Pain in cognitively impaired nursing home residents: how well are physicians diagnosing it?

OBJECTIVES: This study examined the reliability and validity of geriatricians' assessments of pain in cognitively impaired nursing home residents. DESIGN: Cross-sectional analysis.SETTING: A large suburban nursing home. PARTICIPANTS: Seventy-nine nursing home residents participated in the study. Of these, 31 had mild/moderate cognitive impairment (average Mini-Mental State Examination (MMSE) = 16.04) and 48 were severely cognitively impaired (average MMSE = 1.91). More than 80% of the participants were female, and the average age was 87. MEASUREMENTS: Two geriatricians from outside the nursing home examined laboratory results, performed a physical examination, and completed a detailed assessment of pain. The personal geriatricians of 42 of the participants also completed the same assessment. RESULTS: Intergeriatrician agreement rates were statistically significant and moderate in magnitude. When examined by subgroup, the correlations were significant only for those with mild/moderate impairment. Some of the geriatricians' ratings of pain correlated significantly with residents' self-reports. All relationships were weaker in the severely cognitively impaired group. Ratings of greater pain were significantly correlated with higher cognitive functioning. CONCLUSIONS: The results validate geriatricians' evaluations of pain during a medical examination for moderately impaired persons and question their ability to evaluate pain in the severely cognitively impaired. There is a need for increased awareness of pain in this population and a need for improved methodologies to identify it.     

Validity of pain behaviors in persons with mild to moderate cognitive impairment

OBJECTIVES: To evaluate the validity of traditional pain behaviors (guarding, bracing, rubbing, grimacing, and sighing) in persons with and without cognitive impairment and chronic low back pain (CLBP). DESIGN: Prospective observational study. SETTING: Outpatient clinics. PARTICIPANTS: Thirty‐seven cognitively intact and 40 cognitively impaired participants with and without CLBP. MEASUREMENTS: Frequency of traditional pain behaviors. RESULTS: Forty‐six of the participants were pain free, and 31 had CLBP. The internal consistency reliability coefficient of the five pain behaviors was 0.32, suggesting that a unidimensional scale did not exist. Multivariate analysis of variance analysis according to the independent variables pain status (pain free vs CLBP) and cognitive status (intact vs impaired) with the dependent variable frequency of pain behaviors found significant differences according to pain status (F[5,61]=3.06, P=.02) and cognitive status (F[5,61]=5.41, P<.001) but without evidence of an interaction (F[5,61]=1.14, P=.35). Participants with CLBP exhibited significantly higher levels of grimacing (P<.001) and guarding (P=.02) than pain‐free participants. Intact subjects exhibited fewer guarding (P=.02) and rubbing behaviors (P<.001) but a higher number of bracing behaviors (P=.03) than cognitively impaired participants. CONCLUSION: These results support the utility of facial grimacing in assessing pain in patients with mild to moderate cognitive impairment and call into question the validity of guarding and rubbing in assessing pain in persons with mild to moderate cognitive impairment.     

Financial Capacity in Older Adults: A Review of Clinical Assessment Approaches and Considerations

Financial capacity is a critical issue of autonomy for older people. However, determining the point at which a cognitively impaired older adult is no longer capable of independent financial management poses an onerous task for family members, and health and legal professionals. At present, there is no agreed-upon standard for evaluating financial capacity, and issues pertaining to the level of impairment that constitutes incapacity remain largely unresolved. In the absence of validated assessment guidelines, determinations of capacity are frequently based on neuropsychological measures and clinical judgment, although there is limited evidence to support the validity of these methods in capacity determinations. In this paper, various cognitive, psychiatric, social, and cultural factors that potentially contribute to financial incapacity in older adults are described. The strengths and weaknesses of clinical approaches and instruments currently used in capacity determinations are evaluated, and specific recommendations are made regarding broader assessment approaches. Finally, directions for future research and instrument development are offered.     

