The 6-Item Cognitive Impairment Test as a bedside screening for dementia in general hospital patients: results of the General Hospital Study (GHoSt)

Diagnostic performance of the six-item cognitive impairment test as first-step screening for dementia: a meta-analysis

OBJECTIVE

Dementia, a slowly progressive disease, is poorly diagnosed. One reason is that it is difficult to use the screening tools. The six-item cognitive impairment test (6-CIT) is brief, with six items, and has a confirmed scoring system that can easily be used by an average individual. This review aimed to analyze the predictive validity of the 6-CIT including comparisons with other tools such as the Mini-Mental State Examination (MMSE).

METHODS

Literature searches were performed on the MEDLINE, EMBASE, CINAHL, and PsycArticles using the dementia and 6-CITas keywords. The Quality Assessment of Diagnostic Accuracy Studies-2 was applied to assess the risk of bias.

RESULTS

Seven studies with 6,831 participants that met the selection criteria were included. The pooled sensitivity of the 6-CIT analyzed in seven studies was 0.82 (95% CI 0.73-0.89), the pooled specificity was 0.87, and the summary receiver operating characteristic (sROC) curve was 0.90 (SE = 0.04). The diagnostic performance of the 6-CIT and MMSE was compared in three studies. The pooled sensitivity of the 6-CIT was 0.85, the pooled specificity was 0.91, and the sROC curve was 0.91, whereas the MMSE values were 0.70, 0.93, and 0.68, respectively.

CONCLUSION

This review presents evidence that the 6-CIT has excellent dementia screening performance and could be used as a potential alternative to the MMSE. The 6-CIT may provide an opportunity for early detection of dementia.

Neural signatures of task-related fluctuations in auditory attention and age-related changes

Listening in everyday life requires attention to be deployed dynamically - when listening is expected to be difficult and when relevant information is expected to occur - to conserve mental resources. Conserving mental resources may be particularly important for older adults who often experience difficulties understanding speech. In the current study, we use electro- and magnetoencephalography to investigate the neural and behavioral mechanics of attention regulation during listening and the effects that aging has on these. We first show in younger adults (17-31 years) that neural alpha oscillatory activity indicates when in time attention is deployed (Experiment 1) and that deployment depends on listening difficulty (Experiment 2). Experiment 3 investigated age-related changes in auditory attention regulation. Middle-aged and older adults (54-72 years) show successful attention regulation but appear to utilize timing information differently compared to younger adults (20-33 years). We show a notable age-group dissociation in recruited brain regions. In younger adults, superior parietal cortex underlies alpha power during attention regulation, whereas, in middle-aged and older adults, alpha power emerges from more ventro-lateral areas (posterior temporal cortex). This difference in the sources of alpha activity between age groups only occurred during task performance and was absent during rest (Experiment S1). In sum, our study suggests that middle-aged and older adults employ different neural control strategies compared to younger adults to regulate attention in time under listening challenges.

Prevalence, Risk Factors, and Impact of Delirium on Hospitalized Older Adults With Dementia: A Systematic Review and Meta-Analysis

OBJECTIVES

High prevalence of delirium superimposed on dementia (DSD) was previously reported, with associated negative impact on hospitalized older adults. However, data were conflicting, and no meta-analysis has been conducted. Although dementia is the leading risk factor for delirium, risk factors for DSD have not been adequately studied. This systematic review and meta-analysis aims to elucidate the prevalence, risk factors, and impact of DSD in hospitalized older adults. Comparisons were made between older adults with DSD and persons with dementia alone (PWDs).

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

Observational studies reporting prevalence, risk factors, or impact of DSD in hospitalized older adults.

METHODS

Database search was conducted till December 2020 in PubMed, Embase, CENTRAL, PsycINFO, CINAHL, Scopus, Web of Science, ProQuest, and OpenGrey for relevant primary and secondary studies. A piloted data collection form was used for data extraction, and methodological quality was assessed using Joanna Briggs Institute critical appraisal checklists. Meta-analyses, with risk ratio and mean differences as effect measures, were performed using random effects model with Review Manager software. Cochran's Q and I² statistics were used to assess heterogeneity, which was investigated using subgroup analyses.

