Unstructured clinical documentation reflecting cognitive and behavioral dysfunction: toward an EHR-based phenotype for cognitive impairment
Open accessAbstract
Despite increased risk for negative outcomes, cognitive impairment (CI) is greatly under-detected during hospitalization. While automated EHR-based phenotypes have potential to improve recognition of CI, they are hindered by widespread under-diagnosis of underlying etiologies such as dementia—limiting the utility of more precise structured data elements. This study examined unstructured data on symptoms of CI in the acute-care EHRs of hip and stroke fracture patients with dementia from two hospitals. Clinician reviewers identified and classified unstructured EHR data using standardized criteria. Relevant narrative text was descriptively characterized and evaluated for key terminology. Most patient EHRs (90%) had narrative text reflecting cognitive and/or behavioral dysfunction common in CI that were reliably classified (κ 0.82). The majority of statements reflected vague descriptions of cognitive/behavioral dysfunction as opposed to diagnostic terminology. Findings from this preliminary derivation study suggest that clinicians use specific terminology in unstructured EHR fields to describe common symptoms of CI. This terminology can inform the design of EHR-based phenotypes for CI and merits further investigation in more diverse, robustly characterized samples.
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This reduced confidence in their ability to identify and diagnose dementia, subsequently limiting the extent to which discharge planning reflected the patient's care needs (CMOC8).
“This reduced confidence in their ability to identify and diagnose dementia, subsequently limiting the extent to which discharge planning reflected the patient’s care needs (CMOC8) [49, 50, 58, 79–82].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [79]
The Introduction says clinicians face difficulties identifying cognitive impairment and distinguishing dementia from delirium during hospitalization. The Discussion says recognizing cognitive impairment at discharge has immediate implications for the care plan. Neither section reports reduced clinician confidence or shows that it caused discharge plans to reflect patients’ needs less well; page numbers are unavailable in our copy. (LLM, conf=0.84)
Experimental — accuracy not yet measuredMany HCPs, including geriatric specialists, lacked adequate dementia training.
“Many HCPs, including geriatric specialists, lacked adequate dementia training [45, 50, 53, 58, 60, 72, 73, 77, 79–82].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [79]
The Introduction (page unavailable) identifies gaps in clinician knowledge and training as one challenge to recognizing cognitive impairment during hospitalization. The Discussion (page unavailable) says the documentation patterns may reflect inadequate training, but does not establish that many healthcare professionals lacked adequate dementia training or specifically identify geriatric specialists. (LLM, conf=0.87)
Experimental — accuracy not yet measuredThis was linked to inadequate cognitive screening, poor documentation, and hospital readmission.
“This was linked to inadequate cognitive screening, poor documentation, and hospital readmission [49, 58, 79–82].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [79]
The Introduction describes frequent under-detection of cognitive impairment, and the Discussion reports that some patients with dementia had no documentation of cognitive-impairment symptoms. Table 1 lists 30-day re-hospitalizations, but the paper does not link them to inadequate screening or poor documentation; it also does not directly assess whether cognitive screening was inadequate. (LLM, conf=0.83)
Experimental — accuracy not yet measuredHealthcare professionals working outside of geriatric care were often unaware of dementia diagnoses.
“As a result, HCPs working outside of geriatric care were often unaware of dementia diagnoses (CMOC14) [50, 53, 59, 66, 79, 86, 89].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [79]
The Introduction (page not available) says cognitive impairment is frequently under-detected during hospitalization and that poor information transfer can make patients’ baseline cognitive status difficult to identify. The Discussion (page not available) suggests clinicians may document symptoms without recognizing their implications. Neither passage establishes that professionals outside geriatric care were often unaware of existing dementia diagnoses. (LLM, conf=0.82)
Experimental — accuracy not yet measuredLiterature included the use of non-standardised terminology or non-compliance with labelling medical records to indicate dementia.
“Literature included the use of non-standardised terminology, (e.g., ‘confusion’, ‘cognitive impairment’) or non-compliance with labelling medical records to indicate dementia [45, 50, 79, 89].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [79]
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- Authors
- Gilmore-Bykovskyi, A. L., Block, L. M., Walljasper, L., Hill, N., Gleason, C., & Shah, M. N.
- Affiliations
- University of Wisconsin-Madison School of Nursing, Madison, Wisconsin, USA
- University of Wisconsin–Madison (US)
- Pennsylvania State University (US)
- Venue
- Journal of the American Medical Informatics Association
- Publisher
- Oxford University Press (OUP)
- Published
- 2018-06-27
- Volume
- 25
- Issue
- 9
- Pages
- 1206-1212
- ISSN
- 1067-5027 (ISSN-L)
- 1527-974X
- PMC
- PMC6118865
- OpenAlex
- W2810209559
- Cited by
- 21
- References
- 40
- Citations by year
- 2026: 1 · 2025: 4 · 2024: 5 · 2023: 3 · 2022: 4 · 2021: 3 · 2020: 1
- FWCI
- 0.56
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of the American Medical Informatics Association (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Hartford Centers of Gerontological Nursing Excellence
- NIH-NIA
- African Americans Fighting Alzheimer’s at Midlife (R01 AG054059)
- Wisconsin Alzheimer’s Disease Center (P50 AG033514)
- Mentoring and Research in Patient-Oriented Geriatric Emergency Care (K24AG054560-01)
- NIH
- Topics
- Physical Sciences › Computer Science › Artificial Intelligence › Machine Learning in Healthcare
- Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
- Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
- Keywords
- cognitive impairment, dementia, hip fracture, acute care, underdiagnosis, medical terminology
- MeSH terms
- Aged, Aged, 80 and over, Mental Disorders, Documentation, Female, Hospitalization, Humans, Male, Terminology as Topic, Retrospective Studies, International Classification of Diseases, Electronic Health Records, Cognitive Dysfunction
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