Recognition Of Cognitive Impairment Research Articles

Screening and Recognition of Cognitive Impairment in Older People Visiting Hearing Aid Dispensers in the Netherlands

ObjectivesThis study aims to determine how prevalent suspected cognitive impairment is in older people visiting hearing aid dispensers, and to assess whether hearing aid dispensers’ judgment on cognition was in accordance with the outcome of a cognitive screening. DesignThis observational study was conducted between April and May 2022. Setting and ParticipantsFour private hearing aid retail stores in the Netherlands, where cognitive impairment was screened in people aged ≥60 years. MethodsThe Mini-Cog was used for cognitive screening. In addition, hearing aid dispensers were asked to provide their professional judgment if they suspected cognitive impairment. ResultsOf the total 239 older individuals screened, 133 were men [56%, mean age: 79 years (SD 8.6)], and 51 (21.3%) had abnormal outcomes on the Mini-Cog test. The recognition of possible cognitive impairment by the hearing aid dispensers compared to the outcome of the Mini-Cog resulted in correct predictions for 183 of the 239 individuals. Conclusion and ImplicationsCognitive screening in hearing-impaired older adults who visit a hearing aid dispenser suggests that cognitive impairment might be present in approximately 1 in 5 individuals. Hearing aid dispensers' response to the presence of a cognitive impairment was in 2 of 3 in accordance with an abnormal outcome on cognitive screening. To improve hearing care for people with cognitive impairment, it might be important to enhance hearing care professionals’ recognition of cognitive impairment in older individuals.

Prevalence and recognition of cognitive impairment in hospitalized older patients: a flash mob study

Background: It is estimated that over one-third of hospitalized older patients have cognitive impairment. Cognitive impairment directly impacts care across all disciplines during and after hospitalization. Recognition of cognitive impairment is important to provide integrated, person-centred care, involve relatives and informal caregivers in the care plan, prevent adverse outcomes, and identify people that need support after discharge. However, previous studies of medical records and discharge reviews suggested under-recognition of cognitive impairment in hospitalized patients by healthcare professionals. The aim of this study is to investigate the prevalence of cognitive impairment in hospitalized older patients and recognition of cognitive impairment by healthcare professionals.
 Method: This nationwide, cross-sectional, observational study was conducted in thirteen hospitals in the Netherlands on the 21st of September 2022, following a flash mob design. The study was an initiative of Alzheimer Centre Groningen as part of ABOARD (A Personalized Medicine Approach for Alzheimer’s Disease), which is a public-private partnership. Cognitive impairment, indicated by a Mini-Cog score of <3 (out of 5), was assessed in Dutch-speaking, hospitalized patients aged ≥ 65 years old. Patients were excluded if they were unable to perform the Mini-Cog due to sensory impairment or severe delirium, required medical isolation, or were not willing to participate. On the same day, nurses and physicians that took care of the participating patient were asked whether they thought the patient had cognitive impairment. Since the flash mob design entails working with a large group ‘mob’ of data collectors to answer a relatively simple but relevant research question in a short time ‘flash’, we involved many healthcare education students (e.g. nursing, medicine, applied psychology) and hospital staff (e.g. nurse practitioners, researchers) with data collection. 
 Results: In three university hospitals and ten general hospitals, there were a total of 1,308 potentially eligible patients. Of these patients, 378 (29%) were excluded because they were unable to perform the Mini-Cog or were isolated, and 176 (13%) were excluded because they were not willing to participate. Finally, a total of 754 patients (58%) were included (mean [SD] age, 77 [7.43] years; male [%], 383 [51]). Preliminary data showed that 344 patients (46%) had cognitive impairment. Cognitive impairment was recognized by their nurse in 141 of 344 patients (41%). Cognitive impairment was recognized by their physician in 156 patients (45%). In 104 patients (30%) cognitive impairment was recognized by both their nurse and physician. Final results will follow after completion of data analysis.
 
