Documentation and evaluation of cognitive impairment in elderly primary care patients

Evidence for Building an Integrated Dementia Healthcare System: A Systematic Review

OBJECTIVES

Proponents of integrated healthcare systems suggest that such system can improve healthcare experience for individuals with dementia by amalgamating personal and structured resources.

METHODS

We assessed systematically available evidence on the current state of integrated healthcare systems viewed in terms of different levels and dimensions of integration, emphasizing multiple stakeholders' simultaneous perspectives. Studies were eligible for inclusion if they (1) evaluated a health system, (2) adopted a network or integrated care model, (3) cared for individuals with dementia, and (4) provided real-world data.

RESULTS

Our review included 31 studies. Main components of the healthcare system included care mediation, multidisciplinary care, primary care integration, long-term care, community-based service, digital technology, and one undefined. Most studies involved meso-level integration (n = 23), followed by micro-level (n = 12) and macro-level integration (n = 5).

CONCLUSIONS

Key factors that promote an integrated healthcare system for dementia include supportive organizational structure, multidisciplinary collaboration, effective leadership, clear roles, streamlined referral, and community involvement. Macro-level integration should be considered with greater emphasis in conjunction with both meso- and micro-level integration.

CLINICAL IMPLICATIONS

Successful development of comprehensive integrated healthcare network will require thoughtful implementation and transition across all levels of the system.

Effectiveness and utilization of a cognitive screening program for primary geriatric care

BACKGROUND

Effective detection of cognitive impairment in the primary care setting is limited by lack of time and specialized expertise to conduct detailed objective cognitive testing and few well-validated cognitive screening instruments that can be administered and evaluated quickly without expert supervision. We therefore developed a model cognitive screening program to provide relatively brief, objective assessment of a geriatric patient's memory and other cognitive abilities in cases where the primary care physician suspects but is unsure of the presence of a deficit.

METHODS

Referred patients were tested during a 40-min session by a psychometrist or trained nurse in the clinic on a brief battery of neuropsychological tests that assessed multiple cognitive domains. Short questionnaires covering subjective cognitive complaints, symptoms of depression, and medical history were also administered. Results were conveyed to a dementia specialist who reviewed them and returned their judgement of the validity of the cognitive complaint to the primary care provider. Retrospective medical records review was carried out for a random (stratified) half of the sample to determine how screening results were utilized. Screening tests were repeated after two years in a subset of 69 patients.

RESULTS

The 638 patients screened (mean age = 75.9 years; mean education = 14.9 years; 58% women) were classified by screening as having normal cognition (n = 177), depression (with possible cognitive changes; n = 115), mild cognitive impairment (MCI; n = 107), or dementia (n = 239). Classification accuracy was shown by high agreement with the eventual clinical diagnosis in the medical record (69%; Cohen's Kappa = .38; p < .001; 77% if MCI and dementia were collapsed; Cohen's Kappa = .58; p < .001) and longitudinal decline in cognitive test scores only in those initially classified as having MCI or dementia. Medical records documented discussion of screening results with the patient in 69% of cases (80% if MCI or dementia was detected) and often referral to a specialist (62%), new brain imaging (54%), or change in medication (58%) when screening indicated potential cognitive impairment.

CONCLUSION

The cognitive screening program was well accepted by primary care providers as an efficient and effective way to evaluate concerns about cognitive decline in older adults.

A tailored intervention for the detection of patients with coronary heart disease and mental or cognitive comorbidities in the German primary care setting: qualitative evaluation of implementation success

BACKGROUND

Guidelines recommend the identification of potential mental and/or cognitive disorders (MCD) in patients with coronary heart disease (CHD). However, compliance with these guidelines appears to be lacking in primary care. A minimal invasive intervention was tailored with experts for the primary care setting to increase the identification of this patient group and ensure proper treatment. The intervention includes: A trigger question, screening tests and question prompt sheet for patients. Following the implementation of this intervention in primary care physician (PCP) offices, the aim of this study is to evaluate the implementation outcomes.

METHODS

Semi-structured interviews were conducted with ten PCPs who tested the intervention for six months. The study was guided by Proctor's Framework on Implementation Outcomes to understand the appropriateness, feasibility, acceptability, fidelity and sustainability of the intervention as proxies for implementation success.

RESULTS

Relevance of the topic and the need for the intervention is recognised by all of the PCPs. All PCPs were willing to try the intervention and considered it generally appropriate and feasible. Additionally, supporting implementation resources were considered helpful in familiarising with the intervention. Screening of patients with a first diagnosis of CHD, those who have had experienced a recent coronary event and those who have been hospitalised for CHD is considered practical and appropriate. Known barriers such as lack of knowledge, perceived relevance and awareness were successfully addressed. It was not possible to overcome barriers such as time pressure, forgetfulness, and patient reaction. Additionally, the paper format of the information materials was perceived as impractical, and integration into the physician information system was identified as a possible way to increase acceptance. Nevertheless, PCPs stated they will continue to be aware of the link between CHD and MCD and want to maintain their individualised approach.

CONCLUSIONS

The study provides important insights into the use of a minimal invasive intervention in primary care. Despite tailoring the intervention to the primary care setting, implementation success was suboptimal due to individual barriers in PCP offices. This highlights the need for tailored approaches at the level of individual PCP offices to better address context-specific barriers.

Neurocognitive and Neuropsychiatric Implications of Fibrosing Interstitial Lung Diseases

Patients with interstitial lung diseases (ILDs) associate a large variety of comorbidities that have a significant impact on their clinical outcomes and survival. Among these comorbidities is neurological impairment. This review highlights what is known about the cognitive function, central nervous system (CNS), depression, and anxiety in patients with specific forms of fibrosing ILDs, such as idiopathic pulmonary fibrosis, sarcoidosis, hypersensitivity pneumonitis, connective tissue diseases, etc. The most common pathogenic mechanisms for neurocognitive dysfunction as well as the screening methods and tools for their identification are also described in this review.

The Association of Dementia With Incident Adverse Drug Reactions in Hospitalized Older Adults

BACKGROUND

Older adults with dementia commonly receive multiple medications and have higher hospitalization rates, elevating the risk of potentially inappropriate prescribing and in-hospital adverse drug reactions (ADRs). There is limited evidence examining ADRs in older adults with dementia during hospitalization.

OBJECTIVES

Our aim was to assess the association between dementia and incidence of ADRs during hospitalization and to identify prevalent types of ADRs and medications linked to ADRs.

DESIGN

Secondary analysis of the SENATOR trial database, which was a randomized controlled trial of an intervention to reduce ADRs in older inpatients with multimorbidity.

SETTING AND PARTICIPANTS

A total of 1537 patients (47.2% females) with a mean age of 78.1 years were recruited from 6 European hospitals.

METHODS

Sociodemographic data, functional status, cognitive status, clinical information, and ADR-related outcomes were extracted from the SENATOR database. Inpatients with dementia were identified based on prior International Classification of Diseases, Tenth Revision (ICD-10), dementia diagnosis, receiving acetylcholinesterase inhibitors or memantine, or a Mini-Mental State Examination score ≤24 at admission without concurrent delirium.

RESULTS

Among participants, 392 (25.5%) were identified as having dementia. The proportion of patients with probable or certain incident in-hospital ADRs was similar between the groups with and without dementia (22.4% vs 25.4%, P > .05). However, in-hospital rates of probable or certain ADRs from 12 common categories were less frequently identified in patients with dementia compared to those without (19.4% vs 23%, P = .025). Major constipation (6.4% vs 9.9%, P = .03) and acute dyspepsia, nausea, or vomiting (2.8% vs 5%, P = .03) were less commonly observed ADRs in patients with dementia.

CONCLUSIONS AND IMPLICATIONS

We did not observe an increased risk of in-hospital ADRs among inpatients with dementia. However, ADRs related to the gastrointestinal tract and identified by subjective symptoms were less frequently identified in this group. This study lays the groundwork for developing new tools for ADR diagnosis for older patients with dementia.

Patterns in health care use and intensity for diagnosed and undiagnosed cognitive impairment in the older australian community: Implications for primary care management

Objectives

While the economic burden imposed by dementia is well-documented, findings are mixed on health care use for those with mild cognitive impairment (MCI). Our objective was to analyse annual, non-hospital medical and pharmaceutical use patterns for older people with undiagnosed MCI and diagnosed dementia, living in the Australian community.

Methods

We analysed panel data from a community sample, the Sydney Memory and Ageing Study (Australia), linked to administrative data on health care use, using two-part models to estimate the probability of using health care and the annual costs incurred by study participants.

Results

People with MCI, unaware of their diagnoses, were significantly less likely to incur annual pathology and diagnostic imaging costs relative to cognitively normal individuals. This effect was concentrated in individuals with MCI who had non-amnestic symptoms, lived alone, or had limited carer support. Compared to cognitively normal individuals, people with MCI were predicted to have slightly lower annual costs for broad medical care categories related to the management and diagnosis of cognitive impairment, and people with dementia, substantially higher professional attendances, and pharmaceutical costs. These findings were consistent across estimation models adjusting for attrition over the study.

Policy implications

Diagnosis and symptom management in primary care may enable individuals with MCI to improve their quality of life and prevent more costly future health care use. However, our study found potential gaps in medical service use for people with undiagnosed MCI in the community, especially when they had less support or did not have memory symptoms. Primary care services may need to better diagnose and target these individuals.

