The Prevalence of Dementia and Cognitive Impairment in Hospitals
Results from the General Hospital Study (GHoSt)
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Background: The care of elderly patients with comorbid dementia poses an increasing challenge in the acute inpatient setting, yet there remains a lack of representative studies on the prevalence and distribution of dementia in general hospitals.
Methods: We conducted a cross-sectional study of patients aged 65 and older in randomly selected general hospitals in southern Germany. Patients were excluded if they were in an intensive care unit or isolation unit or if they were on specialized wards for psychiatry, neurology, or geriatric medicine. The findings are derived from patient interviews, neuropsychological testing, standardized rating scales, questioning of nursing staff, and the patients’ medical records.
Results: 1469 patients on 172 inpatient wards of 33 hospitals were studied. 40.0% of them (95% confidence interval, [36.2; 43.7]) had at least mild cognitive impairment. The point-prevalence of dementing illnesses was 18.4% [16.3; 20.7]. Delirium, most often on the basis of dementia, was present in 5.1% [3.9; 6.7]. 60.0% had no cognitive impairment. Dementia was more common among patients of very advanced age, those who were dependent on nursing care, those who lived in old-age or nursing homes, and those with a low level of education. Among patients with dementia, only 36.7% had a documented diagnosis of dementia in the medical record. Patients with dementia were treated more often for dehydration, electrolyte disturbances, urinary tract infections, contusions, and bone fractures, as well as for symptoms and findings of an unknown nature, and much less often for cancer or musculoskeletal diseases.
Conclusion: Two out of five elderly patients in general hospitals suffer from a cognitive disturbance. Patients with severe impairments such as dementia or delirium often need special care. Guidelines and model projects offer approaches by which the inpatient care of patients with comorbid dementia can be improved.
In 2016, 8.56 million older patients were treated on an inpatient basis in general hospital departments in Germany. This is equivalent to 44.7% of all inpatients of all age groups. The length of hospital stay of patients aged 65 or older was considerably longer compared with that of younger patients (8.1 days versus 4.9 days); as the result, older patients accounted for 57.1% of all days of inpatient treatment, making them the largest group of inpatients (1). A considerable number of older hospitalized patients with physical illnesses also suffer from dementia and related cognitive impairments. However, the exact number of patients experiencing these health problems is currently not known. Previous studies were almost impossible to compare because the methods they used varied widely and they typically comprised small, non-representative samples and arrived at widely divergent prevalence estimates which are only of limited use for dementia-related healthcare planning (2, 3). Hospital stays can be very stressful for patients with comorbid dementia and complications may arise (4, 5). A rapid decline in cognitive and functional skills is commonly observed (6). The risk of institutionalization and mortality is about twice as high as in patients without cognitive impairment (7–9). This lack of knowledge about the prevalence and distribution of cognitive disorders is an obstacle to improved care which is tailored to the specific needs of these patients.
The aim of this study is to determine the point prevalence of comorbid cognitive disorders and dementia based on a representative sample of general hospital patients aged 65 or older. In addition, distribution of dementia shall be described according to demographic characteristics, departments and reasons for seeking treatment.
A more detailed description of the methods of sampling, investigation and statistical analysis used in this study is provided in the eMethods section und in eFigure 1.
The aim of this study was to achieve representativeness for the German federal states of Baden-Württemberg and Bavaria. In these federal states (10, 11), general hospitals and related wards were drawn randomly. All patients aged 65 or older who were inpatients on the selected wards on the day of survey were invited to participate in the study.
Hospitals with less than 150 in-patient beds, private and specialty hospitals as well as rehabilitation and day or night clinics were excluded. Besides neurology and psychiatry where dementia usually is not a comorbid condition but the primary diagnosis, geriatrics was also not included in this analysis because detailed studies on dementia are already available for this branch of medicine (12, 13).
Patients in intensive care units and on isolation wards were not included because of the critical condition they were in or the infectious nature of their illness. Another exclusion criterion was met when the patient was moribund or did not speak German.
The Ethics Committee of the Faculty of Medicine of the Technical University of Munich approved the study protocol on 21 March 2014 (No. 66/14). In the German Registry of Clinical Studies, this study is registered under DRKS00006028. Following informed consent discussion about the content and aims of this study and provision of written information material, the written consent to participation in the study was obtained from the patients or the legal representatives.