 Conclusion and discussion: Preliminary data showed that cognitive impairment is common in older hospitalized patients, and is poorly recognized by healthcare professionals. Recognition of cognitive impairment by healthcare professionals needs to be improved to be able to provide integrated and person-centred care, and identify patients that need support from other healthcare providers after discharge. By conducting a flash mob study, by means of involving (future) healthcare professionals with data collection and highlighting the topic among participating hospitals, we may already have raised awareness about cognitive impairment in hospitalized older patients.

Prevalence and recognition of cognitive impairment in hospitalized older patients: a flash mob study

AbstractBackgroundIt is estimated that over one‐third of hospitalized older patients have cognitive impairment. Cognitive impairment directly impacts care during and after hospitalization. Recognition of cognitive impairment is important to provide person‐centered care, involve relatives, prevent adverse outcomes, and identify people that need support or diagnostic evaluation for dementia after discharge. Previous studies of medical records suggested under‐recognition of cognitive impairment in hospitalized older patients by healthcare professionals. The aim of this study is to investigate the prevalence of cognitive impairment in hospitalized older patients and the recognition of cognitive impairment by healthcare professionals.MethodA cross‐sectional, observational study was conducted in three university hospitals and ten general hospitals in the Netherlands on a single day in 2022, following a flash mob design. The study was an initiative of Alzheimer Center Groningen as part of ABOARD (A Personalized Medicine Approach for Alzheimer’s Disease). Cognitive impairment, indicated by a Mini‐Cog score of <3 (out of 5), was assessed in Dutch‐speaking, hospitalized patients aged ≥ 65 years old. Patients were excluded if they were unable to perform the Mini‐Cog due to sensory impairment or severe delirium, required medical isolation, or were not willing to participate. The nurses and physicians that took care of the patient that day were asked whether they thought the patient had cognitive impairment.ResultA total of 1,318 potentially eligible patients were available. Of these patients, 374 (28%) were excluded because they were unable to perform the Mini‐Cog or were isolated, and 187 (14%) were excluded because they were not willing to participate. Finally, a total of 757 patients (58%) were included (median age, 77 years [71‐82]; male, 386 [51%]). Of the included patients, 347 patients (46%) had cognitive impairment. Cognitive impairment was recognized by their nurse in 137 of 323 patients (42%) and by their physician in 156 patients (48%). In 135 patients (42%) cognitive impairment was not recognized by either the nurse or physician.ConclusionCognitive impairment is common in older hospitalized patients, and is poorly recognized by healthcare professionals. This study highlights the need for quality improvement of cognitive impairment recognition to provide person‐centered care.

Risk evaluation of cognitive impairment in patients with heart failure: A call for action.

BackgroundCognitive impairment (CI) is common in patients with heart failure (HF) and impacts treatment adherence and other aspects of patient life in HF. Recognition of CI in patients with HF is therefore important. We aimed to develop a risk model with easily available patient characteristics, to identify patients with HF who are at high risk to be cognitively impaired and in need for further cognitive investigation.Methods & resultsThe risk model was developed in 611 patients ≥ 60 years with HF from the TIME-CHF trial. Fifty-six (9 %) patients had CI (defined as Hodkinson Abbreviated Mental Test ≤ 7). We assessed the association between potential predictors and CI with least-absolute-shrinkage-and-selection-operator (LASSO) regression analysis. The selected predictors were: older age, female sex, NYHA class III or IV, Charlson comorbidity index ≥ 6, anemia, heart rate ≥ 70 bpm and systolic blood pressure ≥ 145 mmHg. A model that combined these variables had a c-statistic of 0.70 (0.63–0.78). The model was validated in 155 patients ≥ 60 years with HF from the ECHO study. In the validation cohort 51 (33 %) patients had CI (defined as a Mini Mental State Exam ≤ 24). External validation showed an AUC of 0.56 (0.46–0.66).ConclusionsThis risk model with easily available patient characteristics has poor predictive performance in external validation, which may be due to case-mix variation. These findings underscore the need for active screening and standardized assessment for CI in patients with HF.

