Integrating Neuropsychology into Interprofessional Geriatrics Clinics.

Interprofessional healthcare teams are increasingly viewed as a clinical approach to meet the complex medical, psychological, and psychosocial needs of older adult patients. Despite the fact that older adults are at risk for cognitive difficulties, neuropsychologists are not routinely included on Geriatrics consult teams. The primary aim of this paper is to highlight the utility of neuropsychology within an interprofessional Geriatrics consult clinic. To address this aim, we describe specific benefits to patient care that may be associated with the inclusion of neuropsychologists on Geriatrics consult teams, including differential diagnosis, enhanced patient care, and reduced barriers to care. We provide a description of the integration of neuropsychology within a Veterans Health Administration (VA) interprofessional Geriatrics consult clinic team in order to illustrate the implementation of this model.

Validation of a medical record-based delirium risk assessment.

OBJECTIVES: To improve identification of patients at high risk for delirium, this study developed a chart abstraction tool for delirium risk and validated the tool against clinical expert diagnosis of delirium. DESIGN: Prospective cohort study. SETTING: Tertiary Veterans Affairs hospital in New England. PARTICIPANTS: One hundred veterans admitted to the medical service. MEASUREMENTS: While admitted, each participant underwent serial assessments for delirium by a clinical expert. Using the four criteria of a validated delirium prediction rule (cognitive impairment, sensory deficit, severe illness, and dehydration), chart review terms were selected for each criterion, and delirium risk was the sum of criteria present (range: 0-4; 4 = worst). After discharge, a nurse blinded to the expert's diagnosis completed the chart tool. RESULTS: The participants were mostly male (94%) and older (mean age 81 ± 7), and 23% developed overall delirium (14% incident). The rate of overall delirium was 11% in participants with zero risk factors, 18% in those with one or two, and 50% in those with three or four (P = .01; c-statistic 0.65, 95% confidence interval (CI) = 0.54-0.76). For incident delirium, the rates were 11%, 13%, and 25%, respectively (P = .53; c-statistic 0.56, 95% CI = 0.42-0.74). Discharge to a rehabilitation center or nursing home increased with increasing delirium risk (0%, 18%, 60%, P = .02). CONCLUSION: A chart abstraction tool was effective at identifying overall delirium risk but not incident delirium risk. Although the tool cannot replace clinical assessment and diagnosis of delirium, the use of this tool as an educational, clinical, or quality measurement aid warrants additional study.

Independent association between preoperative cognitive status and discharge location after cardiac surgery.

BACKGROUND: Among cardiac surgery patients, those with impaired cognitive status before surgery may have longer postoperative stays than do patients with normal status and may require additional care upon discharge. OBJECTIVES: To determine if preoperative scores on a screening measure for cognitive status (the Clock-in-the-Box), were associated with postoperative length of stay and discharge to a location other than home in patients who had cardiac surgery. METHODS: A total of 181 consecutive patients scheduled for cardiac surgery at a single site were administered the Clock-in-the-Box as part of the preoperative evaluation. Scores on the Clock-in-the-Box tool, demographic and operative information, postoperative length of stay, and discharge location were collected retrospectively from medical records. RESULTS: The mean age of the patients was 68.1 years (SD, 0.7), and 99% were men. Mean postoperative length of stay was 10.5 days (SD, 8.2), and 35 patients (19%) were discharged to a facility. Scores on the Clock-in-the-Box assessment were not associated with postoperative length of stay. Increasing age, living alone before surgery, and duration of cardiopulmonary bypass were associated with discharge to a facility and were used as covariates in adjusted analyses. After adjustment, better preoperative cognitive status reduced the risk of being discharged to a facility (adjusted relative risk, 0.93; 95% confidence interval, 0.89-0.98) after cardiac surgery. CONCLUSIONS: Cognitive screening before cardiac surgery can identify patients with impaired cognitive status who are less likely than patients with normal cognitive status to return home after cardiac surgery.