Präventive Hausbesuche im Alter: Entwicklung und Pilottestung eines multidimensionalen Abklärungsinstruments

Preventive home visits with multidimensional geriatric assessment have been shown to delay or prevent the onset of disability and reduce nursing home admissions in older people. The purpose of the present study was to develop and test a multidimensional instrument for in-home preventive assessments in older persons. In developing the instrument, we conducted a systematic literature review of risk factors for functional status decline and of appropriate instruments for measuring these risk factors. Based on an Expert Panel using a modified Delphi process [1] the risk factor domains for functional status decline were chosen, [2] the instruments for evaluating each of the included risk factor domains were selected, and [3] the individual instruments were combined into one comprehensive assessment instrument. A German language version of the original English version of the instrument was developed based on translation, backtranslation, and cultural adaptation. The feasibility of use of the new instrument was evaluated in a field test in 150 people aged 75 years and older in Hamburg, Ulm, Germany, and Bern, Switzerland. The instrument was well accepted by the older persons. The prevalence of risk factors for functional status decline in these populations (e.g., physical inactivity, urinary incontinence, vision impairment) was high. There was also a high prevalence of underuse of preventive care measures (e.g., no pneumococcal vaccination in over 95 percent of persons). These preliminary results support the possible usefulness of this instrument for conducting preventive home visits or for epidemiological purposes (e.g., prevention surveillance). In a next phase, the test-retest reliability of the instrument, and the feasibility and reliability of self-administration as compared to interviewer administration will be described in a separate paper.     

Pain Assessment in Persons with Dementia: Relationship Between Self-Report and Behavioral Observation

OBJECTIVES: To investigate the relationship between self-report and behavioral indicators of pain in cognitively impaired and intact older adults.
DESIGN: Quasi-experimental, correlational study of older adults.
SETTING: Data were collected from residents of nursing homes, assisted living, and retirement apartments in north-central Florida.
PARTICIPANTS: One hundred twenty-six adults, mean age 83; 64 cognitively intact, 62 cognitively impaired.
MEASUREMENTS: Pain interviews (pain presence, intensity, locations, duration), pain behavior measure, Mini-Mental State Examination, analgesic medications, and demographic characteristics. Participants completed an activity-based protocol to induce pain.
RESULTS: Eighty-six percent self-reported regular pain. Controlling for analgesics, cognitively impaired participants reported less pain than cognitively intact participants after movement but not at rest. Behavioral pain indicators did not differ between cognitively intact and impaired participants. Total number of pain behaviors was significantly related to self-reported pain intensity (β=0.40, P =.000) in cognitively intact elderly people.
CONCLUSION: Cognitively impaired elderly people self-report less pain than cognitively intact elderly people, independent of analgesics, but only when assessed after movement. Behavioral pain indicators do not differ between the groups. The relationship between self-report and pain behaviors supports the validity of behavioral assessments in this population. These findings support the use of multidimensional pain assessment in persons with dementia.     

Outcomes of pain in frail older adults with dementia

OBJECTIVES: To describe the outcomes of pain in cognitively impaired older adults in a Program of All-inclusive Care for older people (PACE) setting and to determine whether pain and psychotropic drug use, behavioral disturbances, hospital, nursing facility, and emergency department use, or mortality increases with the level of pain reported. DESIGN: Retrospective review of an observational cohort of patients with dementia. SETTING: A first-generation PACE program located in Portland, Oregon. Patients with the diagnosis of dementia had been assessed for pain in a prior study. PARTICIPANTS: One hundred fifty-four cognitively impaired subjects. MEASUREMENTS: Standardized pain assessments were administered to cognitively impaired subjects between June and October 1998. After the pain assessment, information about mortality and healthcare use, including use of medication, was collected and analyzed. Subjects who reported moderate to severe pain were compared with demented subjects who reported no or mild pain. RESULTS: There were no differences in patient characteristics (age, sex, functional limitations, disruptive behaviors, and incontinence), medications (pain and psychotropic), use (hospital, nursing home, or emergency department visit), or mortality by level of pain alone or by levels of pain and dementia together. CONCLUSIONS: The study did not demonstrate that a single point-in-time measurement of pain in demented persons was associated with an increased rate of behavioral problems, narcotic use, or hospital or emergency department use over the following year. Prospective studies are needed that measure pain over time to determine more accurately the relationship between pain and negative outcomes in dementia.     

Older adults' satisfaction with integrated capitated health and long-term care

PURPOSE: The objective of this study is to develop an instrument to evaluate satisfaction with care for older adults in capitated environments. Although satisfaction with care is now widely accepted as an important outcome measure, there are relatively few satisfaction measures developed or validated on older persons. Because many older persons are unable to respond to surveys, separate instruments were developed for individuals and for their families. DESIGN AND METHODS: There were 402 face-to-face interviews conducted at 11 PACE sites with PACE participants or their family members and a non-PACE group. Scales were constructed by use of factor analysis and were evaluated for internal-consistency reliability, validity, and ability to discriminate. RESULTS: For the participant survey, three factors were identified, but only two exhibited adequate internal consistency (Perceived Access and Perceived Interpersonal Quality). For the family survey, all four identified factors had adequate internal consistency (Perceived Access, Family Pressure, Ease of Access, and Family Involvement). The participant survey discriminated between the PACE sites and the non-PACE sites, but the family-member survey did not. IMPLICATIONS: The PACE Satisfaction Survey appears to have adequate reliability and validity for measuring the satisfaction of older persons and their family members with capitated care. The domains of satisfaction differ between individuals and family members.     

