies are most likely to help quality of life of patients and their family or carers

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • inadequately consider the urgency or complexity of clinical situations when assessing and managing patients
  • be unable to recognise the relevance of financial or independent living status during patient consultation
  • not obtain informed consent from patients before making medical decisions

Leadership, management, and teamwork

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • collaborate with patients’ health care teams to determine whether capacity assessment is needed
  • identify carer stress and support strategies individualised to patients, families, and carers
  • facilitate effective professional relationships with practitioners and organisations receiving patients transferred from hospital care, including general practice, residential care facilities, and community aged care providers

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • produce documentation that is unclear to the other members of the multidisciplinary team
  • not seek the input or opinion of other members of the team
  • lack confidence in identifying carer stress or offering support strategies

Health policy, systems, and advocacy

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • facilitate timely access to resources, including the public guardian and/or trustee, legal advice, appeal mechanisms, family education and support
  • implement policy, procedures, and protocols to collect information on patients with cognitive impairment through complaints and incidents systems
  • provide information on services such as support groups, respite services, and other carer support services
  • promote lifestyle choices to optimise healthy cognition, to increase community awareness

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • lack confidence in recommending support services to patients, families, and carers