Is there a need for admission and discharge cognitive screening for the medically ill?

Understanding health-care outcomes of older people with cognitive impairment and/or dementia admitted to hospital: a mixed-methods study

Background

Cognitive impairment is common in older people admitted to hospital, but previous research has focused on single conditions.

Objective

This project sits in phase 0/1 of the Medical Research Council Framework for the Development and Evaluation of Complex Interventions. It aims to develop an understanding of current health-care outcomes. This will be used in the future development of a multidomain intervention for people with confusion (dementia and cognitive impairment) in general hospitals. The research was conducted from January 2015 to June 2018 and used data from people admitted between 2012 and 2013.

Design

For the review of outcomes, the systematic review identified peer-reviewed quantitative epidemiology measuring prevalence and associations with outcomes. Screening for duplication and relevance was followed by full-text review, quality assessment and a narrative review (141 papers). A survey sought opinion on the key outcomes for people with dementia and/or confusion and their carers in the acute hospital (n = 78). For the analysis of outcomes including cost, the prospective cohort study was in a medical admissions unit in an acute hospital in one Scottish health board covering 10% of the Scottish population. The participants (n = 6724) were older people (aged ≥ 65 years) with or without a cognitive spectrum disorder who were admitted as medical emergencies between January 2012 and December 2013 and who underwent a structured nurse assessment. ‘Cognitive spectrum disorder’ was defined as any combination of delirium, known dementia or an Abbreviated Mental Test score of < 8 out of 10 points. The main outcome measures were living at home 30 days after discharge, mortality within 2 years of admission, length of stay, re-admission within 2 years of admission and cost.

Data sources

Scottish Morbidity Records 01 was linked to the Older Persons Routine Acute Assessment data set.

Results

In the systematic review, methodological heterogeneity, especially concerning diagnostic criteria, means that there is significant overlap in conditions of patients presenting to general hospitals with confusion. Patients and their families expect that patients are discharged in the same or a better condition than they were in on admission or, failing that, that they have a satisfactory experience of their admission. Cognitive spectrum disorders were present in more than one-third of patients aged ≥ 65 years, and in over half of those aged ≥ 85 years. Outcomes were worse in those patients with cognitive spectrum disorders than in those without: length of stay 25.0 vs. 11.8 days, 30-day mortality 13.6% vs. 9.0%, 1-year mortality 40.0% vs. 26.0%, 1-year mortality or re-admission 62.4% vs. 51.5%, respectively (all p < 0.01). There was relatively little difference by cognitive spectrum disorder type; for example, the presence of any cognitive spectrum disorder was associated with an increased mortality over the entire period of follow-up, but with different temporal patterns depending on the type of cognitive spectrum disorder. The cost of admission was higher for those with cognitive spectrum disorders, but the average daily cost was lower.

Limitations

A lack of diagnosis and/or standardisation of diagnosis for dementia and/or delirium was a limitation for the systematic review, the quantitative study and the economic study. The economic study was limited to in-hospital costs as data for social or informal care costs were unavailable. The survey was conducted online, limiting its reach to older carers and those people with cognitive spectrum disorders.

Conclusions

Cognitive spectrum disorders are common in older inpatients and are associated with considerably worse health-care outcomes, with significant overlap between individual cognitive spectrum disorders. This suggests the need for health-care systems to systematically identify and develop care pathways for older people with cognitive spectrum disorders, and avoid focusing on only condition-specific pathways.

Future work

Development and evaluation of a multidomain intervention for the management of patients with cognitive spectrum disorders in hospital.

Study registration

This study is registered as PROSPERO CRD42015024492.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.

Poor Mental Status in Older Hospital Patients: Prevalence and Correlates

Some older patients on treatment wards suffer from poor mental status in addition to a primary illness condition. This research 1) compared the relative prevalence of cognitive dysfunction when indexed by a mental status questionnaire (MSQ), physician reports, and nurse ratings, respectively, and 2) examined relationships of the MSQ to other variables. The sample was the entire inpatient population on medical and surgical wards at two general hospitals during a one-week period. Data were obtained from the patients (i.e., the MSQ), case notes by physicians (i.e., diagnoses or symptoms indicative of cognitive dysfunction), and ward nuses (i.e., ratings on several variables). The findings were that prevalence of cognitive dysfunction was greater by the MSQ than by physician reports, than by nurse ratings. Against the criterion of MSQ classification, both physicial reports and nurse ratings exhibited false positive and false negative errors; however, false negative errors were more frequent. The strong correlates of MSQ included capacity for independent living, use of geriatric chair, and physician evaluation. Other signs of normalcy or dysfunction were specific to only one MSQ category: tube feeding, restraint, and basic function capability.

