Centre for Research in Geriatric Medicine
Centre for Research in Geriatric Medicine
COGNITIVE IMPAIRMENT IN
THE HOSPITAL SETTING
Professor Len Gray
April 2014
Centre for Research in Geriatric Medicine
Some key questions…
How common is cognitive impairment among hospitalised older patients?
Which cognitive syndromes are associated with cognitive impairment?
Is there variation among hospital settings and programs?
What comorbidities are associated with cognitive impairment?
What are the outcomes for patients with cognitive impairment?
What is the current quality of care? Is there room for improvement?
Centre for Research in Geriatric Medicine
Our research studies
Emergency Department
– Geriatric syndromes in the Emergency Department
• 13 EDs in 7 nations (n=2282 (273 Australian))
Acute Care
– Geriatric syndromes among older medical inpatients
• 3 Brisbane hospitals (n=577)
– Cognitive syndromes and outcomes among older inpatients
• 4 Brisbane hospitals (n=493)
– Development of Quality Indicators for acute medical patients
• 9 Australian hospitals in 2 states (n=643)
Transition Care
– Geriatric syndromes and outcomes among Transition Care program patients
• 6 TCP services in 2 states (n=351)
Centre for Research in Geriatric Medicine
How did we identify cognitive syndromes?
interRAI Assessment Systems
– Validated screeners for dementia and delirium
Conventional diagnostic screeners
– CAM, MMSE, NPI
Expert opinion
– Clinical experts reviewing data and files
Direct assessment by clinical experts
– For delirium validation study
Centre for Research in Geriatric Medicine
6
interRAI AC
interRAI HC
interRAI ED Screener
The interRAI Hospital Mini-Suite
interRAI AC-PAC
interRAI ED CA
Centre for Research in Geriatric Medicine
interRAI Assessment System C
lin
ical
ob
serv
ati
on
s
Diagnostic
screeners
Risk
assessment Severity
measures Clinical
protocols
Quality
indicators Administrative
tools
Clinical
tools
Problem lists
Clinical
profiles
Casemix
Planning
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Test Sensitivity Specificity PPV NPV Agreement
(kappa)
CPS 0.68 0.92 0.7 0.92 0.61
MMSE 0.75 0.82 0.48 0.93 0.46
Reference standard:
Clinician review of all assessment results (all metrics, file
review) except interRAI cognitive items
Centre for Research in Geriatric Medicine
Sensitivity 0.90
Specificity 0.69
PPV 0.75
NPV 0.86
AUC 0.79
Reference standard:
Geriatrician diagnosis guided by DSM IV criteria
Centre for Research in Geriatric Medicine Centre for Research in Geriatric Medicine
HOW COMMON IS
COGNITIVE IMPAIRMENT
IN HOSPITAL?
