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Dementia in the acute hospital
- Elizabeta B. Mukaetova-Ladinska, Andrew Teodorczuk, Joaquim M. Cerejeira (14 September 2009)
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Elizabeta B. Mukaetova-Ladinska, Senior Lecturer in Old Age Psychiatry Newcastle University, Andrew Teodorczuk, Joaquim M. Cerejeira
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Elizabeta.Mukaetova-Ladinska{at}ncl.ac.uk Elizabeta B. Mukaetova-Ladinska, et al.
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In the July’s issue, Sampson et al1 addressed the importance of additional resources attached to the medical care of the growing population of elderly with dementia or cognitive impairment. Although restricted to elderly undergoing medical acute admissions, the study highlights the under-diagnosis of dementia, its poor short-term outcome and high mortality rates during admission. If we translate these findings in a clinical setting, the problem of undiagnosed dementia in medical milieu appears to be much wider. Thus, in Newcastle alone, out of nearly 17,000 annual non-elective admissions of over 65 years old, only 4.3% are referred to the liaison team for older people’s mental health (LOP), suggesting that a large proportion of elderly (up to 38%, using Sampson et al1 data) that are not referred to specialist mental health liaison teams, may well have undiagnosed and untreated mental health problems, including dementia and dementia-related health problems. Hospital-based LOP teams are seeing a number of elderly people with memory problems in various medical settings and dementia patients in an acute medical setting may represent only a small portion of all elderly admitted on other medical and surgical wards. Thus, our LOP team (providing hospital mental health care for a region of estimated 41,000 elderly, n=730-1,200 referrals/annum) on average gets 26% referrals from acute medical wards, with similar proportion (25%) from care of the elderly wards, and/or rehabilitation wards (16%), whilst additional 33% come from various surgical and other specialised medical wards (e.g. dermatology, infectious disease etc.). Of these, 40.0% are already known to old age psychiatry services. The majority of performed assessments are related to dementia (59%), level of care (25%) and behavioural problems as a result of known memory problems (15%). Importantly, 19% of medically ill patients are obtaining their first diagnosis of dementia via our service, a finding similar to that described by Sampson et al1. An additional 17% of assessments identify various social issues closely related to the presence of cognitive impairment. The high rate of elderly with dementia on medical wards should not come as a surprise, since on average people with dementia (irrespectively of the type of dementia) have three or more physical illnesses2. Furthermore, severity of dementia independently predicts hospitalisation3. However, the impact of comorbidity on survival appears not to be dependent on severity of dementia4, but the number of medical diseases, which in turn contribute to more rapid dementia decline5. The high mortality rates described for people with dementia1 also confirm previous findings of presence of concomitant psychiatric and somatic disorders resulting in poor outcome6. Furthermore, while the burden of chronic medical conditions was similar in demented and non- demented patients, the severity of acute illness (assessed with APACHE II) was higher in subjects with dementia/cognitive impairment1. This finding is consistent with the reported under-diagnosis of medical problems in patients with dementia which can preclude their early detection and treatment7. Interestingly, the authors have incorporated the delirium episodes in the analysis if they have resolved within four days. This per sé may explain the reported high death rates that are very similar to those reported for delirium in the elderly8. In support of the presence of underlying delirium goes the reported finding of higher burden of acute physiological disturbances in the dementia/cognitively impaired subjects1. Attention was drawn in a previous study to difficulties assessing delirium with MMSE in acutely medically ill elderly9. In these patients, the most frequent symptoms reported on CAM are those of memory impairment (55%) and disorientation (37%), whereas the characteristic delirium symptom of altered level of consciousness is reported in only 21%. Similarly, 24% of elderly with an acute medical illness cannot be assessed by MMSE. Thus, although definition of delirium based on CAM (DSM-III) or DSM-IV criteria may be adequately suited for delirium assessment in medically ill elderly with cognitive impairment, there still seems to be a lack of standardised instruments specifically developed to be used in this population. Interestingly 30% of the participants came from sheltered, residential and/or nursing homes and this group in particular had a higher mortality rate1. This raises an additional issue about the healthcare that is provided within these venues and the accessibility to adequate services that in the light of the findings may well need to be provided in situ. Lastly, we agree with the conclusion that additional mental health liaison services will need to be further developed. Moreover, to cope with the rising numbers of people with dementia the educational role of such teams is likely to become increasingly important. Though tailored around the learning needs of each group, the focus should be on increasing awareness and understanding of dementia10. The key challenge, which will determine the success of any educational endeavour and ultimately whether outcomes for the older person with dementia are improved, is to ensure that knowledge is successfully transferred into improved practice behaviour11. REFERENCES: 1. Sampson EL, Blanchard MR, Jones L, Tookman A, King M. Dementia in acute hospital: prospective cohort study or prevalence and mortality. Br J Psychiatry 2009; 195: 61-6. 2. Schubert CC, Boustani M, Callahan CM, Perkins AJ, Carney CP, Fox C, et al. Comorbidity profile of dementia patients in primary care: Are they sicker? J Am Geriatr Soc 2006; 54: 104-9. 3. Albert SM, Costa R, Merchant C, Small S, Jenders RA, Stern Y. Hospitalization and Alzheimer’s disease: results from a community-based study. J Gerontol A Biol Sci Med Sci 1999; 54: 267-71. 4. Doraiswamy PM, Leon J, Cummings JL, Marin D, Neumann PJ. Prevalence and impact of medical comorbidity in Alzheimer’ disease. J Gerontol A Biol Med Sci 2002; 57: M175-7. 5. Boksay I, Boksay E, Reisberg B, Torossian C, Krishnamurthy M. Alzheimer’s disease and medical disease conditions: A prospective cohort study. JAGS 2005; 53: 2235-6. 6. Van Dijk PTM, Dippel DW, Van der Meulen JH, Habbema JD. Comorbidity and its effect on mortality in nursing home patients with dementia. J Nerv Mental Dis 1996; 184: 180-7. 7. Zekry D, Herrmann FR, Grandjean R, Meynet MP, Michel JP, Gold G, et al.Demented versus non-demented very old inpatients: the same comorbidities, but poorer functional and nutritional status. Age Ageing 2008; 37: 83-9. 8. Mukaetova-Ladinska EB, McKeith IG. Delirium and Dementia. Medicine 2004; 32: 44-7. 9. Yates C, Stanley N, Cerejeira JM, Jay R, Mukaetova-Ladinska EB: Screening instruments for delirium in older people with an acute medical illness. Age Ageing 2009; 38: 235-7. 10. Department of Health: Living well with Dementia. London 2009 11. Teodorczuk A, Welfare M, Corbett S, Mukaetova-Ladinska E. Education, hospital staff and the confused older patient. Age Ageing 2009; 38: 252-3. |
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