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How well are the diagnosis and symptoms of dementia recorded in older patients admitted to hospital?

In a paper published in Age and Ageing, Dr George Crowther and his colleagues from the University of Leeds confirm the mismatch between dementia symptom prevalence and the identification of dementia and the recording of its symptoms in patients attending hospital.

In the United Kingdom dementia is generally diagnosed in the community by mental health services. However if the same patients are admitted to a general hospital their care is usually managed by a separate healthcare trust and the handover of clinical information between organisations is potentially unreliable.

Dementia is a common comorbidity in older people admitted to the general hospital. Prevalent in around 42 per cent of patients, these are people who often have difficulty communicating their needs, and in a hospital setting there is a high prevalence of delirium (66 per cent), and psychological symptoms in the absence of delirium - depression (34 per cent), anxiety (35 per cent), delusions (11 per cent) and hallucinations (15 per cent). In order to provide quality care that meets the needs of this patient group, healthcare professionals in hospital need to be aware of the diagnosis and be able to recognise psychological symptoms and delirium.

Previous attempts to describe dementia prevalence, and the symptoms associated with it, in a general hospital setting have involved prospective assessment. These methods may give an accurate account of the hospital prevalence, but they potentially overestimate the actual clinical record, that is, the number of patients with a pre-existing diagnosis of dementia identified as such during their hospital stay and the number of symptoms recorded. Our research aimed to describe any such overestimation in order to highlight areas of unmet need.

We conducted a dataset linkage study, retrospectively reviewing 116 patients with known dementia diagnosed by mental health services, admitted to a general hospital. Both their community psychiatric notes and hospital notes were scrutinised, ascertaining the accuracy of dementia diagnosis recording by the general hospital and all episodes of documented psychological symptoms and delirium.

Diagnostic Accuracy

The results demonstrated that despite a large number of patients with known dementia being admitted to hospital, the diagnosis remains undocumented in around 26 per cent of them. In order to improve this, healthcare professionals need access to reliable diagnostic information. This requires closer collaboration between mental health and hospital healthcare information systems. ‘Patient passport’ systems such as the butterfly scheme or ‘This is me’ booklet that encourage people with dementia to inform hospital staff of their diagnosis also have a role to play, however they all require opt in and are easily fallible to human error. 

Psychological Symptom Recording

The prevalence of documented psychiatric symptoms (10 per cent) and delirium (11 per cent) in people with dementia in the general hospital was also lower than would be expected. This is unlikely to reflect a low symptom prevalence, but rather a mismatch between symptom prevalence and symptom recognition and recording, indicating a possible barrier to providing optimum care. Enabling staff to recognise and record symptoms and researching the most effective ways to achieve this are important priorities for improving care for hospitalised patients with dementia.

George Crowther
NIHR Clinical Lecturer in Old Age Psychiatry, 
John Holmes
Senior Lecturer, Old Age Psychiatry
Michael Bennett
Professor of Palliative Medicine
University of Leeds

Read the full paper in Age and Ageing

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