I have read the journal's policy and the authors of this manuscript have the following conflicts: JRFG is a researcher and clinician in the field covered by this paper, whose employing organisation holds research grant awards from The Alzheimer's Society and the NIHR (through CLAHRC and the PGfAR schemes) on which JRFG is an investigator. RHH holds research grants from the UK National Institute for Health Research (UK government) and is a member of The Alzheimer's Society, the topic review panel for the National Institute for Health Research, the National End of Life Care Intelligence Network steering committee, and the NHS Protect working group on clinically related violence.
In an Essay, Andrew Jackson and colleagues discuss challenges in the diagnosis and management of older people with dementia and delirium in acute hospitals.
Dementia in acute hospitals is common and associated with poor health outcomes.
Dementia in acute hospitals is intricately linked with delirium, and the two should always be considered together when developing future policy.
The decline in health and function after hospitalization among people with dementia may be influenced by discrete disease processes but also by the hospital environment and care itself.
Opportunities for further research into the specific acute hospital management of dementia and its complications are many.
Dementia is very common in patients admitted to acute hospitals, affecting one in four patients, with 6% of people living with dementia being inpatients in acute hospitals at any given time [
“Intellectual failure” is recognised as one of the “geriatric giants.” Both delirium and dementia are disorders of cognitive function, are associated with adverse health outcomes, and are intricately linked [
This essay discusses the clinical manifestation and complications of delirium and dementia in acute hospitals. Diagnosis of both conditions can be uncertain, and treatments are limited, but effective actions and management may improve outcomes. We also highlight areas for future research and suggest policy interventions to improve hospital care.
Estimates of the prevalence of dementia in hospitals vary across published studies [
People with dementia and cognitive impairment are hospitalised for many reasons, but typically in crises. Admission problems include immobility (73%), falls (64%), pain (54%), and breathlessness (23%) [
Although dementia prevalence is high, the proportion undiagnosed or unrecognised by health care staff is approximately 56% (data in
Hospitalised people with dementia typically have more advanced disease than those in the community. A Functional Assessment Staging Scale (FAST) stage of 6d (nearly mute, immobile, and incontinent) or above is present in 46% of hospitalised patients with dementia [
Dementia in general hospitals is associated with more inpatient adverse events, principally mortality, falls, and delirium [
The worst outcomes seen in people with dementia may be avoidable if they are due to poorer standards of care provision. Hospital staff can struggle to meet the complex care needs of people with dementia, often leading to a negative perception of such patients [
Dementia disease trajectories between a person with no hospital admissions (green line) and multiple hospital admissions (red line) are illustrated. The disease trajectory is negatively influenced by baseline frailty and disease expression. However, it may be positively tempered by early diagnosis, leading to better access to services, and advanced care planning. The “multiple hospital admissions” trajectory is further influenced by specific hospital interactions—importantly, delirium—but there are other effects from an acute inflammatory insult, subsequent recovery, and in-hospital iatrogenic insults.
Delirium is an acute, severe neuropsychiatric syndrome seen mainly in older people in hospital and associated with increased morbidity and mortality [
The diagnostic challenge in an older person presenting with “confusion” is to disentangle whether they have delirium, dementia, or both. Persistent delirium is also possible [
Arousal and alertness are usually abnormal in delirium, but these domains are also increasingly affected in severe dementia. Diagnosing delirium in a person with dementia requires competence in cognitive testing, mental state examination, and informant questioning. Few screening tests have tried to detect delirium in the context of dementia; the Confusion Assessment Method (CAM) and the 4AT are examples [
There are four core challenges when diagnosing delirium in dementia. First, dementia with Lewy bodies (DLB) causes around 4% of all cases of dementia [
By definition, manifestations of delirium follow an acute and fluctuating course; therefore, traditional tools to detect dementia by measuring cognitive deficits assumed to be stable are not useful. Many tools available to detect dementia in hospitals have not been validated in patients with delirium [
Despite the clear need, little research is available on how best to provide care. The patient and carer experience of care is often negative, with deterioration in health, perceived poor care, and unrealistic expectations cited [
Evidence to inform nutritional support [
Joint units with geriatric medicine and psychiatry may reduce length of stay and readmissions [
The typical approach to manage cognitive impairment has been to attempt to diagnose delirium, dementia, both, or something else. There is a case for recognising these in-hospital conditions as a complex discrete syndrome, not least because some aspects of management are the same whatever the underlying diagnosis may be [
Assessing cognitive impairment, adverse events risk, and BPSDs should become routine. Delirium prevention, active management of underlying precipitants, and a patient safety approach to minimise harms are especially important [
Dementia is a long-term condition for which the aim is to “live well.” Given that outcomes after hospitalisation are poor, an acute hospital admission should trigger a palliative needs assessment with discussions about goals and expectations of treatments, as part of a shared decision-making process. These discussions are time consuming and difficult in the face of uncertainty but reflect best practice.
There is a dearth of treatments for dementia and delirium and as yet no reliable and meaningful biomarkers to guide management. Evidence is lacking on how best to incorporate carers into hospital care as well as how to best train a fit-for-purpose workforce [
Despite challenges, the proactive diagnosis of dementia and delirium in hospitals is likely to improve patient experience and outcomes. Because cognitive impairment is so common in hospitals and impacts so substantially on long-term outcomes, there is a pressing need for (1) joined-up care to alter a trajectory of decline and (2) more research to improve diagnostics and management, whatever the specific underlying diagnosis.
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The authors gratefully acknowledge Dr. Elizabeth Sapey of the Institute of Inflammation and Ageing, University of Birmingham, for her careful reading and comments on the manuscript.
The AD8: The Washington University Dementia Screening Test
behavioural and psychiatric symptoms of dementia
Confusion Assessment Method
dementia with Lewy bodies
delirium superimposed on dementia
Functional Assessment Staging Scale
hazard ratio
the Informant Questionnaire of Cognitive Decline in the Elderly short form