COGNITIVE IMPAIRMENT IN

Transcription

1 COGNITIVE IMPAIRMENT IN THE HOSPITAL SETTING Professor Len Gray April 2014

2 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?

3 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)

4 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

5 The interrai Hospital Mini-Suite interrai ED Screener interrai ED CA interrai AC interrai AC-PAC interrai HC 6

6 Clinical observations interrai Assessment System Clinical tools Administrative tools Diagnostic screeners Risk assessment Severity measures Clinical protocols Problem lists Clinical profiles Quality indicators Casemix Planning

7 Reference standard: Clinician review of all assessment results (all metrics, file review) except interrai cognitive items Test Sensitivity Specificity PPV NPV Agreement (kappa) CPS MMSE

8 Reference standard: Geriatrician diagnosis guided by DSM IV criteria Sensitivity 0.90 Specificity 0.69 PPV 0.75 NPV 0.86 AUC 0.79

9 HOW COMMON IS COGNITIVE IMPAIRMENT IN HOSPITAL?

10 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

11 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)

12 Geriatric syndromes: Premorbid & admission Patients aged > 70 years in 3 Brisbane hospitals (n=557) Cognition Delirium Communication Admission Premorbid Pressure ulcer Fall in previous 90 days Bladder incontinence Bowel incontinence Any personal ADL Any instrumental ADL % Source: Lakhan P, Wilson A, Hirdes J, Jones M, Gray L (JAGS 2011)

13 New syndromes developed in hospital Cognition Communication Any ADL Bladder incontinence Admission Discharge Bowel incontinence Pressure ulcer Source: Lakhan P, Wilson A, Hirdes J, Jones M, Gray L (JAGS 2011)

14 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

15 Cases Severity of Cognitive Impairment Older medical patients (n=643) CPS interpretation 0=normal 2 or greater=probable dementia 6=severe cognitive impairment Premorbid Admission Discharge CPS Score

16 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, for subsequent delirium)

17 Cognitive impairment in TCP 351 cases assessed using the interrai HomeCare Probable dementia At entry 30% Pre-morbid 14% Symptoms suggestive of delirium 10%

18 Cases Severity of Cognitive Impairment TCP Older medical patients (n=643) CPS interpretation 0=normal 2 or greater=probable dementia 6=severe cognitive impairment Premorbid Admission Discharge CPS Score

19 Outcomes in TCP Outcome Initial hospital stay (days) Admission ADL score (mean) Community discharge Achieved at least one goal Cognitively impaired Cognitively intact p-value < < % 86.4% NS 88% 92.7% NS LOS in TCP Hospital readmission (6 months) 42.3% 39.3% NS

20 IS THERE ROOM FOR IMPROVEMENT?

21 Outcomes are worse... Hospitalised older patients Delirium* Falls (ns) Length of stay (days)* Normal Dementia Died* * P < 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

22 Percentages (%) Cognition: UQFCOG Percentages of documented assessment of cognitive ability within 48 hours of hospital admission A B C D E F G H I Hospital IDs

23 Percentages (%) Delirium: UQFDEL Percentages of patients screened for delirium A B C D E F G H I Hospital IDs

24 Can care be improved? Delirium incidence can be reduced in some cases with mild moderate risk in general medicine Inouye et al, NEJM , 340, 1999 Delirium incidence can be reduced in cases with fractured hip and cardiac surgery Marcantonio et al, JAGS , 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

25 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

26 Funding sources National Health and Medical Research Council The JO and JR Wicking Trust Alzheimer's Australia / Viertel Foundation Queensland Emergency Medicine Foundation

27 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 Mar;56(3): PubMed PMID: 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 /08/01;16(8): 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 ;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 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 March, 2013;43(3):8. Epub March, Travers C, Byrne G, Pachana N, Klein K, Gray L. Delirium in Australian hospitals: A prospective study. Current Gerontology and Geriatrics Research :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 Mar;33(1):55-8. PubMed PMID: Epub 2014/02/14. eng.

28 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

29 Websites... CRGM interrai Australia RAIplus CeGA Online