Working with elderly inpatients at Vancouver General Hospital, I interact with one of Canada’s most vulnerable health care populations every day. Of all the geriatric inpatients that I typically have on my caseload, a particular group stands out to me as being more disadvantaged and particularly exposed to adverse outcomes within our health care system. In my opinion, seniors with age related cognitive impairment are an incredibly vulnerable group that is currently being under-served by the health care system.
According to the Canadian Institute for Health Information (CIHI), one in four Canadians over the age of 85 have been diagnosed with dementia (CIHI, 2018). The term dementia itself is an umbrella term that includes such diagnoses as Alzheimers disease, Vascular Dementia and Lewy Body Dementia, and refers to the progressive decline in thinking and memory, along with a reduced capability when it comes to activities of daily living (CIHI, 2018). Mild Cognitive Impairment, or MCI, refers to changes in thinking/memory that are noticeable but subtler and are not yet impacting daily activities/function (Pottie, K., 2016). The incidence of MCI in Canada is unknown, in part due to a lack of a standard definition or standard “cut-off scores” on cognitive assessment, but is expected to be much higher than the rates of dementia (Pottie, K., 2016).
Figure 1. Dementia in Canada
(Zoomer, 2018)
Being an elderly person with an age-related cognitive impairment means that you are at increased risk of a whole host of undesired health outcomes. Patient falls while in hospital are a problem in any acute care setting that I have ever worked in and can have traumatic outcomes, especially in the frail elderly. In a study by Härlein et al. (2011) nearly 13% of older patients with cognitive impairment experienced a fall during their hospital admission, compared to 4.2% of patients without cognitive decline. This nearly three-fold increase in fall frequency is also correlated with increased length of stay, greater percentage of discharges direct to long term care, and greater incidence of mortality in hospital (Härlein et al., 2011). A similar study by Watkin, L. et al. (2012) examined the rates of adverse hospital events (falls, medication errors, etc) occurring in elderly inpatients with and without mild to moderate cognitive impairment and found that the patients with impairment were twice as likely to experience such an event. Cognitive decline also impacts outcomes in patients presenting to emergency department or requiring acute surgical intervention. In their study Albett, A. et al. (2019) found that cognitive impairment was associated with three times the risk of 30-day mortality, and dementia alone was found to be an independent risk factor for post-operative complications.
In my own experience, patients with dementia or acute confusion tend to lack awareness of their mobility status or physical impairments while in hospital. They will often try and get up and mobilize to the bathroom on their own, for example, potentially resulting in falls (especially in very cramped hospital rooms which pose many potential tripping hazards). Many patients are admitted to the unit after experiencing a fall in the emergency department (the most common place for a hospital fall according to Härlein et al., 2011) which I imagine is due to the busy and chaotic nature of the ER which can result in elderly “stable” patients (often awaiting admission to ward) being left unattended. On the ward, chair alarms and bed alarms are helpful for alerting staff to a patient that is getting up on their own but sometimes patients move very quickly! This solution also relies on staff recognizing the risk posed by a patient and implementing the alarm systems.
Figure 2. Seniors with dementia more frequently admitted to hospitals for fall-related injuries.
(CIHI, 2016)
Of course, the risks for these patients residing in the community can be even greater than the risks they face in a care setting such as the hospital, especially for those who live alone. In a prospective cohort study by Tierney et al. (2004) 21.4% of study participants with cognitive impairment were found to be experiencing some degree of self harm (most commonly failure to eat or drink or perform necessary personal care) in the follow up after hospital discharge. It should be noted that this study only included well educated, urban dwelling seniors who speak English fluently, have a family doctor and have a close friend or relative providing weekly visits (Tierney et al., 2004). The majority of the patients that I see at Vancouver General Hospital are not so lucky as many have limited community supports and lack attachment to a general practitioner in the community.