Self-administered gerocognitive examination (SAGE) aids early detection of cognitive impairment at primary care provider visits

Introduction

Current estimates indicate that up to 50-75% of dementia cases are undiagnosed at an early stage when treatments are most effective. Conducting robust accurate cognitive assessments can be time-consuming for providers and difficult to incorporate into a time-limited Primary Care Provider (PCP) visit. We wanted to compare PCP visits with and without using the self-administered SAGE to determine differences in identification rates of new cognitive disorders.

Methods

Three hundred patients aged 65-89 without diagnosed cognitive disorders completing a non-acute office visit were enrolled (ClinicalTrials.gov identifier: NCT04063371). Two PCP offices conducted routine visits for 100 consecutive eligible patients each. One office used the SAGE in an additional 100 subjects and asked available informants about cognitive changes over the previous year. Chart reviews were conducted 60 days later. One-way analysis of variance and Fisher exact tests were used to compare the groups and outcomes.

Results

When SAGE was utilized, the PCP documented the detection of new cognitive conditions/concerns six times (9% versus 1.5%) as often (p = 0.003). The detection rate was nearly 4-fold for those with cognitively impaired SAGE scores (p = 0.034). Patients having impaired SAGE score and informant concerns were 15-fold as likely to have new cognitive conditions/concerns documented (p = 0.0007). Among providers using SAGE, 86% would recommend SAGE to colleagues.

Discussion

SAGE was easily incorporated into PCP visits and significantly increased identification of new cognitive conditions/concerns leading to new diagnoses, treatment, or management changes. The detection rate increased 15-fold for those with impaired SAGE scores combined with informant reports.

Automating risk stratification for geriatric syndromes in the emergency department

BACKGROUND

Geriatric emergency department (GED) guidelines endorse screening older patients for geriatric syndromes in the ED, but there have been significant barriers to widespread implementation. The majority of screening programs require engagement of a clinician, nurse, or social worker, adding to already significant workloads at a time of record-breaking ED patient volumes, staff shortages, and hospital boarding crises. Automated, electronic health record (EHR)-embedded risk stratification approaches may be an alternate solution for extending the reach of the GED mission by directing human actions to a smaller subset of higher risk patients.

METHODS

We define the concept of automated risk stratification and screening using existing EHR data. We discuss progress made in three potential use cases in the ED: falls, cognitive impairment, and end-of-life and palliative care, emphasizing the importance of linking automated screening with systems of healthcare delivery.

RESULTS

Research progress and operational deployment vary by use case, ranging from deployed solutions in falls screening to algorithmic validation in cognitive impairment and end-of-life care.

CONCLUSIONS

Automated risk stratification offers a potential solution to one of the most pressing problems in geriatric emergency care: identifying high-risk populations of older adults most appropriate for specific GED care. Future work is needed to realize the promise of improved care with less provider burden by creating tools suitable for widespread deployment as well as best practices for their implementation and governance.

Mortality and Discharge Location of Intensive Care Patients With Alzheimer Disease and Related Dementia

BACKGROUND

Intensive care unit (ICU) utilization has increased among patients with Alzheimer disease and related dementia (ADRD), although outcomes are poor.

OBJECTIVES

To compare ICU discharge location and subsequent mortality between patients with and patients without ADRD enrolled in Medicare Advantage.

METHODS

This observational study used Optum's Clinformatics Data Mart Database from years 2016 to 2019 and included adults aged >67 years with continuous Medicare Advantage coverage and a first ICU admission in 2018. Alzheimer disease and related dementia and comorbid conditions were identified from claims. Outcomes included discharge location (home vs other facilities) and mortality (within the same calendar month of discharge and within 12 months after discharge).

RESULTS

A total of 145 342 adults met inclusion criteria; 10.5% had ADRD and were likely to be older, female, and have more comorbid conditions. Only 37.6% of patients with ADRD were discharged home versus 68.6% of patients who did not have ADRD (odds ratio [OR], 0.40; 95% CI, 0.38-0.41). Both death in the same month as discharge (19.9% vs 10.3%; OR, 1.54; 95% CI, 1.47-1.62) and death in the 12 months after discharge (50.8% vs 26.2%; OR, 1.95; 95% CI, 1.88-2.02) were twice as common among patients with ADRD.

CONCLUSIONS

Patients with ADRD have lower home discharge rates and greater mortality after an ICU stay than patients without ADRD.

Dementia Care in the Last Year of Life: Experiences in a Community Practice and in Skilled Nursing Facilities

OBJECTIVE

People living with dementia often have high care needs at the end-of-life. We compared care delivery in the last year of life for people living with dementia in the community (home or assisted living facilities [ALFs]) versus those in skilled nursing facilities (SNFs).

METHODS

A retrospective study was performed of older adults with a dementia diagnosis who died in the community or SNFs from 2013 through 2018. Primary outcomes were numbers of hospitalizations and emergency department visits in the last year of life. Secondary outcomes were completed advance care plans, hospice enrollment, time in hospice, practitioner visits, and intensive care unit admissions.

RESULTS

Of 1203 older adults with dementia, 622 (51.7%) lived at home/ALFs; 581 (48.3%) lived in SNFs. At least 1 hospitalization was recorded for 70.7% living at home/ALFs versus 50.8% in SNFs (P < .001), similar to percentages of emergency department visits (80.2% vs 58.0% of the home/ALF and SNF groups, P < .001). SNF residents had more practitioner visits than home/ALF residents: median (IQR), 9.0 (6.0-12.0) versus 5.0 (3.0-9.0; P < .001). No advance care plan was documented for 12.2% (n = 76) of the home/ALF group versus 4.6% (n = 27) of the SNF group (P < .001). Nearly 57% of SNF residents were enrolled in hospice versus 68.3% at home/ALFs (P < .001). The median time in hospice was 26.5 days in SNFs versus 30.0 days at home/ALFs (P = .67).

CONCLUSIONS

Older adults with dementia frequently receive acute care in their last year of life. Hospice care was more common for home/ALF residents. Time in hospice was short.

Identifying probable dementia in undiagnosed Black and White Americans using machine learning in Veterans Health Administration electronic health records

The application of machine learning (ML) tools in electronic health records (EHRs) can help reduce the underdiagnosis of dementia, but models that are not designed to reflect minority population may perpetuate that underdiagnosis. To address the underdiagnosis of dementia in both Black Americans (BAs) and white Americans (WAs), we sought to develop and validate ML models that assign race-specific risk scores. These scores were used to identify undiagnosed dementia in BA and WA Veterans in EHRs. More specifically, risk scores were generated separately for BAs (n=10K) and WAs (n=10K) in training samples of cases and controls by performing ML, equivalence mapping, topic modeling, and a support vector-machine (SVM) in structured and unstructured EHR data. Scores were validated via blinded manual chart reviews (n=1.2K) of controls from a separate sample (n=20K). AUCs and negative and positive predictive values (NPVs and PPVs) were calculated to evaluate the models. There was a strong positive relationship between SVM-generated risk scores and undiagnosed dementia. BAs were more likely than WAs to have undiagnosed dementia per chart review, both overall (15.3% vs 9.5%) and among Veterans with >90th percentile cutoff scores (25.6% vs 15.3%). With chart reviews as the reference standard and varied cutoff scores, the BA model performed slightly better than the WA model (AUC=0.86 with NPV=0.98 and PPV=0.26 at >90th percentile cutoff vs AUC=0.77 with NPV=0.98 and PPV=0.15 at >90th). The AUCs, NPVs, and PPVs suggest that race-specific ML models can assist in the identification of undiagnosed dementia, particularly in BAs. Future studies should investigate implementing EHR-based risk scores in clinics that serve both BA and WA Veterans.

Assess the documentation of cognitive tests and biomarkers in electronic health records via natural language processing for Alzheimer's disease and related dementias

BACKGROUND

Cognitive tests and biomarkers are the key information to assess the severity and track the progression of Alzheimer's' disease (AD) and AD-related dementias (AD/ADRD), yet, both are often only documented in clinical narratives of patients' electronic health records (EHRs). In this work, we aim to (1) assess the documentation of cognitive tests and biomarkers in EHRs that can be used as real-world endpoints, and (2) identify, extract, and harmonize the different commonly used cognitive tests from clinical narratives using natural language processing (NLP) methods into categorical AD/ADRD severity.

METHODS

We developed a rule-based NLP pipeline to extract the cognitive tests and biomarkers from clinical narratives in AD/ADRD patients' EHRs. We aggregated the extracted results to the patient level and harmonized the cognitive test scores into severity categories using cutoffs determined based on both relevant literature and domain knowledge of AD/ADRD clinicians.

RESULTS

We identified an AD/ADRD cohort of 48,912 patients from the University of Florida (UF) Health system and identified 7 measurements (6 cognitive tests and 1 biomarker) that are frequently documented in our data. Our NLP pipeline achieved an overall F1-score of 0.9059 across the 7 measurements. Among the 6 cognitive tests, we were able to harmonize 4 cognitive test scores into severity categories, and the population characteristics of patients with different severity were described. We also identified several factors related to the availability of their documentation in EHRs.

CONCLUSION

This study demonstrates that our NLP pipelines can extract cognitive tests and biomarkers of AD/ADRD accurately for downstream studies. Although, the documentation of cognitive tests and biomarkers in EHRs appears to be low, RWD is still an important resource for AD/ADRD research. Nevertheless, providing standardized approach to document cognitive tests and biomarkers in EHRS are also warranted.

