Sarah Pendlebury is Associate Professor in the NIHR Oxford Biomedical Research Centre and the Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford and Consultant Physician and Clinical Lead for Dementia and Delirium at the Oxford University Hospitals NHS Foundation Trust. Research and audit interests include cognitive impairment associated with cerebrovascular disease and the interactions between vascular disease, neurodegeneration, co-morbidity and delirium and in the use of short pragmatic cognitive tests in patients with stroke and acute illness. Here she reports on an audit of the actions undertaken by GPs in response to letters informing them of in-hospital identification of cognitive impairment in their patient, which will be presented at the upcoming BGS Spring Meeting in Liverpool.
Dementia and delirium are prevalent in older patients with unplanned admission to hospital and are associated with death and increased dependency, but many confused patients do not have a dementia diagnosis prior to admission. Routine dementia screening for older people (>75 years) hospitalised as an emergency is mandatory in England with onward referral for specialist assessment in those identified as at-risk (dementia CQUIN).
Although specialist referral may be made directly from secondary care, routine referral may not be appropriate in the context of large numbers of screen-positive patients with acute illness and high mortality and co-morbidity. Primary care clinicians might therefore be better placed to decide with patients and families whether specialist referral to memory clinic is appropriate once the patient is medically stable in the community.
In the Oxford University Hospitals NHS Trust, all patients aged >75 years have the abbreviated mental test score (AMTS) and confusion assessment method (CAM) as part of an admission proforma [1,2] and GPs are informed by letter of patient at-risk status (abbreviated mental test score ≤8/10 and/or delirium diagnosis) after patient discharge.
We performed an audit, with the aim of determining the clinical effectiveness of the transfer of information on at-risk of dementia status from secondary to primary care.
We found that although the majority of letters on at-risk status were scanned and incorporated in the primary care record, there was a limited impact on patient care: only a minority of patients had undergone cognitive re-assessment and even fewer had been referred to a memory clinic. In most cases, no reason for non-reassessment was given. Where reasons were cited, these were usually clinical factors (eg frailty, end-of-life, not a priority issue, already under memory clinic follow-up, known dementia) but interestingly, several GPs stated that they had not repeated cognitive testing since they expected temporary cognitive impairment in the context of intercurrent illness. In a few cases, the patient or family declined memory clinic referral.
Confusion in acute illness has important prognostic implications: both delirium and acute transient cognitive impairment (TCI) are associated with increased risk of dementia on follow-up (cf AKI and CKD). Delirium also accelerates cognitive decline in Alzheimer’s disease. Thus, even if a patient’s cognitive function normalises or improves in the short term, there is increased risk of dementia in the longer term. It is likely that this risk is considerably greater in older people than the risk associated with vascular factors which have been used to guide screening for dementia (mid-life rather than late-life vascular risk factors confer the greater dementia risk).
We found evidence for suboptimal primary care use of in-hospital identification of co-morbid cognitive impairment and a lack of awareness of the prognostic utility of the information. Although the National Directed Enhanced Services (DES) for GP dementia case finding has ended, GPs should consider using in-hospital identification of at-risk of dementia status to automatically flag those at particularly high risk in whom memory testing should be offered; and as a frailty marker to help target discussions around end-of-life care. This would also help increase the cost-effectiveness of in-hospital cognitive (dementia) screening given the considerable resources required to screen thousands of patients per quarter. We shall shortly be sending out a newsletter article to all Oxfordshire GPs to improve primary care awareness of the clinical utility of hospital identification of at-risk of dementia status and of the prognostic importance of TCI and delirium.