Abstract
Introduction: routine cognitive screening for in-patients aged ≥75 years is recommended, but there is uncertainty around how this should be operationalised. We therefore determined the feasibility and reliability of the Abbreviated mental test score (AMTS/10) and its relationship to subjective memory complaint, Montreal Cognitive Assessment (MoCA/30) and informant report in unselected older admissions.Methods: consecutive acute general medicine patients aged ≥75 years admitted over 10 weeks (March–May 2013) had AMTS and a question regarding subjective memory complaint (if no known dementia/delirium). At ≥72 h, the 30-point Montreal Cognitive Assessment (MoCA) and Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) were done. Cognitive impairment was defined as AMTS < 9 or MoCA < 26 (mild impairment) and MoCA < 20 (moderate/severe impairment) or IQCODE ≥ 3.6.Results: among 264 patients (mean age/SD = 84.3/5.6 years, 117 (44%) male), 228 (86%) were testable with AMTS. 49/50 (98%) testable patients with dementia/delirium had low AMTS compared with 79/199 (44%) of those without (P < 0.001). Subjective memory complaint agreed poorly with objective cognitive deficit (39% denying a memory problem had AMTS < 9 (kappa = 0.134, P = 0.086)) as did informant report (kappa = 0.18, P = 0.15). In contrast, correlation between AMTS and MoCA was strong (R2 = 0.59, P < 0.001) with good agreement between AMTS < 9 and MoCA < 20 (kappa = 0.50, P < 0.01), although 85% of patients with normal AMTS had MoCA < 26.Conclusions: the AMTS was feasible and valid in older acute medicine patients agreeing well with the MoCA albeit with a ceiling effect. Objective cognitive deficits were prevalent in patients without known dementia or delirium but were not reliably identified by subjective cognitive complaint or informant report.
Highlights
Up to one half of the in-patient population of the average general hospital is aged over 65 years and many have co-morbid cognitive impairment associated with high care needs and poor outcomes including increased mortality, complications and institutionalisation [1, 2]
The proforma included a cognitive screen on the front page (Supplementary data, Appendix S1, available in Age and Ageing online) completed by the admitting team with the abbreviated mental test score (AMTS), confusion assessment method (CAM) [11], documentation of pre-admission dementia and of prevalent delirium and a single question to establish the presence of subjective memory complaint
Among 264 patients (mean age/SD 84.3/5.6 years, range 75–101 years, median (IQR) 84 (80–88) years, 117 (44%) male), 228 (86%) overall, 178/199 (89%) without and 50/65 (77%) with dementia/delirium were testable with the AMTS
Summary
Up to one half of the in-patient population of the average general hospital is aged over 65 years and many have co-morbid cognitive impairment associated with high care needs and poor outcomes including increased mortality, complications and institutionalisation [1, 2]. Services in the general hospital have often failed to adapt to the increasing numbers of frail patients with multiple co-morbidities [1, 2], and cognitive impairment is Routine cognitive screening in older patients admitted to acute medicine often not recognised by staff because of a tendency to focus on physical rather than mental health [4, 7]. Routine cognitive screening for older people admitted to the general hospital is recommended The abbreviated mental test score (AMTS) [8] is recommended as a brief pragmatic test of cognitive function in the general hospital The abbreviated mental test score (AMTS) [8] is recommended as a brief pragmatic test of cognitive function in the general hospital (www.england.nhs.uk/wp-content/uploads/2013/ 02/cquin-guidance.pdf; https://www.rcplondon.ac.uk/sites/ default/.../concise-delirium-2006.pdf; www.alzheimers.org. uk/site/scripts/download.php?fileID=1661), but there are few contemporary data in the hyper-acute setting
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