Dementia screening in acute medical and geriatric hospital admissions

AIMS AND METHOD

We studied a representative cohort of 161 patients over 65 yearsof age, admitted non-electively to medical and geriatric wardsof a large teaching hospital. Assessment for dementia was madeusing DSM–IV criteria. Psychiatric records were thenexamined, masked, to determine the involvement of psychogeriatricservices.

RESULTS

There were 111 possible cases of dementia (69%), of which 30(27%) had prior local psychogeriatric case notes; in 22 cases(20%) the patient had a prior psychiatric diagnosis of dementia.Of 161 patients, 19 (12%) were seen by psychogeriatric servicesduring their admission, of whom 12 (7%) were already knownto psychiatric services. Dementia was diagnosed in 17 (complicatedby delirium in 2), depression in 1 and hypomania in 1. Many patients with a possible diagnosis of dementia had no psychiatric assessment.

CLINICAL IMPLICATIONS

Psychogeriatric assessment was performed on a minority of olderpeople admitted to medical care. This population may includeolder people with undiagnosed dementia and unmet psychiatriccare needs.

Introduction

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Introduction

Dementia is a relatively common diagnosis among the elderlypopulation. The frequency is thought to be higher in hospitalisedpatients than in community dwellers (Royal College of Psychiatrists, 2005),and is often unrecognised in the former group (Jorm & Jolley, 1998; Laurila et al, 2004). Providing hospital care for the olderperson with dementia has implications for individual patientoutcomes and broader financial costs.

Psychiatric assessment of older people in hospital may be an individual’s first contact with mental health services,or may occur because specific review is required of a knownpatient. The aim of this study was to determine the proportionof elderly patients admitted to medical or geriatric wardsthought to have a diagnosis of dementia, and their contact withlocal psychiatric services.

Method

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Method

An observational study of patients aged 65 years and over admittedto an acute medical unit or geriatric assessment unit generated161 sets of patient details (80 acute medical admissions and81 geriatric medical admissions). The patients were examinedby the Department of Medicine for the Elderly (DoME) to determinepotential diagnoses of dementia (using the DSM–IV checklist; see Appendix) (American Psychiatric Association, 1994) anddelirium (using the Confusion Assessment Method; H. Hu, personalcommunication, 2006).

The demographic details of the 161 patients were then used byan assessor masked to patient diagnosis to enable a searchof a computerised database, the Patient Information ManagementSystem, to determine those known to the local psychiatric services.Overall, 45 such patients were identified and the psychiatriccase notes of 44 were examined by hand (one set of notes was missing). A further six patients had psychiatric case notesthat were unavailable because they were outwith the catchmentarea.

Psychiatric diagnosis was sought along with relevant dates andfollow-up where documented. Where data appeared incomplete,community psychiatric nurses were asked to confirm diagnosisusing nursing notes. Once data had been collected from thepsychiatric notes, psychiatric diagnoses given by the DoME wererevealed. The diagnoses documented in the psychiatric case noteswere compared with the diagnoses given by DoME staff. Dementiawas the main diagnosis of interest, but other diagnoses wererecorded.

Results

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Results

Of the 161 patients, 44 had available psychiatry case notes (Fig. 1). Of these 44 patients, 13 were men (30%) and 31 werewomen (70%). The mean age of the cohort was 80 years and themean age of patients known to psychiatric services was also80 years.

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Fig. 1. Study profile.

From the medical cohort of 161 patients, 111 had a likely diagnosisof dementia as defined by the DSM–IV checklist (69%).Of these 111, only 22 (20%) had locally available psychiatriccase notes documenting a diagnosis of dementia. Of the 44 patientswith psychiatric case notes, 20 were known to services priorto the index hospital admission and 19 were referred as new cases. Psychiatric diagnoses are given in Table 1.

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Table 1. Psychiatric diagnoses in the sample

Medical staff referred five patients for psychiatric reviewwho were never seen by psychiatry and whose psychiatric casenotes contained no information regarding follow-up. Proposeddiagnoses by medical staff for these individuals were dementiain three cases. There was disagreement between the DoME proposed diagnosis of dementia and the diagnosis given by psychiatricstaff in two cases: the psychiatric staff diagnosed depressionin one case and hypomania secondary to steroid use in the other.

