Standardized Assessment of Cognitive Function, Mood, and Pain Among Patients Who Are Unable to Communicate

Victoria Shier PhD; Maria O. Edelen PhD; Tara L. McMullen PhD; Michael S. Dunbar PhD; Patricia Bruckenthal PhD; Sangeeta C. Ahluwalia PhD; Emily K. Chen PhD; Sarah E. Dalton MA; Susan Paddock PhD; Anthony Rodriguez PhD; Stella Mandl BSW, BSN, RN; Teresa Mota BSN, RN; Debra Saliba MD, MPH, AGSF


J Am Geriatr Soc. 2022;70(4):1012-1022. 

In This Article

Abstract and Introduction


Background: Assessments of patients have sought to increase the patient voice through direct patient interviews and performance-based testing. However, some patients in post-acute care (PAC) are unable to communicate and cannot participate in interviews or structured cognitive tests. Therefore, we tested the feasibility and reliability of observational assessments of cognitive function, mood, and pain for patients who are unable to communicate in PAC settings.

Methods: We conducted a national test of observational assessments of cognitive function, mood, and pain in 143 PAC facilities (57 home health agencies, 28 Inpatient Rehabilitation Facilities, 28 Long-Term Care Hospitals, and 73 Skilled Nursing Facilities) across 14 U.S. markets from November 2017 to August 2018. For the 548 patients identified as unable to make themselves understood, we assessed descriptive statistics, percent of missing data, time to complete, and inter-rater reliability (IRR) between paired research nurse and facility staff assessors.

Results: Most sampled non-communicative patients were administered all three observational assessments. Among assessed patients, overall missing data was high for some items within the Staff Assessment for Mental Status (2.9% to 33.5%) and Staff Assessment of Patient Mood (12.4% to 44.3%), but not the Observational Assessment of Pain or Distress (0.0% to 4.4%). Average time to complete the data elements ranged from 2.4 to 3.5 min and IRR was good to excellent for all items (kappa range: 0.74–0.98).

Conclusion: The three observational data elements had acceptable reliability. Although results revealed varying feasibility, there was support for feasibility overall in terms of implementing a standardized observational assessment of pain for patients in PAC settings. Additional work is needed for the Staff Assessment for Mental Status and the Staff Assessment of Patient Mood to improve the observable nature of these data elements and enhance instructions and training for standardizing the assessments.


The Centers for Medicare & Medicaid Services (CMS) has sought to ensure that the clinical assessment instruments are patient-centered and consider the "voice" of the patient. Therefore, the assessment instruments have included patient interviews. For example, the testing work on the Minimum Data Set (MDS) 3.0[1] developed and tested data elements that served to increase the resident's own voice and perspective, bolstering person-centered care. However, a number of patients in post-acute care (PAC) are unable to make their needs known through verbal or written communication. In 2018, the nursing home (NH) resident interviews for cognitive status, mood, and pain were not attempted among approximately 10%, 11.5%, and 8.5% of residents, respectively.[2]

The Improving Medicare Post-Acute Care Transformation Act of 2014's (IMPACT Act) mandated CMS to develop and implement standardized patient assessment data.[3] The IMPACT Act requires standardized patient assessment data for home health agencies (HHAs), inpatient rehabilitation facilities (IRFs), long-term care hospitals (LTCH), and skilled nursing facilities (SNFs) with respect to the following categories: (1) cognitive function and mental status; (2) special services, treatments, and interventions; (3) medical conditions and comorbidities; (4) impairments; and (5) other categories.[4] (For readability, we use "patient" to indicate patients of HHAs, IRFs, and LTCHs and residents of SNFs.) The national field test of candidate standardized assessment data elements (SADEs) included patient interviews or direct performance-based testing for cognitive function, mood, and pain, among others. This included the Brief Interview for Mental Status (BIMS), a performance-based testing of cognitive function, that improves identification of cognitive ability and can be used as a brief performance test to expand the assessment of signs and symptoms of delirium.[5,6] The national field test also included the Patient Health Questionnaire–9 (PHQ-9), a structured interview of mood tested in a wide range of populations.[5,7–11] Patient self-report is thought to be foundational for assessing symptoms of depression.[12] Similarly, self-reported pain has widely been seen as the gold standard for assessment[13] and the national field test included a structured pain interview.[14] These three data elements performed well in the national field test and were found to be feasible and reliable in PAC settings.[15–17]

Data elements that can assess observed behaviors are required to assess the patients receiving PAC who are unable to participate in interviews because of cognitive impairment or difficulty communicating. Assessment of these patients will provide staff with important information about how to better meet the patients' unmet needs, including pain or physical discomfort, mental discomfort, loneliness, or need for social interaction. This paper presents the results of feasibility and reliability testing of the three observational assessments for standardization across HHAs, IRFs, LTCHs, and SNFs: Staff Assessment for Mental Status, Observational Assessment of Patient Mood, and Observational Assessment of Pain or Distress. These assess cognitive function, mood, and pain for patients in PAC settings who are unable to communicate.