Original articleDetection and documentation of dementia and delirium in acute geriatric wards
Introduction
Dementia and delirium are two common psychiatric disorders causing cognitive decline among older individuals. Early detection of these syndromes is desirable as both have a poor prognosis [1], [2], [3] and beneficial treatments are available [4], [5], [6], [7], [8].
Several studies have been published on detection of cognitive impairment in hospital settings. The recognition rate varied greatly, from 15.7 to 79% [9], [10], [11], [12], [13], [14]. However, the authors are familiar of only two studies assessing detection of dementia by physicians in hospital settings, with reported detection rates of 26.8% [15] and 84.6% [10]. To our knowledge, no studies have addressed the question of how physicians perform detailed and etiological diagnoses of dementia in their patients.
Numerous studies have also been published on detection of delirium, with reported rates of 6 to 93% by nurses [15], [16], [17] and 17 to 93% by physicians [9], [10], [11], [12], [15], [16], [17], [18], [19], [20], [21].
The purpose of this study was to investigate how physicians and nurses detect and distinguish between dementia and delirium among aged patients in acute hospital care. We also wanted to clarify in which detail physicians assess and detect cognitive decline in their patients.
Section snippets
Patients and methods
This study consisted of interviews and observations of patients in seven acute wards in two geriatric hospitals in Helsinki, Finland. All available patients during the study period were eligible to participate, excluding those aged less than 70 years or in a coma. After complete description of the study to subjects, written informed consent was obtained. In cases of poor judgement capacity or moderate cognitive impairment, informed consent was acquired from the patient's closest proxy. The
Results
Of the 241 patients eligible for enrollment, consent to participate was obtained from 230 (95.4%). Review of medical records was performed for 219/230. Patient demographic variables are shown in Table 1.
Dementia was defined by researchers (golden standard) for 88/219 (40.2%) subjects (Table 1). As a possible sign of a detected cognitive decline, ward physicians had given an order to perform cognitive testing on 42 of these 88 subjects (Fig 1). Ward physicians had also recorded some mention of
Discussion
Over 90% of patients we defined as having dementia were at least suspected of suffering from cognitive decline by their physicians. Unfortunately, a more detailed diagnostic procedure was not always performed, and only about half of these patients were subsequently diagnosed as having dementia. A specific, etiological diagnosis of the dementia was provided for less than 5% of dementia patients, resulting in only incidental actions to provide them with effective treatment with cholinesterase
Acknowledgements
This study was supported by the La Carita Foundation, Uulo Arhio Foundation, The Academy of Finland (Grant No. 48613), and the Helsinki University Central Hospital.
References (46)
- et al.
Delirium and other organic mental disorders in a general hospital
Gen Hosp Psy
(1985) - et al.
The misdiagnosis of delirium
Psychosomatics
(1997) - et al.
Unrecognized delirium in ED geriatric patients
Am J Emerg Med
(1995) - et al.
Mini-mental state—a practical method for grading the cognitive state of patients for the clinician
J Psychiatr Res
(1975) - et al.
Efficacy of rivastigmine in dementia with Lewy bodiesa randomised, double-blind, placebo-controlled international study
Lancet
(2000) - et al.
Efficacy of galantamine in probable vascular dementia and Alzheimer's disease combined with cerebrovascular diseasea randomised trial
Lancet
(2002) The dilemma of deliriumclinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients
Am J Med
(1994)- et al.
Prognosis of delirium in elderly hospital patients
Can Med Assoc J
(1993) - et al.
The risk of dementia and death after delirium
Age Ageing
(1999) - et al.
Alzheimer disease
J Am Med Assoc
(2002)
Functional status outcomes of a nursing intervention in hospitalized elderly
Image
Systematic intervention for elderly inpatients with delirium. A randomized trial
Can Med Assoc J
The prevalence and documentation of impaired mental status in elderly emergency department patients
Ann Emerg Med
Cognitive impairment in medical inpatients. IIDo physicians miss cognitive impairment?
Age Ageing
Recognition of dementia among medical patients
Arch Intern Med
Unsuspected emotional and cognitive disturbances in medical patients
Ann Intern Med
Detection of psychiatric disorders in elderly medical inpatients
Age Ageing
Deliriumthe often overlooked diagnosis
Int J Psychiat Med
Underdiagnosis and poor documentation of acute confusional states in elderly hip fracture patients
J Am Geriatr Soc
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2019, European Journal of PsychiatryCitation Excerpt :However, any of this possibilities are only speculative and could only be correctly addressed by further longitudinal follow-up studies. Finally, similar to previous reports in populations with a high prevalence of dementia,19–22 we found a low rate of delirium diagnosis by patients’ usual health providers. Although many patients may be treated as delirious even without this explicit diagnosis in the medical chart, its correct detection and denomination is necessary to obtain an adequate diagnosis, improve the communication among all members of the clinical team and hence the treatment of the entity, with a positive impact on the prognosis of the patient.18