Improved evaluation and management of cognitive impairment: results of a comprehensive intervention in long-term care

Although as many as 50% of patients in long-term care have dementia, it is often not diagnosed and therefore, undertreated. We determined whether an intervention could improve the diagnosis and management of patients with cognitive impairment (CI) in long-term care.

The assessment phase consisted of a record review of 60 consecutively admitted patients to the San Francisco VA Nursing Home Care Unit (NHCU). Cognitive impairment was determined by admission MMSE < or = 24, indication of cognitive problem on MDS, or chart diagnosis of dementia. The evaluation consisted of a repeat chart review of 60 additional consecutively admitted patients.

The intervention consisted of low-cost and easy-to-implement educational activities (training, focus groups), strategies to document cognitive status, and consultation with dementia experts.

The 2 cohorts of 60 patients did not differ on demographics or on other characteristics (P > .25 for all). Prior to the intervention, of the 23 patients with CI, 52% had an identified etiology, 35% had a physician management plan, and 22% had a multidisciplinary care plan. Postintervention, of the 22 patients with CI, 91% had an identified etiology (P = .007), 86% had a physician plan (P = .001), and 59% had a multidisciplinary plan (P = .016).

Initial results confirmed the underdiagnosis and undertreatment of CI in our long-term care facility. Our intervention with educational programs, increased documentation of cognitive status, and consultation resulted in increased identification of etiology and improved plans for management of patients with CI.