The impact of active community-based survey on dementia detection ratio in Taiwan: A cohort study with historical control

Background

Although early dementia detection is crucial to optimize the treatment outcomes and the management of associated symptoms, the published literature is scarce regarding the effectiveness of active screening protocols in enhancing dementia awareness and increasing the rate of early detection. The present study compared the detection ratio of an active community-based survey for dementia detection with the detection ratio of passive screening during routine clinical practice. Data for passive screening were obtained from the National Health Insurance (NHI) system, which was prospectively collected during the period from 2000 to 2003.

Design

A population-based cohort study with historical control.

Setting

Taiwan.

Participants

A total of 183 participants aged 65 years or older were involved in a community-based survey. Data from 1,921,308 subjects aged 65 years or older were retrieved from the NHI system.

Measurements

An adjusted detection ratio, defined as a ratio of dementia prevalence to incidence was used.

Results

The results showed that the dementia prevalence during the 2000-2003 period was 2.91% in the elderly population, compared with a prevalence of 6.59% when the active survey was conducted. The incidence of dementia in the active survey cohort was 1.83%. Overall, the dementia detection ratio was higher using active surveys [4.23, 95% confidence interval (CI): 2.68-6.69] than using passive detection (1.45, 95% CI: 1.43-1.47) for those aged 65-79 years. Similar findings were observed for those aged 80 years and older.

Conclusion

The implementation of an active community-based survey led to a 3-fold increase in the detection rate of early dementia detection compared to passive screening during routine practice.

Program of Intensive Support in Emergency Departments for Care Partners of Cognitively Impaired Patients: Protocol for a Multisite Randomized Controlled Trial

BACKGROUND

Older adults with cognitive impairment have more emergency department visits and 30-day readmissions and are more likely to die after visiting the emergency department than people without cognitive impairment. Emergency department providers frequently do not identify cognitive impairment. Use of cognitive screening tools, along with better understanding of root causes for emergency department visits, could equip health care teams with the knowledge needed to develop individually tailored care management strategies for post-emergency department care. By identifying and directly addressing patients' and informal caregivers' (or care partners') psychosocial and health care needs, such strategies could reduce the need for repeat acute care. We have used the terms "caregiver" and "care partner" interchangeably.

OBJECTIVE

We aimed to describe the protocol for a randomized controlled trial of a new care management intervention, the Program of Intensive Support in Emergency Departments for Care Partners of Cognitively Impaired Patients (POISED) trial, compared with usual care. We described the research design, intervention, outcome measures, data collection techniques, and analysis plans.

METHODS

Emergency department patients who were aged ≥75 years and screened positive for cognitive impairment via either the Mini-Cog or the proxy-reported Short Informant Questionnaire on Cognitive Decline in the Elderly, with a planned discharge to home, were recruited to participate with their identified informal (family or friend) caregiver in the 2-site POISED randomized controlled trial at New York University Langone Health and Indiana University. The intervention group received 6 months of care management from the POISED Care Team of registered nurses and specialty-trained paraprofessionals, who perform root cause analyses, administer standardized assessments, provide advice, recommend appropriate referrals, and, when applicable, implement dementia-specific comorbid condition protocols. The control group received care as recommended at emergency department discharge (usual care) and were given information about resources for further cognitive assessment. The primary outcome is repeat emergency department use; secondary outcomes include caregiver activation for patient health care management, caregiver depression, anxiety, and experience of social support as important predisposing and time-varying enabling and need characteristics. Data were collected from questionnaires and patients' electronic health records.

RESULTS

Recruitment was conducted between March 2018 and May 2021. Study findings will be published in peer-reviewed journals and presented to peer audiences, decision makers, stakeholders, and other interested persons.

CONCLUSIONS

The POISED intervention is a promising approach to tailoring care management based on root causes for emergency department admission of patients with cognitive impairment with the aim of reducing readmissions. This trial will provide insights for caregivers and emergency department and primary care providers on appropriate, personalized, and proactive treatment plans for older adults with cognitive impairment. The findings will be relevant to audiences concerned with quality of life for individuals with cognitive impairment and their caregivers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03325608; https://clinicaltrials.gov/ct2/show/NCT03325608.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/36607.

Long-Term Intensive Care Unit (ICU) Stays Can Lead to Long-Term Cognitive Impairment (LTCI): Neurosurgery Nursing Strategies to Minimize Risk

Long-term cognitive impairment (LTCI) is a phenomenon predominantly seen in patients within intensive care units (ICU) that causes chronic dysfunction, defined as new or worsening deficits in memory, attention, mental processing speed, executive function, intellectual function, and visual-spatial abilities for over 12 months, inhibiting the necessary return to baseline function without appropriate intervention. Our objective is to provide a guideline of nursing strategies to reduce LTCI through different studies that evaluate pharmacological and non-pharmacological methods. Current literature demonstrates that pharmacotherapy focused on neuronal protection as well as robust physical therapy regimens and regulated sleep schedules show promise in strengthening cognitive function and reducing LTCI. Future studies regarding LTCI should focus on the efficacy of specific pharmacological regimens, large-scale assessments of the implementation of physical therapy to reduce LTCI, as well as, specific interventions to reduce the incidence of delirium in the ICU.

Clinical Predictors and Outcomes Associated with Postoperative Delirium Following Infrainguinal Bypass Surgery

OBJECTIVES

Postoperative delirium (POD) is common yet often underdiagnosed following vascular surgery. Elderly patients with advanced peripheral artery disease may be at particular risk for POD yet understanding of the clinical predictors and impact of POD is incomplete. We sought to identify POD predictors and associated resource utilization after infrainguinal lower extremity bypass.

METHODS

This single center retrospective analysis included all infrainguinal bypass cases performed for peripheral arterial disease from 2012-2020. The primary outcome was inpatient post-operative delirium. Delirium sequelae were also evaluated. Key secondary outcomes were length of stay, non-home discharge, readmission, 30-day amputation, postoperative myocardial infarction, mortality, and 2-year survival. Regression analysis was used to evaluate risk factors for delirium in addition to association with 2-year survival and amputation free survival.

RESULTS

Among 420 subjects undergoing infrainguinal lower extremity bypass, 105 (25%) developed POD. Individuals with POD were older and more likely to have non-elective surgery (p<0.05). On multivariable analysis, independent predictors of POD were age 60-89 years old, chronic limb threatening ischemia, female sex, and non-elective procedure. Consultations for POD took place for 25 cases (24%); 13 (52%) were with pharmacists, and only 4 (16%) resulted in recommendations. The average length of stay for those with POD was higher (17 days vs 9 days; p<.001). POD was associated with increased non-home discharge (61.8% vs 22.1%; p<.001), 30-day major amputation (6.7% vs 1.6%; p<0.01), 30-day postoperative myocardial infarction (11.4% vs 4.1%; p<0.01), and 90-day mortality (7.6% vs 2.9%; p=0.03). Survival at 2 years was lower in those with delirium (89% vs 75%; p<.001). In a Cox proportional hazards model, delirium was independently associated with decreased survival (HR=2.0; 95% CI=1.15-3.38; p=0.014) and decreased major-amputation free survival (HR=1.9; 95% CI=1.18-2.96; p=0.007).

CONCLUSIONS

Postoperative delirium is common following infrainguinal lower extremity bypass and is associated with other adverse post-operative outcomes and increased resource utilization, including increased hospital length of stay, non-home discharge, and worse 2-year survival. Future studies should evaluate the role of routine multidisciplinary care for high-risk patients to improve perioperative outcomes for vulnerable older adults undergoing infrainguinal lower extremity bypass.

Clinical judgement by primary care physicians for the diagnosis of all-cause dementia or cognitive impairment in symptomatic people

BACKGROUND

In primary care, general practitioners (GPs) unavoidably reach a clinical judgement about a patient as part of their encounter with patients, and so clinical judgement can be an important part of the diagnostic evaluation. Typically clinical decision making about what to do next for a patient incorporates clinical judgement about the diagnosis with severity of symptoms and patient factors, such as their ideas and expectations for treatment. When evaluating patients for dementia, many GPs report using their own judgement to evaluate cognition, using information that is immediately available at the point of care, to decide whether someone has or does not have dementia, rather than more formal tests.

OBJECTIVES

To determine the diagnostic accuracy of GPs' clinical judgement for diagnosing cognitive impairment and dementia in symptomatic people presenting to primary care. To investigate the heterogeneity of test accuracy in the included studies.

SEARCH METHODS

We searched MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), Web of Science Core Collection (ISI Web of Science), and LILACs (BIREME) on 16 September 2021.

SELECTION CRITERIA

We selected cross-sectional and cohort studies from primary care where clinical judgement was determined by a GP either prospectively (after consulting with a patient who has presented to a specific encounter with the doctor) or retrospectively (based on knowledge of the patient and review of the medical notes, but not relating to a specific encounter with the patient). The target conditions were dementia and cognitive impairment (mild cognitive impairment and dementia) and we included studies with any appropriate reference standard such as the Diagnostic and Statistical Manual of Mental Disorders (DSM), International Classification of Diseases (ICD), aetiological definitions, or expert clinical diagnosis.

DATA COLLECTION AND ANALYSIS

Two review authors screened titles and abstracts for relevant articles and extracted data separately with differences resolved by consensus discussion. We used QUADAS-2 to evaluate the risk of bias and concerns about applicability in each study using anchoring statements. We performed meta-analysis using the bivariate method.

