Hospital Neuropsychological Assessment: Cognitive Impact of Hospitalization and Clinical Recommendations

Neuropsychologist Diego Carracedo Sanchidrián offers a guide to hospital neuropsychological assessment.

Hospital neuropsychological assessment is a brief, contextualized cognitive evaluation performed during a hospital stay, particularly in people with neurological risk factors or advanced age. It can detect cognitive impairment, acute confusional syndrome (delirium), and difficulties with medical decision-making, optimizing clinical safety and discharge planning.

Introduction

A hospital admission can be a significant stressor for anyone, since it involves not only a fragile state of health but also the loss of routines, social networks, and usual activities. This situation can have an emotional, but also cognitive, impact, especially in people with preexisting vulnerability such as neurological diseases, neurodegenerative conditions, prior brain injury, or advanced age (Escriche-Martínez et al., 2025). 

Detecting cognitive problems, whether acute or persistent, is essential, as they affect a person’s ability to understand medical information, follow recommendations, and make important decisions about their health. Neuropsychological screening tests are available to assess cognitive status and guide the adaptations needed to improve the person’s health (Amaral et al., 2022). 

Assessing and understanding cognitive status is also important for adapting how professionals and family members convey information, explaining some of the symptoms and coping strategies to the latter, and taking this into account when planning treatment and follow-up at discharge. In cases of severe impairment, ethical and legal issues also arise and must be integrated into decision-making.

Effects of Hospitalization on Cognition

Factors Influencing Cognition During Hospitalization

Multiple factors affect cognition in this situation: 

1. First, a fragile state of health limits the resources available for the brain to function normally. This is especially true in more serious situations, such as cardiac or pulmonary problems, moderate or severe infections, cancer, and traumatic situations such as accidents involving burns or high levels of pain (Amini and Kawser, 2020). 
2. In addition, medical interventions such as surgery involve a process of physical recovery that can also reduce the availability of cognitive resources. 
3. This is compounded by frequent polypharmacy, which may include drugs that interfere with general arousal and cognition, such as hypnotics, benzodiazepines, sedatives, and analgesics (Wilson et al., 2020). 

Other factors that sometimes go unnoticed include environmental deprivation and emotional state. Hospitalization often means spending weeks or even months in a room with little stimulation, limited mobility, suboptimal conditions for rest, and limited social contact, all of which reduce cognitive activation. Fear, anxiety, sadness, or insomnia may also occur and intermittently interfere with cognitive processes (Petty et al., 2020; Walker et al., 2021). 

Risk Profiles for Cognitive Impairment During Hospitalization

People who, because of their characteristics and preexisting health conditions, are at greater risk for cognitive impairment are especially vulnerable during a hospital stay. This includes those who have had brain injury, such as a stroke or TBI; those with a potentially neurodegenerative disease such as multiple sclerosis, Huntington’s disease, or Parkinson’s disease; those who already have a process of cognitive impairment such as Alzheimer’s disease; and those with severe mental health problems, such as psychosis, as well as older adults (Park, Kim, and Kim, 2023; Boucher et al., 2025). 

In fact, in some cases, the admission itself is the event that enables the detection of cases of incipient cognitive impairment that had gone unnoticed until then; hence the importance of paying attention to the cognitive functioning of these populations with risk factors (Emery et al., 2020). 

In addition, the likelihood of acute confusional syndrome or delirium is much higher in these people. Acute confusional syndrome is a transient alteration in mental status characterized by rapid onset and fluctuations in consciousness, with impairment of attention, orientation, and other cognitive functions. Its likelihood increases with surgery, medication, and infections, and it may be hypoactive or hyperactive. Delirium is a pathological process distinct from cognitive impairment, and its diagnosis is clinical; it must be ruled out before interpreting the results of a cognitive assessment (Lange, Verhaak, and van der Meer, 2021).  

Tools and Strategies for Hospital Neuropsychological Assessment

In the hospital setting, a neuropsychological assessment is not intended to provide an exhaustive characterization of cognitive functioning, but rather an adapted evaluation that can identify risks, guide clinical decisions, and prevent complications.

