Cognitive decline and dementia in elderly medical inpatients remain underestimated and underdiagnosed in a recently established university general hospital in Greece

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Abstract

The aim of this study was to report the prevalence of cognitive decline as well as its recognition rates in elderly inpatients in a general hospital in Greece. Two hundred randomly selected patients, 65 years old and over, hospitalized in surgery and internal medicine departments, were assessed for cognitive decline in a period of 12 months by means of structured clinical interview for DSM-IV axis-I disorders, clinical version (SCID-IV), mini-mental state examination (MMSE) and the clock drawing test (CDT). During the next 12 months the liaison calls were evaluated and the two periods were compared. During the first screening period, when psychiatric assessment was performed, 61 patients (30.5%) were diagnosed to present cognitive decline. During the second period, there were only 20 liaison calls from the same departments for patients over 65 years of age, from which 15 patients were found to present cognitive decline. Comparison between the two periods showed significant underestimation of cognitive decline. In the general hospital the cognitive decline of elderly inpatients remains still under-recognized.

Introduction

Old age is naturally associated with greater morbidity and mortality. It is well established that health services are used mostly by elderly individuals. Campbell and Howe (1989) showed that 51% of all beds in a general hospital, at any given time are occupied by individuals aged 60 years or more. Depression and dementia as well as delirium are more common in elderly general hospital patients, compared to elderly individuals living in the community (Schuckit et al., 1975, Copeland et al., 1987).

Dementia is diagnosed with increasing frequency as the age increases (Neugoschl et al., 2005, Wang and Ding, 2008). Nevertheless, the epidemiology of dementia in Greek community-samples is not established since there are few community studies (Argyriadou et al., 2001). However, there is good empirical evidence that dementia largely remains undiscovered, whilst the absence of a developed network of services for these patients in the community means that the burden of care remains with the nearest relatives. This leads to an increasing burden of care, reduction of the quality of life and enhancement of individual psycho-pathology.

The detection and treatment of psychiatric disorders in elderly general-hospital patients presents a challenge for the psychiatrist. Some factors hinder this effort. Firstly, the patients might be unable to cooperate because of hearing or sight problems, but also because of forgetfulness and difficulties in concentration. Secondly, the urgent physical problems that led to admission can distract the physician from a comprehensive mental assessment. The differential diagnosis and follow-up on treatment have also many difficulties.

All these conditions emphasize the great and urgent need for training in old age psychiatry for the doctors of general hospitals. There is also a great need for the introduction of easy to use screening tools in order to facilitate detection of cognitive deficits thus assisting appropriate assessment and referral for treatment. Little is known about the care elderly patients with physical and psychiatric illnesses receive in the general hospitals. There are reports though that psychiatric condition leads to longer admissions and increased morbidity in the general hospital wards (Campbell et al., 2004). Additionally the general hospital admission offers a good opportunity for diagnosing any uncovered psychiatric disorder through the psychiatric liaison services. If the diagnosis of mental illness is made during the admission for a physical problem, the person can be linked to the psychiatric services and followed up thereafter.

Our hypothesis was that cognitive decline and dementia in the elderly still remains underestimated. Thus the aim of this study was twofold: (a) firstly to report the prevalence of cognitive decline, and (b) to estimate its recognition rates in elderly inpatients in a general hospital in Greece.

Section snippets

Population and setting

This was a two-phase study. Patients aged 65 years and over consecutively admitted in the 4th Department of Internal Medicine and in the 3rd Department of Surgery in “Attikon” University Hospital were included in the study. This general hospital is located in the West district of Athens’ greater area, covering a population of more than 1,000,000.

Phase I: screening

During this first screening period 956 elderly patients were admitted. The study period lasted 12 months. Every fourth patient was examined within 3

Phase I: screening findings

Two hundred of the total 936 geriatric admissions were examined. The demographic data of our sample were as follows: 106 were male (53%), 94 female (47%), 133 lived with family or spouse (66.7%) and 67 alone (32.8%), the mean age of the patients was 74.0 ± 6.7 years (±S.D.) and the mean duration of their education lasted 6.4 ± 3.9 years, their mean length of stay (LOS) in the hospital (was 18.8 ± 13.6 days. The sample's mean MMSE total score was 24.5 ± 5.6 and clock test 5.0 ± 3.1.

From the total of 200

Discussion

The prevalence of cognitive decline in elderly hospital inpatients was found to be high (30.5%). Cognitive decline, however, was greatly under-recognized by physicians. The prevalence of cognitive decline in the liaison period was only 1.26%. The MMSE and the CDT gave similar results and were equally sensitive and easy to use. During the screening period, more cognitively declined subjects were was among the female, older and less educated patients. No affect by the mental state on the LOS in

Conclusions

All the above findings underline the need for regular screening for cognitive decline in the elderly. Screening tools (like the ones used in this study) for dementia are reliable, available, easy to use and score. All medical specialties that are in regular contact with elderly patients should be able to recognize cognitive decline and be confident in administering and scoring screening tests like the MMSE and clock test. Subsequently an appropriate referral should be made.

Conflict of interest statement

None.

References (21)

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