MAIN RESULTS

We identified 18,202 potentially relevant articles, of which 12,427 remained after de-duplication. We assessed 57 full-text articles and extracted data on 11 studies (17 papers), of which 10 studies had quantitative data. We included eight studies in the meta-analysis for the target condition dementia and four studies for the target condition cognitive impairment. Most studies were at low risk of bias as assessed with the QUADAS-2 tool, except for the flow and timing domain where four studies were at high risk of bias, and the reference standard domain where two studies were at high risk of bias. Most studies had low concern about applicability to the review question in all QUADAS-2 domains. Average age ranged from 73 years to 83 years (weighted average 77 years). The percentage of female participants in studies ranged from 47% to 100%. The percentage of people with a final diagnosis of dementia was between 2% and 56% across studies (a weighted average of 21%). For the target condition dementia, in individual studies sensitivity ranged from 34% to 91% and specificity ranged from 58% to 99%. In the meta-analysis for dementia as the target condition, in eight studies in which a total of 826 of 2790 participants had dementia, the summary diagnostic accuracy of clinical judgement of general practitioners was sensitivity 58% (95% confidence interval (CI) 43% to 72%), specificity 89% (95% CI 79% to 95%), positive likelihood ratio 5.3 (95% CI 2.4 to 8.2), and negative likelihood ratio 0.47 (95% CI 0.33 to 0.61). For the target condition cognitive impairment, in individual studies sensitivity ranged from 58% to 97% and specificity ranged from 40% to 88%. The summary diagnostic accuracy of clinical judgement of general practitioners in four studies in which a total of 594 of 1497 participants had cognitive impairment was sensitivity 84% (95% CI 60% to 95%), specificity 73% (95% CI 50% to 88%), positive likelihood ratio 3.1 (95% CI 1.4 to 4.7), and negative likelihood ratio 0.23 (95% CI 0.06 to 0.40). It was impossible to draw firm conclusions in the analysis of heterogeneity because there were small numbers of studies. For specificity we found the data were compatible with studies that used ICD-10, or applied retrospective judgement, had higher reported specificity compared to studies with DSM definitions or using prospective judgement. In contrast for sensitivity, we found studies that used a prospective index test may have had higher sensitivity than studies that used a retrospective index test.

AUTHORS' CONCLUSIONS

Clinical judgement of GPs is more specific than sensitive for the diagnosis of dementia. It would be necessary to use additional tests to confirm the diagnosis for either target condition, or to confirm the absence of the target conditions, but clinical judgement may inform the choice of further testing. Many people who a GP judges as having dementia will have the condition. People with false negative diagnoses are likely to have less severe disease and some could be identified by using more formal testing in people who GPs judge as not having dementia. Some false positives may require similar practical support to those with dementia, but some - such as some people with depression - may suffer delayed intervention for an alternative treatable pathology.

Older Adults' Likelihood of Participating in Home-Based Cognitive Assessment

INTRODUCTION

Timely detection of cognitive impairment among older adults has shown to lead to better health and financial outcomes but is hampered by psychological, financial, and physical barriers to participation in cognitive assessment. Home-based cognitive assessment (HBCA) could help overcome some of these barriers. This study aimed to examine older adults' likelihood of participation in HBCA and identify factors predicting this likelihood.

MATERIALS AND METHODS

A cross-sectional online survey distributed through Amazon Mechanical Turk, was used to collect data from adults aged 50 years or older residing in the USA The survey was designed to gauge attitudes toward technology and cognitive assessment and to measure psychological variables including subjective cognitive decline (SCD), depression, and anxiety. Information on income and geographic location (rural vs. suburban and urban) was also collected. Univariate and hierarchical regression analyses were conducted to examine the contributions of these variables to a composite measure of likelihood of participation in HBCA.

RESULTS

Complete data were obtained on n = 483 (age 50-79). Approximately, two-thirds of respondents described themselves as likely or very likely to participate in HBCA. In univariate analyses, younger age, higher income, higher technology assessment acceptance scores, and higher SCD burden were associated with higher likelihood of participation. Hierarchical regression revealed significant stepwise increments in explained variance: demographic variables 4.1%, technology acceptance 25.2%, assessment acceptance 15.4%, and SCD burden 1.6%. The contribution of SCD was moderated by sex and found for women but not for men.

DISCUSSION/CONCLUSION

A large proportion of adults aged 50 and above described themselves likely to participate in HBCA. Middle-aged, technology-savvy, higher income adults expressed the most positive attitudes toward this type of service. Of interest is that HBCA may be particularly acceptable among older women with SCD, a group known to be at risk of cognitive decline. Our findings support the expansion of cognitive assessment services to the home setting.

Genetic Algorithms for Optimized Diagnosis of Alzheimer's Disease and Frontotemporal Dementia Using Fluorodeoxyglucose Positron Emission Tomography Imaging

Genetic algorithms have a proven capability to explore a large space of solutions, and deal with very large numbers of input features. We hypothesized that the application of these algorithms to 18F-Fluorodeoxyglucose Positron Emission Tomography (FDG-PET) may help in diagnosis of Alzheimer's disease (AD) and Frontotemporal Dementia (FTD) by selecting the most meaningful features and automating diagnosis. We aimed to develop algorithms for the three main issues in the diagnosis: discrimination between patients with AD or FTD and healthy controls (HC), differential diagnosis between behavioral FTD (bvFTD) and AD, and differential diagnosis between primary progressive aphasia (PPA) variants. Genetic algorithms, customized with K-Nearest Neighbor and BayesNet Naives as the fitness function, were developed and compared with Principal Component Analysis (PCA). K-fold cross validation within the same sample and external validation with ADNI-3 samples were performed. External validation was performed for the algorithms distinguishing AD and HC. Our study supports the use of FDG-PET imaging, which allowed a very high accuracy rate for the diagnosis of AD, FTD, and related disorders. Genetic algorithms identified the most meaningful features with the minimum set of features, which may be relevant for automated assessment of brain FDG-PET images. Overall, our study contributes to the development of an automated, and optimized diagnosis of neurodegenerative disorders using brain metabolism.

Utility of olfactory identification test for screening of cognitive dysfunction in community-dwelling older adults

Background

There is a need for a large-scale screening test that can be used to detect dementia in older individuals at an early stage. Olfactory identification deficits have been shown to occur in the early stages of dementia, indicating their usefulness in screening tests. This study investigated the utility of an olfactory identification test as a screening test for mild cognitive dysfunction in community-dwelling older people.

Methods

The subjects were city-dwelling individuals aged over 65 years but under 85 years who had not been diagnosed with dementia or mild cognitive impairment. The Japanese version of the Mild Cognitive Impairment Screen was used to evaluate cognitive function. Based on the results, the subjects were divided into two groups: healthy group and cognitively impaired group. Olfactory identification abilities based on the Japanese version of the University of Pennsylvania Smell Identification Test were compared between the groups.

Results

There were 182 participants in total: 77 in the healthy group and 105 in the cognitively impaired group. The mean olfactory identification test score of the cognitively impaired group was significantly lower than that of the healthy group. The cognitive impairment test score was significantly correlated with the olfactory identification test score.

Conclusions

Cross-sectional olfactory identification deficits at baseline in community-dwelling older adults reflected cognitive dysfunction. Assessing olfactory identification ability might be useful as a screening test for mild cognitive dysfunction in community-dwelling older people.

Prominent Cognitive Impairment Sequelae in Adult Survivors of Acute Respiratory Distress Syndrome

PURPOSE

The primary objective of this scoping review was to identify prominent cognitive impairment sequelae in adult survivors of an intensive care unit admission for acute respiratory distress syndrome (ARDS).

DESIGN

A scoping review was performed.

METHODS

Search terms were entered into multiple EBSCOhost databases. Articles pertaining to pediatric survivors, not in English, lacking cognitive impairment sequelae, or focused on a single sequela were excluded; 12 articles remained.

RESULTS

Cognitive impairment developed in 83.5% of patients with ARDS prior to discharge and persisted in 51.3% (n = 300/585) of survivors at the 1 year mark after discharge (range: 16.7%-100% across studies). Prominent sequelae included impairments in executive function, mental processing speed, immediate memory, and attention/concentration.

CONCLUSIONS

Survivors of an intensive care unit stay for ARDS often develop cognitive impairment persisting long after their admission. Clinicians in rehabilitation facilities should screen for these sequelae and connect survivors with treatment to improve cognitive outcomes.

CLINICAL RELEVANCE

Early recognition of prominent cognitive impairment sequelae by rehabilitation clinicians and referrals to neuropsychologists by providers are critical to limiting the severity of impairment.

Comorbidity Trajectories Associated With Alzheimer's Disease: A Matched Case-Control Study in a United States Claims Database

Background: Trajectories of comorbidities among individuals at risk of Alzheimer's disease (AD) may differ from those aging without AD clinical syndrome. Therefore, characterizing the comorbidity burden and pattern associated with AD risk may facilitate earlier detection, enable timely intervention, and help slow the rate of cognitive and functional decline in AD. This case-control study was performed to compare the prevalence of comorbidities between AD cases and controls during the 5 years prior to diagnosis (or index date for controls); and to identify comorbidities with a differential time-dependent prevalence trajectory during the 5 years prior to AD diagnosis. Methods: Incident AD cases and individually matched controls were identified in a United States claims database between January 1, 2000 and December 31, 2016. AD status and comorbidities were defined based on the presence of diagnosis codes in administrative claims records. Generalized estimating equations were used to assess evidence of changes over time and between AD and controls. A principal component analysis and hierarchical clustering was performed to identify groups of AD-related comorbidities with respect to prevalence changes over time (or trajectory), and differences between AD and controls. Results: Data from 186,064 individuals in the IBM MarketScan Commercial Claims and Medicare Supplementary databases were analyzed (93,032 AD cases and 93,032 non-AD controls). In total, there were 177 comorbidities with a ≥ 5% prevalence. Five main clusters of comorbidities were identified. Clusters differed between AD cases and controls in the overall magnitude of association with AD, in their diverging time trajectories, and in comorbidity prevalence. Three clusters contained comorbidities that notably increased in frequency over time in AD cases but not in controls during the 5-year period before AD diagnosis. Comorbidities in these clusters were related to the early signs and/or symptoms of AD, psychiatric and mood disorders, cerebrovascular disease, history of hazard and injuries, and metabolic, cardiovascular, and respiratory complaints. Conclusion: We demonstrated a greater comorbidity burden among those who later developed AD vs. controls, and identified comorbidity clusters that could distinguish these two groups. Further investigation of comorbidity burden is warranted to facilitate early detection of individuals at risk of developing AD.

