Neither screening for cognitive impairment nor screening followed by computerized alerts to the health care team improved patient outcome according to the first randomized, controlled study of care provided to hospitalized patients with cognitive impairment.
The study, conducted by researchers from the Regenstrief Institute and Indiana University School of Medicine, screened 998 older adults for cognitive impairment within 48 hours of admission to the hospital. Approximately 40 percent were found to have cognitive impairment and were enrolled in the study. The mean age of those with cognitive impairment was 75. Fifty-nine percent were African-American, and 68 percent were female.
"Physicians are bombarded with information," said study first author Malaz Boustani, M.D., MPH, a Regenstrief Institute investigator, associate professor of medicine at the Indiana University School of Medicine and IU Center for Aging Research associate director. "Our study determined that screening for cognitive impairment and providing information to physicians on the best care for patients with cognitive impairment is not the solution to improving care that we seek. We need to consider ways to tackle the difficult task of altering physician behavior. Nationwide, 40 percent of hospitalized older adults have CI, and six out of 10 of these cases are unrecognized. But with the negative findings of this study, we see that we need to think beyond screening; it's not enough.
"If the next step after screening is computerized reminders, we also found that these reminders need to be personalized to both the physician and the patient," said Dr. Boustani, a geriatrician and director of the Healthy Aging Brain Center at Wishard Health Services.
In the study -- which was conducted at Wishard Hospital, a large public institution in Indianapolis -- half of those with cognitive impairment received routine care. Physicians treating the other patients with cognitive impairment received alerts through an electronic medical record system. These alerts advised the physician of the cognitive impairment diagnosis, recommended consultation with a geriatrician, suggested discontinuation of physical restraints, and also advised that the physician not prescribe anticholinergic drugs.
Anticholinergics block acetylcholine, a nervous system neurotransmitter, and are widely used for hypertension, congestive heart failure and other health issues common to older adults. Previous studies by Dr. Boustani and colleagues in the U.S. and U.K. have linked this class of drugs with cognitive impairment.
The simple computerized alerts did not significantly change physician behavior. Referrals for geriatric consultation did not increase. Use of physical restraints did not diminish. Anticholinergics continued to be prescribed at the same rate as the control group.
The combination of screening plus computerized alerts had no impact on health outcomes, did not decrease mortality, and did not improve recognition of cognitive impairment at hospital discharge according to the study findings.
"In previous work, Regenstrief Institute investigators have definitively shown that computer-generated reminders and care suggestions can have substantial impact on doctors' provision of preventive care, such as ordering mammograms," said Regenstrief Institute President William Tierney, M.D, associate dean for clinical effectiveness research at the IU School of Medicine and an international leader in biomedical informatics and health services research. "However, computers and electronic health records often don't help doctors make difficult decisions about treating complex chronic conditions such as impaired cognition in the elderly. Doctors' decisions require more detailed thinking and support beyond simply reminding them about their patients' conditions and care they might need. It may also be that doctors don't mind computers helping them with preventive care but balk when computers try to tell them how to treat their chronically ill patients."
"Enhancing Care for Hospitalized Older Adults With Cognitive Impairment: A Randomized Controlled Trial" appears in the May 2012 issue of the Journal of General Internal Medicine.
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