Dementia in the acute hospital setting what should we be doing and who should be doing it? Sarah Pendlebury Consultant Physician and Associate Professor NIHR Oxford Biomedical Research Centre Departments of Medicine and Geratology John Radcliffe Hospital, Oxford and Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford
Talk Outline 1. Focus on previously unrecognised/acute cognitive impairment in the general hospital 2. Background and drivers 3. Rates/associates of cognitive co-morbidity 4. OUHT cognitive screening protocol and rationale 5. Primary care responses to in-hospital identification of at-risk of dementia status 6. Implications/conclusions
Changing patients, changing needs Royal College of Physicians Report 2012 National Dementia Strategy, 2009 Nearly 2/3 of people admitted are over 65 and up to 50% may have cognitive impairment ~50% of these have no previous cognitive diagnosis
Mandatory screening for dementia in emergency admissions >75 years
Confusion in hospitalised patients Neurodegeneration Acute illness Environment Delirium Acute confusion Reversible Cerebrovascular disease Memory Executive Language Attention Pain Medication
Cognitive function MMSE Cognitive function is a dynamic entity Especially in acute illness Cognition #NOF normal MCI Dementia Stroke Death Time Stroke Sepsis UTI TIA Time/months Time
OUHT AGM: Prior known dementia and inhospital cognitive impairment Preadmission diagnosis of dementia <65yrs 0.5% (1/207) 65-75yrs 4.3% (3/69) 75yrs 21.8% (51/234) But in the cohort overall (aged >70 years) 54.5% ( 114/209) had AMTS <8 or MMSE <24 BMJ Open 2015, 16;5(11):e007808.
20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85 86-90 91-95 >95 Number of patients 0% 0% 0% 0% 42.9% 0% 0% 0% 1.5% 17.7% 42.9% 9.5% 20.6% 11.1% 31.5% 35.8% 40.6% Age-specific delirium rates in AGM in OUHT n=503, consecutive sample 80 70 60 50 No Delirium Delirium 40 30 20 10 0 Age/years BMJ Open 2015, 16;5(11):e007808.
Age-stratified delirium rate in AGM in OUHT Overall burden of delirium 20% (102/510) <65yrs 3% (6/207) 65-75 yrs 15.9% (11/69) >75 yrs 36.3% (85/234) Delirium > 10-fold higher 65yrs vs <65yrs BMJ Open 2015, 16;5(11):e007808.
Delirium: Associated factors (on admission) Strength of Factor association Age >75yrs ++ Dementia ++ Falls +++ TIA/stroke + Care package/care Home ++ Low cognitive score +++ Dehydration ++ Severe illness ++ Pressure sore risk +++ BMJ Open 2015.16;5(11):e007808.
Delirium: Associated factors during admission Factor Strength of relationship Urinary incontinence +++ Faecal incontinence +++ Bedbound +++ Sleep deprivation +++ Falls +++ Urinary catheter insertion +++ Infection +++ IHD - Stroke + Heart failure - Stay >7 days ++ New care home on discharge +++ Increased care ++ Death +++ BMJ Open 2015.16;5(11):e007808.
Ambulatory care: delirium and admission Among 379 patients (age=83.3/8.5 years), 62 (16%) had delirium at presentation after adjustment for age, delirium was associated with admission vs ambulatory care (OR=14.6, 7.3-29.2) 49/62 (79%) with delirium were admitted BGS, spring 2016
Mortality Risk (%) Co-morbid cognitive impairment and delirium are associated with mortality and co-morbidity 45 40 35 30 25 20 15 10 5 0 0 100 200 300 400 500 600 700 Days from admission delirium no delirium BMJ Open 2015.16;5(11):e007808. Co-morbid cognitive impairment is associated with mortality, falls, pressure sore risk, high care needs, length of stay. Also with dementia in the longer term Rockwood et al, Age and Ageing, 1999
Readmission Risk (%) Delirium is associated with a reduced risk of readmission in OUHFT AGM 80 no delirium 70 60 50 40 delirium 30 20 10 0 0 250 500 750 1000 1250 Days since discharge BMJ Open 2015.16;5(11):e007808.
