Individualized Acute Medical Care for Cognitively Impaired Individuals: A Call Always to Pause Before Hospitalization

Staying “mentally sharp” was recently identified as American retirees’ number one health priority.1 For those living with mild cognitive impairment (MCI) and dementia, the lack of disease-modifying treatment precludes this goal. Worse, delivery of health care through hospitalization drives and accelerates cognitive decline for those at risk. Although most frail elderly adults experience posthospitalization disability, those with MCI and dementia are at greatest risk of permanent functional and cognitive losses. A health systems-wide intervention that addresses the unique needs of this population and offers cognitively protective medical care is needed. Acute illness combined with hospitalization is common and poses a significant risk of delirium that often results in permanent cognitive and functional losses.2 An estimated 66% of community-dwelling persons with dementia are hospitalized at least once a year. Considering the 56% risk of delirium from hospitalization, upwards of one in three community-dwelling individuals with dementia will experience some degree of accelerated cognitive decline from hospitalization per year.2, 3 Although we deliver care with the best of intentions, the health system fails to appreciate cognitive impairment as chronic organ failure and thus does not take proper steps to protect brains in the same manner it protects other organs. Electronic decision support and safety checklists mitigate iatrogenic injury in a myriad of other organ failure scenarios. Imaging studies with contrast cannot be ordered until creatinine is assessed in individuals with chronic renal disease. Hepatotoxic medications require pharmacy override in individuals with sepsis with chronic liver failure. Surgeons require an international normalized ratio before taking a person with cirrhosis to the operating room. All these cases underscore how our health system recognizes the harm of interventions in the context of underlying organ failure, yet for neurodegenerative disease—chronic brain failure—we ignore what is arguably the greatest known threat: hospitalization. No evidence suggests that cognitively impaired individuals are warned of hospitalization threats or that health systems appreciate the connection between dementia, delirium, and permanent cognitive and functional deterioration. There are well-established protections against the hazards of hospitalization; considering the critical nature of the problem, these alternatives remain vastly underused. Hospitalization comes in two varieties: unplanned and planned. Hospital at Home can safely treat acute medical illness that necessitates hospitalization in nearly one-third of cases of older adults with certain acute medical illnesses.4 Better sleep, encouraged ambulation, and familiar surroundings are a few of the many reasons why Hospital at Home averts delirium and subsequent decline.5-8 Hospital at Home advocates often champion the lower costs, greater patient satisfaction, and better medical outcomes, including significant mortality benefit (20% risk reduction at 6 months, number needed to treat = 50) of this alternate treatment venue.9 The paramount benefit of avoiding iatrogenic cognitive decline from hospitalization is particularly compelling in cognitively impaired individuals. Cognitively impaired individuals are also prone to the phenomenon of “social admission,” wherein they arrive in the emergency department for unclear reasons and are hospitalized because they are judged “unsafe” for return home—despite no medical justification. Models of emergency department–based geriatric case management exist, but they have not been widely disseminated.10, 11 Although it may be difficult to return people to their origin (assuming safety evaluations), the reflexive admission should be viewed as a last resort after thoroughly exhausting alternatives. This may disrupt emergency department workflow with prolonged visits, but no individual should be subjected to the gauntlet of hospitalization simply because it was the easiest exit for social disposition problems. For the remainder of individuals for whom inpatient hospitalization is unavoidable because of illness severity or treatment complexity, it is well validated that inpatient delirium prevention mitigates acute or chronic brain failure (delirium superimposed on dementia). Multifactorial interventions such as the Hospital Elder Life Program (HELp)12 and individualized hospital Acute Care for Elders Units13 succeed at reducing iatrogenic harm in cognitively impaired individuals. Despite conclusive evidence, these interventions show marginal dissemination and adoption. Multiple barriers may explain this paradox, including institutional culture that normalizes delirium as the “cost of doing business,” underappreciation of the effects of delirium superimposed on dementia, and the perceived difficulty funding these programs. Just as we never second-guess the protocols that place individuals with neutropenia in reverse isolation (regardless of expenses in contact garments and a private room), enacting similar systems for cognitively impaired individuals could make cognitively minded care the standard of care. Planned hospitalizations are almost always surgical. Delirium risks include all of those inherent in a nonsurgical admission plus the effects of general anesthesia and surgically induced inflammation. Burgeoning work in prehabilitation,14 along with standardized preoperative frailty assessments,15 share the premise that this population has a vulnerable organ that needs protection. Applying the chronic organ-failure paradigm, chronic renal failure does not preclude the massive contrast loads of angioplasty. Instead, evidence-based protocols for prehydration and toxic-mitigating medications lessen the likelihood of worsening kidney impairment. Likewise, in cognitively impaired individuals, elective hospitalization should not be withheld; instead, a strategy of brain-protective prehabilitation and postoperative delirium prevention should be implemented to prevent subsequent cognitive decline. Pilots that provide immediate postoperative acute care through Hospital at Home are underway. Recent research leveraging HELP has already shown significant reductions in postoperative delirium.16 While ongoing studies assess the robustness of these associations, there is no reason to wait for more evidence to enact systems-level changes to protect this population. Efforts to build age-friendly health systems and hospitals are budding through efforts of the John A. Hartford Foundation and the Institute for Healthcare Improvement.17 Systems innovations focusing on cognitive protection will benefit the aging U.S. population able to receive their services, but we should not wait for age-friendly hospitals to sweep the nation to enact the changes required to serve this population. One exemplar that addresses the unwanted effects of hospitalization on at-risk individuals is the allergy paradigm; electronic chart flags signify intolerance to medications and medical products. These under-appreciated systems-level innovations save countless lives and often invite shared decision making about risks and benefits of treatment.18 Hospitalizing cognitively impaired individuals can lead to reactions that are no less lethal than those of many allergies. Leveraging risk calculators to inform complicated decisions is nothing new in medicine. For older adults, the Hospital Admission Risk Profile is a well-validated instrument that stratifies people into categories based on likelihood of functional decline.19 Although it may be imprecise, a poor instrument should not preclude cognitively protective acute care. The problem stems from a lack of systematic consideration and disclosure of the information at all. Looking to the adjacency of surgery, anyone undergoing surgery must be informed of the risks before consenting to the procedure. A similar approach could be used in admitting persons with cognitive impairment. To be clear, shepherding cognitively impaired individuals into Hospital at Home or other care delivery models that help older adults avoid the traditional inpatient environment should not be viewed as rationed care or shunting this population away from tertiary medical centers. It is simply a matter of providing the right care in the right place for a population that has too much to lose under the current treatment paradigm of inpatient care. To operationalize the medical system around the significant threats of hospitalization, electronic decision support could pause workflow and alert medical providers to the dangers of hospitalization such that admission orders cannot be signed before considering alternatives to inpatient care. For individuals for whom Hospital at Home is not feasible, robust inpatient delirium prevention protocols become standard of care. In the event of elective surgery, case bookings routinely include enrollment in prehabilitation and arrangement for delirium prevention postoperatively. Making such a pause an “always event” in the U.S. healthcare system is an opportunity to improve the quality of care of individuals with MCI and dementia significantly. Conflict of Interest: The authors declare no conflicts of interest. Author Contributions: All authors contributed to the conception, drafting, and writing of this manuscript. Sponsor's Role: None.