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Cognitive impairment is a major geriatric giant, affecting at least 40% of older inpatients cared for in Departments of Geriatric Medicine.

Cognitive impairment has a profound effect upon course and outcome[1, 2, 3], and it is unarguable that it should be identified and managed appropriately in all geriatrics inpatients.

It is necessary to set a minimum standard of care for inpatients with cognitive impairment. We suggest that routine practice should ensure that all patients with cognitive impairment have this identified, and also that any cognitive impairment is diagnosed as delirium, dementia, or both; a minority of cases will not come under these three categories and in this case specialist referral might be appropriate. Going beyond simply identifying that there is cognitive impairment is crucial, for example delirium is often a presenting feature of serious acute illness, and because patients with dementia often have not had appropriate medical work-up and community support services arranged.

However, it is clear that modern medicine largely falls short of these standards[1, 4, 5]. Cognitive impairment is missed in many patients, and even when it is identified, an attempt at formal diagnosis is often not made.

There are undoubtedy several reasons for these suboptimal standards, including pressure of time, lack of familiarity with the diagnostic criteria for delirium and dementia, lack of standard methods for diagnosis, and so on.

To help address this, the consensus group have designed a toolkit for the detection and broad classification of cognitive impairment in older inpatients. The toolkit contains the screening algorithm initially published in the BGS document ‘Delirious about Dementia’[6], plus the cognitive tests (apart from the MMSE which could not be included for copyright reasons) and detailed instructions on their use.

We appreciate that applying the screening algorithm to inpatients will require additional time. However, the broad consensus is that, somehow, current poor standards of care need to be improved. Patients with cognitive impairment must be formally identified in every case, the nature of the cognitive impairment determined, and appropriate management instituted. Only by screening every patient with appropriate methods will this be achieved. The toolkit here provides one way of doing this.

We would be grateful to have feedback on any aspect of it.

Alasdair MacLullich
Duncan Forsyth
(on behalf of the consensus statement group)

References:

1. Who Cares Wins

2. Joray S, et al. (2004) Cognitive impairment in elderly medical inpatients - detection and associated six-month outcomes. American Journal of Geriatric Psychiatry 12 (6): 639-647

3. Sands LP, et al. (2003) Cognitive screening predicts magnitude of functional recovery from admission to 3 months after discharge in hospitalized elders. Journals Of Gerontology Series A - Biological Sciences and Medical Sciences 58 (1): 37-45

4. Laurila JV, et al. (2004) Detection and documentation of dementia and delirium in acute geriatric wards. General Hospital Psychiatry 26 (1): 31-35

5. Department of Health. (2001) National Service Framework for Older People. London: Department of Health.

6. Delirious-about dementia.pdf