Detection and Prediction of Incident Alzheimer Dementia over a 10-Year or Longer Medical History: A Population-Based Study in Primary Care

BACKGROUND

Despite the crucial role played by general practitioners in the identification and care of people with cognitive impairment, few data are available on how they may improve the early recognition of patients with Alzheimer dementia (AD), especially those with long (i.e., 10 years and longer) medical history.

AIMS

To investigate the occurrence and the predictors of AD during a 10-year or longer period prior AD diagnosis in primary care patients aged 60 years or older.

MATERIALS AND METHODS

A cohort study with a nested case-control analysis has been conducted. Data were extracted from the Italian Health Search Database (HSD), an Italian database with primary care data. AD cases have been defined in accordance with the International Classification of Diseases, ninth edition (ICD-9-CM) codes and coupled with the use of anti-dementia drugs. Prevalence and incidence rates of AD have been calculated. To test the association between candidate predictors, being identified in a minimum period of 10 years, and incident cases of AD, we used a multivariate conditional logistic regression model.

RESULTS

As recorded in the primary care database, AD prevalence among patients aged 60 years or older was 0.8% during 2016, reaching 2.4% among nonagenarians. Overall, 1,889 incident cases of AD have been identified, with an incidence rate as high as 0.09% person-year. Compared with 18,890 matched controls, history of hallucinations, agitation, anxiety, aberrant motor behavior, and memory deficits were positively associated with higher odds of AD (p < 0.001 for all) diagnosis. A previous diagnosis of depression and diabetes and the use of low-dose aspirin and non-steroidal anti-inflammatory drugs were associated with higher odds of AD (p < 0.05 for all).

CONCLUSION

Our findings show that, in accordance with primary care records, 1% of patients aged 60 years and older have a diagnosis of AD, with an incident AD diagnosis of 0.1% per year. AD is often under-reported in primary care settings; yet, several predictors identified in this study may support general practitioners to early identify patients at risk of AD.

Multispecialty Interprofessional Team Memory Clinics: Enhancing Collaborative Practice and Health Care Providers' Experience of Dementia Care

This study explored whether working within Multispecialty INterprofessional Team (MINT) memory clinics has an impact on health care professionals' perceptions of the challenges, attitudes, and level of collaboration associated with providing dementia care. Surveys were completed by MINT memory clinic members pre- and 6-months post-clinic launch. A total of 228 pre-and-post-training surveys were matched for analysis. After working in the MINT memory clinics for 6 months, there were significant reductions in mean ratings of the level of challenge associated with various aspects of dementia care, and significant increases in the frequency with which respondents experienced enthusiasm, inspiration, and pride in their work in dementia care and in ratings of the extent of collaboration for dementia care. This study provides some insights into the effect of collaborative, interprofessional approaches on health care professionals' perceptions of the challenges and attitudes associated with providing dementia care and level of collaboration with other health professionals.

Examining the benefits and harms of Alzheimer's disease screening for family members of older adults: study protocol for a randomized controlled trial

BACKGROUND

Multiple national expert panels have identified early detection of Alzheimer's disease and related dementias (ADRD) as a national priority. However, the United States Preventive Services Task Force (USPSTF) does not currently support screening for ADRD in primary care given that the risks and benefits are unknown. The USPSTF stresses the need for research examining the impact of ADRD screening on family caregiver outcomes.

METHODS

The Caregiver Outcomes of Alzheimer's Disease Screening (COADS) is a randomized controlled trial that will examine the potential benefits or harms of ADRD screening on family caregivers. It will also compare the effectiveness of two strategies for diagnostic evaluation and management after ADRD screening. COADS will enroll 1800 dyads who will be randomized into three groups (n = 600/group): the 'Screening Only' group will receive ADRD screening at baseline and disclosure of the screening results, with positive-screen participants receiving a list of local resources for diagnostic follow-up; the 'Screening Plus' group will receive ADRD screening at baseline coupled with disclosure of the screening results, with positive-screen participants referred to a dementia collaborative care program for diagnostic evaluation and potential care; and the control group will receive no screening. The COADS trial will measure the quality of life of the family member (the primary outcome) and family member mood, anxiety, preparedness and self-efficacy (the secondary outcomes) at baseline and at 6, 12, 18 and 24 months. Additionally, the trial will examine the congruence of depressive and anxiety symptoms between older adults and family members at 6, 12, 18 and 24 months and compare the effectiveness of two strategies for diagnostic evaluation and management after ADRD screening between the two groups randomized to screening (Screening Only versus Screening Plus).

DISCUSSION

We hypothesize that caregivers in the screening arms will express higher levels of health-related quality of life, lower depressive and anxiety symptoms, and better preparation for caregiving with higher self-efficacy at 24 months. Results from this study will directly inform the National Plan to Address Alzheimer's Disease, the USPSTF and other organizations regarding ADRD screening and early detection policies.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03300180. Registered on 3 October.

Evaluation of the Ottawa 3DY as a screening tool for cognitive impairment in older emergency department patients

OBJECTIVE

This study sought to evaluate the implementation of the Ottawa 3DY Tool, a simple screening instrument for cognitive impairment, by front-line ED clinicians.

METHODS

We conducted a prospective cohort study in an academic ED. Patients ≥75 years underwent cognitive screening with the Ottawa 3DY by front-line nurses and physicians. Descriptive statistics were used to describe level of implementation and acceptability of the tool. Sensitivity and specificity was calculated using an Mini-Mental State Exam <25 as the cut-off for cognitive impairment. A weighted kappa was calculated to establish inter-rater agreement.

RESULTS

Cognitive screening was completed in 260/332 eligible patients (78.3%), who were 60% female and had a mean age of 83.7 years. Facilitators to screening: perceived importance and ownership of screening and feasibility of Ottawa 3DY. Barriers to screening were: over confidence in clinical judgement and perceived lack of patient benefit. Ottawa 3DY had a sensitivity of 84.6% (64.3-95.0) and specificity of 54.2% (39.3-68.4) when completed by nurses. When completed by emergency physicians, sensitivity was 78.9% (53.9-93.0) and specificity was 70.0% (45.7-87.2). Inter-rater agreement kappa score was 0.67.

DISCUSSION

This study demonstrated that incorporating the Ottawa 3DY tool into the routine evaluation of older ED patients by front-line ED clinicians is both feasible and effective. With its demonstrated good inter-rater reliability and moderate level of sensitivity and specificity when compared with the much longer MMSE, the routine adoption of this tool may help lead to improved recognition of cognitive impairment and ultimately patient and system outcomes.

Machine learning models to predict onset of dementia: A label learning approach

Introduction

The study objective was to build a machine learning model to predict incident mild cognitive impairment, Alzheimer's Disease, and related dementias from structured data using administrative and electronic health record sources.

Methods

A cohort of patients (n = 121,907) and controls (n = 5,307,045) was created for modeling using data within 2 years of patient's incident diagnosis date. Additional cohorts 3–8 years removed from index data are used for prediction. Training cohorts were matched on age, gender, index year, and utilization, and fit with a gradient boosting machine, lightGBM.

Results

Incident 2-year model quality on a held-out test set had a sensitivity of 47% and area-under-the-curve of 87%. In the 3-year model, the learned labels achieved 24% (71%), which dropped to 15% (72%) in year 8.

Discussion

The ability of the model to discriminate incident cases of dementia implies that it can be a worthwhile tool to screen patients for trial recruitment and patient management.

Risks and Benefits of Screening for Dementia in Primary Care: The Indiana University Cognitive Health Outcomes Investigation of the Comparative Effectiveness of Dementia Screening (IU CHOICE)Trial

BACKGROUND/OBJECTIVE

The benefits and harms of screening of Alzheimer disease and related dementias (ADRDs) are unknown. This study addressed the question of whether the benefits outweigh the harms of screening for ADRDs among older adults in primary care.

DESIGN, SETTING, AND PARTICIPANTS

Single-blinded, two-arm, randomized controlled trial (October 2012-September 2016) in urban, suburban, and rural primary care settings in Indiana. A total of 4005 primary care patients (aged ≥65 years) were randomized to ADRD screening (n = 2008) or control (n = 1997).

INTERVENTION

Patients were screened using the Memory Impairment Screen or the Mini-Cog and referred for a voluntary follow-up diagnostic assessment if they screened positive on either or both screening tests.

MEASUREMENTS

Primary measures were health-related quality of life (HRQOL; Health Utilities Index) at 12 months, depressive symptoms (Patient Health Questionnaire-9), and anxiety symptoms (Generalized Anxiety Disorder seven-item scale) at 1 month.

