Cognitive impairment in older hospital inpatients: prevalence, care needs and carer perceptions

Abstract

Objectives The aim of this study was to describe the prevalence of cognitive impairment in hospital inpatients, the associated need for assistance with activities of daily living (ADL) and carer perceptions of hospital care. Methods A prospective cross-sectional observational study was conducted in a large metropolitan teaching hospital in Brisbane, Australia. Participants were inpatients aged ≥65 years and their carers. Cognitive impairment was measured by clinician auditors using the validated 4 ‘A’s test (4AT), with a score >0 indicating cognitive impairment (1–3, probable dementia; >3, probable delirium). The need for supervision and/or assistance with ADL was recorded from daily nursing documentation. Carers were invited to complete a brief questionnaire. Results In all, 92 of 216 older inpatients (43%) had cognitive impairment, including 52 (24%) with probable delirium. The need for supervision and/or assistance with ADL increased significantly with 4AT score. Fifty-two carers of patients with cognitive impairment reported feeling welcome and that care was safe. They identified opportunities for better information, greater support and more inclusion of carers. Conclusions Cognitive impairment is common in older inpatients and is associated with increased care needs. Workforce planning and health professional training need to acknowledge the needs of patients with cognitive impairment. There are opportunities for greater support and more involvement of carers. What is known about the topic? Cognitive impairment due to delirium and dementia increases with age, and is common in older medical and surgical inpatients. However, cognitive impairment remains under-recognised by healthcare staff. Australian guidelines now recommend routine screening using valid tools, and including carers, when appropriate, when assessing, caring for and communicating with people with cognitive impairment. What does this paper add? This cross-sectional study using the validated 4AT showed 43% of hospital inpatients aged ≥65 years had cognitive impairment. Participants with cognitive impairment had higher care needs and much longer hospitalisations. Carers of people with cognitive impairment reported unmet information needs in hospital and had limited involvement in assessment and care. What are the implications for practitioners? Cognitive impairment is common in older inpatients. Hospitals and healthcare professionals must be prepared and equipped to recognise cognitive impairment, and address the accompanying patient and carer needs.

Identification and information management of cognitive impairment of patients in acute care hospitals: An integrative review

“…Twenty-two primary studies were included in the review, including fourteen quantitative [ 12 , [42] , [43] , [44] , [45] , [46] , [47] , [48] , [49] , [50] , [51] , [52] , [53] , [54] ], four qualitative [ 30 , [55] , [56] , [57] ], and four mixed methods studies [ 29 , [58] , [59] , [60] ] ( Table 3 ). The included studies were published between 2003 and 2023 and were conducted in the UK ( n = 7), the USA ( n = 4), Australia ( n = 4), Canada ( n = 3), New Zealand, Finland, Italy, and Germany.…”

“… Not reported Concerns: none Voyer et al., 2008 [ 50 ] Canada Analytical cross-sectional study Delirium Source: nurse evaluation within 48 h of admission Screening tool: no Record and store: patient medical records and nursing notes Report: reported to other clinicians either orally or in writing, Utilise: utilised for treatment for monitoring and response to treatment, Refer: referral and post-care information depend on the organisation (varies) Always some interaction with patients, sometimes with relatives as well depending on the severity of the diagnosed impairment. Concerns: incomplete measurements Mudge et al., 2022 [ 12 ] Australia Multimethod study (descriptive cross-sectional study and survey) Dementia, delirium, CI Source: routine admission assessment information sought from patients, family (most commonly), friends, GP, community services) screening tool: 4AT Record and store: 4AT screening result is recorded on paper and generally remain at the bedside for the duration of admission; a scanned copy is stored and available at subsequent admission. Report: abnormal screen score reported by the assessing nurse to the admitting medical officer, formal assessment for delirium by a trained health professional (doctor or occupational therapist), Refer: diagnosis of delirium conveyed to primary care doctor in discharge summary (in the survey, 78% of those with a medical diagnosis of delirium had CI documented) Only half of carers had been asked about changes in cognition, fewer than half felt invited to contribute to the care, only one in seven had received any information about delirium prevention, quality of communication changed depending on ward and team.…”

“…Information about patient interaction in practice was obtained from nine studies ( n = 9/22). Patient interaction was valued but was lacking ( n = 6) [ 12 , 42 , 48 , 55 , 56 , 59 ]. Three papers reported the interaction with patients, families, and carers to provide education and support regarding the diagnosis, prognosis, and management [ 30 , 43 , 50 ].…”

“…CI is common among patients admitted to acute care hospitals [ 11 ], affecting up to two-fifths of older inpatients in medical wards at any given time [ 12 , 13 ]. People with CI have greater needs for hospital services than those without CI [ 14 ].…”