RESULTS

A total of 81 studies were eligible. The pooled prevalence of DSD was 48.9%, with the highest prevalence found in the Americas and orthopedic wards. Risk factors, including nonmodifiable hospital-, illness-, and medication-related factors, were found to precipitate DSD. Patients with DSD had longer length of hospitalization, disclosed worse cognitive and functional outcomes, and a higher risk of institutionalization and mortality than patients with dementia.

CONCLUSIONS AND IMPLICATIONS

These findings suggested high prevalence and detrimental impact of DSD in hospitalized older adults, highlighting a need for early identification, prevention, and treatments. Further research on risk factors of DSD should be conducted as data were sparse and conflicting. Future high-quality studies regarding DSD are warranted to improve knowledge of this common but under-recognized phenomenon.

Unmet care needs in the oldest old with social loss experiences: results of a representative survey

Background

Loss experiences such as the loss of a spouse, a close relative or significant others become more likely in old age and may be strongly related to specific unmet health care needs. These unmet needs may often remain undetected and undertreated followed by a negative impact on well-being and social role functioning. The present study aims at exploring the relationship between loss experiences and specific unmet care needs in old age.

Methods

As part of the study „Need assessment in the oldest old: application, psychometric examination and establishment of the German version of the Camberwell Assessment of Need for the Elderly (CANE)”, the adapted German version of the CANE was used in a population-representative telephone survey in a sample of 988 individuals aged 75+ years. Loss experiences within the last 12 months were assessed within the structured telephone survey. Descriptive and interferential statistical analyses were run in order to examine the association between loss experiences and occurring unmet care needs.

Results

Overall, 29.7% of the oldest old reported at least one social loss with other relatives losses being the most frequent (12.5%), followed by non-family losses (10.7%). A significant relationship between loss experiences and a higher number of unmet care needs was observed, especially for close family losses. Other risk factors for unmet care needs were age, marital status, depression, social support and morbidity.

Conclusions

This study provides, for the first time in Germany, data on the association between loss experiences and unmet needs. These findings may substantially contribute to the development of loss-specific interventions, effective treatment and health care planning for the bereaved elderly.

Cultural Adaptation and Psychometric Properties Assessment of the NOC Outcome "Cognition" in a Sample of Portuguese Adults With Mental Illness

PURPOSE

Cultural adaptation and psychometric properties assessment of the Nursing Outcomes Classification (NOC) outcome "Cognition" in a sample of Portuguese adults with mental illness.

METHODS

Methodological study.

FINDINGS

The final European Portuguese version of the NOC outcome "Cognition", consisting of 13 items, showed good psychometric properties. An exploratory factor analysis was performed from which only one factor was established.

CONCLUSIONS

The European Portuguese version of the NOC outcome "Cognition" seems to gather very satisfactory psychometric properties for assessing cognition in the Portuguese population.

IMPLICATIONS FOR NURSING PRACTICE

This study contributed to advance the nursing body of knowledge and to better assess cognition in a clinical context.

Communication behavior of cognitively impaired older inpatients : A new setting for validating the CODEM instrument

BACKGROUND AND OBJECTIVE

Acutely ill older patients with cognitive impairment represent a major subgroup in acute care hospitals. In this context, communication plays a crucial role for patients' well-being, healthcare decisions, and medical outcomes. As validated measures are lacking, we tested the psychometric properties of an observational instrument to assess Communication Behavior in Dementia (CODEM) in the acute care hospital setting. As a novel feature, we were also able to incorporate linguistic and social-contextual measures.

MATERIAL AND METHODS

Data were drawn from a cross-sectional mixed methods study that focused on the occurrence of elderspeak during care interactions in two German acute care hospitals. A total of 43 acutely ill older patients with severe cognitive impairment (CI group, Mage ± SD = 83.6 ± 5.7 years) and 50 without cognitive impairment (CU group, Mage ± SD = 82.1 ± 6.3 years) were observed by trained research assistants during a standardized interview situation and rated afterwards by use of CODEM.