Data were obtained in standardized form by means of personal examination of the patient, an interview with the responsible nurse and documentation of study-relevant information from medical records. In unclear cases, additional interviews were conducted with relatives or the legal representative (eMethods section).
The cognitive status was assessed using a test battery designed for bedside assessment. This battery comprised the screening tool 6-Item Cognitive Impairment Test (14) as well as established methods of measuring primary and secondary memory, verbal fluency, attention, and executive functions (15). Dementia was diagnosed according to DSM-IV criteria, delirium according to the criteria of the Confusion Assessment Method (16, 17). Global severity of cognitive impairment was assessed using the five-point Clinical Dementia Rating (CDR) scale (18). A value of 0.5 on the CDR scale was interpreted as mild dementia (19, 20).
Point prevalence rates were calculated with 95% confidence intervals, taking intra-cluster correlations (ICC) into account (21). In order to determine the extent to which the prevalence of dementia in the hospital setting differs from that in the general population, the indirect standardized rate ratio (IRR) was calculated. For comparison with the age- and sex-specific prevalence in the older general population, the EuroCoDe data were used which are based on European field studies (22). Age- and sex-adjusted analyses of the association between dementia and demographic variables, departments or reasons for seeking treatment were performed. The cluster structure of the data was taken into account by means of logistic Generalized Estimation Equation (GEE) models (23). Data analyses were performed using OpenEpi (24), the R package (25) and SPSS 25.
Description of sample
Of the 55 contacted hospitals, 33 (60%) participated in this study. A response rate breakdown is provided in Figure 1. Of the altogether 2534 patients aged 65 or older who were present on one of the 172 wards on the day of survey, 380 met an exclusion criterion or were not available on the ward at that day. From the gross sample of 2154 inpatients, 635 patients capable of consenting to participation in this study refused to take part; in another 50 cases, the legal representative did not consent or could not be contacted. Finally, the net sample comprised 1469 participants, corresponding to a participation rate of 68.2%. In all cases, a nurse was interviewed and information from the patient records was available for 99.5% of study participants. In addition, relatives or legal representatives of 149 patients were interviewed. There was no statistically significant difference between participating and non-participating patients with regard to age and sex.
The age of the assessed patients ranged between 65 and 105 years, the mean age was 78.6 years (s = 7.4). Slightly more than half of the participants were female (53.8%). Most patients were treated on medical wards (50.2%), followed by trauma surgery (20.1%), general surgery (17.0%), and other specialties, such as orthopedics, urology, gynecology, and ENT, each accounting for a percentage share of less than 4%. One third of the patients had been in hospital for up to 2 days at the time of survey, one third for 3 to 7 days, and another third for 8 or more days. The median length of inpatient stay prior to the survey day was 5 days.
Figure 2 provides an overview of the distribution of the sample broken down by type and severity of the cognitive disorder. Altogether 60.0% of patients were assessed, using the CDR scale, as having no cognitive impairments, while the remaining 40.0% (95% confidence interval (CI): [36.2; 43.7]) experienced, in equal parts, mild (CDR = 0.5) or severe (CDR ≥ 1) cognitive impairments. The prevalence of dementia was 18.4% [16.3; 20.7]. Mild dementia was present in 6.8% [5.4; 8.5], moderate dementia in 6.6% [5.3; 8.2] and severe dementia in 5.0% of participants [3.7; 6.6]. Seventy-five (5.1% [3.9; 6.7]) patients were diagnosed with delirium. The intracluster correlation coefficients were ICC = 0.006 for dementia, ICC = 0.014 for mild cognitive disorder and ICC = 0.012 for delirium.
In two-thirds of cases, delirium was associated with underlying dementia. Only 27 patients (1.8% of the total sample) were diagnosed with delirium without underlying dementia. Among the assessed patients with dementia, the risk of delirium was significantly increased (odds ratio [OR]: 9.34 [5.13; 17.00]). With increasing severity of dementia, the percentage of associated delirium episodes increased, rising from 8.0% with mild dementia to 28.8% with severe dementia.
The percentage of participants without cognitive impairment decreased with increasing age from 85.8% among the 65-to 69-year olds to 32.0% among participants older than 90 years, while the prevalence of dementia simultaneously rose from 6.4% to 41.0% (Table 1). Only in 36.7% of these patients with dementia, the diagnosis of dementia was listed in the medical records. However, with increasing severity, the percentage of known dementia rose from 12.0% to 37.1% to 69.9% for existing mild, moderate and severe dementia, respectively.