Cognitive trajectories after delirium/tci Delirium and acute transient cognitive impairment (TCI) are associated with dementia risk (cf AKI and CKD) Rockwood et al. Age Ageing. 1999;28:551-6; Pendlebury et al. Stroke. 2011;42:3116-21 Delirium accelerates cognitive decline in Alzheimer s disease Fong et al. Neurology. 2009;72:1570-5.
Cognitive co-morbidity in OUH inpatients: summary For patients aged 75+ years admitted as emergency: Over one third are acutely confused (delirium) Over one fifth have known dementia Over one half score low on thinking/memory tests
0 Percent 10 20 30 40 0 0 Percent 10 20 30 Percent 10 20 30 0 Percent 10 20 30 40 AMTS by speciality 2013-15 Gen surgery 0 2 4 6 8 10 Score General Surgery AMTS in 167/895 (19%) patients AGM Urology 0 2 4 6 8 10 Score General medicine AMTS in 5112/8448 (61%) patients 0 2 4 6 8 10 Score Urology AMTS in 27/177 (15%) patients Vasc surgery OUH unpublished data 2 4 6 8 10 Score Vascular Surgery AMTS in 39/182 (21%) patients
Looking after a confused patient Individualising patient care Identifying/quantifying cognitive impairment getting to the right ward quickly individualised nursing care plans Knowing Me document reduce risk of deterioration (nutrition, hydration, pain) quiet environment involve families in discussions/decisions discharge planning (dossette box, care package) inform GPs psychological medicine
Implications for capacity/consent Capacity cannot be assumed on the basis of the patient s premorbid ability Over half of >75 year olds in AGM have delirium or dementia and or low AMTS In medicine, capacity assessment is only usually triggered by need for a procedure eg biopsy or in discharge planning (safety)
OUH Cognitive screening Protocol Done on admission as part of the clerking
0 2 4 6 8 0 1 2 3 Frequency 0 10 20 30 40 0 2 4 6 8 10 AMTS and MoCA scores in patients aged >75 years with vs without dementia/delirium No dementia/delirium 0 1 2 3 4 5 6 7 8 9 10 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 Dementia/delirium 0 1 2 3 4 5 6 7 8 9 10 AMTS 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 MoCA Pendlebury et al, Age and Ageing, 2015;44:1000-5.
AMTS 0 2 4 6 8 10 AMTS vs MoCA in AGM patients >/= 75 years 0 5 10 15 20 25 30 MOCA AMTS </= 8, high likelihood of a cognitive problem AMTS=9 or 10, a cognitive problem is less likely but cannot be excluded Age and Ageing 2015;44:1000-5
Subjective memory complaint does not agree well with objective measurement N~250 consecutive patients >75 years Age and Ageing 2015;44:1000-5
Cognitive screen/oxfordshire clerking proforma Revised cognitive screen without memory question
Risk stratification for delirium in AGM Susceptibility score using factors from pooled risk factor data. Data available from routine assessment at entry to acute care pathway Factor Score Age >80 years 2 Cognitive impairment 2 AMTS<9 or MMSE<24 and or known dementia Infection 1 Severe illness (SIRS>2) 1 >2 of heart rate >90 beats per minute, temperature <36 or >38 C, respiratory rate >20 breaths per minute, white blood cell count <4x10 9 or >12x10 9 cells/l. Vision impairment 1 Total 7 75% with scores 5-7 have delirium Age Ageing. 2016;45:60-5; Age and Ageing 2016 epub ahead of print
Cognitive screen/oxfordshire clerking proforma GPs informed of low AMTS (<9) and or delirium diagnosis after discharge (FAIR) Primary care clinicians best placed to decide whether specialist referral is appropriate
Audit of primary care responses to inhospital identification of at-risk status ie to determine the clinical effectiveness of the transfer of information on at-risk of dementia status from secondary to primary care.