Brief, Adapted Tests for Hospitalized Patients

The circumstances of neuropsychological assessment during hospitalization are very particular and involve limitations and conditions that must be considered:

1. First, the person is not in optimal condition and may even have limited mobility, ability to write or sit up, as well as a greater tendency to fatigue because of their health status. 
2. Second, the assessment setting contains potentially significant distractions, such as a roommate, staff who may interrupt, sounds from equipment or neighboring rooms, and so on; the available assessment space may also be limited. 
3. Third, it is generally not possible to bring large neuropsychological test batteries and their materials to the patient’s room (Casey et al., 2023).

For these reasons, clinicians typically use neuropsychological screening tests and/or bedside tests to provide a tentative estimate of the patient’s cognitive status, sufficient for an initial assessment and to guide decision-making. The best known are the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA). These tests provide a general impression of cognitive status within a few minutes and without causing excessive fatigue (Khaw et al., 2021; Harmon and Gillen, 2023). 

Functional Observation and Structured Interviews for Family Members

As in any neuropsychological assessment, functional observation provides information that is as important as, or more important than, the information obtained from tests. Clinicians should attend to how the person responds to our questions and functions in this new environment (for example, whether they recognize professionals or other patients, remember recommendations, can perform basic activities, or can use devices such as a cell phone or television). 

In addition, to distinguish a newly emerging cognitive problem from the progression of an insidious process, collateral information is extremely useful. In this regard, family members who live with the person are a very valuable source of information, as they can describe the person’s baseline, whether there were previous difficulties, whether they have noticed a striking change, and so on. Interviews such as the Informant Questionnaire on Cognitive Decline in the Elderly, or IQCODE, facilitate this task by asking about basic cognitive functions such as memory and attention compared with 5 or 10 years earlier (Burton et al., 2021). 

Multidisciplinary Coordination

In the hospital setting, other professionals can also contribute information about the person’s cognitive status from their own areas of expertise. This is especially true of neurologists, geriatricians, and psychiatrists, who can use their respective disciplines to rule out or report biological markers of impairment, medical or pharmacological processes that interfere with cognitive function, and severe psychopathology affecting functions such as attention, memory, and language (Hshieh et al., 2015; Devlin et al., 2018). 

Likewise, neuropsychology provides these professionals with a more refined and precise assessment of cognitive status, thereby achieving a holistic evaluation of the person’s condition and capacity (Rice, Bryant, and Fisher, 2023). 

Clinical Recommendations Based on the Assessment

Once we know the cognitive status of the person assessed, the person, family members, and professionals should be guided in adopting the measures necessary to safeguard their well-being. In mild cases, it is usually necessary to adapt the language so that it is simpler and more direct, clarify questions, and provide support with decision-making.

Early rehabilitation or post-discharge rehabilitation recommendations can also be made, directing the person to specialized resources and support services, particularly because readapting to everyday life can sometimes be complex (Chen et al., 2022). 

In cases of more severe impairment, it is essential to involve the family, monitor cognitive status, and probably request additional testing to clarify the diagnosis and impairment process (Escriche-Martínez et al., 2025).  

In many cases, it is advisable to schedule a more comprehensive neuropsychological reevaluation after hospital discharge, when the person has recovered a more stable context and it is possible to distinguish temporary deficits caused by the hospitalization from persistent impairment (Kaushik et al., 2024). 

Once the neuropsychological assessment process is complete, whether in the hospital setting or later as an outpatient, a report should be prepared for the individual and family, as well as for other professionals, with the assessment conclusions and resulting recommendations (Rice et al. 2023). 

Ethical and Family Considerations

When conducting a hospital neuropsychological assessment, it is always necessary to consider whether the person has the capacity to make decisions, in this case about their health. Thus, the assessment should also allow us to determine whether the person can understand the information, appreciate how it affects them, reason through a logical decision based on that information, and express their opinion and choice (Simón-Lorda, 2008). Skills such as attention, language, memory, and executive functions are involved here. Decision-making capacity is not dichotomous and is subject, moment by moment, to the specific issue on which the person must decide, which can vary greatly, from whether to accept a medical intervention to a transfer, a legal procedure, and so on (Darby and Dickerson, 2017). 

Thus, there is a significant ethical and legal component, in which the person’s value system must be respected, along with their biographical history, meanings, and preferences; the position of family members or people they have designated for these matters; and a coherent fit with existing medical recommendations (John, Rowley, and Bartlett, 2020).

