Introduction: The Growing Challenge of Cognitive Impairment in Acute Care
As the global population ages, the landscape of acute hospital care is shifting. Older adults now represent a significant and growing proportion of unplanned hospital admissions. These patients often present with a complex interplay of physical illness and cognitive impairment, a combination that complicates diagnosis, prolongs hospital stays, and increases the risk of adverse outcomes. Despite the clinical intuition that cognitive issues are common, there has been a lack of comprehensive, specialty-specific data to guide service planning and health policy.
The Oxford and Reading Cognitive Comorbidity, Frailty and Ageing Research Database (ORCHARD-EPR) study addresses this gap by providing a massive-scale analysis of cognitive morbidity—encompassing delirium, dementia, and low cognitive test scores—across a diverse range of medical and surgical specialties. The results suggest that cognitive impairment is not just a geriatric specialty concern but a universal reality of modern hospital medicine.
Highlights of the ORCHARD-EPR Study
– Prevalence: Out of 51,202 admissions of patients aged 70 or older, 35.6% presented with some form of cognitive morbidity.
– Dominance of Delirium: Delirium was the most frequent cognitive morbidity, affecting 24.0% of all admissions and appearing as the leading subtype in 24 out of 29 specialties.
– Specialty Impact: While prevalence was highest in geriatrics (44.5%) and general medicine (42.8%), it remained significant in surgical fields such as neurosurgery (22.9%) and general surgery (21.5%).
– Clinical Infrastructure: The study advocates for mandatory, hospital-wide delirium screening and enhanced access to multidisciplinary team (MDT) support regardless of the admitting department.
Disease Burden: The Silent Epidemic in Hospital Wards
Cognitive morbidity in the acute setting is a major driver of poor clinical outcomes. Delirium, an acute change in mental status characterized by fluctuating levels of consciousness and inattention, is frequently missed by clinicians unless systematic screening tools are employed. When delirium is superimposed on pre-existing dementia, the complexity of care increases exponentially.
Patients with cognitive impairment are at higher risk for falls, pressure ulcers, medication errors, and hospital-acquired infections. Furthermore, the presence of delirium is a strong predictor of post-discharge institutionalization and mortality. Despite these stakes, many hospital systems lack a standardized approach to identifying and managing these conditions outside of specialized geriatric units. The ORCHARD-EPR study highlights that the ‘burden’ is widely distributed, affecting everything from trauma surgery to infectious disease wards.
Study Design and Methodology
The ORCHARD-EPR study utilized a cross-sectional design, pulling data from the Oxford and Reading Cognitive Comorbidity, Frailty and Ageing Research Database. The cohort included consecutive patients aged 70 years or older with a length of stay of at least one day between January 1, 2017, and December 31, 2019. The study covered four hospitals in Oxfordshire, UK.
Data Collection and Definitions
The researchers leveraged a mandatory on-admission cognitive screen integrated into the Electronic Patient Record (EPR). This screen included:
1. The 10-point Abbreviated Mental Test (AMT): A score of less than 8 was used to identify low cognitive function.
2. Dementia History: Recorded at the time of admission.
3. Delirium Assessment: A holistic assessment incorporating the AMT, the Confusion Assessment Method (CAM), and clinical notes.
To ensure robustness, these primary screens were supplemented by ICD-10 discharge codes for delirium and dementia. This multi-faceted approach allowed for a more accurate capture of cognitive status than relying on administrative data alone.
Key Findings: A Detailed Look at the Data
The study analyzed 51,202 admissions with a mean age of 82 years. The data revealed a striking prevalence of cognitive issues across the board.
Prevalence Breakdown
Of the total admissions, 18,225 (35.6%) had at least one form of cognitive morbidity. When broken down by subtype:
– Delirium Only: 14.3% (7,332 admissions)
– Delirium + Dementia: 9.7% (4,957 admissions)
– Dementia Only: 8.7% (4,450 admissions)
– Low AMTS (<8) without other diagnosis: 2.9% (1,486 admissions)
These numbers indicate that nearly one-quarter of all older patients admitted emergently are experiencing delirium, either as a new onset or as an exacerbation of underlying dementia.
Specialty-Specific Prevalence
The study categorized prevalence across 29 specialties, revealing that cognitive morbidity is a near-universal challenge:
– Geriatrics and General Medicine: As expected, these specialties saw the highest rates (44.5% and 42.8%, respectively).
– Trauma and Orthopaedics: 36.4% prevalence, likely driven by hip fracture patients who are notoriously susceptible to delirium.
– Palliative Care and Stroke: 36.0% and 30.8%, respectively.
– Surgical Specialties: General surgery reported a 21.5% prevalence, while neurosurgery sat at 22.9%.
– Other Specialties: In 27 out of 29 specialties, the prevalence exceeded 10%, and in many, it hovered around 20%.
Critically, delirium was the most common subtype in the vast majority of specialties (24/29), suggesting that acute cognitive failure is a frequent complication of various primary illnesses, regardless of the organ system involved.
Expert Commentary: Interpreting the Implications
The ORCHARD-EPR findings serve as a wake-up call for hospital administrators and clinical leads. The high prevalence of delirium in specialties like neurosurgery and general surgery suggests that surgical teams must be as proficient in cognitive management as they are in procedural skills.
The Screening Mandate
The success of the ORCHARD-EPR study in capturing this data was largely due to the ‘mandatory on-admission’ nature of the screening. Experts argue that without such mandates, delirium often goes unrecognized, leading to ‘silent’ complications. Implementing a systematic screen, such as the 4AT or the AMT-10 used in this study, should be a priority for all acute care settings.
Multidisciplinary Integration
Because cognitive morbidity is so widespread, it is no longer feasible to rely solely on a small team of geriatricians to manage all cases. Instead, the data supports a model where geriatric expertise is integrated into other specialties—often referred to as ‘orthogeriatrics’ or ‘perioperative medicine for older people.’ Providing all specialties with access to multidisciplinary teams (MDTs) including specialist nurses, occupational therapists, and pharmacists is essential for managing the behavioral and functional aspects of delirium.
Conclusion: Moving Toward Cognitive-Friendly Hospitals
The ORCHARD-EPR study provides the most comprehensive map to date of cognitive morbidity in the acute hospital setting. With over one-third of older patients affected, cognitive impairment is a core component of acute medicine.
To improve care, hospital systems must:
1. Standardize Screening: Use electronic patient records to prompt and record cognitive assessments for every older patient at the point of admission.
2. Expand Specialized Support: Increase the reach of geriatric MDTs beyond dedicated elder-care wards.
3. Educate the Workforce: Ensure that clinicians in all specialties, from surgery to infectious disease, are trained to recognize and manage delirium.
By acknowledging that cognitive health is inseparable from physical health, hospitals can begin to provide the holistic care that the aging population requires.
Funding and References
Funding: This research was supported by the Rhodes Trust, the Canadian Institutes of Health Research, and the National Institute for Health and Care Research (NIHR).
Reference:
Boucher EL, Smith SC, Singh S, Shepperd S, Pendlebury ST. Prevalence of cognitive morbidity including delirium in 51,202 emergency hospital admissions across 29 medical and surgical specialties in ORCHARD-EPR: a cross-sectional study. EClinicalMedicine. 2025 Nov 24;90:103641. doi: 10.1016/j.eclinm.2025.103641. PMID: 41377909; PMCID: PMC12686935.