Оцінка прогностичної значущості товщини інтими-медії сонної артерії і характеру перебігу гіпертонічної хвороби у визначенні когнітивної дисфункції

Актуальність. У наш час великий інтерес викликає проблема підвищеного артеріального тиску як фактора ризику розладів когнітивних функцій. Мета. Оцінка прогностичної значущості товщини інтими-медії сонної артерії і характеру перебігу гіпертонічної хвороби у визначенні когнітивної дисфункції. Матеріали та методи. Обстежено 76 пацієнтів із гіпертонічною хворобою II стадії і 12 практично здорових осіб, середній вік яких становив 51,55 ± 0,86 року і 54,25 ± 2,74 року відповідно. Пацієнти були розподілені на дві групи з відсутністю і наявністю когнітивних порушень, що оцінювали за допомогою Монреальської шкали. З метою визначення прогностичної значущості показників, для встановлення ймовірності розвитку когнітивних порушень у хворих на гіпертонічну хворобу застосовували аналіз кривих операційних характеристик (ROC-аналіз). Результати. У групі хворих на гіпертонічну хворобу II стадії з когнітивними порушеннями частка пацієнтів з показниками товщини інтими-медії сонної артерії вище від нормальних значень і частка пацієнтів з частими гіпертонічними кризами була вище, ніж у пацієнтів без когнітивних порушень, що становило 61,1 і 63, 8 % відповідно. Площа під ROC-кривою для товщини інтими-медії сонної артерії, частоти гіпертонічних кризів і коефіцієнта когнітивних порушень у прогнозуванні ймовірності розвитку когнітивних порушень у хворих на гіпертонічну хворобу становила 0,60 ± 0,07; 0,68 ± 0,06; 0,80 ± 0,05 відповідно, що свідчить про погану, середню та добру якість моделі відповідно. Висновки. Показник коефіцієнта когнітивних порушень понад 3,10 достовірно асоціюється з імовірним розвитком когнітивних порушень у хворих на гіпертонічну хворобу і може бути маркером прогнозу когнітивної дисфункції у пацієнтів з гіпертонічною хворобою.

Recognition of Cognitive Impairment in Adult Moyamoya Disease: A Classifier Based on High-Order Resting-State Functional Connectivity Network.

Objective: Vascular cognitive impairment (VCI) is a common complication in adult patients with moyamoya disease (MMD), and is reversible by surgical revascularization in its early stage of mild VCI. However, accurate diagnosis of mild VCI is difficult based on neuropsychological examination alone. This study proposed a method of dynamic resting-state functional connectivity (FC) network to recognize global cognitive impairment in MMD.Methods: For MMD, 36 patients with VCI and 43 patients with intact cognition (Non-VCI) were included, as well as 26 normal controls (NCs). Using resting-state fMRI, dynamic low-order FC networks were first constructed with multiple brain regions which were generated through a sliding window approach and correlated in temporal dimension. In order to obtain more information of network interactions along the time, high-order FC networks were established by calculating correlations among each pair of brain regions. Afterwards, a sparse representation-based classifier was constructed to recognize MMD (experiment 1) and its cognitive impairment (experiment 2) with features extracted from both low- and high-order FC networks. Finally, the ten-fold cross-validation strategy was proposed to train and validate the performance of the classifier.Results: The three groups did not differ significantly in demographic features (p > 0.05), while the VCI group exhibited the lowest MMSE scores (p = 0.001). The Non-VCI and NCs groups did not differ significantly in MMSE scores (p = 0.054). As for the classification between MMD and NCs, the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity of the classifier reached 90.70, 88.57, 93.67, and 73.08%, respectively. While for the classification between VCI and Non-VCI, the AUC, accuracy, sensitivity, and specificity of the classifier reached 91.02, 84.81, 80.56, and 88.37%, respectively.Conclusion: This study not only develops a promising classifier to recognize VCI in adult MMD in its early stage, but also implies the significance of time-varying properties in dynamic FC networks.

