A comprehensive collateral history is a standard of care recommended both in Ireland, by the Irish National Audit of Dementia Care in Acute Hospitals (INAD) and internationally, by the EuGMS. We sought to establish if this standard was being met. Only 44% of patients with cognitive impairment had a collateral history. The level of detail attained was often inadequate and assessment of patients’ current and premorbid cognition was poor. Obtaining a comprehensive collateral history is imperative to the diagnosis of delirium and dementia. It is not possible to make a competent clinical assessment or a management plan without exercising this core clinical skill. Patients with cognitive impairment are often unable to provide information relating to their pre-morbid cognition and function. Such information is essential to correctly identifying delirium and dementia, as well as making an accurate diagnosis and planning appropriate treatment. It is the standard of care recommended by the EuGMS. We reviewed medical notes and administered a short questionnaire to nursing staff of a convenience sample of 100 patients aged ≥ 75 years admitted to medical wards in a tertiary teaching hospital. There were 100 patients with a mean age of 82.3 years, 49% of whom were female. Of 43 patients with cognitive impairment, 19 (44%) had a collateral history. Half of the patients described as having dementia did not have any further detail on the severity of dementia documented. Among those for whom a collateral history was obtained, the level of detail regarding pre-morbid cognition, function, mobility, and continence was sparse. Of the total sample, 13% had formal cognitive testing. Acute illness characteristically causes significant impairments in cognition and function in frail older patients. Identifying and reversing these impairments is impossible without a comprehensive collateral history. It is alarming that such an essential component of clinical assessment is so often disregarded and highlights the lack of awareness from clinicians of the importance of collateral history in the management of patients with dementia and delirium. This must be emphasised in both undergraduate and postgraduate teaching.

中文翻译：

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附带病史：一项被忽视的核心临床技能


全面的附带病史是爱尔兰国家急性医院痴呆症护理审计 (INAD) 和国际上 EuGMS 推荐的护理标准。我们试图确定该标准是否得到满足。只有 44% 的认知障碍患者有附带病史。所获得的详细程度往往不够，对患者当前和病前认知的评估也很差。获得全面的附带病史对于谵妄和痴呆的诊断至关重要。如果不运用这一核心临床技能，就不可能做出有效的临床评估或管理计划。患有认知障碍的患者通常无法提供与其病前认知和功能相关的信息。这些信息对于正确识别谵妄和痴呆以及做出准确的诊断和规划适当的治疗至关重要。这是 EuGMS 推荐的护理标准。我们查阅了病历，并向护理人员进行了一份简短的调查问卷，随机抽取了三级教学医院内科病房收治的 100 名年龄≥ 75 岁的患者。共有100名患者，平均年龄82.3岁，其中49%为女性。 43 名认知障碍患者中，19 名（44%）有附带病史。一半被描述为患有痴呆症的患者没有记录痴呆症严重程度的任何进一步细节。在获得附带病史的患者中，有关病前认知、功能、活动能力和失禁的详细信息很少。在总样本中，13% 接受了正式的认知测试。 急性疾病通常会导致体弱的老年患者认知和功能显着受损。如果没有全面的抵押品历史记录，就不可能识别和扭转这些损害。令人震惊的是，临床评估的这一重要组成部分经常被忽视，并突显出临床医生对附带病史在痴呆和谵妄患者治疗中的重要性缺乏认识。无论是本科生还是研究生的教学都必须强调这一点。