RESULTS

Factor analysis supported the expected two-factor solution for the CI group, i.e., a verbal content and a nonverbal relationship aspect. Findings of the current study indicated sound psychometric properties of the CODEM instrument including internal consistency, convergent, divergent, and criterion validity.

CONCLUSION

CODEM represents a reliable and valid tool to examine the communication behavior of older patients with CI in the acute care hospital setting. Thus, CODEM might serve as an important instrument for researcher and healthcare professionals to describe and improve communication patterns in this environment.

Nurses' emotional tone toward older inpatients: Do cognitive impairment and acute hospital setting matter?

The emotional tone of nurses' voice toward residents has been characterized as overly controlling and less person-centered. However, it is unclear whether this critical imbalance also applies to acutely ill older patients, who represent a major subgroup in acute hospitals. We therefore examined nurses' emotional tone in this setting, contrasting care interactions with severely cognitively impaired (CI) versus cognitively unimpaired older patients. Furthermore, we included a general versus a geriatric acute hospital to examine the role of different hospital environments. A mixed-methods design combining audio-recordings with standardized interviews was used. Audio-recorded clips of care interactions between 34 registered nurses (M _age = 38.9 years, SD = 12.3 years) and 92 patients (M _age = 83.4 years, SD = 6.1 years; 50% with CI) were evaluated by 12 naïve raters (M _age = 32.8 years, SD = 9.3 years). Based on their impressions of the vocal qualities, raters judged nurses' emotional tone by an established procedure which allows to differentiate between a person-centered and a controlling tone (Cronbach's α = .98 for both subscales). Overall, findings revealed that nurses used rather person-centered tones. However, nurses' tone was rated as more controlling for CI patients and in the geriatric hospital. When controlling for patients' functional status, both effects lost significance. To our knowledge, this is the first study that examined nurses' emotional tone in the acute hospital setting. Findings suggest that overall functional status of older patients may play a more important role for emotional tone in care interactions than CI and setting differences.

Supporting elderly people with cognitive impairment during and after hospital stays with intersectoral care management: study protocol for a randomized controlled trial

BACKGROUND

The sectorization of health-care systems leads to inefficient treatment, especially for elderly people with cognitive impairment. The transition from hospital care to primary care is insufficiently coordinated, and communication between health-care providers is often lacking. Consequences include a further deterioration of health, higher rates of hospital readmissions, and institutionalization. Models of collaborative care have shown their efficacy in primary care by improving patient-related outcomes. The main goal of this trial is to compare the effectiveness of a collaborative care model with usual care for people with cognitive impairment who have been admitted to a hospital for treatment due to a somatic illness. The aim of the intervention is to improve the continuity of treatment and care across the transition between the in-hospital and adjoining primary care sectors.

METHODS/DESIGN

The trial is a longitudinal multisite randomized controlled trial with two arms (care as usual and intersectoral care management). Inclusion criteria at the time of hospital admission due to a somatic illness are age 70+ years, cognitive impairment (Mini Mental State Examination, MMSE ≤26), living at home, and written informed consent. Each participant will have a baseline assessment at the hospital and two follow-up assessments at home (3 and 12 months after discharge). The estimated sample size is n = 398 people with cognitive inmpairement plus their respective informal caregivers (where available). In the intersectoral care management group, specialized care managers will develop, implement, and monitor individualized treatment and care based on comprehensive assessments of the unmet needs of the patients and their informal caregivers. These assessments will occur at the hospital and in participants' homes. Primary outcomes are (1) activities of daily living, (2) readmission to the hospital, and (3) institutionalization. Secondary outcomes include (a) frailty, (b) delirium, (c) quality of life, (d) cognitive status, (e) behavioral and psychological symptoms of dementia, (f) utilization of services, and (g) informal caregiver burden.

DISCUSSION

In the event of proving efficacy, this trial will deliver a proof of concept for implementation into routine care. The cost-effectiveness analyses as well as an independent process evaluation will increase the likelihood of meeting this goal. The trial will enable an in-depth analysis of mediating and moderating effects for different health outcomes at the interface between hospital care and primary care. By highlighting treatment and care, the study will provide insights into unmet needs at the time of hospital admission, and the opportunities and barriers to meeting those needs during the hospital stay and after discharge.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03359408 ; December 2, 2017.