THE IMPACT OF MANDATED COGNITIVE ASSESSMENTS ON ALZHEIMER’S DISEASE AND RELATED DEMENTIA DIAGNOSIS RATES

Although no cure for Alzheimer’s disease exists, early diagnosis allows clinicians to detect reversible causes of memory loss, inform pharmacologic treatment options that may delay cognitive decline, and inform patients about clinical trial opportunities. It allows patients to communicate medical, legal, financial, living, and end-of-life desires. Barriers to diagnosis include low public awareness of early symptoms, stigma and misconceptions about the disease that delay seeking medical assistance. Provider-related barriers include low recognition of cognitive impairment and/or insufficient training in dementia diagnosis, and reimbursement issues. The new annual wellness visit (AWV) benefit available to Medicare Part B beneficiaries may reduce some of these barriers. The Patient Protection and Affordable Care Act of 2010 mandated an AWV that, along with routine preventive services, included for the first time, a cognitive screen at each visit. In this study, we analyze the effect of the introduction of the AWV benefit on Alzheimer’s disease and related dementias (ADRD) diagnoses rates, average age at diagnosis and geographic dispersion of diagnoses. We use the 100% sample of Medicare claims and regression discontinuity to estimate the impact of the legislation enactment. Preliminary analyses show immediate and increasing take-up in AWV visits after the policy went into effect. The total number of preventative exams claims went from about 2,500 to 27,000 immediately after the policy and continued to grow in subsequent months. We also observe an increase in ADRD incidence in the months immediately following ACA, from about 14,000 claims in December 2010 to about 16,000 in January 2011.

Cognitive dysfunction is associated with abnormal responses in cerebral blood flow in patients with single ventricular physiology: Novel insights from transcranial Doppler ultrasound.

Improvements in the management of complex congenital heart disease, including those with single ventricle physiology, have resulted in increased survival. As this population ages, the recognition of cognitive impairment is increasingly important. At present, little is known about the potential mechanisms of cognitive dysfunction. In this cross-sectional study, we aimed to characterize the nature of abnormalities in cerebral blood flow and the relationship to cognitive deficits in adults with single ventricular physiology. Ten adults with single ventricular physiology (age 18-40years) and 12 age- and gender-matched controls underwent transcranial Doppler ultrasound and accompanying cognitive assessment. Patients underwent neuropsychological testing that assessed differing cognitive domains, with subjective cognitive decline determined from a 24-question survey. Transcranial Doppler ultrasound was used to assess baseline cerebral blood flow as well as change in cerebral blood flow velocities from baseline and during cognitive testing. Age, ethnicity, individual, and parental education levels were considered in the multivariate analyses. On assessment of cognitive function, the patient group performed more poorly across each of the measured domains. The control group had a significantly greater increase in cerebral blood flow in response to cognitive stimuli compared to the patient cohort; these differences in response to cognitive stimuli were seen to a similar extent across each of the measured cognitive domains. Adults with Fontan physiology are underperforming in assessments of executive function with associated abnormalities in cerebral perfusion potentially contributing to cognitive deficits.

A Systematic Review of Cognitive Impairments Associated With Kidney Failure in Adults Before Natural Age-Related Changes.

Recognition of cognitive impairment in chronic kidney disease (CKD) and its impact on functioning in adults is growing. The vast majority of studies to date have been conducted in older populations where CKD is more pronounced; however, the degree to which age-related cognitive changes could be influencing these findings remains unaddressed. This current study thus aimed to review cognitive impairment findings by stage in non-elderly CKD samples. PubMed and Medline via Scopus were searched for cross-sectional or cohort studies and randomized controlled trials that assessed cognitive function in individuals with CKD in any research setting. CKD studies including patients at any illness stage were included providing participants were below 65 years old, were not on peritoneal dialysis and had not undergone a kidney transplant. Fifteen studies, with a total of 9304 participants, were included. Cognitive function broadly deteriorated from stage 1 to stage 5. Early stage CKD was associated with a drop in speed of processing, attention, response speed, and short-term memory abilities. Moderate stage CKD was associated with deficits in executive functioning, verbal fluency, logical memory, orientation and concentration. People with end stage kidney disease manifested significant deficits in all previous cognitive domains, along with cognitive control, delayed and immediate memory, visuospatial impairment, and overall cognitive impairment. Cognitive impairment is evident across the stages of CKD, independent of age-related changes, for both lower-order and higher-order cognitive abilities. These impairments also increase between the stages, suggesting a cumulative effect. Future directions for research are discussed. (JINS, 2019, 25, 101-114).