Educational differentials in life expectancy with cognitive impairment among the elderly in the United States

OBJECTIVE: This article provides estimates of education differentials in life expectancy with and without cognitive impairment for the noninstitutionalized population aged 70 years and older in the United States. METHOD: Life expectancy with cognitive impairment was calculated using multistate models, allowing transitions between cognitively intact and cognitively impaired states and from each of these states to death and allowing transition rates to vary across age and education. Four waves of the Assets and Health Dynamics of the Oldest Old survey were used. RESULTS: Those with low levels of education are more likely to become cognitively impaired and do so at an earlier age. After age 70, persons with low educational levels can expect to live 11.6 years, and persons with high education 14.1 years, without cognitive impairment. Length of life with cognitive impairment differs by education (1.6 years and 1.0 years at age 70, respectively) but differs little by age. DISCUSSION: Although those with higher education have lower rates of both cognitive impairment and mortality, those who do become cognitively impaired appear to be in poorer health, leading to a reduced probability of improved cognition and increased probability of mortality relative to those with lower educational levels.     

The Geriatric Pain Measure: validity, reliability and factor analysis

BACKGROUND: Pain is a multidimensional experience that should be evaluated beyond an estimate of intensity. A multidimensional pain measure has not been developed for older persons undergoing comprehensive geriatric assessment. OBJECTIVE: To develop and evaluate validity and reliability of a multidimensional pain assessment instrument for older persons. RESEARCH DESIGN: A series of steps in instrument development and evaluation. SUBJECTS: A total of 176 subjects (mean age 84 +/- 6.0 years) in ambulatory geriatric clinics; 64% were women, and 73% had a history of chronic pain. MEASUREMENTS: Measurements included the Geriatric Pain Measure (GPM), the McGill Pain Questionnaire, Yesavage GDS, Katz ADLs, Lawton IADLs, Tinetti Gait and Balance, Folstein MMSE, and other demographic and clinical characteristics from interview and chart review. RESULTS: The GPM demonstrated a standardized alpha = 0.9445, homogeneity ratio =0.457, and average inter-item correlation =0.415. A subgroup of 50 subjects demonstrated concurrent validity of the GPM in comparison with the McGill Pain Questionnaire (Pearson's r correlation 0.6269 (P < .0000). Test-retest reliability was demonstrated in another subgroup of 50 subjects who repeated the GPM within 48 to 72 hours (Pearson's r = 0.9018; P < .0000). Factor analysis revealed five clusters of components: Pain Intensity, Disengagement, Pain with Ambulation, Pain with Strenuous Activities, and Pain with Other Activities. CONCLUSIONS: The GPM is a 24-item questionnaire that is easy to administer and has significant validity and reliability in older persons with multiple medical problems. The GPM may be a useful addition to the multidimensional geriatric assessment process.     

The yield,reliability, and validity of a postal survey for screening community-dwelling older people

OBJECTIVES: To assess the yield, reliability, and validity of a postal survey developed to identify older persons in need of outpatient geriatric assessment and follow-up services. DESIGN: A longitudinal cohort study. SETTING: Outpatient primary care clinic at a Department of Veterans Affairs teaching ambulatory care center. PARTICIPANTS: Patients (N = 2,382) aged 65 and older who returned a Geriatric Postal Screening Survey (GPSS) that screened for common geriatric conditions (depression, cognitive impairment, urinary incontinence, falls, and functional status impairment). Validity and reliability testing was performed with subsamples of patients classified as high or lower risk based on responses to the GPSS. MEASUREMENTS: Test-retest reliability was measured by percentage agreement and kappa statistic. The diagnostic validity of the 10-item GPSS was tested by comparing single GPSS items to standardized geriatric assessment instruments for depression, mental status and functional status, as well as direct questions regarding falls, urinary incontinence, and use of medications. Validity was also tested against clinician evaluation of the specific geriatric conditions. Predictive validity was tested by comparing GPSS score with 1-year follow-up data on functional status, survival, and healthcare use. RESULTS: Respondents identified as high risk by the GPSS had scores that indicated significantly greater impairment on structured assessment instruments than those identified as lower risk by GPSS. The overall mean percentage agreement between the test and retest surveys was 88.3%, with a mean weighted kappa of 0.70. In comparison with a structured telephone interview and with a clinical assessment, individual items of the GPSS showed good accuracy (range 0.71-0.78) for identifying symptoms of depression, falls, and urinary incontinence. Over a 1-year follow-up period, the GPSS-identified high-risk group had significantly (P <.05) more hospital admissions, hospital days and nursing home admissions than the lower-risk group. CONCLUSION: A brief postal screening survey can successfully target patients for geriatric assessment services. In screening for symptoms of common geriatric conditions, the GPSS identified a subgroup of older outpatients with multiple geriatric syndromes who were at increased risk for hospital use and nursing home admission and who could potentially benefit from geriatric intervention.     