Perhaps an even greater problem is the under diagnosis and decreased awareness of MCI and even dementia among healthcare workers and physicians. Gibson, A. & Richardson, V. (2017) studied cognitive impairment in elderly seniors living alone and found that most of the patients that they identified as having impairments had never received any type of formal diagnosis. The Watkin, L. et al. study (2012) mentioned above found that only one third of patients who met the DSM criteria for the diagnosis of dementia were identified by staff working with the patient as being confused or impaired.Torrison, G. et al. (2012) attest that nurses do a better job, in general, of recognizing cognitive impairment compared to physicians.I imagine that this is because nurses tend to spend much more time with a patient as physicians are responsible for overseeing a much larger caseload.When you only spend a few minutes with a patient, it is easy to miss a mild cognitive impairment.A common theme I hear in rounds and see in charting is “A+O x3” (meaning alert and oriented to person, place and time).It seems to be a general assumption amongst many clinicians that if a person is A + O x3 then they are cognitively intact. I believe that if you use this as your sole assessment of patient’s level of cognition you are missing a lot of patients with MCI or even greater impairments.I have seen countless patients who are technically A+O x3 (I often suspect that patients are learning the answers after being asked the same question dozens of time in a day) but when you start having a conversation with them, they start to contradict themselves and their stories fall apart.
Figure 3. How does Alzheimer's disease affect the brain?
(National Institute on Aging, 2019)
Noticing and documenting cognitive changes is critical. For one thing, physicians can have more frank and realistic conversations about the risks and benefits of a procedure (such as a surgery) with family members if they know that their loved one has dementia and is at increased odds of a bad outcome (Albett, A. et al., 2019). As well, patients with MCI and dementia are much more likely to have undiagnosed (and often treatable) additional medical conditions (Löppönen et al., 2004). I suspect that this may be due to their decreased likelihood of seeking attention for new or different medical symptoms (Tierney, M., 2004). Finally, and perhaps most importantly, cognitive impairment precedes and often predicts subsequent functional impairments (Gibson, A. & Richardson, V., 2017). A longitudinal study by Boyle, P. et al. (2012) found that a decline in cognitive status over the study period predicted poor decision making and poorer judgement, often impacting the safety of those living alone.
Although the science is still in its early stages, there is some evidence that early interventions and lifestyle changes may be able to slow or even prevent the progression of MCI to greater impairment. In their longitudinal study, Katayama, O. et al. (2021) found that patients who engaged in “lifestyle activities” (such as grocery shopping, reading newspapers, gardening, engaging in a hobby, and performing household chores) were significantly less likely to progress to a diagnosis of dementia compared to those who were more sedentary and dependent on others. Li,H. et al (2011) found that cognitive based interventions had moderate sized effects on language, anxiety level and functional ability in patients with MCI in addition to mild effects on working memory, attention and depression. Cognitive interventions can include environmental adaptations and compensatory strategies (for example, keeping a notepad by the phone or using a timer on your phone to remember medications) as well as cognitive rehabilitation training to work on memory and attention (Booth, V. et al., 2018). One study has even found that these interventions can result in effects that are visible on functional MRIs, suggesting that neuroplasticity is possible in individuals with MCI to a greater extent then previously thought (Miotto, E., 2018).
Figure 4. Alzheimer's disease: signs and symptoms.
(Brain Institute, nd)
Based on the evidence, coloured by what I have observed working with geriatric inpatients, I argue that the first and most important issue that needs to be addressed is increased awareness and identification of age-related cognitive impairment by all health care professionals. Determining a patients cognitive status based solely on if a patient is alert to person, place and time is inadequate. All health care staff, especially nurses who tend to spend a far greater amount of time with patients compared to physicians, should be provided with adequate education on how to recognize signs of mild cognitive impairment and the importance of communicating this to members of the interdisciplinary team. As well, it would be prudent to embark on education campaigns to the general public on what constitutes “normal aging” when it comes to cognition. I come across situations almost daily where I speak to family members of a confused patient and hear something along the lines of “of course they don’t remember x, they’re old” when in reality the patient has undiagnosed dementia. If families and caregivers are aware of diagnoses such as dementia, this can (and should) lead to conversations with the care team on strategies to reduce risk of injury or harm to the patient, especially if they live in the community.