Prevalence of cognitive impairment among long-term care residents: a comparison between nursing homes and residential homes in Poland.

Large-scale nationwide comparative studies of older adults with cognitive impairment (CI) in long-term care institutions (LTCI) hardly exist in Poland. This paper compares the prevalence of CI and its symptoms in residents of nursing homes (NHs) and residential homes (RHs) in Poland. A cross-sectional survey of a country-representative sample of 23 LTCIs was conducted in the years 2015-2016. In total, 1587 residents were included: 626 residents in 11 NHs and 961 residents in 12 RHs. All individuals were assessed with a Cognitive Performance Scale (CPS) using a cutoff of ≥ 2 points to define the presence of CI. Descriptive statistics and Chi square test were used. The median age was 80years, 67.7% were women. Overall, 65.2% of residents (n = 1035) were identified as having CI, ranging from 59.2% in RHs to 74.5% in NHs, after excluding residents in a coma. Furthermore, the prevalence of severe CI was significantly higher in NHs than in RHs (respectively, 41.2 and 20.5%). It concerned specifically impairment of memory: procedural (72.3 vs 55.2%), long-term (56.5 vs 32.1%), short-term (46.8 vs 33.4%), and situational one (40.2 vs 26.4%), as well as problems with being understood by others (44.6 vs 24.7%) and severely impaired capacity of daily decision making (44.7 vs 21.5%). A high prevalence of CI was found in both LTCI types, but its severity differed, with statistically significantly higher rates in NHs compared to RHs. Therefore, we call for more attention to be paid to better recognition of CI in LTCI residents, regardless of the facility type.

Neurovascular Function and Cognition in Adult Patients With Complex Congenital Heart Disease

Background: Improvements in the management of complex congenital heart disease (CHD), including single ventricle physiology, have resulted in increased survival. As this population ages, the recognition of cognitive impairment is increasingly becoming important. At present, little is known about the nature, mechanism and rate of decline in cognitive function. This cross-sectional study characterised the nature of cognitive deficits in adults with Fontan circulation.

Optimising care for patients with cognitive impairment and dementia following hip fracture.

The global shift in demographics towards aging populations is leading to a commensurate increase in age-related disease and frailty. It is essential to optimise health services to meet current needs and prepare for anticipated future demands. This paper explores issues impacting on people living with cognitive impairment and/or dementia who experience a hip fracture and are cared for in acute settings. This is important given the high mortality and morbidity associated with this population. Given the current insufficiency of clear evidence on optimum rehabilitation of this patient group, this paper explored three key themes namely: recognition of cognitive impairment, response by way of training and education of staff to optimise care for this patient group and review of the importance of outcomes measures. Whilst there is currently insufficient evidence to draw conclusions about the optimal ways of caring for patients living with dementia following hip fracture, this paper concludes that future research should improve understanding of healthcare staff education to improve the outcomes for this important group of patients.

Using Administrative Data to Examine Health Disparities and Outcomes in Neurological Diseases of the Elderly

The fields of neurodegenerative disease and dementia research have grown considerably in the last several decades. Due to tremendous efforts of basic and clinical research scientists, we know a great deal about dementia risk factors and have multiple treatment options. Clinician recognition of cognitive impairment has increased considerably, national policies which support screening for and documenting cognitive dysfunction now exist, and public awareness of neurodegenerative disease has never been greater. These conditions promote (and demand) the growth of translational epidemiology and health services research, which focuses on examining outcomes in groups of individuals as a function of health care experiences. This review discusses the use of administrative data to answer health care outcomes and disparities questions in dementia. Of particular interest are publically available datasets that contain varying amounts of diagnostic, clinical, pharmacy, and patient information. Methodological challenges that are frequently encountered and must be understood to minimize biased inference are also discussed.

P-028: Early recognition of cognitive impairment in the ED: a pilot study

P-028: Early recognition of cognitive impairment in the ED: a pilot study

Factors associated with primary care physicians' recognition of cognitive impairment in their older patients.