The principle of personal autonomy must always be respected, unless there is clear evidence that the person cannot make decisions. In that case, efforts should be made to enable them to do so with support or, when possible, delay nonurgent decisions until they recover a level of cognitive functioning, if recovery is expected, that allows more active participation. In this regard, neuropsychological assessment helps adjust the degree of support needed without making the mistake of unnecessary overprotection or paternalism (Craigie et al., 2018). 

Conclusion

In conclusion, it is important to remember that a hospital admission is a situation of high cognitive vulnerability, especially for certain people with risk factors. An assessment adapted to this context can detect deficits that might otherwise go unnoticed, improve communication with professionals, prevent complications, and guide discharge recommendations. 

Integrating neuropsychological assessment into the hospital process enables safer, more personalized, and more respectful care that takes each person’s abilities into account. 

References

• Amaral, A. S., Simões, M. R., Freitas, S., Vilar, M., Sousa, L. B., & Afonso, R. M. (2022). Healthcare decision-making capacity in old age: A qualitative study. Frontiers in Psychology, 13, 1024967. https://doi.org/10.3389/fpsyg.2022.1024967
• Amini, R., & Kawser, B. (2020). Impact of the interaction between mild and mild-to-moderate cognitive impairment with chronic health problems on hospital admission among community-dwelling older adults. Geriatrics & Gerontology International, 20(12), 1213–1220. https://doi.org/10.1111/ggi.14070
• Boucher, E. L., Smith, S. C., Singh, S., Shepperd, S., & Pendlebury, S. T. (2025). Prevalence of cognitive morbidity including delirium in 51,202 emergency hospital admissions across 29 medical and surgical specialties in ORCHARD-EPR: a cross-sectional study. EClinicalMedicine, 90(103641), 103641. https://doi.org/10.1016/j.eclinm.2025.103641
• Burton, J. K., Fearon, P., Noel-Storr, A. H., McShane, R., Stott, D. J., & Quinn, T. J. (2021). Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the detection of dementia within a secondary care setting. Cochrane Database of Systematic Reviews, 7(7), CD010772. https://doi.org/10.1002/14651858.CD010772.pub3
• Casey, K., Sim, E., Lavezza, A., Iannuzzi, K., Friedman, L. A., Hoyer, E. H., & Young, D. L. (2023). Identifying cognitive impairment in the Acute Care hospital setting: Finding an appropriate screening tool. The American Journal of Occupational Therapy: Official Publication of the American Occupational Therapy Association, 77(1). https://doi.org/10.5014/ajot.2023.050028
• Chen, Y., Almirall-Sánchez, A., Mockler, D., Adrion, E., Domínguez-Vivero, C., & Romero-Ortuño, R. (2022). Hospital-associated deconditioning: Not only physical, but also cognitive. International Journal of Geriatric Psychiatry, 37(3). https://doi.org/10.1002/gps.5687
• Craigie, J., Bach, M., Gurbai, S., Kanter, A., Kim, S. Y. H., Lewis, O., & Morgan, G. (2019). Legal capacity, mental capacity and supported decision-making: Report from a panel event. International Journal of Law and Psychiatry, 62, 160–168. https://doi.org/10.1016/j.ijlp.2018.09.006
• Darby, R. R., & Dickerson, B. C. (2017). Dementia, decision making, and capacity. Harvard Review of Psychiatry, 25(6), 270–278. https://doi.org/10.1097/HRP.0000000000000163
• Devlin, J. W., Skrobik, Y., Gélinas, C., Needham, D. M., Slooter, A. J. C., Pandharipande, P. P., Watson, P. L., Weinhouse, G. L., Nunnally, M. E., Rochwerg, B., Balas, M. C., van den Boogaard, M., Bosma, K. J., Brummel, N. E., Chanques, G., Denehy, L., Drouot, X., Fraser, G. L., Harris, J. E., … Alhazzani, W. (2018). Clinical Practice Guidelines for the prevention and management of Pain, Agitation/sedation, Delirium, Immobility, and Sleep disruption in Adult Patients in the ICU. Critical Care Medicine, 46(9), e825–e873. https://doi.org/10.1097/CCM.0000000000003299