References
Ablett, A. D., McCarthy, K., Carter, B., Pearce, L., Stechman, M., Moug, S., Hewitt, J., & Myint, P. K. (2019). Cognitive impairment is associated with mortality in older adults in the emergency surgical setting: Findings from the Older Persons Surgical Outcomes Collaboration (OPSOC): A prospective cohort study. Surgery, 165(5). https://doi.org/10.1016/j.surg.2018.10.013
Brain Institute, (nd). Alzheimer’s disease: signs and symptoms [Figure]. Brain Institute website. https://www.ohsu.edu/brain-institute/understanding-alzheimers-disease
Booth, V., Harwood, R. H., Hood-Moore, V., Bramley, T., Hancox, J. E., Robertson, K., Hall, J., van der Wardt, V., & Logan, P. A. (2018). Promoting activity, independence and stability in early dementia and mild cognitive impairment (PrAISED): development of an intervention for people with mild cognitive impairment and dementia. Clinical Rehabilitation, 32(7). https://doi.org/10.1177/0269215518758149
Boyle, P. A., Yu, L., Wilson, R. S., Gamble, K., Buchman, A. S., & Bennett, D. A. (2012). Poor decision making is a consequence of cognitive decline among older persons without Alzheimer’s Disease or Mild Cognitive Impairment. PLoS ONE, 7(8). https://doi.org/10.1371/journal.pone.0043647
Canadian Institute for Health Information (2016). Seniors with dementia more frequently admitted to hospitals for fall-related injuries [Figure]. CIHI website. https://www.cihi.ca/en/dementia-in-canada/spotlight-on-dementia-issues/dementia-and-falls
Canadian Institute for Health Information (2018). How dementia impacts Canadians. Canadian Institute for Health Information website. https://www.cihi.ca/en/dementia-in-canada/how-dementia-impacts-canadians
Gibson, A. K., & Richardson, V. E. (2017). Living alone with cognitive impairment. American Journal of Alzheimer’s Disease & Other Dementias, 32(1). https://doi.org/10.1177/1533317516673154
Härlein, J., Halfens, R. J., Dassen, T., & Lahmann, N. A. (2011). Falls in older hospital inpatients and the effect of cognitive impairment: A secondary analysis of prevalence studies. Journal of Clinical Nursing, 20(1–2). https://doi.org/10.1111/j.1365-2702.2010.03460.x
Katayama, O., Lee, S., Bae, S., Makino, K., Shinkai, Y., Chiba, I., Harada, K., & Shimada, H. (2021). Lifestyle changes and outcomes of older adults with mild cognitive impairment: A 4-year longitudinal study. Archives of Gerontology and Geriatrics, 94. https://doi.org/10.1016/j.archger.2021.104376
Li, H., Li, J., Li, N., Li, B., Wang, P., & Zhou, T. (2011). Cognitive intervention for persons with mild cognitive impairment: A meta-analysis. Ageing Research Reviews, 10(2). https://doi.org/10.1016/j.arr.2010.11.003
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Miotto, E. C., Batista, A. X., Simon, S. S., & Hampstead, B. M. (2018). Neurophysiologic and cognitive changes arising from cognitive training interventions in persons with Mild Cognitive Impairment: A systematic review. Neural Plasticity, 2018. https://doi.org/10.1155/2018/7301530
National Institute on Aging (2019). How does Alzheimers disease affect the brain? [Figure]. National Institute on Aging website. https://www.nia.nih.gov/health/alzheimers-disease-fact-sheet
Pottie, K., Rahal, R., Jaramillo, A., Birtwhistle, R., Thombs, B. D., Singh, H., Gorber, S. C., Dunfield, L., Shane, A., Bacchus, M., Bell, N., & Tonelli, M. (2016). Recommendations on screening for cognitive impairment in older adults. Canadian Medical Association Journal, 188(1). https://doi.org/10.1503/cmaj.141165
Tierney, M. C., Charles, J., Naglie, G., Jaglal, S., Kiss, A., & Fisher, R. H. (2004). Risk factors for harm in cognitively impaired seniors who live alone: A prospective study. Journal of the American Geriatrics Society, 52(9). https://doi.org/10.1111/j.0002-8614.2004.52404.x
Torisson, G., Minthon, L., Stavenow, L., & Londos, E. (2012). Cognitive impairment is undetected in medical inpatients: a study of mortality and recognition amongst healthcare professionals. BMC Geriatrics, 12(1). https://doi.org/10.1186/1471-2318-12-47
Watkin, L., Blanchard, M. R., Tookman, A., & Sampson, E. L. (2012). Prospective cohort study of adverse events in older people admitted to the acute general hospital: Risk factors and the impact of dementia. International Journal of Geriatric Psychiatry, 27(1). https://doi.org/10.1002/gps.2693
Zoomer. (2018). Dementia in Canada [Figure]. Zoomer website. https://www.everythingzoomer.com/health/2018/08/13/help-wanted-caregivers/
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