Centre for Research in Geriatric Medicine
Cognitive Impairment in the
Emergency Department
13 Emergency departments, 7 nations (n=2282)
Subjects aged 75+
Geriatric Syndromes
– 48% had a premorbid geriatric syndrome
– 78% had at least one geriatric syndrome at presentation
Evidence of cognitive impairment
– 20% had premorbid evidence of CI
– 26% at presentation
– 16% had probable delirium
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Cognitive impairment in the ED
Medical file review, 273 patients aged > 75 years at 2
major Brisbane EDs
20% evidence of cognitive impairment
51% evidence of documentation of cognition
– Predominantly brief comments alluding to cognitive function
– 16% formal screening tool for cognition applied
– NO application of screening tool for delirium
Schnikter L., Martin-Khan M., Burkett E., Beattie E., Gray L. (2011)
Centre for Research in Geriatric Medicine
Geriatric syndromes: Premorbid & admission
0 20 40 60 80 100
Any instrumental ADL
Any personal ADL
Bowel incontinence
Bladder incontinence
Fall in previous 90 days
Pressure ulcer
Communication
Delirium
Cognition
%
Admission
Premorbid
Source: Lakhan P, Wilson A, Hirdes J, Jones M, Gray L (JAGS 2011)
Patients aged > 70 years in 3 Brisbane hospitals (n=557)
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New syndromes developed in hospital
0 10 20 30 40 50 60
Pressure ulcer
Bowel incontinence
Bladder incontinence
Any ADL
Communication
Cognition
Admission
Discharge
Source: Lakhan P, Wilson A, Hirdes J, Jones M, Gray L (JAGS 2011)
Centre for Research in Geriatric Medicine
Dementia prevalence: 4 Brisbane hospitals
493 patients, aged 70 years and older
Geriatrician data and file review
Dementia present:
–General medicine – 29%
–General surgery – 16%
–Orthopaedic surgery – 15%
Source: Travers C, Byrne G, Pachana N, Klein K, Gray L. Prospective observational study
of dementia and delirium in the acute hospital setting. Internal Medicine Journal. 2013
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Severity of Cognitive Impairment Older medical patients (n=643)
0
50
100
150
200
250
300
350
400
450
0 1 2 3 4 5 6
Cases
CPS Score
Premorbid
Admission
Discharge
CPS interpretation
0=normal
2 or greater=probable dementia
6=severe cognitive impairment
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Delirium
4 major Brisbane hospitals, general medical, surgical and orthopaedic patients
Geriatrician data and file review diagnosis
9.7% delirium at admission
7.6% incident delirium after admission
Major predictor of delirium – dementia (OR 3.18 for admission delirium, 4.82 for subsequent delirium
Delirium major predictor of mortality (OR 5.19 for admission delirium, 31.07 for subsequent delirium)
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Cognitive impairment in TCP
351 cases assessed using the interRAI HomeCare
Probable dementia
– At entry 30%
– Pre-morbid 14%
Symptoms suggestive of delirium
– 10%
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Severity of Cognitive Impairment TCP Older medical patients (n=643)
0
50
100
150
200
250
0 1 2 3 4 5 6
Cases
CPS Score
Premorbid
Admission
Discharge
CPS interpretation
0=normal
2 or greater=probable dementia
6=severe cognitive impairment
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Outcomes in TCP
Outcome Cognitively
impaired
Cognitively
intact
p-value
Initial hospital stay
(days)
30.8 22.8 <0.001
Admission ADL
score (mean)
2.6 1.3 <0.001
Community
discharge
84.6% 86.4% NS
Achieved at least
one goal
88% 92.7% NS
LOS in TCP 58 50 0.004
Hospital readmission
(6 months)
42.3% 39.3% NS
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IS THERE ROOM FOR
IMPROVEMENT?
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Outcomes are worse... Hospitalised older patients
0 5 10 15
Died*
Length of stay (days)*
Falls (ns)
Delirium*
Normal
Dementia
* P < 0.05
Source: Travers C, Byrne G, Pachana N, Klein K, Gray L. Prospective observational study
of dementia and delirium in the acute hospital setting. Internal Medicine Journal. 2013
Centre for Research in Geriatric Medicine
Cognition: UQFCOG05
0
10
20
30
40
50
60
70
80
90
100
A B C D E F G H I
Perc
en
tag
es (
%)
Hospital IDs
Percentages of documented assessment of cognitive ability within 48 hours of hospital admission
Centre for Research in Geriatric Medicine
Delirium: UQFDEL01
0
10
20
30
40
50
60
70
80
90
100
A B C D E F G H I
Perc
en
tag
es (
%)
Hospital IDs
Percentages of patients screened for delirium
Centre for Research in Geriatric Medicine
Can care be improved?