Although there are accurate screens for cognitive impairment, there is as yet no evidence that screening improves outcomes including primary care physicians' (PCP) medical decision making. PCPs' recognition of cognitive impairment being suboptimal, we investigated factors associated with improved recognition. Eligible patients were aged 65 years and above, without documented dementia or previous work-up for dementia, seen consecutively over 2 months by one of 13 PCPs. PCPs indicated whether they, the patient, or the family had concerns about each patient's cognition. We enrolled 130 patients with any cognitive concerns and a matched sample of 133 without cognitive concerns, and administered standardized neuropsychological tests. PCP's judgments of cognitive concern showed 61% sensitivity and 86% specificity against the neuropsychological standard. When combined with a Mini-Mental State Examination score ≤26, PCP recognition improved in sensitivity (82%) with some loss in specificity (74%). True positives increased when PCPs' practices included more cognitively impaired patients and when patients reported poor memory. False positives increased when patients had diabetes, reported poor memory, or no or light alcohol consumption. Medical decision making can be improved by the Mini-Mental State Examination and greater exposure to cognitively impaired patients, but knowledge of certain risk factors for cognitive impairment negatively affected these decisions.

Cognitive Impairment in Older Adults with Heart Failure: Prevalence, Documentation, and Impact on Outcomes

BackgroundDespite the fact that 80% of patients with heart failure are aged more than 65 years, recognition of cognitive impairment by physicians in this population has received relatively little attention. The current study evaluated physician documentation (as a measure of recognition) of cognitive impairment at the time of discharge in a cohort of older adults hospitalized for heart failure. MethodsWe performed a prospective cohort study of older adults hospitalized with a primary diagnosis of heart failure. Cognitive status was evaluated with the Folstein Mini-Mental State Examination at the time of hospitalization. A score of 21 to 24 was used to indicate mild cognitive impairment, and a score of≤20 was used to indicate moderate to severe impairment. To evaluate physician documentation of cognitive impairment, we used a standardized form with a targeted keyword strategy to review hospital discharge summaries. We calculated the proportion of patients with cognitive impairment documented as such by physicians and compared characteristics between groups with and without documented cognitive impairment. We then analyzed the association of cognitive impairment and documentation of cognitive impairment with 6-month mortality or readmission using Cox proportional hazards regression. ResultsA total of 282 patients completed the cognitive assessment. Their mean age was 80 years of age, 18.8% were nonwhite, and 53.2% were female. Cognitive impairment was present in 132 of 282 patients (46.8% overall; 25.2% mild, 21.6% moderate-severe). Among those with cognitive impairment, 30 of 132 (22.7%) were documented as such by physicians. Compared with patients whose cognitive impairment was documented by physicians, those whose impairment was not documented were younger (81.3 vs 85.2 years, P<.05) and had less severe impairment (median Mini-Mental State Examination score 22.0 vs 18.0, P<.01). After multivariable adjustment, patients whose cognitive impairment was not documented were significantly more likely to experience 6-month mortality or hospital readmission than patients without cognitive impairment. ConclusionsCognitive impairment is common in older adults hospitalized for heart failure, yet it is frequently not documented by physicians. Implementation of strategies to improve recognition and documentation of cognitive impairment may improve the care of these patients, particularly at the time of hospital discharge.

Reconceptualizing models of delirium education: findings of a Grounded Theory study

Effectiveness of educational interventions targeted at improving delirium care is limited by implementation barriers. Studying factors which shape learning needs can overcome these knowledge transfer barriers. This in-depth qualitative study explores learning needs of hospital staff relating to care needs of the confused older patients. Fifteen research participants from across the healthcare spectrum working within an acute care setting were interviewed. Five focus groups were undertaken with patients, carers, and mental health specialists. A Grounded Theory methodology was adopted and data were analyzed thematically in parallel to collection until theoretical saturation was reached. Eight categories of practice gap emerged: ownership of the confused patient, negative attitudes, lack of understanding of how frightened the patient is in hospital, carer partnerships, person-centered care, communication, recognition of cognitive impairment and specific clinical needs (e.g. capacity assessments). Conceptually, the learning needs were found to be hierarchically related. Moreover, a vicious circle relating to the core learning needs of ownership, attitudes and patient's fear emerged. A patient with delirium may be frightened in an alien environment and then negatively labeled by staff who subsequently wish for their removal, thereby worsening the patient's fear. These findings reconceptualize delirium education approaches suggesting a need to focus interventions on core level practice gaps. This fresh perspective on education, away from disease-based delirium knowledge toward work-based patient, team and practice knowledge, could lead to more effective educational strategies to improve delirium care.

