Hospitalization May Accelerate Cognitive Decline in the Elderly

Abstract

A new study suggests that hospitalization puts elders on a slippery slope to long-term cognitive loss. The researchers followed nearly 1,870 community-dwelling seniors, interviewing them and giving brief cognitive tests every 3 years for up to 12 years. Among the 1,335 who were hospitalized at least once during the study, mean global cognitive score declined 0.031 per year before hospitalization and more than twice that, 0.075 per year, afterward. The authors said that the association between hospitalization and accelerated cognitive decline is uncertain but noted that delirium is common in older patients with acute illnesses and surgical procedures. They suggested that severity of illness, older age, and longer hospital stays may also be associated with cognitive decline after hospitalization (Neurology doi 10. 1212/WNL 0b013e31824d5894). The loss of cognition isn’t especially surprising, the study authors said. Hospitalization increases the risk of decline in activities of daily living and thus independence in the elderly, and this has been associated with impaired cognitive functioning. Additionally, some diseases common in this population – such as diabetes and chronic obstructive pulmonary disease – have been associated with cognitive decline late in life. “Predictably, it also appears that the frailer and more cognitively impaired elders are prior to hospitalization, the more at risk they are for cognitive decline afterward,” said lead author Dr. Robert Wilson, PhD, senior neuropsychiatrist of the Rush Alzheimer’s Disease Center in Chicago. However, he added, “I was surprised that the effect of hospitalization on cognition was as strong as it was.” Dr. Wilson noted that many unanswered questions remain. “Our study didn’t identify what can be done right before or after hospitalization to limit cognitive decline,” he said. Nevertheless, “it suggests that we need to fundamentally rethink how we are delivering health care to older adults. There may be instances where there are alternatives [to hospitalization], and we have to look at those carefully. ... The advantage of a large observational study such as ours is the ability to identify the problem. Now we need to follow up with more detailed studies that track cognitive function as patients move through the system.” Dr. Wilson noted that interventions that might benefit older patients include keeping them active socially, physically, and mentally, as well as minimizing depression. Dr. Dan Haimowitz, CMD, a multifacility medical director in Pennsylvania, noted, “This study provides yet another reason why physicians should do everything possible to keep older patients out of the hospital. ... While this study does not address nursing home patients and does not mention whether patients in the study ever were admitted to a long-term care facility, it certainly is reasonable to extrapolate that elderly nursing home patients also may be at risk for cognitive decline after hospitalization.” Dr. James Lett, CMD, chief medical officer and vice president of medical affairs at Charles E. Smith Life Communities in Maryland, added, “This study reinforces what has been anecdotally felt to be true.” The cost of cognitive impairment on a human level is “huge,” he said. “Residents have lessened pleasure in life, less rewarding interactions with their environment, and likely will attain a lower level of functioning on return.” A resident is also at greater risk of psychotropic use if behaviors occur as a result of lessened cognitive functioning. Dr. Haimowitz said that the disadvantages of hospitalization typically mentioned to families include nosocomial infections, delirium, confusion, inappropriate medications, and deconditioning from being bedbound. “Physicians now could reasonably add the risk of worsening cognitive decline as a possibility,” he said. CfA