Feasibility and measurement properties of the functional reach and the timed up and go tests in the Canadian study of health and aging

BACKGROUND: Physical performance measures may offer advantages over self-report in the functional assessment of older people. Estimates of the feasibility, reliability, and construct validity of these measures in large, heterogeneous samples are necessary to establish their importance relative to traditional measures of function. METHODS: Analysis of clinical data from Phase 2 of the Canadian Study of Health and Aging, a nation-wide representative survey of elderly people in Canada (N = 2,305). RESULTS: Both physical performance measures proved infeasible in many subjects (29.3% for the Timed Up and Go [TUG], 35.9% for the Functional Reach [FR]). Cognitive impairment was the most important determinant of inability to complete the tests. For those able to complete the tests, cognitively unimpaired subjects could reach farther (median 29 cm) and complete the TUG in less time (median 12 seconds) than those cognitively impaired (25 cm for FR, 15 seconds for the TUG). Test-retest reliability between the screening and clinical administrations of the TUG was .56 for all participants (intra-class correlations), .50 for the cognitively unimpaired, and .56 for the cognitively impaired. Construct validity was substantial, and correlations between performance measures and self-report activities of daily living (ADL) measures ranged from .40 to .70. Compared with a global clinical measure of frailty, correlations were more modest (.38 to .60). CONCLUSIONS: The FR and the TUG were not feasible tools in this study. The TUG showed poor test-retest reliability. Our data support the observation that subsequent studies of measurement instruments typically reveal lower performance than the original reports.     

Reliability and Validity of Prehospital Case Finding for Depression and Cognitive Impairment

OBJECTIVES: To evaluate the test–retest reliability, the concurrent criterion validity, and the construct validity of prehospital, emergency medical service (EMS) case finding for depression and cognitive impairment in older adults.
DESIGN: Cross-sectional study.
SETTING: Prehospital EMS system and hospital emergency department.
PARTICIPANTS: EMS providers and community-dwelling older adult (aged ≥60) patients.
INTERVENTIONS: Case finding instruments for depression (Patient Health Questionnaire-2; PHQ-2) and cognitive impairment (Six-Item Screener).
MEASUREMENTS: The reliability and validity of these instruments.
RESULTS: Moderate test–retest reliability was found for prehospital application of the PHQ-2 (kappa=0.50) and Six-Item Screener (kappa=0.52), fair concurrent criterion validity for depression (kappa=0.36), and slight to fair concurrent criterion validity for cognitive impairment (kappa=0.11–0.23). Construct validity was demonstrated using the Multitrait-Multimethod Matrix.
CONCLUSION: Moderate test–retest reliability and construct validity were demonstrated for prehospital case finding by EMS providers for cognitive impairment and depression using these instruments. Slight to fair concurrent criterion validity was found, a result that methodological limitations could explain. These findings provide additional support for the concept of using EMS providers to detect older adults at risk for these conditions. Further work is needed to confirm the validity and effectiveness of prehospital screening before such programs are implemented.     