Results: GP responses ~80% had low AMTS recorded (letter scanned, minority were coded) ~70% had been seen in primary care since discharge In only 1 case was this clearly in response to notification of cognitive impairment 5% were already under memory clinic with MCI 10% had had dementia diagnosed prior to admission 18% had cognition re-assessed 9% were referred for specialist assessment 4% had received a new dementia diagnosis
GP responses: reasons for non-reassessment No reasons were given for lack of cognitive re-assessment in the majority of patients Cited reasons for lack of reassessment included: patient already diagnosed with dementia (n=6) no concerns expressed by patient (n=2) patient unwell/clinically inappropriate (n=9) referral/reassessment declined by patient/family (n=3) abnormal cognition expected in context of acute illness (n=5)
Results: GP comments GPs expected abnormal cognition in context of acute illness Patient had sepsis due to renal abscess at time of admission V. frail. Dip in cognition attributed to acute admission with AKI Patient admitted with septicaemia leading to his poor cognition An admission AMTS is unhelpful. Many elderly patients are confused when acutely unwell. A discharge AMTS would be much more useful and we might then follow up. Clinically inappropriate End stage renal failure, not for resus or any further hospital contact - terminal care. Having treatment for oesophageal Ca so not considered appropriate Seen frequently by GP who has known pt for years. Further decline from CVA and death in July - focus not on long term dementia care but short-term supportive measures the priority. Patient/family decision Patient does not feel concerned enough at present. Further admission with GI bleeds. Pt has refused 3 times for memory referral. Son aware Process issues Patients should be instructed to make an appointment to see their GP a few weeks following discharge to discuss this. I do not have spare time in GP to review the patient records of 5 patients in detail. If you would like info that is accurate you will need to send some admin staff into surgeries to do this work Discharge letter v. poor diagnosis confusion no other details. No AMTS score sent to GP
Summary and Implications For patients aged 75+ years admitted as emergency: Over one third have delirium Over one fifth have known dementia Over one half score low on thinking/memory tests 10% are untestable Subjective complaints are not reliable Different cognitive tests have different strengths/weaknesses Capacity/consent issues
Summary and Implications Delirium risk stratification is feasible at entry to acute care Delirium and cognitive impairment is associated with mortality and in-hospital complications Routine memory clinic referral/review in secondary care is not appropriate Readmission risk lower in those with delirium
Summary and Implications The National Directed Enhanced Services (DES) for GP dementia case finding has ended (vascular factors, PD, learning disability) Cognitive function may normalise/improve but increased risk of dementia in the long term. Dementia risk is likely greater than from late-life vascular factors But GPs could use in-hospital identification of at-risk status to: -record cognitive vulnerability in the patient s problem list -automatically flag those in whom memory testing should be considered -help target discussions around end-of-life care (frailty) This would increase the cost-effectiveness of in-hospital cognitive screening which is resource intensive.
Acknowledgements NIHR Oxford Biomedical Research Centre Ana Phelps Bethany Kingston Caroline Mills Rose Wharton Stephen Klaus Melissa Mather Nicola Lovett Sarah Smith THE WOLFSON FOUNDATION
Summary and Implications The National Directed Enhanced Services (DES) for GP dementia case finding has ended (vascular factors, PD, learning disability) But GPs could use in-hospital identification of at-risk status to: -record cognitive vulnerability in the patient s problem list -automatically flag those in whom memory testing should be considered -help target discussions around end-of-life care (frailty) This would increase the cost-effectiveness of in-hospital cognitive screening which is resource intensive.
Prognostic implications Delirium and acute transient cognitive impairment (TCI) are associated with dementia risk (cf AKI and CKD) Rockwood et al. Age Ageing. 1999;28:551-6; Pendlebury et al. Stroke. 2011;42:3116-21 Delirium accelerates cognitive decline in Alzheimer s disease Fong et al. Neurology. 2009;72:1570-5. Cognitive function may initially normalise or improve but there is increased risk of dementia in the longer term. Risk is likely greater than the risk associated with vascular factors (mid-life rather than late-life vascular risk factors confer greater dementia risk).
Risk Prediction in Individuals: Screening, Trials Primary care: vascular risk, stroke, learning disability, PD Delirium/TCI probably confers greater risk in older patients Epidemiologic studies: After TIA and stroke: Framingham risk profile CAIDE (Rotterdam) Midlife factors and long-term risk severity baseline cognitive score pre-morbid Rankin frailty previous/recurrent stroke dysphasia age, education