Johns Hopkins Adapted Cognitive Exam (ACE)

The ACE is a 100-point bedside cognitive screen designed for critically ill patients, including those who are intubated or cannot speak. Non-verbal response modes — nodding, pointing, gesture — are built into the administration protocol, which is its key advantage over tools like the SLUMS or MMSE that require verbal output. Use it when you need to quantify cognitive function across multiple domains in a patient who may or may not be able to speak. Administration takes approximately 15–20 minutes.

Target Population

ICU patients who are following commands and have at least one reliable response mode, verbal or non-verbal. Most appropriate for patients at RLAS V–VI or equivalent: awake, following commands, but cognitively impaired in ways that are difficult to characterize without a structured tool. The ACE gives you a profile, not just a label.

Domains

1. Orientation (24 pts): year, season, date, day of week, country, state, city, type of building — each answered by selecting from a multiple-choice array

2. Language (24 pts): identifying objects by name and use; following a written command; following a 3-step command

3. Registration (7 pts): reproduce a sequence of finger positions shown by the examiner (2 fingers → 1 finger → 4 fingers)

4. Attention/Calculation (21 pts): simple calculations and picture-word matching using flashcards

5. Recall (24 pts): reproduce the registration finger sequence from memory; recall and perform the verbal 3-step command; recall and perform the written command

Materials Required

• Assessment form

• Flashcards for attention and calculation sections (laminate for reuse)

• Pencil or dry-erase marker

Scoring

For multiple-choice items in the orientation and language sections:

• 3 = Correct

• 2 = Slightly incorrect

• 1 = Vastly incorrect

• 0 = Inappropriate response

If the patient is unable to respond to a particular item due to motor, sensory, or communication limitations, score UN (unable) — not 0. This distinction preserves the accuracy of the score as a measure of cognition rather than physical capacity.

Scoring for registration, attention/calculation, and recall varies by question and is specified on the assessment form.

Cutpoints for Cognitive Status Classification

• ≤28: Severely impaired

• 29–55: Moderately impaired

• ≥56: Mildly impaired or normal

Clinical Interpretation

The ACE gives you a baseline and a number to track. A patient moving from 38 to 52 over two weeks is progressing from moderate to mild impairment — meaningful, documentable, and relevant for goal-writing and discharge planning.

Note confounders: sedation, uncontrolled pain, sleep deprivation, and acute illness all suppress scores. If results seem inconsistent with your clinical observation, reassess after confounders are addressed before drawing conclusions about baseline function. Document any modifications to standard administration and specify which items were scored UN and why.