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Diagnostic Failure of Cognitive Impairment in Nursing Home Residents May Lead to Impaired Medical Care
Linköping University, Department of Clinical and Experimental Medicine, Division of Neuro and Inflammation Science. Linköping University, Faculty of Medicine and Health Sciences. Department of Geriatrics, County Hospital Ryhov, Region Jönköping County, Jönköping, Sweden.ORCID iD: 0000-0002-2491-4232
Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Primary Care Center, Primary Health Care Center Ödeshög.
Department of Clinical Sciences in Malmö, Center for Primary Health Care Research, Lund University, Malmö, Sweden.
Linköping University, Department of Clinical and Experimental Medicine, Division of Neuro and Inflammation Science. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in Central Östergötland, Department of Acute Internal Medicine and Geriatrics.
2019 (English)In: Dementia and Geriatric Cognitive Disorders, ISSN 1420-8008, E-ISSN 1421-9824Article in journal (Refereed) Epub ahead of print
Abstract [en]

Background/Objectives: Dementia and cognitive impairment are common in nursing homes. Few studies have studied the impact of unnoted cognitive impairment on medical care. This study aimed to estimate the prevalence of diagnostic failure of cognitive impairment in a sample of Swedish nursing home residents and to analyze whether diagnostic failure was associated with impaired medical care. 

Method: A total of 428 nursing home residents were investigated during 2008–2011. Subjects without dementia diagnosis were grouped by result of the Mini Mental State Examination (MMSE), where subjects with <24 points formed a possible dementia group and the remaining subjects a control group. A third group consisted of subjects with diagnosed dementia. These three groups were compared according to baseline data, laboratory findings, drug use, and mortality. 

Results: Dementia was previously diagnosed in 181 subjects (42%). Among subjects without a dementia diagnosis, 72% were cognitively impaired with possible dementia (MMSE <24). These subjects were significantly older, did not get anti-dementia treatment, and had higher levels of brain natriuretic peptide compared to the diagnosed dementia group, but the risks of malnutrition and pressure ulcers were similar to the dementia group. 

Conclusions: Unnoted cognitive impairment is common in nursing home residents and may conceal other potentially treatable conditions such as heart failure. The results highlight a need to pay increased attention to cognitive impairment among nursing home residents.

Place, publisher, year, edition, pages
S. Karger, 2019.
Keywords [en]
Cognitive impairment, Nursing homes, Morbidity, Dementia, Heart failure
National Category
Geriatrics
Identifiers
URN: urn:nbn:se:liu:diva-159107DOI: 10.1159/000499671PubMedID: 31269489Scopus ID: 2-s2.0-85068515589OAI: oai:DiVA.org:liu-159107DiVA, id: diva2:1338909
Available from: 2019-07-25 Created: 2019-07-25 Last updated: 2019-09-04Bibliographically approved
In thesis
1. Geriatric Aspects of Frail Nursing Home Residents: A Swedish cohort study
Open this publication in new window or tab >>Geriatric Aspects of Frail Nursing Home Residents: A Swedish cohort study
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: The number and proportion of older people are increasing in Sweden as well as throughout the western world. Older people with increasing assistance needs that can no longer be met in their own home need institutional long-term care in nursing homes. A successive reduction of nursing home beds in combination with a future demographic development with a rapidly increasing number of older people will lead to higher demands on future medical care in nursing homes. Consequently, increased knowledge about the medical needs of nursing home residents is of great value.

Objectives: This thesis explores some important geriatric aspects of frail nursing home residents. The specific aims was to characterise the population of nursing home residents, to explore the prevalence of anaemia, paying particular attention to risk factors and mortality, to investigate associations between falls and use of possible fall risk drug classes and to estimate the prevalence of diagnostic failure of cognitive impairment and to investigate whether diagnostic failure was associated with impaired medical care.

Methods: All data originate from SHADES (the Study of Health and Drugs in Elderly nursing home residents in Sweden), a prospective cohort study that included nursing home residents at 12 nursing homes situated in three municipalities in southern Sweden between 2008 and 2011. The subjects were followed every six months with data collection from medical records concerning medications, diagnoses, hospital referrals and mortality, examinations including blood sample analyses, assessments with validated rating scales for cognitive evaluation, depression, risk of pressure ulcers, malnutrition or falls, and the need for care was rated through a questionnaire.

Results: SHADES included a total of 428 subjects with a mean age of 85 years, of whom 71% were women. They demonstrated comorbidity with a mean of three registered medical diagnoses, and polypharmacy with a mean of seven regularly used drugs. More than half of the sample (60%) were at risk of malnutrition and one third were at risk of developing pressure ulcers. A set of single items from the performed risk assessments was found to be important in understanding frailty and need for care. One third of the women and half of the men had anaemia. For the men, anaemia was associated with significantly higher mortality. Haemoglobin decline was also associated with higher mortality. Almost everyone (93%) had an increased fall risk and 62% had fallen during the last year. There was an association between falls during the last year and regular use of non-benzodiazepine hypnotics. In the older age group there was also an association between these drugs and serious falls the next 6 months. Dementia was previously diagnosed in 42%. However, among subjects without a dementia diagnosis, 72% were cognitively impaired (Mini Mental State Examination <24). These subjects were significantly older, did not get anti-dementia treatment and had higher levels of brain natriuretic peptide compared to the diagnosed dementia group, possibly indicating heart failure. Their risks of malnutrition and pressure ulcers were similar to the dementia group.

Conclusions: Nursing home residents are generally frail. Anaemia is associated with higher mortality among men. The fall risk is generally high and use of non-benzodiazepine hypnotics is associated with a higher occurrence of falls. Cognitive impairment is undiagnosed in half of the cases and may indicate underlying heart failure. Consequently, regular medical follow-ups in this population are proposed to include blood count, drug review, and cognitive evaluation. In the case of cognitive impairment, exclusion of underlying disease such as heart failure should be considered.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2019
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1674
National Category
Geriatrics
Identifiers
urn:nbn:se:liu:diva-155641 (URN)10.3384/diss.diva-155641 (DOI)978-91-7685-101-2 (ISBN)
Public defence
2019-05-03, Originalet, Qulturum, Hus B4, Länssjukhuset Ryhov, Jönköping, 10:00 (Swedish)
Opponent
Supervisors
Available from: 2019-03-25 Created: 2019-03-21 Last updated: 2019-07-25Bibliographically approved

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Westerlind, BjörnÖstgren, Carl JohanMarcusson, Jan
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