Dementia among older in-hospital patients with obstructive airway disease: Frequency and consequences

Association between Chronic Obstructive Pulmonary Disease and Dementia: Systematic Review and Meta-Analysis of Cohort Studies

Background

Chronic obstructive pulmonary disease (COPD) is a common disease among the elderly, which has been linked to cognitive decline. However, the relationship between COPD and dementia remains unclear.

Summary

We conducted a systematic literature review by searching databases such as Pubmed, Embase, EBSCO, and Cochrane Library (from inception to April 18, 2018) for studies on COPD that also investigated the prevalence of dementia. We found 3 cohort studies including a total of 39,392 COPD patients. Then we applied the Newcastle-Ottawa Scale to evaluate the risk of bias.

Key Messages

COPD patients faced a higher risk of dementia (HR 1.46; 95% CI 1.22–1.75; p < 0.001). Subgroup analysis on gender determined that the association between COPD and dementia was stronger in male patients (HR 1.49, 95% CI 1.20–1.86, p < 0.001) than in female patients (HR 1.41, 95% CI 1.27–1.57, p < 0.001). A subset study of patients aged >65 years revealed that the HR was greater for patients aged ≥75 years (HR 1.46, 95% CI 1.07–2.00, p = 0.02) than for those aged 65–74 years (HR 1.40, 95% CI 1.28–1.53, p < 0.001). The cohort studies included were from similar population-based databases, suggesting possible regional limitations and publication bias.

Memory, attention and fluency deficits in COPD may be a specific form of cognitive impairment

There is increasing evidence demonstrating an association between chronic obstructive pulmonary disease (COPD) and cognitive impairment. We present a narrative review of published studies on the subject and a cross-sectional study investigating domain-specific cognitive impairment in people with COPD compared to people with known Alzheimer's dementia, and controls without known COPD or cognitive impairment. The aim of the study was to compare prevalence and pattern of cognitive impairment between the three groups using the Addenbrooke's Cognitive Examination (ACE)-III tool.

A total of 89 participants were recruited (44 with COPD, 17 with Alzheimer's and 28 controls).

Patients with COPD had significantly lower total ACE-III scores than controls (p<0.001). When comparing the COPD group to the known Alzheimer's dementia group, overall ACE-III scores were significantly lower in the Alzheimer's dementia group than the COPD group (p=0.019). The domain-specific scores for attention (p<0.004), memory (p<0.004) and fluency (p<0.001) were significantly lower in the Alzheimer's dementia group than the COPD group.

Our result suggest that the COPD group were significantly more likely to have cognitive impairment than the healthy control group. This was supported by the results of a narrative review of the published literature. Our results show that the pattern of impairment in the COPD group is different to the pattern of impairment shown in the known Alzheimer's dementia group, with significant differences in the cognitive domains affected. These results are in keeping with the findings of other previously published studies included in the narrative review.

People with COPD are more likely than controls to have cognitive impairment. When compared to people with known Alzheimer's disease, the pattern of impairment and cognitive domains affected are significantly different.http://bit.ly/2VPFxjh

Cognitive impairment is independently associated with mortality, extended hospital stays and early readmission of older people with emergency hospital admissions: A retrospective cohort study

BACKGROUND

Older adults admitted to hospital are often cognitively impaired. It is not clear whether the presence of cognitive impairment conveys an additional risk for poor hospital outcomes in this patient population.

OBJECTIVES

To determine whether cognitive impairment in hospitalised older adults is independently associated with poor outcomes.

DESIGN

Retrospective cohort study using electronic, routinely collected data from linked clinical and administrative databases.

SETTING

Large, acute district general hospital in England.

PARTICIPANTS

21,399 incident emergency admissions of people aged ≥75, screened for cognitive impairment, categorised to 3 groups: (i) cognitive impairment with a diagnosis of dementia, (ii) cognitive impairment with no dementia diagnosis, (iii) no cognitive impairment.

METHODS

Multivariable logistic regression and Fine and Gray competing risks survival models were employed to explore associations between cognitive impairment and mortality (in-hospital alone, and in-hospital plus up to 30 days after discharge), time to hospital discharge, and hospital readmission within 30 days of discharge. Covariates included age, severity of illness, main diagnosis, comorbidities and nutritional risk.

