Study design and setting
This was a retrospective cross-sectional study conducted by extracting 24 months of data from the electronic medical records of elderly patients (age more than or equal to 60 years) diagnosed with a major neurocognitive disorder based on the Diagnostic and Statistical Manual of Mental Disorders fifth edition criteria (DSM-5) [13] who are attending in-patient and/or out-patient geriatric psychiatry services at Sultan Qaboos University Hospital (SQUH), a tertiary referral hospital located in Muscat, the capital city and is providing specialist mental health care services.
Study sample and sampling method
We included all elderly patients (age ≥ 60 years) attending in-patient and or out-patient geriatric psychiatry services at SQUH who met the DSM-5 criteria [13] for the major neurocognitive disorder during the study period. The study sample was recruited using a systemic random sampling (every second patient) approach. Any recruited participant who failed to meet the inclusion criteria was excluded from the study and replaced with the next potential participant.
Inclusion and exclusion criteria of the study participants
We included elderly patients (age ≥ 60 years), who were diagnosed with a major neurocognitive disorder based on the DSM-5 criteria [13] during the period from January 2020 to December 2021. We excluded patients whose clinical records had missing data, we tried to compensate by collecting the missing data from the treating psychiatrist, and when this is not possible the patient is excluded.
Data source and collection
Data were extracted from patients’ electronic medical records from January 2020 to December 2021 through the hospital information system department after obtaining ethical approval from Sultan Qaboos University Hospital Research and Ethics Committee (MREC2636). The research protocols and procedures conformed to the guidance of the World Medical Association’s Declaration of Helsinki for ethical human research.
Outcome measures
The data extracted from patients’ medical records were classified into (1) socio-demographic factors, following information solicited age, gender, marital status, educational level, and region of residence; (2) type and severity of dementia. The type of dementia was classified based on DSM-5 criteria [13] and the severity of dementia was classified into mild, moderate, and severe, based on the dementia classification in the Rockwood Clinical Frailty Scale [14]; (3) presence of co-morbid medical or mental illness based on DSM-5 criteria [13]; (4) The prescribed anti-psychotic, and anti-dementia medications; (5) the anti-psychotic medication name, duration of use was solicited as well.
Rockwood Clinical Frailty Scale
A frailty assessment tool is useful for assessing individuals with cognitive impairment. These are helpful in guiding decisions about treatment plans, and there are several scales that can be applied, but a straightforward instrument like the Rockwood Clinical Frailty Scale can be a quick method for assessing individuals who have cognitive impairment. It requires the clinician to observe the patient mobilizing and inquire about their routine physical activity and capacity for self-care. The level of frailty is correlated with the degree of dementia [15]. It has three dementia classifications: mild, moderate, and severe. Individuals with mild frailty are correlated with mild dementia, those individuals forget details of recent events, though they still remember the event itself, repeat the same question/story, and experience social withdrawal. Individuals with moderate dementia, have very impaired recent memory, even though they seemingly can remember their past life events well. As with moderate frailty, they can do personal care with prompting. Individuals with severe dementia, as in severe frailty, cannot perform personal care without help. The scale has moderate to good inter-rater reliability [16] and is a validated diagnostic tool to assess frailty in elderly hospital patients and patients in the emergency room [17].
Co-morbid medical or mental conditions
The co-morbid medical or mental conditions were measured by the presence of at least one medical or mental illness. The participant’s medical records were reviewed for whether they had one or more medical or mental co-morbid conditions, for example, respiratory disorders (such as obstructive sleep apnea, asthma), cardiovascular disorders (for example dyslipidemia, coronary acute syndrome, hypertension), endocrine disorders (for example diabetes, thyroid dysfunction), hematological disorders (for example, iron deficiency anemia), and neurological disorders (for example, stroke). For mental conditions, we reviewed the medical records and documented co-morbid mental illnesses which were diagnosed based on the DSM-5 criteria [13], for example, affective and anxiety disorders.
Statistical analysis
Collected data were analyzed using IBM SPSS Statistics 27.0 (IBM Corp. Released 2020. IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp). For descriptive purposes, continuous variables were presented with mean with standard deviation, and categorical variables were presented with frequency and percentages. The chi-square test was used for comparison between groups; multivariate logistic regression analysis was done using enter method, considering the significant factors from univariate and close to the significant factors (up to 0.2 level). A p-value of < 0.05 was taken as statistical significance.