Changing clinical practice through research: the case of delirium

Promoting application of study findings to the clinical setting is a constant challenge for nurse researchers. This project used change theory to include staff RNs in a research study on delirium and to use relevant findings. The research hypothesis was: Staff nurses who use a standardized protocol will have improved ability to identify delirium in elderly hospital patients. Staff nurses on the intervention unit used this protocol to screen for delirium on all consenting inpatients 75 years of age and over, and control unit nurses continued using their standard assessment practices. Intervention unit nurses demonstrated an improved ability to identify the presence and absence of delirium, and voluntarily requested to continue using the protocol after the study was terminated. Use of a theoretical model to include nurses in the study promoted the successful conduct of the research and subsequent use of findings.

The appearance and disappearance of cognitive impairment in elderly patients during treatment for hip fracture

We studied the natural course of cognitive state in 256 consecutive hip fracture patients who were admitted from an independent living situation. We employed a treatment programme that focused on preventing postoperative cognitive impairment. Cognitive function was assessed with the SPSMQ screening test. The incidence of postoperative cognitive impairment among those lucid on admission was 13%, which generally was reversed before discharge. Thirty-seven percent were cognitively impaired on admission; of those, 51% reached normal test scores while in hospital. Those who recovered within the first week had as good a prognosis during the first year as those who remained lucid throughout the hospital stay. Cognitive impairment was associated with an increased complication rate, e.g. a three-fold increase of early fracture displacement and a four-fold increase of wound infection. This increased risk was present even in patients with mild/moderate cognitive impairment and could not entirely be explained by age. Our results suggest that it is possible to decrease postoperative cognitive impairment by routine monitoring of cognitive status, a high level of continuity and a reorientation programme. The routine assessment of the cognitive function is recommended in geriatric patients who are admitted for surgery.

The utility of the ten-point clock test as a screen for cognitive impairment in general hospital patients

The object of this work was to illustrate the utility of the ten-point clock test as a screen for cognitive impairment in the general hospital by examining a range of diagnoses and estimating sensitivity for each. A total of 195 consecutive medical and surgical inpatients were examined who were referred for psychiatric consultation and histories from patient, family, nurses, physicians, and hospital records were obtained. Seventy-six percent of these patients were administered the ten-point clock test at the initial evaluation. The percentages of patients scoring less than 8 points on the ten-point clock test for the following primary diagnoses were delirium (92%), dementia (90%), and adjustment disorder (5%). Thirty-nine to seventy percent of patients with a delirium, dementia, opioid intoxication, or a cognitive disorder n. o. s. scored lower than 5 points but none of the patients with a major depressive disorder, alcohol dependence, or adjustment disorder did so. The sensitivities of the ten-point clock test and minimental state examinations appeared similar in a subset of patients. The ten-point clock test is a useful screen for cognitive impairment in general hospital patients.

The effect of cimetidine and ranitidine on cognitive function in postoperative cardiac surgical patients

OBJECTIVE

To compare the incidence of delirium in postoperative cardiac surgical patients treated with either cimetidine or ranitidine.

METHOD

Cardiac surgery patients were randomized to receive either cimetidine or ranitidine postoperatively. Each patient underwent three Mini-Mental Status Examinations (MMSE) and the medical record was reviewed for pertinent past medical history, laboratory data, and evidence of delirium on three occasions: one day preoperatively (before H-2 blocker was given), in the early postoperative period (while receiving the H-2 blocker); usually two days postoperatively on the day of hospital discharge (several days after the H2 blocker had been discontinued).

RESULTS

Overall, both groups in the early postoperative period showed a significant decrease in the MMSE score (27.11 +/- 4.44 to 25.38 +/-2.87, mean +/- SD; t = 5.16, p < .0005), which resolved by the time of hospital discharge. There was no significant difference between cimetidine and ranitidine. Both age and preoperative MMSE score were strongly associated with the development of delirium.

CONCLUSIONS

We found no significant difference between cimetidine's versus ranitidine's effect upon cognitive functioning in the postoperative cardiac surgical patient. This was true even when controlling for age and length of stay.

Home health nurses' assessments of cognition

Assessments of mental status in elderly persons admitted to home health agencies are the basis for decision-making related to resources provided. A home health nurse's perceptions of an elderly client's capacity for self-care determines whether community services will be prescribed. In institutional settings, evaluation of cognition by professional nurses is often incomplete or inaccurate. It was the purpose of this study to compare the judgements of cognition made by nine home health nurses who were admitting elderly clients to a visiting nurse association with scores from an objective measure of mental status. Findings suggest that these nurses relied primarily on orientation as an indicator of cognitive abilities.

Primary or depressive dementia: mental status screening

In the course of interviewing a patient, several aspects of everyday functioning must be covered to provide a range of observations necessary to suggest a provisional diagnosis. First organized by Adolf Meyer, the mental status examination consists of several techniques which, in recent times, have been shortened, structured and standardized to cover maximal ground in minimal time. In this article, the most popular scales are reviewed psychometrically for their capacity to detect, as first-stage instruments, cognitive impairment suggestive of primary dementia in the context of varying prevalence rates and confounding factors like sensory impairments, sociodemographics and depressive states. Several of the measures are found adequate in some respects though not in others, but all of the better ones, when used as front line implements during clinical intake, regularly improve detection over base rates. An analytical method modelled on ROC procedures is then described contrasting two of them before newer instruments are considered which aim to improve sensitivity at relatively little cost to specificity.