The Prevalence of Dementia and Cognitive Impairment in Hospitals

BACKGROUND

The care of elderly patients with comorbid dementia poses an increasing challenge in the acute inpatient setting, yet there remains a lack of representative studies on the prevalence and distribution of dementia in general hospitals.

METHODS

We conducted a cross-sectional study of patients aged 65 and older in randomly selected general hospitals in southern Germany. Patients were excluded if they were in an intensive care unit or isolation unit or if they were on specialized wards for psychiatry, neurology, or geriatric medicine. The findings are derived from patient interviews, neuropsychological testing, standardized rating scales, questioning of nursing staff, and the patients' medical records.

RESULTS

1469 patients on 172 inpatient wards of 33 hospitals were studied. 40.0% of them (95% confidence interval, [36.2; 43.7]) had at least mild cognitive impairment. The point-prevalence of dementing illnesses was 18.4% [16.3; 20.7]. Delirium, most often on the basis of dementia, was present in 5.1% [3.9; 6.7]. 60.0% had no cognitive impairment. Dementia was more common among patients of very advanced age, those who were dependent on nursing care, those who lived in old-age or nursing homes, and those with a low level of education. Among patients with dementia, only 36.7% had a documented diagnosis of dementia in the medical record. Patients with dementia were treated more often for dehydration, electrolyte disturbances, urinary tract infections, contusions, and bone fractures, as well as for symptoms and findings of an unknown nature, and much less often for cancer or musculoskeletal diseases.

CONCLUSION

Two out of five elderly patients in general hospitals suffer from a cognitive disturbance. Patients with severe impairments such as dementia or delirium often need special care. Guidelines and model projects offer approaches by which the inpatient care of patients with comorbid dementia can be improved.

Adaptation and validation into Portuguese language of the six-item cognitive impairment test (6CIT)

BACKGROUND

The six-item cognitive impairment test (6CIT) is a brief cognitive screening tool that can be administered to older people in 2-3 min.

OBJECTIVE

To adapt the 6CIT for the European Portuguese and determine its psychometric properties based on a sample recruited from several contexts (nursing homes; universities for older people; day centres; primary health care units).

METHOD

The original 6CIT was translated into Portuguese and the draft Portuguese version (6CIT-P) was back-translated and piloted. The accuracy of the 6CIT-P was assessed by comparison with the Portuguese Mini-Mental State Examination (MMSE). A convenience sample of 550 older people from various geographical locations in the north and centre of the country was used.

RESULTS

The test-retest reliability coefficient was high (r = 0.95). The 6CIT-P also showed good internal consistency (α = 0.88) and corrected item-total correlations ranged between 0.32 and 0.90. Total 6CIT-P and MMSE scores were strongly correlated. The proposed 6CIT-P threshold for cognitive impairment is ≥10 in the Portuguese population, which gives sensitivity of 82.78% and specificity of 84.84%. The accuracy of 6CIT-P, as measured by area under the ROC curve, was 0.91.

CONCLUSION

The 6CIT-P has high reliability and validity and is accurate when used to screen for cognitive impairment.

Behavioural and psychological symptoms in general hospital patients with dementia, distress for nursing staff and complications in care: results of the General Hospital Study

AIMS

Little is known about how behavioural and psychological symptoms of dementia (BPSD) manifest in the general hospital. The aim was to examine the frequency of BPSD in general hospitals and their associations with nursing staff distress and complications in care.

METHODS

Cross-sectional representative study with 1469 patients aged ≥65, including 270 patients with dementia, of 33 randomly selected general hospitals in Germany. BPSD and complications were reported by nurses.

