Take time to talk! The importance of an informant history

Adam Dyer is a Final Year Medical Student in Trinity College Dublin. Dr. Sean Kennelly (MB PhD FRCPI) is a Consultant Physician in Geriatric and Stroke Medicine in Tallaght Hospital (Dublin, Ireland) and a Clinical Senior Lecturer in Medical Gerontology at Trinity College Dublin (TCD). The following work was presented as a platform presentation at the 64th Irish Gerontological Society Meeting in Killarney, Ireland (October, 2016).

Imagine you’re seeing a consult or you’re on a post-take ward round. How often do we examine a patient and identify cognitive deficits, see that the CT brain scan report and the MMSE score are readily on hand, but then ask staff about the patient’s premorbid cognition and function and are met with blank expressions?

An important factor which complicates the presentation of older people to acute hospitals is the presence of impaired cognitive status (either in the form of dementia, delirium or both). The key to unlocking the diagnosis of underlying diminished cognitive status in an older person is the low tech, often overlooked, but vitally important informant/collateral history. This refers to information obtained from a suitable contact (friend/relative/worker etc.) about the cognitive and functional abilities of those experiencing problems with memory/cognition.

Despite a welcome emphasis on the development of psychometric screening tools for “measuring” cognitive impairment in the acute setting, little has been written on the informant history, which has rarely been discussed as a distinct clinical entity. This is all the more remarkable when we consider the establishment of progressive functional loss is where a diagnosis of mild cognitive impairment ends and a diagnosis of dementia begins. It is notably absent from textbooks on geriatric medicine, undergraduate/postgraduate medical curricula and the academic literature. We conducted a study in a busy urban Emergency Department (ED) on the utility, availability and conduct of the informant history. This is the first empirical study to examine this important clinical entity.

We assessed over two hundred patients in the ED for the presence of impaired mental status using traditional screening tools for delirium (CAM-ICU) and general cognitive impairment (sMMSE) and where either of these were positive, we administered the AD8 (Eight Item Interview to Differentiate Ageing and Dementia) interview for dementia (a structured tool to guide the informant history).

The overall availability of the informant history in this acute context was just under two-thirds (61.1%) and where available, the informant history indicated a diagnosis of previously undiagnosed dementia in 39.4%. Most informants were relatives/friends of the patient and were rated ‘excellent’ or ‘very good’ in their ability to provide useful information and in their contribution to a patient’s care. The acute environment was also rated as suitable to brief (<6 minutes on average) informant interviews, and was rated suitable in terms of privacy and accessibility by the trained assessors. When the attending ED physician’s notes were examined, the documentation of an informant history was only made in 5.6%

Thus, despite the rich addition that the informant history offers in terms of characterising cognitive impairment in the ED, as well as the suitability of the acute environment to informant interviewing, its use remains rare. Our work advocates for increased inclusion of the informant history in medical curricula and academic literature, in addition to increased emphasis on the availability of structured informant tools such as the one used in the present study, AD8 Dementia Screening Interview.

Read the Age & Ageing Paper: INVESTIGATING COGNITIVE IMPAIRMENT IN THE EMERGENCY DEPARTMENT: THE ROLE OF THE INFORMANT HISTORY

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