Low cognition at discharge may impede elderly patients' self-care

It may be worthwhile to screen patients for low cognition at hospital discharge and to offer care instructions after—rather than at the time of—discharge for those who score poorly, a new study suggests.

To determine the frequency of low cognition at hospital discharge, researchers conducted face-to-face surveys at the time of discharge and one month later in the homes of 200 community-dwelling seniors. The subjects had been admitted for more than 24 hours to the acute medicine service of Northwestern Memorial Hospital in Chicago. Their mean age was 79.6 years (range, 70 to 100 years) and 58% were women. Patients had consented to their own procedures, did not have previously documented cognitive loss, and were not admitted for cognitive changes. Results appeared online March 4 in the Journal of General Internal Medicine.

Researchers applied the Mini-Mental Status Examination (MMSE), Backward Digit Span, and 15 Word Immediate and Delayed Recall Tests to evaluate cognition. Upon hospital discharge, 31.5% of subjects (n=60) had previously unrecognized low cognition. One month later, only 13.5% (n=27) had low cognition (P<0.001). Patients with low cognition had a mean score on the MMSE of 20.56 (range, 14 to 24) at discharge, which improved to a mean of 24.57 (range, 18 to 29) by one month (P<0.001). Orientation, task completion, registration, repetition, naming, reading, writing and calculation improved significantly. At discharge, only 54% of low-cognition subjects were able to correctly complete a three-step task of folding paper, placing it in their left hands, and handing the pieces to an interviewer. One month later, 98.4% were able to perform the task correctly.

According to assessment by the Backward Digit Span test, low cognition in working memory was present at discharge in 35.5% of the subjects, and declined to only 31.5% one month later (P=0.014). With the 15 Word Immediate and Delayed Recall Tests, 50% of subjects had low cognition and were not able to remember more than one word from the 15-word list after eight minutes. One month post-discharge, significant improvements were seen, but 34.5% of subjects still had trouble (P<0.001).

Transient cognitive impairment threatens the comprehension and fulfillment of discharge instructions for seniors, half of whom lived alone and 85% of whom managed their own medications in this study, the authors said. Screening for low cognition at discharge and educating caregivers to provide more attention to those who score poorly would help seniors transition back into their home environments, the authors wrote. “This tailoring of discharge interventions would decrease the costs to the hospital of initiating sweeping interventions to all discharged seniors,” they wrote. “These seniors may also benefit from closer follow-up with their primary care physician to ensure that the discharge plan is being followed and to monitor the cognitive impairment.”