Delirium incidence can be reduced in some cases with
mild – moderate risk in general medicine
– Inouye et al, NEJM 669-72, 340, 1999
Delirium incidence can be reduced in cases with
fractured hip and cardiac surgery
– Marcantonio et al, JAGS 516-22, 49, 2001
Identification of cognitive impairment early may increase
the reliability and efficiency of care delivery
Sensitive care may improve patient and family
satisfaction, and reduce stress
Centre for Research in Geriatric Medicine
Contributors
CRGM, UQ
– Melinda Martin-Khan
– Catherine Travers
– Nancye Peel
– Prabha Lakhan
– Linda Schnikter
– Ellen Burkett
University of Queensland
– Gerard Byrne
– Nancy Pachana
– Olivia Wright
External
Rich Jones, – Harvard Medical School,
Boston, USA
John Morris, – Hebrew Senior Life, Boston
Caroline Brand, – Melbourne Health
Elizabeth Beattie, – QUT
John Hirdes, – University of Waterloo,
Canada
Centre for Research in Geriatric Medicine
Funding sources
National Health and Medical Research Council
The JO and JR Wicking Trust
Alzheimer's Australia / Viertel Foundation
Queensland Emergency Medicine Foundation
Centre for Research in Geriatric Medicine
The CRGM Dementia in Hospitals research program:
Citations
1. Gray LC, Bernabei R, Berg K, Finne-Soveri H, Fries BE, Hirdes JP, et al. Standardizing assessment of elderly people in acute care: the interRAI Acute Care instrument. J Am Geriatr Soc. 2008 Mar;56(3):536-41. PubMed PMID: 18179498. Epub 2008/01/09. eng.
2. Lakhan P, Jones M, Wilson A, Courtney M, Hirdes J, Gray L. A Prospective Cohort Study of Geriatric Syndromes Among Older Medical Patients Admitted to Acute Care Hospitals. Journal of American Geriatric Society. 2011;59(11).
3. Salih SA, Paul S, Klein K, Lakhan P, Gray L. Screening for delirium within the interrai acute care assessment system. The Journal of Nutrition, Health & Aging. 2012 2012/08/01;16(8):695-700. English.
4. Gray LC, Peel NM, Costa AP, Burkett E, Dey AB, Jonsson PV, et al. Profiles of older patients in the emergency department: Findings from the interrai multinational emergency department study. Annals of Emergency Medicine 2013 November 2013;62(5):8. Epub 2013 Jun 25. English.
5. Peel NM, Hubbard RE, Gray L. Impact of post-acute transition care for frail older people: a prospective study Journal of Frailty and Aging. 2013 2013;2(3):7.
6. Travers C, Byrne G, Pachana N, Klein K. Validation of the interRAI Cognitive Performance Scale against independent clinical diagnosis and the Mini-Mental State Examination in older hospitalized patients. The Journal of Nutrition, Health and Aging. 2013 May, 2013;17(5):5. English.
7. Travers C, Byrne G, Pachana N, Klein K, Gray L. Prospective observational study of dementia and delirium in the acute hospital setting. Internal Medicine Journal. 2013 March, 2013;43(3):8. Epub March, 2013.
8. Travers C, Byrne G, Pachana N, Klein K, Gray L. Delirium in Australian hospitals: A prospective study. Current Gerontology and Geriatrics Research. 2013 2013:8.
9. Travers C, Byrne GJ, Pachana NA, Klein K, Gray LC. Prospective observational study of dementia in older patients admitted to acute hospitals. Australasian journal on ageing. 2014 Mar;33(1):55-8. PubMed PMID: 24520824. Epub 2014/02/14. eng.
Centre for Research in Geriatric Medicine
Conclusions
Cognitive impairment is common among hospitalised older
patients
– 25% in the ED
– 30% in general medical services
– 15% in general surgical services
– 15% in orthopaedic services
– 30% in TCP
Delirium occurs in 15% of general medical inpatients
Outcomes are worse for patients with cognitive impairment
There may be opportunities for improvement…
Centre for Research in Geriatric Medicine
Websites...
CRGM www.som.uq.edu.au/research/crgm
interRAI Australia
www.interrai-au.org
RAIplus
www.raiplus.com
CeGA Online
www.cegaonline.com