• de Lange, E., Verhaak, P. F. M., & van der Meer, K. (2013). Prevalence, presentation and prognosis of delirium in older people in the population, at home and in long term care: a review: Delirium in the elderly population. International Journal of Geriatric Psychiatry, 28(2), 127–134. https://doi.org/10.1002/gps.3814
• Emery, A., Wells, J., Klaus, S. P., Mather, M., Pessoa, A., & Pendlebury, S. T. (2020). Underestimation of cognitive impairment in older inpatients by the Abbreviated Mental Test Score versus the Montreal Cognitive Assessment: Cross-sectional observational study. Dementia and Geriatric Cognitive Disorders Extra, 10(3), 205–215. https://doi.org/10.1159/000509357
• Escriche-Martinez, S., Diaz-Orueta, U., Gala-Serra, C., Sierra-Martínez, E., López-Crespo, G., & López-Antón, R. (2025). Cognitive decline in hospitalized older adults: A scoping review. Psychogeriatrics, 25(6), e70102. https://doi.org/10.1111/psyg.70102
• Harmon, E. Y., & Gillen, R. W. (2023). Comparison of the Brief Interview for Mental Status (BIMS) and Montreal Cognitive Assessment (MoCA) for identifying cognitive impairments and predicting rehabilitation outcomes in an inpatient rehabilitation facility. PM & R: The Journal of Injury, Function, and Rehabilitation, 15(9), 1083–1091. https://doi.org/10.1002/pmrj.12908
• Hshieh, T. T., Yue, J., Oh, E., Puelle, M., Dowal, S., Travison, T., & Inouye, S. K. (2015). Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis: A meta-analysis. JAMA Internal Medicine, 175(4), 512–520. https://doi.org/10.1001/jamainternmed.2014.7779
• John, S., Rowley, J., & Bartlett, K. (2020). Assessing patients decision-making capacity in the hospital setting: A literature review. The Australian Journal of Rural Health, 28(2), 141–148. https://doi.org/10.1111/ajr.12592
• Kaushik, R., McAvay, G. J., Murphy, T. E., Acampora, D., Araujo, K., Charpentier, P., Chattopadhyay, S., Geda, M., Gill, T. M., Kaminski, T. A., Lee, S., Li, J., Cohen, A. B., Hajduk, A. M., & Ferrante, L. E. (2024). In-hospital delirium and disability and cognitive impairment after COVID-19 hospitalization. JAMA Network Open, 7(7), e2419640. https://doi.org/10.1001/jamanetworkopen.2024.19640
• Khaw, J., Subramaniam, P., Abd Aziz, N. A., Ali Raymond, A., Wan Zaidi, W. A., & Ghazali, S. E. (2021). Current update on the clinical utility of MMSE and MoCA for stroke patients in Asia: A systematic review. International Journal of Environmental Research and Public Health, 18(17), 8962. https://doi.org/10.3390/ijerph18178962
• Park, D., Kim, H. S., & Kim, J. H. (2023). The effect of all-cause hospitalization on cognitive decline in older adults: a longitudinal study using databases of the National Health Insurance Service and the memory clinics of a self-run hospital. BMC Geriatrics, 23(1), 61. https://doi.org/10.1186/s12877-022-03701-4
• Petty, S., Dening, T., Griffiths, A., & Coleston, D. M. (2020). Meeting the emotional needs of hospital patients with dementia: A freelisting study with ward staff. The Gerontologist, 60(1), 155–164. https://doi.org/10.1093/geront/gny151
• Rice, R., Bryant, J., & Fisher, R. S. (2023). Documentation of cognitive impairment screening amongst older hospitalised Australians: a prospective clinical record audit. BMC Geriatrics, 23(1), 672. https://doi.org/10.1186/s12877-023-04394-z
• Simón-Lorda, P. (2008). La capacidad de los pacientes para tomar decisiones: una tarea todavía pendiente. Revista de la Asociación Española de Neuropsiquiatría, 28(2), 327–350. https://doi.org/10.4321/s0211-57352008000200006
• Walker, J., van Niekerk, M., Hobbs, H., Toynbee, M., Magill, N., Bold, R., Hampsey, E., Harriss, E., Frost, C., & Sharpe, M. (2021). The prevalence of anxiety in general hospital inpatients: A systematic review and meta-analysis. General Hospital Psychiatry, 72, 131–140. https://doi.org/10.1016/j.genhosppsych.2021.08.004
• Wilson, J. E., Mart, M. F., Cunningham, C., Shehabi, Y., Girard, T. D., MacLullich, A. M. J., Slooter, A. J. C., & Ely, E. W. (2020). Delirium. Nature Reviews. Disease Primers, 6(1), 90. https://doi.org/10.1038/s41572-020-00223-4

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