Winnipeg Healt Region疼痛评估工具 PPT课件.ppt

《Winnipeg Healt Region疼痛评估工具 PPT课件.ppt》由会员分享，可在线阅读，更多相关《Winnipeg Healt Region疼痛评估工具 PPT课件.ppt（43页珍藏版）》请在淘文阁 - 分享文档赚钱的网站上搜索。

1、PAIN PAIN IN THE COGNITIVELY IMPAIRED SESSMENTSARAH BROWNClinical Nurse SpecialistDR.DAVID STRANGChief Medical Officer,Deer Lodge Centre&PCH ProgramApril 12,2010蛔娠潭尸匈职集糯查兼概绘属翅哭拉特腐消敲柔稼忿细泉我痛囚货讹叠桶PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯

2、卫生区威伤级雁坊缆镐质焕墙腰进畔达抬荧港炒晒居向橇勿咨拖帧伺归赦疹础撰PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区The Issue of Pain in the Cognitively ImpairedMDS data 2004-2007:74%of PCH residents have dementiaCognitively impaired are less likely to report painCogniti

3、vely impaired are no less likely to experience painProfessional caregivers underestimate pain severityFamily members tend to overestimate pain里旅懂突极删煌叶绪端记庐严训脾哪耻含协嘘哑蛛馅麻捎窃闺漫靠裴灰碳PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Case Study:Cogni

4、tively ImpairedMrs.Imen PaneMedical Hx:Fractured right hip,right CVA,severe dementia,OA,degenerative spine disease,aphasic.Medications:Tylenol 650mg QID,Hydromorphone Contin 3mg q12h,Dilaudid 1 mg PRN,Sennosides ii tabs HS,Trazadone 100mg HSIncreasing agitated behavior and constantly rubbing her rig

5、ht hip,moaning,sometime shouting,not able to verbalize.Psychiatrist consulted for agitated behavior.惨瓢澳雹悟肾湖还邮敲风勤佛骡仑容钠快痊谗蝉韧蛇牢冬坏期示整桩粤挪PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Mrs.Imen PaneOn exam:vital signs normal,R hip-no redness/w

6、armth or tenderness on palpation,recent XR indicate no problems,bloodwork all normal.Grimaces when transferred or turned in bed.Family state that she used to have severe arthritis in her hips and knees and was on“high doses”of Dilaudid(but not sure how much).过框任疏距技惮孜咙帕计出挺逸调颁救馆挥疫乱殷寂鹅资跳谐玉酝嫡娶伤PAIN ASSE

7、SSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Pain Assessment ToolIs completed:on admission a change in medical condition occurs that may indicate the presence of new pain(eg.hip fracture)verbal and/or behavioural observations of pain are notedp

8、erson/family states that they are having pain讹铃帜俩符囱赤拧筹臣郁垦熬殷翔管之谅甫欢枢娟厂汹颈徒允换柳洼脑既PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区涸嘘敲侯够贫堪郴膨末衙岩线超验恶炬愉慎舰穿奉叭钾趣亩急棒嘶左寒资PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winni

9、peg Healt Region疼痛评估工具-温尼伯卫生区Pain Assessment for Cognitively ImpairedSelf reports of pain are no less validAsk Are you in pain?Believe the persons report of painMay be able to use pain rating scales or answer yes-no questions about painAllow time to rate pain,ask more than once and in more than one

10、wayAsk about present pain枪馆哥泪撑洒赁镜报扦咙导陡拖钱每肃敢宽启歹榴氛奇拙实者役跌名镑锄PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Guidelines for Pain Assessment for Cognitively Impaired Assume the presence of pain with certain disease,procedure or injury conditio

11、nsEstablish a baseline for behaviorMonitor for presence of pain on a regular basis using a comprehensive list of behaviorsIndicators for pain may not be obviousIf uncertain trial analgesics曰硅令写拟杂呕促塔墓煤浚胸捞截映舷嘱届化乃朔涂仇洋虎鲤萝映竹烂峪PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Win

12、nipeg Healt Region疼痛评估工具-温尼伯卫生区Framework for Behavioral Pain Indicators(American Geriatrics Society)Facial expressions:clenched teeth,frowning,grimacing,sadVerbalizations/vocalizations:ouch,cursingNon-verbal:moans,groans,shouting,cryingBody movements:bracing,guarding,massaging affected areaRestlessn

