Domain 8 of 12

Cognition

Cognitive function, decision-making capacity, and recognition of risk.

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What this domain measures

The Cognition domain captures cognitive function — the ability to make decisions, understand the environment, recognise people and places, and appreciate risk. Cognition rarely secures CHC eligibility on its own, but it routinely interacts with Behaviour, Mobility, and Continence: cognitive impairment that drives wandering, refusal of care, or non-recognition of danger amplifies the scoring of those companion domains.

How it's scored (Annex C wording)

DST scoring levels for the Cognition domain, with verbatim Annex C descriptors.
Level	DST descriptor
No needs	No evidence of impairment, confusion or disorientation.
Low	Cognitive impairment which requires some supervision, prompting or assistance with more complex activities of daily living, such as finance and medication, but awareness of basic risks that affect their safety is evident. OR Occasional difficulty with memory and decisions/choices requiring support, prompting or assistance. However, the individual has insight into their impairment.
Moderate	Cognitive impairment (which may include some memory issues) that requires some supervision, prompting and/or assistance with basic care needs and daily living activities. Some awareness of needs and basic risks is evident. The individual is usually able to make choices appropriate to needs with assistance. However, the individual has limited ability even with supervision, prompting or assistance to make decisions about some aspects of their lives, which consequently puts them at some risk of harm, neglect or health deterioration.
High	Cognitive impairment that could, for example, include frequent short-term memory issues and maybe disorientation to time and place. The individual has awareness of only a limited range of needs and basic risks. Although they may be able to make some choices appropriate to need on a limited range of issues they are unable to consistently do so on most issues, even with supervision, prompting or assistance. The individual finds it difficult even with supervision, prompting or assistance to make decisions about key aspects of their lives, which consequently puts them at high risk of harm, neglect or health deterioration.
Severe	Cognitive impairment that may, for example, include, marked short or long-term memory issues, or severe disorientation to time, place or person. The individual is unable to assess basic risks even with supervision, prompting or assistance, and is dependent on others to anticipate their basic needs and to protect them from harm, neglect or health deterioration.

Evidence that moves the score up

Formal cognitive assessments — MMSE, MoCA, ACE-III, with dates and scores trended over time
Mental Capacity Act 2005 assessments, specifying which decisions capacity has been assessed for
DoLS or Liberty Protection Safeguards authorisation if in place
Wandering or absconding incident log with location, time, and intervention required
Care plan section describing prompts, supervision level, and decision-making support
GP or consultant letters documenting cognitive decline trajectory
Best Interests decision documentation for major care decisions
Care home daily records showing repeated confusion, non-recognition of family, or unsafe action

How ICBs commonly under-score this domain

Pattern: Assessor scored Moderate because the person is 'settled' with familiar staff.

Rebuttal: Familiarity with staff is the intervention (consistent care team), not the absence of need. The Cognition descriptors turn on the cognitive impairment itself, not on whether a familiar carer can mitigate it. Per paras 162–166, score the present-day need if familiar staff were not available.

Source: para 162-166

Pattern: Assessor scored Low because the person 'still recognises family'.

Rebuttal: Recognition of family is one indicator among several. The descriptors turn on the level of cognitive impairment overall — including disorientation, decision-making capacity, and awareness of basic risks. A person can recognise family and still meet the Moderate or High descriptor due to limited awareness of risk.

Source: DST Annex C Cognition Moderate and High descriptors

Pattern: Assessor scored High instead of Severe because cognitive impairment is 'long-standing and stable'.

Rebuttal: Stability of the impairment is not a Severe disqualifier. The Severe descriptor turns on the person being unable to assess basic risks even with supervision, prompting or assistance, and being dependent on others to anticipate their basic needs and protect them from harm. Long-standing impairment meeting that test scores Severe regardless of stability.

Source: DST Annex C Cognition Severe descriptor

4-line rebuttal template

I disagree with the [LEVEL] score for Cognition. The evidence shows [SPECIFIC PATTERN — disorientation / decision-making failure / inability to assess basic risks] which meets the [HIGHER LEVEL] descriptor. On [DATE/PERIOD], [DESCRIBE: cognitive assessment scores, wandering incidents, capacity decisions, safety events arising from cognitive impairment]. Per the well-managed needs principle (National Framework paras 162–166), [the supervision level / familiar staff / structured environment] is the intervention, not the absence of need. If [SUPPORT] were withdrawn, the present-day risk would be [DESCRIBE: harm from unsafe action, non-recognition of medication, exit-seeking]. I therefore request the Cognition domain be re-scored to [HIGHER LEVEL] with reference to the [SPECIFIC EVIDENCE: MMSE/MoCA scores, MCA assessment, DoLS authorisation, wandering log].

Cognition rarely secures eligibility on its own

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