Global & Community Health: Brief in-hospital cognitive screening anticipates complex admissions and may detect dementia

Abstract

Objective: With the long-term goal of improving community health by screening for dementia, we tested the utility of integrating the Six-Item Screener (SIS) into our emergency department neurology consultations.

Methods: In this cross-sectional observational study, we measured SIS performance within 24 hours of hospital arrival in 100 consecutive English-speaking patients aged ≥45 years. Performance was compared to patient age, previously charted cognitive impairment, and proxies for in-hospital complexity: whether or not a patient was admitted to the hospital and the number of medical studies ordered.

Results: Those with poor SIS performance were older (p = 0.02) and more likely to have previously charted cognitive impairment (p < 0.01; sensitivity 86%, specificity 77%). Poor performers were more likely to be admitted to the hospital (p = 0.04; odds ratio 3.6) and were subjected to more tests once admitted (p < 0.01), relationships that persisted after accounting for age and history of cognitive impairment.

Conclusions: Poor performance on the SIS was associated with previously charted cognitive impairment, justifying future study of its ability to detect unrecognized dementia cases. Until then, its ability to inexpensively anticipate medically complex hospital admissions motivates broader emergency department use of the SIS.

Figure. Six-Item Screener (SIS) performance predicts the number of diagnostic studies ordered during hospitalization

The number of studies is the sum of laboratory and imaging orders during an admission. For example, a patient receiving a chest x-ray, basic metabolic panel, and serum lactate would be counted as having 3 studies. In these analyses of patients admitted to the hospital, the number of studies increases with length of stay (LOS), and is predicted by SIS performance. To help visualize overlapping points on LOS of 1 and 2 days, points are jittered slightly around their integer x-axis value. The final model displayed here included the interaction between SIS performance and LOS (p = 0.012): the intercept for both best-fit lines (shown with ± 95% confidence interval) is nearly identical, but poor performers have a steeper slope (ln[studies] = 0.65 * ln[LOS] + 3.0 vs ln[studies] = 0.36 * ln[LOS] + 3.0) (p = 0.012 for LOS × performance interaction). The full model of ln(LOS) + SIS performance + the interaction explains 55% of the variance in ln(studies) (R² = 0.553). Based on the best-fit lines, ∼40% more studies will be ordered on a poor performer than on a good performer during a 3-day hospitalization.