RESULTS

Overall frequency of BPSD was higher in patients with dementia (76%) than without (38%). The most frequent symptoms in patients with dementia were nighttime disturbances (38%), depression (29%) and aberrant motor behaviour (28%) and the most distressing symptoms for nursing staff were delusions, aggression and nighttime disturbances. The overall frequency of BPSD increased from 67% in mild dementia, to 76% in moderate dementia and to 88% in severe dementia. The most frequent symptoms in patients without dementia were depression (19%), nighttime disturbances (13%) and irritability (13%). The most distressing symptoms were aggression and delusions, while the same symptoms were consistently rated as less distressing than in patients with dementia. Factor analysis revealed three independent groups of BPSD that explained 45% of the total variance. First, expansive symptoms (aggression, irritability, nighttime disturbances, aberrant motor behaviour and disinhibition) were frequent, distressing for nursing staff and associated with many complications. Second, psychotic symptoms (delusions and hallucinations) were infrequent, distressing and associated with some complications. Third, affective symptoms (apathy, anxiety and depression) were frequent, non-distressing and associated with few complications. The results did not change when cases with delirium were excluded from both groups.

CONCLUSIONS

BPSD are common in older hospital patients with dementia and associated with considerable distress in nursing staff, as well as a wide range of special treatments needs and additional behavioural and medical complications. Management strategies are needed to improve the situation for both patients and hospital staff.

[Dementia friendly care services in general hospitals : Representative results of the general hospital study (GHoSt)]

BACKGROUND

Mostly model projects report on special care services and procedures for general hospital patients with cognitive impairment. The objective of this study was to determine the frequency of special care services and procedures in general hospitals on the basis of a representative cross-sectional study.

METHODS

From a list of all general hospitals in southern Germany we randomly selected a specified number of hospitals und somatic wards. The hospitals were visited and all older patients on the selected wards on that day were included in the study. Information about care services and their utilization was collected with standardized instruments.

RESULTS

A total of 33 general hospitals and 172 wards participated in the study. The patient sample included 1469 persons over 65 (mean age 78.6 years) and 40% of the patients showed cognitive impairments. The staff reported that the most frequent measures for patients with cognitive impairments concerned patients with wandering behavior (63.1%), efforts to involve the patients' relatives to help with their daily care (60.1%), conducting nonintrusive interviews to identify cognitive impairments (59.9%), allocation to other rooms (58%) and visual aids for place orientation of patients (50.6%). In accordance with earlier studies our results show that other dementia friendly services implemented in pilot projects were rare. The existing special services for patients with cognitive impairment were rarely used by the patients or their relatives.

DISCUSSION

The results demonstrate the urgent need to improve special care services and routines for identification of elderly patients with cognitive impairment and risk of delirium in general hospitals.

[People with dementia in primary care : Prevalence, incidence, risk factors and interventions]

BACKGROUND

Approximately 110 years after the first description of Alzheimer's disease (AD) healthcare systems worldwide face the challenge of increasing numbers of people affected by dementia. There is a need to develop (national) dementia plans on a societal level to implement strategies to combat these challenges. These plans, among other topics, explicitly aim at scientific and research strategies as well as support and healthcare structures.

OBJECTIVE

This article describes a selection of current healthcare research studies and projects in Germany. Selected studies are presented which deliver concepts and approaches to answer the most pressing issues in dementia healthcare research in primary care and the scientific evidence is summarized. Future needs in dementia research and healthcare research are presented.

MATERIAL AND METHODS

The projects under examination are (a) the Leipzig longitudinal study of the aged (LEILA75+), (b) the German study on aging, cognition and dementia (AgeCoDe), (c) the dementia care initiative in primary practice (IDA), (d) the Dementia: life- and person-centered help in Mecklenburg-Western Pomerania (DelpHi) trial, (e) studies analyzing dementia care networks (IDEMUCK and DemNet-D) and (f) the general hospital study (GHoSt).

RESULTS AND DISCUSSION

Prevalence and incidence studies have shown how high the impact of AD is on the current healthcare systems and how it is expected to be in the future. Other studies have identified risk factors as well as protective factors that can serve as target points for the development of effective interventions. They also give hints on where the healthcare system might benefit from changes. Healthcare research has identified scientific methods helpful in providing sound evidence for decision makers in health policy. These have been applied in healthcare research close to routine care and have shown their impact on routine care; however, there are healthcare-specific challenges when applying scientific methods in routine care, which are briefly described.