RESULTS

Twenty-seven percent of patients had cognitive impairment; of these, 61.5% had a diagnosis of dementia and 38.5% did not. Patients with cognitive impairment and no diagnosis of dementia were most likely to die in hospital or be readmitted, they also had the longest hospital stays. Cognitive impairment was independently associated with mortality in hospital (Odds Ratio 1.34 [1.17-1.55] with dementia; Odds Ratio 1.78 [1.52-2.07] without), mortality in hospital or within 30 days of discharge (Odds Ratio 1.66 [1.48-1.86]; Odds Ratio 1.67 [1.46-1.90]); readmission (Odds Ratio 1.21 [1.04-1.40]; Odds Ratio 1.47 [1.25-1.73]), and increased time until discharge (sub-hazard ratio 0.80 [0.76-0.83]; sub-hazard ratio 0.66 [0.63-0.69]).

CONCLUSIONS

Cognitive impairment is associated with an increased risk of adverse outcomes in hospitalised older people with an unscheduled admission, by increasing hospital mortality, extending hospital stays and increasing frequency of readmissions. Future research should focus on understanding the mechanisms contributing to poorer outcomes in this population.

Hospital outcomes of older people with cognitive impairment: An integrative review

OBJECTIVES

To summarise existing knowledge of outcomes of older hospital patients with cognitive impairment, including the type and frequency of outcomes reported, and the additional risk experienced by this patient group.

METHODS

Integrative literature review. Health care literature databases, reports, and policy documents on key websites were systematically searched. Papers describing the outcomes of older people with cognitive impairment during hospitalisation and at discharge were analysed and summarised using integrative methods.

RESULTS

One hundred four articles were included. A range of outcomes were identified, including those occurring during hospitalisation and at discharge. Older people with a dementia diagnosis were at higher risk from death in hospital, nursing home admission, long lengths of stay, as well as intermediate outcomes such as delirium, falls, dehydration, reduction in nutritional status, decline in physical and cognitive function, and new infections in hospital. Fewer studies examined the relationship of all-cause cognitive impairment with outcomes. Patient and carer experiences of hospital admission were often poor. Few studies collected data relating to hospital environment, eg, ward type or staffing levels, and acuity of illness was rarely described.

CONCLUSIONS

Older people with cognitive impairment have a higher risk of a variety of negative outcomes in hospital. Prevalent intermediate outcomes suggest that changes in care processes are required to ensure maintenance of fundamental care provision and greater attention to patient safety in this vulnerable group. More research is required to understand the most appropriate ways of doing this and how changes in these care processes are best implemented to improve hospital outcomes.

The impact of cognitive impairment on self-management in chronic obstructive pulmonary disease: A systematic review

OBJECTIVE

To determine the characteristics of persons with cognitive impairment being able to self-manage in chronic obstructive pulmonary disease (COPD).

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance this systematic review examined all studies in English from 1st January 2000 to 20 February 2016, describing the relationship between cognition and COPD self-management domains in older community dwelling persons with dementia or cognitive impairment.

RESULTS

Of 4474 studies identified, thirteen studies were eligible for inclusion. No studies differentiated populations into recognized dementia subtypes. Study aims were variable; most (n = 7) examined inhaler competency alone. Studies identified a link between worsening cognition and the need for assistance in activities of daily living. Only one study evaluated the impact of cognition on overall self-management and found no association between cognitive impairment and self-rated self-management. Mild degrees of cognitive impairment were associated with reduced symptom recall. Cognitive impairment in COPD was associated with high degrees of inhaler incompetency. Basic cognitive screening tests were able to predict inhaler incompetence with reduced overall cognitive function, dyspraxia, and/or executive function identified as predictors of incompetency.

CONCLUSIONS

Multiple measures of disability consistently demonstrated that cognitive impairment in COPD significantly increased the need for assistance in many aspects of daily living, treatment adherence, and effective self-management. Given the nature of neuropsychological deficits seen in COPD, dedicated screening tools are required. Future research should investigate the impact of cognitive dysfunction in COPD and identify how to support those that lack capacity to self-manage.