Boustani MA, Campbell NL, Khan BA, Abernathy G, Zawahiri M, Campbell T, Tricker J, Hui SL, Buckley JD, Perkins AJ, Farber MO, Callahan CM.
Enhancing Care for Hospitalized Older Adults with Cognitive Impairment: A Randomized Controlled Trial.
J Gen Intern Med. 2012 Feb 3;
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The article by Boustani et al., appearing in the May issue of the Journal of General Internal Medicine, describes a randomized clinical trial to test the effectiveness of a Clinical Decision Support System (CDSS), which was employed to: 1) alert physicians to the presence of cognitive impairment in acutely hospitalized elderly patients, and 2) provide specific recommendations to optimize care and prevent complications in the hospital setting. The recommendations offered by the CDSS for cognitively impaired patients included: 1) avoidance of anticholinergic medications (alternative drugs were suggested by the system); 2) avoidance of physical restraints or the insertion of Foley catheters; and 3) the need for geriatric consultation services. The physicians who were in the control group and did not receive the CDSS intervention were provided access to the medical records, which contained the cognitive scores of these elderly patients, but these physicians did not receive any specific alerts regarding cognitive impairment or recommendations about management of the cognitively impaired elderly.
In the setting of a highly specialized medical center in which this trial was conducted, it was found that patients of physicians in the intervention group did not receive any of the CDSS recommendations more frequently than patients of the control group. Further, patients of physicians in the CDSS intervention group did not have fewer hospital-acquired complications, nor were their outcomes on various parameters any different from those of patients of physicians in the control group.
As discussed by the authors of this very interesting and well-conducted study, it is likely that the lack of effectiveness of the CDSS intervention, in this relatively esoteric hospital setting, could be attributed to the greater level of training and awareness about geriatric care among all its physicians, whether or not they were in the intervention group. To support this hypothesis, it was found that use of anticholinergic medications, physical restraints, and Foley catheters in the control group was much lower than was anticipated, and, as such, did not provide enough power in the study to see any differences between control and intervention groups.
Nevertheless, this article does serve to provide the methodology that could be employed, in a less sophisticated setting, to evaluate the importance of taking simple measures to avoid in-hospital complications among cognitively impaired elderly, using CDSS intervention. A superficial reading of this paper may lead the reader to conclude that cognitive screening of hospitalized elderly patients has no measurable impact on the quality of care they receive or their outcomes. In fact, this article did not test the effect of cognitive screening per se, but instead, the use of a CDSS system to alert physicians about the cognitive screening results and subsequent measures that should be taken among those who are found to be cognitively impaired, to avoid complications and improve outcomes.
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