RESULTS

The mean age was 74.2 years (SD = 6.9 years); 2257 (66%) were female and 2301 (67%) were white. At 12 months, we were unable to detect differences in HRQOL between the groups (effect size = 0.009 [95% confidence interval {CI} = -0.063 to 0.080]; P = .81). At 1 month, differences in mean depressive symptoms (mean difference = -0.23 [90% CI = -0.42 to -0.039]) and anxiety symptoms (mean difference = -0.087 [90% CI = -0.246 to 0.072]) were within prespecified equivalency range. Scores for depressive and anxiety symptoms were similar between the groups at all time points. No differences in healthcare utilization, advance care planning, and ADRD recognition by physicians were detected at 12 months.

CONCLUSION

We were unable to detect a difference in HRQOL for screening for ADRD among older adults. We found no harm from screening measured by symptoms of depression or anxiety. Missing data, low rates of dementia detection, and high rate of refusal for follow-up diagnostic assessments after a positive screen may explain these findings. J Am Geriatr Soc 68:535-543, 2020.

30-Day Emergency Department Revisit Rates among Older Adults with Documented Dementia

OBJECTIVES

Published literature on national emergency department (ED) revisit rates among older adults with dementia is sparse, despite anecdotal evidence of higher ED utilization. Thus we evaluated the odds ratio (OR) of 30-day ED revisits among older adults with dementia using a nationally representative sample.

DESIGN

We assessed the frequency of claims associated with a 30-day ED revisit among Medicare beneficiaries with and without a dementia diagnosis before or at index ED visit. We used a logistic regression model controlling for dementia, age, sex, race, region, Medicaid status, transfer to a skilled nursing facility after ED, primary care physician use 12 months before index, and comorbidity.

SETTING

A nationally representative sample of claims data for Medicare beneficiaries aged 65 and older who maintained continuous fee-for-service enrollment during 2015 and 2016. Only outpatient claims associated with an ED visit between January 2016 and November 2016 were included as a qualifying index encounter.

PARTICIPANTS

We identified 240 249 patients without dementia and 54 622 patients for whom a dementia code was recorded in the year before the index encounter in 2016.

RESULTS

Our results indicate a significant difference in unadjusted 30-day ED revisit rates among those with an ED dementia diagnoses (22.0%) compared with those without (13.9%). Our adjusted results indicated that dementia is a significant predictor of 30-day ED revisits (P < .0001). Those with a dementia diagnosis at or before the index ED visit were more likely to have experienced an ED revisit within 30 days (OR = 1.27; 95% confidence interval = 1.24-1.31).

CONCLUSION

Dementia diagnoses were a significant predictor of 30-day ED revisits. Further research should assess potential reasons why dementia is associated with markedly higher revisit rates, as well as opportunities to manage and transition dementia patients from the ED back to the community more effectively. J Am Geriatr Soc 67:2254-2259, 2019.

Predictors and prognosis of delirium among older subjects in cardiac intensive care unit: focus on potentially preventable forms

BACKGROUND

Delirium is a common and potentially preventable condition in older individuals admitted to acute and intensive care wards, associated with negative prognostic effects. Its clinical relevance is being increasingly recognised also in cardiology settings. The aim of the present study was to assess the prevalence, incidence, predictors and prognostic role of delirium in older individuals admitted to two cardiology intensive care units.

METHODS

All patients aged over 65 years consecutively admitted to the two participating cardiology intensive care units were enrolled. Assessment on admission included acute physiological derangement (modified rapid emergency medicine score, REMS), chronic comorbidity, premorbid disability and dementia. The Confusion Assessment Method-Intensive Care Unit was applied daily for delirium detection.

RESULTS

Of 497 patients (40% women, mean age 79 years), 18% had delirium over the entire cardiology intensive care unit course, half of whom more than 24 hours after admission (incident delirium). Advanced age, a main diagnosis of ST-segment elevation myocardial infarction or acute respiratory failure, modified REMS, comorbidity and dementia were independent predictors of delirium. Adjusting for patient's features on admission, incident delirium was predicted by invasive procedures (insertion of peripheral arterial catheter, urinary catheter, central venous catheter, naso-gastric tube and intra-aortic balloon pump). In a logistic regression model, delirium was an independent predictor of inhospital mortality (odds ratio 3.18, 95% confidence interval 1.02, 9.93).

CONCLUSIONS

Eighteen per cent of older cardiology intensive care unit patients had delirium, with half of the cases being incident, thus potentially preventable. Invasive procedures were independently associated with incident delirium. Delirium was an independent predictor of inhospital mortality. Awareness of delirium should be increased in the cardiology intensive care unit setting and prevention studies are warranted.

Computerized Cognitive Testing in Primary Care: A Qualitative Study

Computerized cognitive assessment tools may facilitate early identification of dementia in the primary care setting. We investigated primary care physicians' (PCPs') views on advantages and disadvantages of computerized testing based on their experience with the Computer Assessment of Mild Cognitive Impairment (CAMCI). Over a 2-month period, 259 patients, 65 years and older, from the family practice of 13 PCPs completed the CAMCI. Twelve PCPs participated in an individual interview. Generally, PCPs felt that the relationship between them and their patients helped facilitate cognitive testing; however, they thought available paper tests were time consuming and not sufficiently informative. Despite concerns regarding elderly patients' computer literacy, PCPs noticed high completion rates and that their patients had generally positive experiences completing the CAMCI. PCPs appreciated the time-saving advantage of the CAMCI and the immediately generated report, but thought the report should be shortened to 1 page and that PCPs should receive training in its interpretation. Our results suggest that computerized cognitive tools such as the CAMCI can address PCPs' concerns with cognitive testing in their offices. Recommendations to improve the practicality of computerized testing in primary care were suggested.

Identifying incident dementia by applying machine learning to a very large administrative claims dataset

Alzheimer's disease and related dementias (ADRD) are highly prevalent conditions, and prior efforts to develop predictive models have relied on demographic and clinical risk factors using traditional logistical regression methods. We hypothesized that machine-learning algorithms using administrative claims data may represent a novel approach to predicting ADRD. Using a national de-identified dataset of more than 125 million patients including over 10,000 clinical, pharmaceutical, and demographic variables, we developed a cohort to train a machine learning model to predict ADRD 4-5 years in advance. The Lasso algorithm selected a 50-variable model with an area under the curve (AUC) of 0.693. Top diagnosis codes in the model were memory loss (780.93), Parkinson's disease (332.0), mild cognitive impairment (331.83) and bipolar disorder (296.80), and top pharmacy codes were psychoactive drugs. Machine learning algorithms can rapidly develop predictive models for ADRD with massive datasets, without requiring hypothesis-driven feature engineering.

How many patients are eligible for disease-modifying treatment in Alzheimer's disease? A French national observational study over 5 years

OBJECTIVE

We aimed to study the epidemiology of the prodromal and mild stages of Alzheimer's disease (AD) patients who are eligible for clinical trials with disease-modifying therapies.

SETTINGS

We analysed two large complementary databases to study the incidence and characteristics of this population on a nationwide scope in France from 2014 to 2018. The National Alzheimer Database contains data from 357 memory centres and 90 private neurologists. Data from 2014 to 2018 have been analysed.

PARTICIPANTS

Patients, 50-85 years old, diagnosed with AD who had an Mini-Mental State Exam (MMSE) score of ≥20 were included. We excluded patients with mixed and non-AD neurocognitive disorders.

PRIMARY OUTCOME MEASURE

Descriptive statistics of the population of interest was the primary measure.

RESULTS

In the National Alzheimer Database, 550 198 patients were assessed. Among them, 72 174 (13.1%) were diagnosed with AD and had an MMSE ≥20. Using corrections for specificity of clinical diagnosis of AD, we estimated that about 50 000 (9.1%) had a prodromal or mild AD. In the combined electronic clinical records database of 11 French expert memory centres, a diagnosis of prodromal or mild AD, certified by the use of cerebrospinal fluid AD biomarkers, could be established in 195 (1.3%) out of 14 596 patients.

CONCLUSIONS

AD was not frequently diagnosed at a prodromal or mild dementia stage in France in 2014 to 2018. Diagnosis rarely relied on a pathophysiological marker even in expert memory centres. National databases will be valuable to monitor early stage AD diagnosis efficacy in memory centres when a disease-modifying treatment becomes available.

Harnessing the Power of Machine Learning in Dementia Informatics Research: Issues, Opportunities, and Challenges

Dementia is a chronic and degenerative condition affecting millions globally. The care of patients with dementia presents an ever-continuing challenge to healthcare systems in the 21st century. Medical and health sciences have generated unprecedented volumes of data related to health and wellbeing for patients with dementia due to advances in information technology, such as genetics, neuroimaging, cognitive assessment, free texts, routine electronic health records, etc. Making the best use of these diverse and strategic resources will lead to high-quality care of patients with dementia. As such, machine learning becomes a crucial factor in achieving this objective. The aim of this paper is to provide a state-of-the-art review of machine learning methods applied to health informatics for dementia care. We collate and review the existing scientific methodologies and identify the relevant issues and challenges when faced with big health data. Machine learning has demonstrated promising applications to neuroimaging data analysis for dementia care, while relatively less effort has been made to make use of integrated heterogeneous data via advanced machine learning approaches. We further indicate future potential and research directions in applying advanced machine learning, such as deep learning, to dementia informatics.

