Recognition of Dementia in Hospitalized Older Adults
Issue #5 of Dementia Series
WHY: About one fourth of older hospital patients have dementia (Maslow, 2006). Their dementia may never have been formally diagnosed, and even if it has been diagnosed, the diagnosis may not be noted in their hospital record. Because of stress caused by acute illness and being in an unfamiliar setting, some older patients show symptoms of dementia for the first time in the hospital. In addition, the stress of a hospitalization may worsen the cognition of people with Mild Cognitive Impairment (MCI) (Peterson, 2011).
Older hospital patients with dementia are at much higher risk than other older hospital patients for delirium, falls, dehydration, inadequate nutrition, untreated pain, and medication-related problems. They are more likely to wander, to exhibit agitated and aggressive behaviors, to be physically restrained, and to experience functional decline that does not resolve following discharge. This Try This document suggests ways hospitals can increase recognition of dementia in their older patients, to lessen or avoid any of these problems.
TARGET POPULATION: The prevalence of dementia in people 65 and over is between 10-20% (Peterson, 2011). Dementia should be considered a possibility in every hospital patient age 75 and over and can be present in younger patients as well. People with dementia usually come into a hospital for treatment of their other medical conditions, although some come in because of complications of their dementia. Of older people with dementia, 30% also have coronary artery disease; 28% congestive heart failure (CHF); 21% diabetes; and 17% chronic obstructive pulmonary disease (COPD) (Bynum et al, 2004).
BEST PRACTICES: Ideally older patients in hospitals would be routinely assessed using a valid and reliable cognitive assessment instrument. Given that this is not standard practice today, several approaches can be used to increase recognition of dementia in older hospital patients. One approach is to ask the person and family if the person has “severe memory problems.”i Another approach is to ask if a doctor has ever said that the person has Alzheimer’s disease or dementia.ii The easiest way to do this is to add the items “severe memory problems,” “Alzheimer’s disease,” and “dementia” to the list of diseases and conditions patients and families are routinely asked about on intake forms and in intake interviews.
Two instruments on the second page can also be used to alert staff to the possibility of dementia. The approaches exemplified in these instruments identify “triggers” that indicate a possible problem and need for further assessment. It should be noted that reliability for these instruments has not been established. Hospitals should consider which approach(es) will work best within their existing admission procedures. A combination of approaches may be most effective.
When no prior diagnosis of dementia is reported:
1. Family Questionnaire. A family member or friend who accompanies the patient to the hospital can be handed a print copy of the 7-item Family Questionnaire.iii This questionnaire is intended to identify memory problems that interfere with day to day activities – a hallmark sign of possible dementia. As an alternative to the print questionnaire, the intake interviewer or other hospital staff can ask the family member or friend the seven questions. Responses can be scored by staff.
2. Patient Behavior Triggers for Clinical Staff:iv This tool includes signs and symptoms that suggest the need to consider dementia. The intake interviewer and other hospital staff can be asked to record or report their own observations of these signs and symptoms (Mion et al., 2001).
Note: At the time of hospital intake, it is very difficult to differentiate dementia from delirium, and many older patients with dementia also have delirium (Fick et al., 2000). None of the approaches above rule out delirium. Further assessment is needed for this purpose (See Try This: issues related to delirium assessment: Confusion Assessment Method, Confusion Assessment Method for the ICU, and Assessing and Managing Dementia in Persons with Dementia.
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