Many older people suffer from some level of cognitive decline, due to normal aging or pathological conditions. When older people make use of health care services it is important that health care providers are aware of their cognitive abilities, both for the diagnostic and treatment process and for nursing interventions. Nurses are in the unique position of being able to observe patients intensively and for long periods of time, and they therefore see the direct results of patients’ cognitive abilities.
In the case presented in the Prologue of this thesis we described an unstructured method of assessing cognitive functioning by daily observation in geriatric patients. Because this unstructured method is not practical, not manageable, nor teachable, we felt the necessity to standardise such observations. This final chapter summarises and discusses the results of the studies described in this thesis.

SUMMARY OF RESULTS

This summary gives a brief narrative outline of the results from the studies conducted. For a more quantitative summary we refer to the abstracts at the beginning of each chapter.

Chapter 1 reviews the literature on valid and reliable Dutch-language behavioural rating scales that can be used to structure direct nursing observations. The intention was to implement the most appropriate scale in our daily practice in a geriatric unit of an acute hospital. The (sub) scales that were traced were discussed with regard to content, validity and reliability. Thirteen scales were found. There was great variety in the number of dimensions of cognitive domains assessed, from two to eight in number. Of all scales that we traced, the A-one is the most extensive: eight domains are included. However, this scale is developed for use by occupational therapists, who ask the patient to perform specific tasks, and it requires a specific test-room to conduct the observations. We concluded that there is no daily practice scale available for nurses, which allows for the assessment of patients’ cognitive functioning in a sufficiently comprehensive way.

Chapter 2 reports why and how geriatric nurses observe their patients’ cognitive abilities. 84 nurses from seven Dutch hospitals described their reasons for assessing older patients’ cognitive functioning in free text. We categorised their answers and this led to three main objectives for cognition observations: to guide nursing interventions, to determine discharge arrangements and to support medical diagnoses. The respondents also reported the cognitive domains they included in their daily observation in free text. After categorising these topics, it was demonstrated that many different domains were observed. This may explain the heterogeneity in the general use of the concept of cognitive functioning, which in turn leads to vague, incomplete or incorrect descriptions.

Chapter 3 demonstrates the methodology used by geriatric nurses to observe patients. We invited ten geriatric nurse experts, often nurse specialists, for a semi-structured interview on the methodology of the observational assessment by their bedside colleagues. Firstly, all the respondents stated that daily observation of cognitive abilities yields valuable information. However, the concept of cognitive functioning was implemented differently for each ward, and by each nurse.
The data showed considerable variation not only in the cognitive domains included, but also with respect to the time of day for observation, the number of days, the goals to be achieved, registration in the nursing files, summarising the information and drawing conclusions. Factors that contributed to the variation were the number of years of professional experience in geriatric nursing, the absence of written policy on behavioural observation on the ward, and high workload. Interpretation of the observed behaviour was difficult due to the fact that the pre-morbid condition is unknown. In conclusion: daily observation of cognitive functioning was conducted in a non-systematic way.

Chapter 4 examines the agreement between nurses in their assessments of cognitive functioning in geriatric patients. A self-developed scale was used to measure the patient’s level of cognitive functioning. We constructed a short 10-item questionnaire, each item addressing one cognitive domain to be scored on a 5-point Likert-type scale (from no problems to severe problems). Additionally, the Clinical Dementia Rating (CDR) scale was also employed as a well-validated scale to stage the severity of dementia symptoms. Sixty patients were assessed, each patient by two nurses. In total, 90 nurses participated in the study. The agreement between the nurses’ assessments for the 10 self-developed items of cognitive functioning was poor to fairly good. However, the agreement regarding the severity of dementia symptoms on the well-validated CDR was much higher. We concluded that the agreement on the assess