Discussion

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Discussion

In this sample, 20% of patients considered by DoME staff tohave dementia were known to psychiatric services as havingdementia. A minority were referred during the study periodas new cases. It would seem that the majority of individualswith dementia in our sample were being managed by primary care and other services without ever coming to the attention ofmental health services. It is possible that some patients werenot known to health or social services at all and that admissionto a medical ward was the first time a diagnosis of dementiahad been considered. There is potentially substantial unmetclinical need. It could be argued that involvement with psychiatric services is not always necessary when a person has dementiabut only when particular problems arise. It seems likely thatthe diagnosis of dementia is not solely determined by psychiatristsand that sharing of this information between professionalsis not universal.

The DoME and psychiatric staff might have used different screeningtools with potentially different validity to reach diagnosis.The DSM–IV checklist was used by DoME staff to definecases, but psychiatric notes generally did not contain informationas to how the diagnosis had been reached. It is likely thatdiagnoses by psychiatric staff were based on the Mini MentalState Examination (Folstein et al, 1975) and clinical presentation.There may be subtle differences in the way in which diagnosiswas reached, as the psychiatric assessment could have beenmade by a liaison nurse, a consultant psychiatrist or a specialistregistrar; it was not obvious from perusing the notes whichprofessional had carried out the assessment.

There was disagreement about diagnosis in some cases. Dementiawas diagnosed by DoME staff in one case in which psychiatricstaff diagnosed depression and in one case thought to be anorganic state secondary to steroid use. It would be difficultto be certain about these individuals’ diagnoses withoutaccurate longitudinal information which is not yet available.Five patients were referred for psychiatric assessment but were never seen by psychiatric services; three of these patientswere thought to have dementia. There are implications for patientswho ‘slip through the net’. It was not possiblefrom examining the notes to determine whether these individualswere later picked up by primary care or social work services.

The proportion of patients in medical and geriatric wards thoughtto have dementia in the original sample was high, with a pointprevalence of 69%. This is greater than the prevalence of 5–45%(mean prevalence 31%) mentioned in the Who Cares Wins documentfrom the Royal College of Psychiatrists (2005). This studypopulation may, therefore, not be entirely typical of olderpeople in hospital. It is also possible that there is over-diagnosisof dementia in this sample due to observational bias or relianceon the DSM–IV checklist.

Hospital care or DoME admission could represent a default pathwaywhereby older people with dementia come into hospital whena crisis arises at home. It is possible that the DoME is moreaccessible than psychogeriatric services, especially out ofhours. Relatives and carers may be more familiar with the ideaof being sent to the accident and emergency department withtheir loved one, rather than relying on the referrer contactinga community psychiatric nurse or psychiatrist for telephoneadvice.

This study may have limitations because of the small numberof psychiatric case notes examined. The six out-of-area casenotes were not examined for pragmatic reasons and it is notpossible to comment how the final results might have been affected.

Future research could examine if these results are similar tofindings in other geographical locations and whether the modelof psychiatric liaison provided has any impact on numbers ofpatients seen. Longitudinal information on service use andindividual outcomes would be interesting to determine if thereis a key time when psychiatric input becomes most valuable.Follow-up information on the cases where there is disagreementon diagnosis may be of educational value.

The optimal balance between confidentiality and coordinatedteam working may be difficult to determine, but could offerbenefits to individual patients by avoiding hospital admission,shortening length of stay and improving outcomes. Providingexpert advice on diagnosis and management has scope to improvecare for some of our most vulnerable elderly people.

Appendix

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Appendix

DSM–IV dementia checklist
For a diagnosis of dementia to be made according to DSM–IVall criteria A to D must be satisfied.

The presence of multiple cognitive deficits, one of which mustinclude memory impairment.
At least one of the followingcognitive disturbances:
- dysphasia
- dyspraxia
- agnosia
- disturbanceof executive functioning.
The above symptoms must be sufficientlysevere to cause significant impairment in the patient’ssocial or occupational functioningand represent a declinefrom previous level of functioning.
Delirium must be excluded.

Acknowledgments

Many thanks to the staff of the Glasgow Royal Infirmary academicdepartment for providing the original data. We thank ProfessorStott for his encouragement and advice on editing. Thanks arealso due to the secretarial staff at Parkview Resource Centreand the records staff at Parkhead Hospital for sourcing casenotes needed for the study.

References

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