Cognitive status, body mass index, and hip fracture in older Hispanic adults

OBJECTIVES: To examine the interactive effect of cognition and body weight on hip fracture. DESIGN: A 7-year (1993-2000) prospective cohort study. SETTING: Five southwestern states (Texas, New Mexico, Arizona, Colorado, and California). PARTICIPANTS: Noninstitutionalized Mexican Americans (N=2,653) aged 65 and older and free of hip fracture at baseline interview. MEASUREMENTS: Incidence of hip fracture at 2-, 5-, and 7-year follow-up interviews. Body weight and cognition were measured using body mass index (BMI) and Mini-Mental State Examination score, respectively. Covariates included sociodemographics, self-reported medical conditions, visual acuity, and Short Physical Performance Battery. RESULTS: A significant interaction between BMI and hip fracture was found in persons with cognitive impairment (hazard ratio =0.91, 95% confidence interval=0.85-0.98; P=.02), after adjusting for covariates. In the lowest BMI category, the hip fracture rate in cognitively impaired subjects was more than four times the hip fracture rate for subjects who were not cognitively impaired with the same BMI (34.6% vs 8.7%). Hip fracture rates in the highest BMI category were similar in persons with and without cognitive impairment (9.3% vs 6.1%). CONCLUSION: Low cognitive function increased the conditional association between BMI and hip fracture in older Mexican Americans. The relationship between BMI and cognition is potentially important in identifying persons at risk for hip fracture and supports the need to include cognitive and anthropometric measures in the assessment of hip fracture risk into osteoporosis screening programs.     

Do impaired older persons with health care needs occupy U.S. assisted living facilities? An analysis of six national studies

OBJECTIVES: The assisted living facility (ALF) is the fastest-growing noninstitutional long-term care alternative for frail older persons in the United States. This analysis assesses the extent to which older persons with physical and cognitive disabilities and health care needs occupy ALFs in the United States. METHODS: Information on study design and six indicators of the occupancy patterns of older persons in ALFs were abstracted from six national studies. The collected data were based on reports by the administrators of ALFs. RESULTS: The six reviewed studies had several methodologic weaknesses, resulting in different statistical populations of ALFs, samples with very different numerical and attribute properties, and findings based on disparate indicators. The older residents in ALFs were less physically and cognitively impaired than those in nursing homes. ALF facilities were more likely to admit or retain frail older persons when they had relatively minor or less serious physical or cognitive impairment or health care needs. DISCUSSION: ALFs are currently serving older residents who require less nursing care and who are less functionally and cognitively impaired than those found in nursing homes. The more restrictive admitting and discharge criteria of a substantial share of ALFs guarantee their less frail occupant profile. This is, however, an extraordinarily diverse shelter and care alternative, and very frail older persons with serious chronic health problems can be found in ALFs. Average duration of stays may be as long as 3 years. Researchers must conduct more carefully executed studies with replicable methodologies that produce unbiased and generalized findings.     

Pain in elderly people with severe dementia: A systematic review of behavioural pain assessment tools

Background

Pain is a common and major problem among nursing home residents. The prevalence of pain in elderly nursing home people is 40–80%, showing that they are at great risk of experiencing pain. Since assessment of pain is an important step towards the treatment of pain, there is a need for manageable, valid and reliable tools to assess pain in elderly people with dementia.

Methods

This systematic review identifies pain assessment scales for elderly people with severe dementia and evaluates the psychometric properties and clinical utility of these instruments. Relevant publications in English, German, French or Dutch, from 1988 to 2005, were identified by means of an extensive search strategy in Medline, Psychinfo and CINAHL, supplemented by screening citations and references. Quality judgement criteria were formulated and used to evaluate the psychometric aspects of the scales.

Results

Twenty-nine publications reporting on behavioural pain assessment instruments were selected for this review. Twelve observational pain assessment scales (DOLOPLUS2; ECPA; ECS; Observational Pain Behavior Tool; CNPI; PACSLAC; PAINAD; PADE; RaPID; Abbey Pain Scale; NOPPAIN; Pain assessment scale for use with cognitively impaired adults) were identified. Findings indicate that most observational scales are under development and show moderate psychometric qualities.

Conclusion

Based on the psychometric qualities and criteria regarding sensitivity and clinical utility, we conclude that PACSLAC and DOLOPLUS2 are the most appropriate scales currently available. Further research should focus on improving these scales by further testing their validity, reliability and clinical utility.     