In eFigure 2, the prevalence of dementia in the sample is depicted, broken down by age and sex. Among the 65- to 84-year-olds, men experienced dementia more frequently than women, while in the age group 90 years or older, a female preponderance was noted. Overall, there was no difference between the prevalence rates for male and female patients (18.3% vs. 18.5%).
In comparison with the general population, the age- and sex-specific point prevalence rates in the general hospital setting (eFigure 3) were found significantly increased, especially in the lower age groups. Among the 65- to 69-year-olds, the rates were 4-times higher compared to the general population. With increasing age, they gradually converged to become identical in the oldest age group. Overall, with an IRR = 1.51 [1.33; 1.70] for the general hospital setting, the prevalence of dementia was found increased by 51% compared to the rate to be expected on the basis of the demographic composition of the participants. A significant overrepresentation by 89% was found among male patients (eFigure 4) (IRR: 1.89 [1.57; 2.25]), while the prevalence of dementia among female patients (eFigure 5) was only increased by 29% (IRR: 1.29 [1.09; 1.52]).
Nursing home residents and persons requiring nursing care were among the patient groups most frequently affected by dementia. Among the nursing home residents, 67.2% of patients had dementia, while among the patients with a nursing care level (“Pflegestufe”) the prevalence was 43.7% (Table 2). By department, the highest prevalence of dementia was found in internal medicine departments with 21.3%, followed by trauma surgery departments with 19.7%. The rates were significantly lower in general surgery and the remaining departments where patients with dementia account for just over 12% of patients.
Age, education, residential living arrangement and need of assistance were associated with dementia (eTable 1). Most affected were patients aged older than 80 years or in need of nursing care, with low school-leaving qualifications, living together with family or other caregivers, or living in a nursing home. Sex and marital status were not associated with dementia.
In eTable 2, the reasons for seeking treatment were compared between patients with dementia versus cognitively unimpaired patients. Even after adjustment for age and sex, diagnoses from four key groups, created based on ICD-10, were significantly more common among patients with dementia, while diagnoses from two groups were rarer. In patients with dementia, dehydration and electrolyte imbalances as well as urinary tract infections and lower respiratory tract infections were more common. They also experienced signs and symptoms such as vomiting, fever, dysphagia, and urinary retention more frequently. In addition, general physical decline, injuries and bruises, as well as rib and hip fractures were more common in this patient group. By contrast, patients with dementia less frequently presented for inpatient treatment because of cancer and various types of musculoskeletal disorders.
In general hospitals, comorbid dementia and cognitive disorders are common. Altogether, 40% of older patients had cognitive disorders, ranging from mild impairments to severe dementia; 60% showed no cognitive impairment. These estimates refer to patients from general departments, excluding the departments of psychiatry, neurology and geriatrics as well as intensive care units and isolation wards.
In our sample, the prevalence of dementia of 18.4% was about twice as high compared to the general German population aged 65 or older where it was, according to epidemiological estimates, 9.1% (26). Indirect standardization of the prevalence rate by age and sex showed that half of this overrepresentation of dementia was explained by the older age of the hospital patients. When the inpatients’ age structure was taken into account, the expected value was only surpassed by 51%. This residual increase in the prevalence of dementia is primarily explained by male patients and the age groups below 90 years of age. It could be brought about by the fact that older patients with dementia are more frequently admitted and their duration of hospital stay is longer. According to health insurance data from the federal state of Saxony, the increase is primarily the result of an increased risk of admission for patients with dementia and not due to longer duration of stay (27).
One fifth of hospital patients had mild cognitive disorders. So far, hardly any research has been conducted to clarify whether these mild impairments are already associated with treatment complications and require special healthcare measures. However, it appears to be advantageous to also study the impact of mild cognitive disorders on the course and outcome of inpatient treatment.
Even though delirium was not uncommon in our sample, the prevalence of 5.1% which we found was still at the lower end of the estimates reported so far (28). However, it should be noted that the point prevalence of our study cannot be directly compared with the period prevalence of the delirium studies. Due to its relapsing and remitting course which tends to fluctuate throughout the day, delirium is a disorder which cannot be fully captured by an examination performed at one point in time. In this case, it would be more appropriate to determine the period prevalence over the entire length of inpatient stay, closely monitoring the patient so that short and night-time episodes of delirium are captured
The results were as expected for the risk groups. Dementia was especially common among at least 80-year-olds, patients requiring nursing care and nursing home residents. The departments of internal medicine and trauma surgery had the highest percentages of patients with dementia. By paying more attention to so-called ambulatory care sensitive conditions, opportunities to reduce dementia prevalence in hospitals may open up. As described in numerous other studies (29–31), patients with dementia were often admitted for health problems which could have been treated on an outpatient basis or ideally even prevented.