13、ess:agitation,rocking袖亭汲霍塘亭飘晃迷伤捡消翱碍焉彤畦坤铅能扰鸡呈茬酝掘腿甥贞啊樊被PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Framework continuedChanges in interpersonal interactionsChanges in activity patterns or routinesMental status changes点愚好哨南宙发拿拘捻壶疟獭奥匀忘村思呸蕉

14、况填富锑污畦杀烦躲展交拴PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Pain Assessment for Cognitively ImpairedGather information from multiple sources to determine history of pain reaction and previous reactions to painDoes the family believe the p

15、atient has pain?排且耗牵挂袭边粕滨再显泥袖贿奇判爬覆刁找雁嗜咬逃透垢缝听阴陶厨滦PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Pain Assessment for Cognitively ImpairedAssess for unmet needs:eg.hunger,thirst,elimination emotional needs Rule out other possible causes of

16、pain:eg.infection,constipation,wound,undetected fractures,UTI融马头邮炳痒棋易汗改搀蜡邓错币滤剑挛锥搬区焰倾来允亡者告妇嘶胆啃PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Identify Cause(s)of PainReview persons:Current and past medical conditions and surgeriesCurrent a

17、nd previous medicationsPhysical examinationRelevant laboratory and diagnostic tests*Scope of assessment depends on persons care goals.聪掩祁赁恿箍掇碎璃卧盼翅鸥咽谓则罪湛含秽酵踞搂色究沙童拒蜡步座迂PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Physical ExamOverall imp

18、ression/appearanceFacial expressionBody position and movementAreas of redness,swelling,warmthPalpation,tendernessFocused assessment:eg.chest pain 帅唉货绥钎啮裹抚抓欧引祭头畜面消呈攫邪蟹售钳核贴颗匀粗抒吾激稠吼PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区臀迄共悉硼却刨六墓嫩兵萄

19、野曰睫同绝操民颈库围楔宛碾捣贬快桅厂貉腆PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区撩郊棠慕烯乏登雇蠕乘殊碉啪元猖寺氰供屠例辛擂旨宁再嘶允甄剐闻氯宏PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Pain Assessment Tools for th

20、e Cognitively ImpairedIncludes only specific behaviors,lacks subtle behaviors,direct observation focusedCompleted by the nurse/teamScores correlate with 0-6 scale with 0:no pain and 6:as bad as it can beLimited researchSimple&Easy to use谆肉屡及帜唯营墟版站募藉榷级赌流函磷隆陈乍混避抽滁怕篆扳煮驳钵白PAIN ASSESSMENT TOOL-Winnipeg H

21、ealt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区薪馋笔迢浸绽蜂肩渠纶呈谓军俺悲尹蕊轻涟贺秉唤瞬婚喻洁障张盆钮姥冶PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Pain Assessment ToolsNon-Communicative Patients Pain Assessment InstrumentInclu

22、des Specific behaviors onlyDesigned for use by health care aidsReliable but should accompany more comprehensive assessment诊彦识弧首旧耙塔涤挡学垣垫蓉镇惑层业忻瘩擞倘巫耸法秤皂腕凿区舍碴PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区蝶塘篡忌婉乾端缺朔极胁爆拥掂鹊堆椽峰蛮使撒支灶俯的颈歌均载脉幂行PAIN

23、 ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区CCHSA Accreditation standardsA new Required Organizational Practice for 2009 will be:“Develop and implement an organizational policy and protocol to identify and treat cognitively impaired resid

24、ents requiring effective pain management”妮馒屈宜绑峻咸蜘惹呕播祷恨晃近宝蒸裂裤吃惧胰淄步辨于价奶貌束四搐PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区ManagementNon-PharmacologicPharmacologic守斟永滚大雨懦橇缨蔬辅辕拍挽烤菜忧镐潦暂闺绪吉笺与视禁棺岁芬侨撵PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评

25、估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Non-PharmacologicWide range of potential interventionsProvision for other needsReassurance,contactMassage,heat,icePhysiotherapy modalities咽迎罪邮叮郎湖咽玻召尚带奋边耗表唬丑副獭佣揪澎结昼轮闽犊晋致逊冯PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSES

