Unrecognized Cognitive Impairment and Its Effect on Heart Failure Readmissions of Elderly Adults
Unrecognized Cognitive Impairment and Its Effect on Heart Failure Readmissions of Elderly Adults
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DOI：
10.1111/jgs.14471
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发表时间：
2016-11-01
影响因子：
6.3
通讯作者：
Taffet, George E.
中科院分区：
文献类型：
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作者：
Agarwal, Kathryn S.;Kazim, Rabia;Taffet, George E.
目的
确定心力衰竭（HF）老年患者与其他诊断的老年患者相比，30天再入院是否与认知障碍的存在更相关，以及医疗团队是否识别出认知障碍。
设计
一项为期一年的认知筛查前瞻性队列质量改进项目以及对文件记录和结果的回顾性病历审查。
环境
一家以心血管疾病为重点且具有强化的个性化患者教育出院计划的三级学术医疗中心内科病房。
参与者
70岁及以上在出院回家前接受筛查的个体（241次入院病例；121例以HF为主要诊断，120例无HF）。HF队列包括射血分数保留和降低的个体。排除接受过移植、心室辅助装置植入、血液透析或有原发性肿瘤诊断或临终关怀转诊的个体。
测量
出院前48小时或更短时间内进行简易认知评估（Mini - Cog）、30天全因再入院率、痴呆或认知障碍的记录以及照顾者教育。
结果
在157次病例中简易认知评估得分小于4（表明存在认知障碍）[82例（67.7%）患有HF，75例（62.5%）未患HF]。两组之间简易认知评估得分在比率和分布上相似。患有HF且存在认知障碍的个体30天再入院率显著高于其他组（26.8%对13.2%；P = 0.01；HF且无认知障碍为12.8%；无HF且无认知障碍为13.3%；无HF但有认知障碍为13.3%）。在患有HF且存在认知障碍的个体中，有照顾者教育记录的个体再入院率低于无此记录的个体（14.3%对36.2%；P = 0.03）。在病历中记录有认知障碍的不到9%。
结论
经常未被记录的认知障碍可能表明HF患者比无HF患者再入院风险更高。对认知障碍进行筛查、根据其调整出院安排以及让家属和照顾者参与出院教育可能有助于减少再入院。
ObjectivesTo determine whether 30-day readmissions were associated with presence of cognitive impairment more in elderly adults with heart failure (HF) than in those with other diagnoses and whether medical teams recognized cognitive impairment.DesignOne-year prospective cohort quality improvement program of cognitive screening and retrospective chart review of documentation and outcomes.SettingAcademic tertiary care hospital medical unit with a cardiovascular focus and an enhanced discharge program of individualized patient education.ParticipantsIndividuals aged 70 and older screened before home discharge (241 admission encounters; 121 with HF as a primary diagnosis, 120 without). The HF cohort included individuals with preserved and reduced ejection fraction. Individuals who had undergone transplantation, ventricular assist device implantation, or hemodialysis or who had a primary oncology diagnosis or hospice referral were excluded.MeasurementsMini-Cog administered 48 hours or less before discharge, 30-day all-cause readmission rates, documentation of dementia or cognitive impairment, and caregiver education.ResultsMini-Cog scores were less than 4 (indicating cognitive impairment) in 157 encounters (82 (67.7%) with HF, 75 (62.5%) without). Mini-Cog scores were similar in rate and distribution between groups. Individuals with HF and cognitive impairment had a significantly higher 30-day readmission rate than did the other groups (26.8% vs 13.2%; P = .01; HF, no cognitive impairment, 12.8%; no HF, no cognitive impairment, 13.3%; cognitive impairment, no HF, 13.3%). In individuals with HF and cognitive impairment, those with documented caregiver education had lower readmission rates than those without (14.3% vs 36.2%; P = .03). Fewer than 9% had documentation of cognitive impairment in the medical record.ConclusionCognitive impairment, which is frequently undocumented, may indicate greater risk of readmission for individuals with HF than those without. Screening for cognitive impairment, adapting discharge for it, and involving family and caregivers in discharge education may help reduce readmissions.