Early recognition of cognitive impairment in people with diabetes: role of primary care nurses

Dementia is one of the commonest and most devastating diseases of later life. People with mild cognitive impairment and diabetes mellitus are reported to be at increased risk of developing dementia. In this article, the key role of primary care nurses in early recognition of memory problems in people with diabetes is emphasized. There is also a need for improving understanding of cognitive impairment. It is important that primary care nurses receive training in recognising impairment early

Impact and recognition of cognitive impairment among hospitalized elders

Older adults are predisposed to developing cognitive deficits. This increases their vulnerability for adverse health outcomes when hospitalized. To determine the prevalence and impact of cognitive impairment (CI) among hospitalized elders based on recognition by lCD-coding versus screening done on admission. Observational cohort study. Urban public hospital in Indianapolis. 997 patients age 65 and older admitted to medical services between July 2006 and March 2008. Impact of CI in terms of length of stay, survival, quality of care and prescribing practices. Cognition was assessed by the Short Portable Mental Status Questionnaire (SPMSQ). 424 patients (43%) were cognitively impaired. Of those 424 patients with CI, 61% had not been recognized by ICD-9 coding. Those unrecognized were younger (mean age 76.1 vs. 79.1, P <0.001); had more comorbidity (mean Charlson index of 2.3 vs.1.9, P = 0.03), had less cognitive deficit (mean SPMSQ 6.3 vs. 3.4, P < 0.001). Among elders with CI, 163 (38%) had at least one day of delirium during their hospital course. Patients with delirium stayed longer in the hospital (9.2 days vs. 5.9, P < 0.001); were more likely to be discharged into institutional settings (75% vs. 31%, P < 0.001) and more likely to receive tethers during their care (89% vs. 69%, P < 0.001), and had higher mortality (9% vs. 4%, P = 0.09). Cognitive impairment, while common in hospitalized elders, is under-recognized, impacts care, and increases risk for adverse health outcomes.

Should cognitive impairment be included in the diagnostic criteria for schizophrenia?

Neurocognitive impairment is considered a core component of schizophrenia, and is increasingly under investigation as a potential treatment target. On average, cognitive impairment is severe to moderately severe compared to healthy controls, and almost all patients with schizophrenia demonstrate cognitive decrements compared to their expected level if they had not developed the illness. Compared to patients with affective disorders, cognitive impairment in schizophrenia appears earlier, is more severe, and is more independent of clinical symptoms. Although the DSM-IV-TR and ICD-10 descriptions of schizophrenia include several references to cognitive impairment, neither the diagnostic criteria nor the subtypology of schizophrenia include a requirement of cognitive impairment. This paper forwards for consideration a proposal that the diagnostic criteria include a specific criterion of "a level of cognitive functioning suggesting a consistent severe impairment and/or a significant decline from premorbid levels considering the patient's educational, familial, and socioeconomic background". The inclusion of this criterion may increase the "point of rarity" with affective psychoses and may increase clinicians' awareness of cognitive impairment, potentially leading to more accurate prognosis, better treatment outcomes, and a clearer diagnostic signal for genetic and biological studies. Future research will need to address the validity of these possibilities. The reliable determination of cognitive impairment as part of a standard diagnostic evaluation will present challenges to diagnosticians with limited resources or insufficient expertise. Cognitive assessment methods for clinicians, including brief assessments and interview-based assessments, are discussed. Given the current emphasis on the development of cognitive treatments, the evaluation of cognition in schizophrenia is an essential component of mental health education.