Association Between Executive Dysfunction and Instrumental Activities of Daily Living: Racial and Ethnic Differences Among Community-Dwelling Older Adults in the Southeastern US

OBJECTIVE

Examining cultural differences in assessment of cognitive/functional disability among older Americans is needed. This analysis examined associations between day-to-day function, measured by activities of daily living (ADL), and cognition, measured by CLOX scores, among older African American (AA) and non-Hispanic White (nHW) community-dwelling women and men.

METHODS

Design- Cross-sectional.

SETTING

Homes of community-dwelling older adults. Participants- 893 Medicare beneficiaries >65 living in west-central Alabama, without diagnoses of dementia, who were participants in the University of Alabama at Birmingham (UAB) Study of Aging, and who had complete data. Measurements- Physical function was assessed by self-reported ADL difficulty; cognitive function by CLOX, a clock drawing-task. Multivariable, linear regression models were used to examine associations within race/sex specific groups.

RESULTS

After controlling for socio-demographic factors and comorbidities, CLOX1 scores were inversely and significantly correlated with ADL for AA men (β = -0.205, P = 0.003). CLOX2 scores were similarly associated with ADL and IADL for the total group (β = -0.118, P = 0.001, and β = -0.180, P < 0.001, respectively); for ADL, significant associations were seen for AA men and nHW women (β = -0.203, P = 0.004, and β = -0.139, P = 0.02, respectively) and, for IADL, in AA women and men (β = -0.156, P = 0.03, and β = -0.24, P < 0.001, respectively).

CONCLUSION

While African American women reported the highest difficulty with ADLs and IADLs among all race/sex groups, CLOX1 scores were correlated with ADL for AA men only. CLOX1 may have limitations to identify functional disability for older AA women. [Word Count = 234].

Correlates of Cognitive Impairment among Indian Urban Elders

BACKGROUND

Cognitive impairment among elderly is increasing owing to increases in life expectancy globally. The problem is multifactorial. The objective of the present paper was to study the correlates of cognitive impairment in an urban elderly population in India.

METHODS

A cross sectional study was conducted among 100 randomly selected urban elderly population. Data was collected upon household visits using a predesigned pretested questionnaire administered by a trained investigator. Measurements included cognitive function assessment using Mini Mental State Examination, depression assessment using Geriatric Depression Scale, blood pressure measurement and anthropometry. Cognitive impairment was defined at MMSE score <24. Logistic regression was done to identify independently associated factors with cognitive impairment.

RESULTS

Prevalence of cognitive impairment among elderly was 10%. Women had a higher prevalence than men. Higher age, no schooling, living single, lower weight, lower waist and hip ratios, difficulty in activities of daily living, poor self-reported health, bedridden and depression significantly associated with cognitive impairment. The independently associated factors upon logistic regression were increasing age, no schooling and bedridden status for past six months.

CONCLUSION

Although the current prevalence of cognitive impairment among Indian urban elderly is low, several associated factors exist in this population that may increase the burden in future. Geriatric health policy should address the modifiable risk factors to manage the problem of cognitive impairment and its consequent outcomes.

Patient characteristics associated with screening positive for Alzheimer's disease and related dementia

INTRODUCTION

Screening all older adults for Alzheimer's disease and related dementias (ADRD) in primary care may not be acceptable or feasible. The goal of this study was to identify factors that could optimize screening in primary care and enhance its feasibility.

METHODS

This is a cross-sectional study in rural, suburban, and urban primary care practices in Indiana. A total of 1,723 patients ≥65 years of age were screened for ADRD using the Memory Impairment Screen. Logistic regression was used to identify patient-specific factors associated with screening positive for ADRD.

RESULTS

The positive screening rate was 4.9%. Rates varied significantly across the three study sites. The rural site had the lowest rate (2.8%), which was significantly lower than the rates at the suburban (5.6%) and urban (6.6%) sites (P<0.01). Patient age, sex, and education were significantly (P<0.05) associated with screening positive for ADRD.

CONCLUSION

Targeted screening of patients at risk for ADRD may represent a more optimal and feasible screening alternative to population screening.

Patient-Family Agenda Setting for Primary Care Patients with Cognitive Impairment: the SAME Page Trial

BACKGROUND

Establishing priorities for discussion during time-limited primary care visits is challenging in the care of patients with cognitive impairment. These patients commonly attend primary care visits with a family companion.

OBJECTIVE

To examine whether a patient-family agenda setting intervention improves primary care visit communication for patients with cognitive impairment DESIGN: Two-group pilot randomized controlled study PARTICIPANTS: Patients aged 65 + with cognitive impairment and family companions (n = 93 dyads) and clinicians (n = 14) from two general and one geriatrics primary care clinic INTERVENTION: A self-administered paper-pencil checklist to clarify the role of the companion and establish a shared visit agenda MEASUREMENTS: Patient-centered communication (primary); verbal activity, information disclosure including discussion of memory, and visit duration (secondary), from audio recordings of visit discussion RESULTS: Dyads were randomized to usual care (n = 44) or intervention (n = 49). Intervention participants endorsed an active communication role for companions to help patients understand what the clinician says or means (90% of dyads), remind patients to ask questions or ask clinicians questions directly (84% of dyads), or listen and take notes (82% of dyads). Intervention dyads identified 4.4 health issues for the agenda on average: patients more often identified memory (59.2 versus 38.8%; p = 0.012) and mood (42.9 versus 24.5%; p = 0.013) whereas companions more often identified safety (36.7 versus 18.4%; p = 0.039) and personality/behavior change (32.7 versus 16.3%; p = 0.011). Communication was significantly more patient-centered in intervention than in control visits at general clinics (p < 0.001) and in pooled analyses (ratio of 0.86 versus 0.68; p = 0.046). At general clinics, intervention (versus control) dyads contributed more lifestyle and psychosocial talk (p < 0.001) and less biomedical talk (p < 0.001) and companions were more verbally active (p < 0.005). No intervention effects were found at the geriatrics clinic. No effect on memory discussions or visit duration was observed.

CONCLUSION

Patient-family agenda setting may improve primary care visit communication for patients with cognitive impairment.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT02986958.

MIND at Home-Streamlined: Study protocol for a randomized trial of home-based care coordination for persons with dementia and their caregivers

BACKGROUND

Dementia is associated with high health care costs, premature long-term care (LTC) placement, medical complications, reduced quality of life, and caregiver burden. Most health care providers and systems are not yet organized or equipped to provide comprehensive long-term care management for dementia, although a range of effective symptoms and supportive care approaches exist. The Maximizing Independence at Home-Streamlined (MIND-S) is a promising model of home-based dementia care coordination designed to efficiently improve person-centered outcomes, while reducing care costs. This report describes the rationale and design of an NIA-funded randomized controlled trial to test the impact of MIND-S on time to LTC placement, person with dementia outcomes (unmet needs, behavior, quality of life), family caregiver outcomes (unmet needs, burden), and cost offset at 18 (primary end point) and 24 months, compared to an augmented usual care group.

METHODS

This is a 24-month, parallel group, randomized trial evaluating MIND-S in a cohort of 304 community-living persons with dementia and their family caregivers in Maryland. MIND-S dyads receive 18 months of care coordination by an interdisciplinary team comprised of trained non-clinical community workers (e.g. Memory Care Coordinators), a registered nurse, and a geriatric psychiatrist. Intervention components include in-home dementia-related needs assessments; individualized care planning; implementation of standardized evidence-based care strategy protocols; and ongoing monitoring and reassessment. Outcomes are assessed by blinded evaluators at baseline, 4.5, 9, 13.5, 18, and 24 months.

DISCUSSION

Trial results will provide rigorous data to inform innovations in effective system-level approaches to dementia care.

Association Between Dementia Severity and Recommended Lifestyle Changes: A Retrospective Cohort Study

OBJECTIVE

Early diagnosis of dementia leads to early treatment which is beneficial to patients and the community. We reviewed initial evaluations from the Spectrum Health Medical Group Neurocognitive Clinic (SHMGNC) to evaluate dementia stage at the time of diagnosis.

METHODS

We retrospectively reviewed 110 randomly chosen initial evaluations from September 2008 to December 2015 at the SHMGNC. Patients underwent a neurological examination, Montreal Cognitive Assessment, and a battery of neuropsychological testing.

RESULTS

Of all, 78.9% had moderate or severe dementia at diagnosis. The SHMGNC recommended lifestyle changes (medication assistance, financial assistance, driving restrictions, and institutional care) in 75.8% of patients with dementia. The severity of dementia was associated with the number of lifestyle changes recommended. Cohabitation with a caregiver did not lead to an early diagnosis of dementia.

CONCLUSIONS

Patients are not undergoing evaluation at the onset of the dementia process. Diagnosis is delayed. Home-based, patient-centered care may improve early screening and detection of dementia.

A Longitudinal Analysis of General Practitioner Service Use by Patients with Mild Cognitive Disorders in Australia

BACKGROUND

The aim of this study was to ascertain if participants diagnosed with any mild cognitive disorder (MCD) visited a general practitioner (GP) more than those without MCD and the effect of either depression or arthritis on GP use longitudinally.

METHODS

2,551 participants aged 60-64 years at baseline completed the Personality and Total Health Through Life (PATH) study in Canberra. Follow-up data were collected after 4 and 8 years. A cognitive screening battery was used to screen participants into a substudy of MCD.

RESULTS

Participants with any MCD had greater GP use than cognitively healthy participants across all three waves (wave 1, M = 7.35 vs. 5.59; wave 2, M = 7.77 vs. 5.86; wave 3, M = 9.01 vs. 6.81). After adjusting for demographic and health factors, MCD was a significant predictor of GP use at all three waves (p < 0.05, CI 0.84-0.99).

