Annals of Long Term Care

Best Practices in Nursing Care for Hospitalized Older Adults with dementia from the John A. Hartford Institute for Geriatric Nursing and the Alzheimer’s Association

Issue Number D3, Revised 2007
Series Editor: Marie Boltz, MSN, APRN, BC, GNP
Managing Editor: Sherry A. Greenberg, MSN, APRN, BC, GNP
New York University College of Nursing

WHY: A hospital admission may surface a previously undetected dementia in some older adults. While at home in a familiar environment, patients and family members may fail to recognize subtle, slowly progressive cognitive changes. Such changes however, often become apparent in the unfamiliar, disorienting setting of the hospital provoking family to report “my mother was never like this at home.”

This Try This recommends assessing executive function for older patients not thought to have dementia prior to hospitalization but where the patient, family or staff feel the patient has not returned to baseline cognitive status at the time of discharge. Particularly when the older patient is alert and verbal and memory is not obviously impaired, screening for executive dysfunction can be critical to a safe, realistic treatment and discharge plan. Patients who exhibit executive dysfunction should be referred to their primary care provider, or to a provider with expertise in dementia assessment.

Executive dysfunction defined: Executive function is an interrelated set of abilities that includes cognitive flexibility, concept formation, and self-monitoring. Assessing executive function can help determine a patient’s capacity to execute health care decisions and with discharge planning decisions. With impaired executive dysfunction, instrumental activities of daily living (accounting, shopping, medication management, driving) may be beyond the person’s capacity even though memory impairment is mild. The person’s capacity to exercise command and self-control, and to direct others to provide care, becomes diminished. Executive dysfunction is one element in the DSM-IV criteria for the diagnosis of dementia and occurs in all dementing diseases.

NOTE: Patients with impaired executive function need not have impaired memory.

BEST PRACTICES: Few practitioners are familiar with testing for executive function, yet there are brief valid and reliable instruments. The instruments listed below have good internal consistency, inter-rater reliability and are strongly correlated with the Folstein Mini-Mental Status Exam (MMSE) and with lengthier neuropsychological assessments of executive function:

• Royall’s CLOX (clock drawing),
• Controlled Oral Word Association Test, and
• Trail Making Test, oral version.

TARGET POPULATION: Older patients:
• Not thought to have dementia prior to hospitalization but where the patient, family or staff feel the patient has not returned to baseline cognitive status at the time of discharge.
• For whom other screening (e.g., Try This: Mini-Cog, CAM) reveals no discernable cause for a cognitive impairment.
• For whom cognitive impairment, observed as alterations in memory, use of language and abstract thinking, and spatial sense, persists even when delirium has been identified and treated or ruled out.

VALIDITY AND RELIABILITY: Studies of executive dysfunction suggest that its presence predicts level of care among community residents making the transition to less independent living. And among older adults without dementia who have recovered from a major depressive episode, the presence of executive dysfunction is associated with excess, persistent disability.

STRENGTHS AND LIMITATIONS: The accurate characterization of executive dysfunction is confounded by language, education, and time of assessment. If the patient and examiner do not share a common mother tongue, the Controlled Oral Word Association and the oral version of the Trail Making tests become too difficult.