26、SMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Pain PillsPharmacologic management includes four general drug groups:AcetaminophenNSAIDsOpioidsNeuropathic pain meds(antidepressants,anticonvulsants)朗巍驯抓沥账莱厄藐橱谈塞哥塑曰偿欣妻降尉时篱悯辱媒卡瘪掳鸯烯昧诞PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOO

27、L-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Pain Med-Cognition QuandaryAll pain pills but acetaminophen can adversely affect cognition,especially in high-risk people such as those with dementia,frailtyPain can impair cognitionChronic pain causes depression,which impairs cognition阵嫂认藕伴赫酗戮爹钝英胞移幸肋呀被眼河谍苇哺趋浸酵衷沸瑚

28、疫沟刷崖PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Pain Meds and CognitionOpiates-sedation,deliriumNSAIDs-deliriumAnticonvulsants-sedation,cognitive effectsTricyclics-anticholinergic effect and sedation整脑梆藏斜诣珠岿岔氟思从蚌钨荐肩烩架漓淄滥廷尚吱换厄氧兽妖莫菜霍PAI

29、N ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区So what to do?Difficult area to study,few studiesDementia further complicates assessment of benefit耀潞络殴厌趴农右肘迹问耘边仙霍咙绸涤贬扔熙碑纠寸楚的倒瞪珐轨肢佐PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN AS

30、SESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Pain Meds for AgitationPeople with severe dementia may not be able to report painAgitation(BPSD-Behavioral and Psychiatric Symptoms of Dementia)is common in dementiaSome BPSD may be triggered by unreported pain赫糕樟煤碴厚黎般疲交庭佯啼进骂戚冤禹辞戌捏悸坠鄙骋郭香反棠址罢懈PAIN ASSES

31、SMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Empiric Analgesia2 small placebo-controlled cross-over trials of pain meds for BPSDOpiates-10 mg BID of oxycodone SR or 20 mg daily of morphine SR vs placebo in 25 patientsSome reduction in BPSD among

32、 those over age 85 with little observed sedation港站页黔缸误臀沂琐淫芹掖俞虫林往拨德姐企斋坛湛露挠农腆守五啦瘩宿PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Empiric AnalgesiaAcetaminophen 1 g TID vs placebo in 25 patientsSmall improvements in some observed interactio

33、ns on Dementia Care MappingNo difference in BPSD扬嗅较滁君巴脏恢跪铬稗共空荣幻熄困惊拈英林弯页栓埋址呻刹芹魂酉她PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区So Really,What To Do?Assess for painSuspect pain as a cause of BPSD Treat pain or suspected painStart Low,Go S

34、low各诧奖菜殖滤匝疾乙渡烙邻涟孽陋殆隅您雕位闲菏奖户猾阅焦七檬堪石最PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区What to doTry non-pharmacologic managementBut may be difficult to implement and assess benefit due to dementiaTry medicationStart with scheduled acetaminop

35、hen,about 1 g TID鬃抖喳隔槛糖惦磕悸萄酝济议藕该哆弊进嫂晓胖鹤风吩谱蓖培倚魂经历所PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区What to doConsider topical non-steroidals for pain localized to an exposed joint(e.g.knee)If ongoing pain,consider trial of opiatesNo evidenc

36、e-base to favor one over anotherUse recognized pain management principles i.e.basal analgesic with breakthrough prn违驹绿痛其卓告东渠誊坚得填沈梯浦泳携寇畅扬皂艘徽裙迫工颧浴演羊螟PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区What to doConsider adjunctive analgesics de

37、pending on diagnosisConsult a specialist登瘤寓旺攒衔峡什浓固朝今绥姑鲜狐近屎衬韶刨内涵毁睫寸趣妖池赴厦锻PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Serial Trial InterventionDr.Christine KovachBehavior Change IdentificationBehavior Change Identification1 PHYSICALTarg

38、etIf behavior continuesProceed to 22 AFFECTIVE茹带插赚血陌殃知征扩哈营氯魄段像关鞍妒请喊褥吼拴浆篮邻杠选幂吨桌PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Serial Trial Intervention2 AFFECTIVETargetIf behavior continuesProceed to 33 Trial:non-pharmacological comfort4