CONCLUSION

This study has shown that MCD is associated with a higher use of GP visits, especially if the patient has a comorbid condition.

Comprehensive home-based care coordination for vulnerable elders with dementia: Maximizing Independence at Home-Plus-Study protocol

INTRODUCTION

Despite availability of effective care strategies for dementia, most health care systems are not yet organized or equipped to provide comprehensive family-centered dementia care management. Maximizing Independence at Home-Plus is a promising new model of dementia care coordination being tested in the U.S. through a Health Care Innovation Award funded by the Centers for Medicare and Medicaid Services that may serve as a model to address these delivery gaps, improve outcomes, and lower costs. This report provides an overview of the Health Care Innovation Award aims, study design, and methodology.

METHODS

This is a prospective, quasi-experimental intervention study of 342 community-living Medicare-Medicaid dual eligibles and Medicare-only beneficiaries with dementia in Maryland. Primary analyses will assess the impact of Maximizing Independence at Home-Plus on risk of nursing home long-term care placement, hospitalization, and health care expenditures (Medicare, Medicaid) at 12, 18 (primary end point), and 24 months, compared to a propensity-matched comparison group.

DISCUSSION

The goals of the Maximizing Independence at Home-Plus model are to improve care coordination, ability to remain at home, and life quality for participants and caregivers, while reducing total costs of care for this vulnerable population. This Health Care Innovation Award project will provide timely information on the impact of Maximizing Independence at Home-Plus care coordination model on a variety of outcomes including effects on Medicaid and Medicare expenditures and service utilization. Participant characteristic data, cost savings, and program delivery costs will be analyzed to develop a risk-adjusted payment model to encourage sustainability and facilitate spread.

Screening tools for the identification of dementia for adults with age-related acquired hearing or vision impairment: a scoping review

BACKGROUND

Cognitive screening tests frequently rely on items being correctly heard or seen. We aimed to identify, describe, and evaluate the adaptation, validity, and availability of cognitive screening and assessment tools for dementia which have been developed or adapted for adults with acquired hearing and/or vision impairment.

METHOD

Electronic databases were searched using subject terms "hearing disorders" OR "vision disorders" AND "cognitive assessment," supplemented by exploring reference lists of included papers and via consultation with health professionals to identify additional literature.

RESULTS

1,551 papers were identified, of which 13 met inclusion criteria. Four papers related to tests adapted for hearing impairment; 11 papers related to tests adapted for vision impairment. Frequently adapted tests were the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MOCA). Adaptations for hearing impairment involved deleting or creating written versions for hearing-dependent items. Adaptations for vision impairment involved deleting vision-dependent items or spoken/tactile versions of visual tasks. No study reported validity of the test in relation to detection of dementia in people with hearing/vision impairment. Item deletion had a negative impact on the psychometric properties of the test.

CONCLUSIONS

While attempts have been made to adapt cognitive tests for people with acquired hearing and/or vision impairment, the primary limitation of these adaptations is that their validity in accurately detecting dementia among those with acquired hearing or vision impairment is yet to be established. It is likely that the sensitivity and specificity of the adapted versions are poorer than the original, especially if the adaptation involved item deletion. One solution would involve item substitution in an alternative sensory modality followed by re-validation of the adapted test.

Poor Performance on a Preoperative Cognitive Screening Test Predicts Postoperative Complications in Older Orthopedic Surgical Patients

BACKGROUND

The American College of Surgeons and the American Geriatrics Society have suggested that preoperative cognitive screening should be performed in older surgical patients. We hypothesized that unrecognized cognitive impairment in patients without a history of dementia is a risk factor for development of postoperative complications.

METHODS

We enrolled 211 patients 65 yr of age or older without a diagnosis of dementia who were scheduled for an elective hip or knee replacement. Patients were cognitively screened preoperatively using the Mini-Cog and demographic, medical, functional, and emotional/social data were gathered using standard instruments or review of the medical record. Outcomes included discharge to place other than home (primary outcome), delirium, in-hospital medical complications, hospital length-of-stay, 30-day emergency room visits, and mortality. Data were analyzed using univariate and multivariate analyses.

RESULTS

Fifty of 211 (24%) patients screened positive for probable cognitive impairment (Mini-Cog less than or equal to 2). On age-adjusted multivariate analysis, patients with a Mini-Cog score less than or equal to 2 were more likely to be discharged to a place other than home (67% vs. 34%; odds ratio = 3.88, 95% CI = 1.58 to 9.55), develop postoperative delirium (21% vs. 7%; odds ratio = 4.52, 95% CI = 1.30 to 15.68), and have a longer hospital length of stay (hazard ratio = 0.63, 95% CI = 0.42 to 0.95) compared to those with a Mini-Cog score greater than 2.

CONCLUSIONS

Many older elective orthopedic surgical patients have probable cognitive impairment preoperatively. Such impairment is associated with development of delirium postoperatively, a longer hospital stay, and lower likelihood of going home upon hospital discharge.

Discrepancies between Perceived and Measured Cognition in Kidney Transplant Recipients: Implications for Clinical Management

BACKGROUND

Cognitive impairment is common in kidney transplant (KT) recipients and affects quality of life, graft survival, morbidity, and mortality. Failure to identify patients with cognitive impairment can withhold appropriate and timely intervention. This study determines whether measured cognition with standard screening tools offers any advantage over perceived cognition in screening transplant patients for cognitive impairment.

METHODS

Cognition was assessed in 157 KT recipients using the Montreal Cognitive Assessment (MoCA; measured cognition). In addition, transplant physicians and nurse coordinators were asked to rate transplant recipients' level of cognition after routine clinical interactions (perceived cognition). Physicians and nurses were blind to MoCA scores. Perceived cognition scores were compared to MoCA scores.

RESULTS

Perceived cognition scores fairly correlated with MOCA scores (γ = 0.24, p = 0.001 for physicians and γ = 0.33, p < 0.0001 for nurses). Physician scores moderately correlated with nurses scores (κ = 0.44, p < 0.0001). Clinical perception had a low accuracy for identifying patients with cognitive impairment (sensitivity 66% for physicians, 65% for nurses), and those without cognitive impairment (specificity 67% for physicians, 76% for nurses).

CONCLUSION

Clinical perception is inaccurate at detecting cognitive impairment in KT recipients. Objective tests should be considered to screen KT recipients for cognitive impairment.

Adversity in childhood and measures of aging in midlife: Findings from a cohort of british women

Very few studies have assessed whether socioeconomic and psychosocial adversity during childhood are associated with objective measures of aging later in life. We assessed associations of socioeconomic position (SEP) and total psychosocial adversity during childhood, with objectively measured cognitive and physical capability in women during midlife. Adverse childhood experiences were retrospectively reported at mean ages 28-30 years in women from the Avon Longitudinal Study of Parents And Children (N = 2,221). We investigated associations of childhood SEP and total psychosocial adversity, with composite measures of cognitive and physical capability at mean age 51 years. There was evidence that, compared with participants whose fathers had professional occupations, participants whose fathers had managerial/technical, skilled nonmanual, skilled manual, and partly or unskilled manual occupations had, on average, lower physical and cognitive capability. There was a clear trend for increasing magnitudes of association with lowering childhood SEP. There was also evidence that greater total psychosocial adversity in childhood was associated with lower physical capability. Total psychosocial adversity in childhood was not associated with cognitive capability. Lower SEP in childhood is detrimental to cognitive and physical capability in midlife, at least in part, independently of subsequent SEP in adulthood. Greater psychosocial adversity in childhood is associated with poorer physical capability, independently of social disadvantage in childhood. Our findings highlight the need for interventions to both identify and support children experiencing socioeconomic or psychosocial of adversity as early as possible. (PsycINFO Database Record

Preoperative Cognitive Stratification of Older Elective Surgical Patients: A Cross-Sectional Study

BACKGROUND

Preexisting cognitive impairment is emerging as a predictor of poor postoperative outcomes in seniors. We hypothesized that preoperative cognitive screening can be performed in a busy preadmission evaluation center and that cognitive impairment is prevalent in elective geriatric surgical patients.

METHODS

We approached 311 patients aged 65 years and older presenting for preoperative evaluation before elective surgery in a prospective, observational, single-center study. Forty-eight patients were ineligible, and 63 declined. The remaining 200 were randomly assigned to the Mini-Cog (N =100) or Clock-in-the-Box [CIB; N = 100)] test. Study staff administered the test in a quiet room, and 2 investigators scored the tests independently. Probable cognitive impairment was defined as a Mini-Cog ≤ 2 or a CIB ≤ 5.

RESULTS

The age of consenting patients was 73.7 ± 6.4 (mean ± SD) years. There were no significant differences between patients randomly assigned to the Mini-Cog and CIB test in age, weight, gender, education, ASA physical status, or Charlston Index. Overall, 23% of patients met criteria for probable cognitive impairment, and prevalence was virtually identical regardless of the test used; 22% screened with the Mini-Cog and 23% screened with the CIB scored as having probable cognitive impairment (P = 1.0 by χ analysis). Both tests had good interrater reliability (Krippendroff α = 0.86 [0.72-0.93] for Mini-Cog and 1 for CIB).

CONCLUSIONS

Preoperative cognitive screening is feasible in most geriatric elective surgical patients and reveals a substantial prevalence of probable cognitive impairment in this population.