The strengths of our study include the large sample size and the use of multiple sources of information, contributing to the high external and internal validity of the results. Generalizability is limited by the fact that participation rates of hospitals and patients were under 70% and that small hospitals, intensive care units and isolation wards, as well as moribund patients and patients who did not speak German were excluded.
Analyzing sample failures and effects of the study design, no indication of systematic bias was found. There was no difference between participants and non-participants with regard to age and sex. The refusal rates among patients capable of consenting to participation was as high as the non-participation rates among patients with legal representatives. The number of beds of the hospitals was not correlated with the prevalence rates of dementia, delirium or mild cognitive disorders, making potential bias due to variations in hospital size unlikely. The excluded hospitals with less than 150 in-patient beds account for only 9% of the days of stay (1). The prevalence of dementia was not higher among patients assessed after surgery than among the remaining patients (data not shown). This could indicate that transient postoperative cognitive dysfunction was not misdiagnosed as dementia. In addition, our results are in line with those of other primary studies (Table 3).
When subgroups are formed and dementia prevalence rates are calculated for the same patient groups which the other primary studies referred to, the values are almost identical. This fact indicates an almost equal prevalence of comorbid dementia across the hospitals of industrialized countries. For the 3 earlier studies evaluating moderate and severe dementia, the median prevalence was 11.9% (32–34); in our study, the rate for severe dementia is 12.2%. For all levels of dementia severity, from mild to severe, the median in seven earlier studies was 20.7% (9, 35–40) compared to 20.3% in our study. A large Scottish study has recently reported a prevalence for the entire spectrum of cognitive disorders among older patients of 38.5% (40). This value is almost identical with our rate of 40.0%.
According to the hospital statistics, in Germany in 2016 about on average 190 000 at least 65-year-olds received inpatient treatment in general departments (without psychiatry/psychosomatics) (1). When the point prevalence rates are applied to these patient numbers, every day on average about 76 000 older patients with comorbid cognitive impairments are treated in hospital, including approximately 35 000 with dementia and 38 000 with mild cognitive disorders. There is an urgent need to take greater account of the special healthcare needs of this vulnerable patient group.
The Robert Bosch Foundation enabled us to carry out the project “Dementia and Delirium in the General Hospital: Prevalence and Care Situation“. We received additional funding from the German Alzheimer‘s Association (Deutsche Alzheimer Gesellschaft). We extend our sincere thanks to the participating patients and their relatives, the hospital staff members and the hospitals for their cooperation. We appreciate very much the practical support of the Ministry of Employment and Social Order, Family, Women and Senior Citizens, Baden-Württemberg, the Bavarian State Ministry of Health and Care, the regional hospital associations of Baden-Württemberg and Bavaria as well as the German Alzheimer’s Association. We would also like to thank the healthcare experts who supported us with their advice during the planning stage of the study.
Conflict of interest
Dr. Bickel received reimbursement of travel expenses and study support (third-party funding) from the Robert Bosch Foundation. Mrs. Hendlmeier received reimbursement of congress fees and travel expenses, lecture fees, and study support (third-party funding) from the Robert Bosch Foundation. Prof. Schäufele received reimbursement of travel expenses and study support (third-party funding) from the Robert Bosch Foundation.
The remaining authors declare no conflict of interest.
Manuscript received on 4 April 2018; revised version accepted on
13 August 2017
Translated from the original German by Ralf Thoene, MD.
Dr. phil. Dipl.-Psych. Horst Bickel
Klinik und Poliklinik für Psychiatrie und Psychotherapie der TU München
Klinikum rechts der Isar
Ismaninger Str. 22,
81675 München, Germany
For eReferences please refer to:
eFigures, eMethods, eTables:
Faculty of Social Sciences, University of Mannheim, Mannheim, Germany: Dipl.-Geront. Dipl.-Soz.Arb.(FH) Ingrid Hendlmeier;
Sarah Leonhardt-Achilles M.A.; Joshua Weber M.A.; Prof. Dr. sc. hum. Dipl.-Psych. Martina Schäufele
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