A new tool for consultation-liaison funding: modified DRGs to reflect psychiatric comorbidity

Funding for consultation-liaison (C-L) psychiatry remains an overriding obstacle to its implementation and practice. Several methods have been described to access funds for this subspecialty of psychiatry, but none has been enacted as a policy by third party payers to reimburse adequately for the service. In addition, although the consultation portion of the effort can be reimbursed in part in some cases through fee for services, the liaison portion is dependent on the donation of psychiatry time or the largesse of the host department. The efforts at Stanford to capitalize on the findings that psychiatric and medical comorbidity results in prolonged length of hospital stay and increased health resource utilization suggest that specific DRGs would be important patient groups to screen and charge for psychiatric services. Furthermore, DRGs that are accompanied by a high frequency of psychiatric comorbidity are a "target" for an additional funding aliquot to assess and manage the patient's psychiatric status.

Comorbidity, age, and hospital use among elderly Medicare patients

This article reports the findings of a retrospective study of elderly Medicare patients (N = 8,915) discharged from New York City hospitals prior to the implementation of the Medicare Prospective Payment System in New York State. Its purpose was to investigate physical comorbidity, mental comorbidity, age, and other factors for their relationship with hospital use. Study findings suggest that age, as used in the diagnosis-related group (DRG) classification scheme, is less powerful than comorbidity as a predictor of hospital use. Dementia, which is not recognized as a valid comorbid condition by the DRG system, was also found to be positively associated with use.

Reducing acute confusional states in elderly patients with hip fractures

The extent to which the incidence of postoperative acute confusional states could be reduced in elderly (greater than or equal to age 60) patients with hip fractures was tested. Interpersonal and environmental nursing interventions were carried out with 57 patients on orthopedic units in three hospitals. The incidence of confusion was reduced from 51.5% in the comparison group (n = 170) to 43.9%. Analysis that controlled for risk factors in the two groups showed the drop in incidence to be significant (p less than .02). The most effective interventions appeared to be those that provided orientation and clarification, corrected sensory deficit, and increased continuity of care.

Assessment of cognitive deficit in geriatric patients. A study of physician behavior

A crucial factor in promoting a vigorous quality of life in the aging population is assessment and treatment of cognitive deficits. A very high percentage of delirium and at least 20% of dementia is eminently treatable. This study of patients over 65 years of age admitted to a university general hospital reveals that 79% of cognitive deficits were missed by the examining physicians. Furthermore, in 394 examinations of 165 patients, only four mental status examinations were recorded. A clear-cut cognitive deficit on admission was predictive of later acute episodes of confusion. The global techniques of evaluation deserve remediable action by medical schools and hospital training programs if the medical care of the elderly is to be improved.

Informed consent--mandating the consultation

This article illustrates how a mandatory consult procedure identified treatable psychiatric problems. Using a computerized data-based format, 372 (37.4%) patients (the "judgment" group) of 996 psychiatric consultations were identified as referred to assess the patient's capacity to execute a consent form for a medical or surgical procedure. One hundred twenty-nine (35%) of the 372 patients thus referred by hospital mandate were given psychiatric diagnoses (DSM-II) by the consultant and received recommendations for primary psychiatric treatment. The "judgment" group had significantly more organic brain syndrome and psychoses associated with CNS conditions (p less than 0.001), whereas the "nonjudgment" group was diagnosed as exhibiting significantly more neurosis, alcoholism, psychophysiologic disorders, transient situational reactions, and personality disorders (p less than 0.001). Without a required psychiatric consultation sanctioned by administrative hospital mandate, the majority of the "judgment" cases with major psychopathology would not have been identified. The use of the mandated psychiatric consultation in the general hospital is discussed.

An oral examination of the psychiatric knowledge of medical housestaff: assessment of needs and evaluation baseline

To assess the psychiatric knowledge of medical housestaff, the authors devised an oral examination based on two simulated clinical encounters and administered it to 26 medical residents. The case material embodied those psychiatric problems known to be common in medical populations, namely depression, delirium, dementia, and "psychogenic" pain. The standardized simulations were punctuated by standardized "open" questions with followup probes. A panel of experienced clinicians developed rating criteria for each question such that responses could be categorized ad "good," "adequate," "inadequate," or "poor," in terms of "what an internist needs to know." Blind raters of the exam achieved an interrater reliability of 0.08. The results indicate major deficits in the knowledge needed for assessment and treatment of these common problems. Only 16% of answers were "good," where as 42% were "inadequate" or "poor". For example, 88% of the doctors could not name three factors that help distinguish organic from "functional" psychosis, and 88% could not list three side-effects of tricyclic antidepressants. The doctors' level of experience was not correlated with test scores, either overall or question by question. These results, together with measures of attitude and skill, have been used to develop a needs-based liaison psychiatry curriculum and to evaluate the effectiveness of that curriculum.