Exposure to opioid analgesia in cognitively impaired and delirious elderly hip fracture patients

The objectives of this study were to characterize patterns of opioid analgesia in elderly hip fracture patients, to investigate the possible differences in the treatment of cognitively impaired, delirious, or cognitively intact patients, and to study the factors that may affect the doses received by such patients. This retrospective study comprised 184 elderly patients with hip fractures undergoing surgical fixation. Data collection included age, sex, length of stay, type of fracture, cognitive status by mini-mental state examination, assessment of possible delirium by the confusion assessment method, type and doses of opioid received by these patients. We found that the amount of morphine equianalgesic dose differed significantly between demented and non-demented patients (7.5 +/- 1.8 vs. 14.1 +/- 4.9, P<0.001). Patients with cognitive decline or with delirium received only 53 and 34%, respectively, of the amount of opioid that was administered to cognitively intact patients. A significant association was observed between cognitive status, or delirium, and amount of opioid analgesia (P<0.001 and P=0.003, respectively). Other parameters such as age, length of stay and type of fracture, had no effect on the use of opioid analgesia. It is concluded that the management of pain in older persons with hip fracture surgery is suboptimal with regards to insufficient administration of opioid analgesia in demented and delirious patients. The adoption of a standardized protocol for pain control may help in reducing the extent of this problem.     

Effekte k?rperlicher Aktivit?t und k?rperlichen Trainings auf den psychischen Status bei ?lteren Menschen mit und ohne kognitive Sch?digung

Fear of falling and depression in the elderly and among cognitively impaired people lead to restrictions in quality of life. Being more active is associated with improved mental health as documented in cross-sectional and longitudinal studies. This is especially true for depression. Such epidemiologic evidence is lacking in fear of falling. This review summarizes current evidence from epidemiological and randomized controlled trials (RCTs) and gives an outlook for future research perspectives. The majority of studies included in this review document a significant reduction of depression and fear of falling in older persons by physical training with less evidence in persons with cognitive impairment. With respect to intensity, duration, and amount of exercise, evidence-based recommendations were limited by the small number of high-quality comparative RCTs. High-intensity strength or endurance training was the most effective for reducing depression, while participation in Tai-Chi or multifactorial training programs was most effective to reduce fear of falling.     

Early Cognitive Change in the General Population: How Do Different Definitions Work?

OBJECTIVES: To explore the application of existing classifications of mild cognitive impairment (MCI) and associated states in a large population sample. DESIGN: Prospective cohort study, baseline phase (cross-sectional analysis). SETTING: Large-scale multicenter study in the United Kingdom. PARTICIPANTS: Thirteen thousand four individuals aged 65 and older from the Medical Research Council Cognitive Function and Aging Study. From this, a subsample of 2,640 individuals was selected and completed a more-detailed cognitive assessment. MEASUREMENTS: Information on sociodemographic status, general health, cognitive impairment (measured using the Mini-Mental State Examination), and functional ability was collected in a structured interview at baseline. The Geriatric Mental State Automated Geriatric Examination for Computer-Assisted Taxonomy and the Cambridge Cognitive Examination were used in assessment to determine cognitive status. Using a systematic literature review to collect all symptom classifications for nonnormal dementia states, these were then operationalized retrospectively. Each participant was classified according to each. RESULTS: Population prevalence estimates were variable (range 0.1-42%), reflecting differences in the focus and content of each state. Limited overlap existed between states such that many individuals were concurrently classified as normal and impaired. This highlights the heterogeneity in classification as captured using different definitions. CONCLUSION: Classification of cognitively impaired and cognitively normal individuals is dependent on the way criteria are defined and operationalized. Each classification captures a unique group of individuals, with little concordance. Given the importance of early detection of dementia and the calls for screening, and recruitment into pharmacological trials of cognitively impaired individuals, there is an urgent need for an agreed-upon standard MCI case definition to use as a criterion standard.     

Prevalence of cognitive impairment in patients attending pre-dialysis clinic

Approximately 20-30% of patients on renal replacement therapy (RRT) have cognitive impairment. Less is known about the prevalence of cognitive impairment in patients with advanced kidney disease awaiting the initiation of dialysis. Routine cognitive assessment was implemented in the pre-dialysis clinic, which enabled the Nephrologist and Pre-dialysis Nurse to identify those patients with impaired cognitive function and utilise this information to assess the suitability for self-care treatments, such as peritoneal dialysis, as well as to adapt information to meet their needs. Subsequently, a cross-sectional single-centre audit was undertaken to identify the prevalence of cognitive impairment in 132 consecutive new referrals to the pre-dialysis clinic using the Mini-mental State Examination (MMSE). Twenty percent (95% CI = 0.13, 0.27) were classified as cognitively impaired. Those with cognitive impairment were significantly older, and had lower eGFR and higher serum creatinine. It can be concluded that approximately 1 in 5 patients attending the pre-dialysis clinic has cognitive impairment, which may not be apparent on a routine clinical history. Cognitive function assessment is recommended for all, but particularly to the older patient, before advising on choice of dialysis modality or opting for conservative treatment.