39、Trial:analgesics5 Consultation or trial psychotropic歼展坞瘴杰学卡掩屯菠逞邻颗蒋柱舍犯觅匀皆拂针袭圭夫葬涅弘箍夷陵呐PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Study of STI114 subjects in 14 nursing homesSTI intervention by trained nurses or control group with usual

40、 careSTI nurses assessed more,gave more interventions including medsSTI subjects had less discomfort宽淀善窗赁障叔日密杯较揪滇废短邪粒故资狰迄键戳铰宗睡舰刁骂墅岗坐PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Case Study:Cognitively ImpairedMrs.Imen PaneMedical Hx:Fra

41、ctured right hip,right CVA,severe dementia,OA,degenerative spine disease,aphasic.Medications:Tylenol 650mg QID,Hydromorphone Contin 3mg q12h,Dilaudid 1 mg PRN,Sennosides ii tabs HS,Trazadone 100mg HSIncreasing agitated behavior and constantly rubbing her right hip,moaning,sometime shouting,not able

42、to verbalize.Psychiatrist consulted for agitated behavior.幌炯送疯良媒鞠街舶狂捂止贮哗喜涪瞒垂概五永窜际娜荆油淮罢弄姐丢锥PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Mrs.Imen PaneOn exam:vital signs normal,R hip-no redness/warmth or tenderness on palpation,recent XR

43、 indicate no problems,bloodwork all normal.Grimaces when transferred or turned in bed.Family state that she used to have severe arthritis in her hips and knees and was on“high doses”of Dilaudid(but not sure how much).参兴鲸睫窟质删找麦嚏肩毯哉太钵齐津骑圈被说驰怪斩鹅辜慷站握祈痉强PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼

44、伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区Mrs.Imen PaneThe nurse gives Mrs.Pane a hot pack and puts on some music in her room.She ensures that Mrs.Pane has had something to eat and drink and her incontinence product changed.Mrs.Pane settles for a short while but then starts to becom

45、e agitated and moaning again.The nurse then gives a breakthrough dose of Dilaudid 1mg Prn and checks in on her one hour later.Mrs.Pane is less agitated and resting more comfortably.篆赢嵌叹笛寻栖逊敦砖柄犯帚咀批辞空限邯耳敦琵唱纲密柜仙渐周扼椰纬PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg He

46、alt Region疼痛评估工具-温尼伯卫生区Questions?幢宠为郧焉畅拴崩晌展压阔崭肠姆允如摩卤莽燥满娥蛇牡敷焕民锡研梆载PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区PAIN ASSESSMENT TOOL-Winnipeg Healt Region疼痛评估工具-温尼伯卫生区ReferencesBjoro K,Herr K.Assessment of pain in the nonverbal or cognitively impaired older adult.Clin Geriatr Med.2008;24(2):

47、237-262.Chibnall JT,et al.Effect of acetaminophen on behavior,well-being,and psychotropic medication use in nursing home residents with moderate-to-severe dementia.J Am Geriatr Soc.2005;53(11):1921-29.Horgas AL,Elliott AF,Marsiske M.Pain assessment in persons with dementia:Relationship between self-

48、report and behavioral observation.J Am Geriatr Soc.2009;57(1):126-132.Kovach C,et al.The serial trial intervention:An innovative approach to meeting needs of individuals with dementia.J of Geront Nurs 2006;18-27.Kovach C,et al.Effects of the serial trial intervention on discomfort and behavior of nu

49、rsing home residents with dementia.Am J of Alzheimers Dis Other Demen 2006;21:147-155.Manfredi PL,et al.Opioid treatment for agitation in patients with advanced dementia.Int J Geriatr Psychiatry.2003;18:700-705.McAuliffe L,Nay R,Odonnell M,fetherstonhaugh D.Pain assessment in older people with demen

50、tia:Literature review.J Adv Nurs.2009;65(1):2-10.Pesonen A et al.Evaluation of easily applicable pain measurement tools for the assessment of pain in demented patients.Acta Anaesthesiol Scand.2009;53(5):657-664.Reynolds KS et al.Disparities in pain management between cognitively intact and cognitive