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PRINCIPLE 1: Cognitive screening

Patients aged 65 years and over will be screened for confusion on admission or within 24 hours of admission using a validated screening tool.

Cognitive screening tools

A range of validated cognitive screening tools is available.

An agreed cognitive screening tool should be used across the healthcare facility. Healthcare facilities should base their selection of a cognitive screening tool on their target population, time required to complete the tool and ease of use.

The Abbreviated Mental Test Score (AMTS) (1,2) is recommended and is available on FirstNet.

Other validated cognitive screening tools include:

  • the Six Item Screener (SIS) (3)
  • Standardised Mini mental state examination (SMMSE) (4)
  • DRS-R-98 (for older persons with hip fracture) (5)
  • Short Portable Mental Status Questionnaire SPMSQ (6)
  • Rowland Universal Dementia Assessment Scale (RUDAS) (7).

The Rowland Universal Dementia Assessment Scale (RUDAS) is designed to enable the easy translation of the items into other languages and to be culture fair. It is recommended for use with those from culturally and linguistically diverse backgrounds (4) and can also be useful for individuals with limited education.

The Kimberley Indigenous Cognitive Assessment (KICA-Cog) is validated for use with older indigenous adults from remote areas and has been adapted for individuals from rural and urban areas as Modified KICA (8).

Cognitive screening tools


  1. Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age and ageing. 1972;1(4):233-8.
  2. Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. 1972. Age and ageing. 2012;41 Suppl 3:iii35-40.
  3. Callahan CM, Unverzagt FW, Hui SL, Perkins AJ, Hendrie HC. Six-item screener to identify cognitive impairment among potential subjects for clinical research. Medical care. 2002;40(9):771-81.
  4. Dementia Outcomes Measurement Suite (DOMS). Cognitive Assessment Measures Dementia Collaborative Research Centres 2007. Available from: http://dementiakt.com.au/doms/.
  5. Andrew MK, Bhat R, Clarke B, Freter SH, Rockwood MR, Rockwood K. Inter-rater reliability of the DRS-R-98 in detecting delirium in frail elderly patients. Age and ageing. 2009;38(2):241-4.
  6. Gornemann I, Zunzunegui MV, Martinez C, Onis MD. Screening for impaired cognitive function among the elderly in Spain: reducing the number of items in the Short Portable Mental Status Questionnaire. Psychiatry research. 1999;89(2):133-45.
  7. Basic D KA, Conforti DA, Rowland JT, Vrantsidis F, LoGiudice D, Hill K, Harry J, Lucero K PR. Rowland Universal Dementia Assessment Scale, MiniMental State Examination and General Practitioner Assessment of Cognition in a multicultural cohort of community-dwelling older persons with early dementia. Australian Psychologist. 2009;44:40 - 53.
  8. Ageing Western Australia Country Health Service. Kimberley Indigenous Cognitive Assessment. Available from: http://www.wacountry.health.wa.gov.au/fileadmin/sections/policies/Managed/MR66.11_WACHS_Kimberley_