Cognitive Decline and Dementia
Freddi Segal-Gidan2018, Physician Assistant Clinics
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Abstract
Cognitive impairment in older adults is underrecognized and dementia is underdiagnosed by providers in primary care. Early detection of cognitive impairment in older adults can improve care, reduce complications, and potentially reduce costs. Validated tools to screen for depression, mental status, and function are readily available, easy to use, and can easily be incorporated into regular care of older adults. A basic evaluation for memory or thinking complaints to identify treatable conditions should be part of primary care.
Related papers
Detection and Management of Cognitive Impairment in Primary Care: The Steel Valley Seniors Survey
Journal of the American Geriatrics Society, 2004
OBJECTIVES: To identify characteristics of older primary care patients who were cognitively impaired and who underwent mental status testing by their physicians. DESIGN: Cross-sectional and retrospective analysis. SETTING: Seven small-town primary care practices. PARTICIPANTS: A total of 1,107 patients with a mean AE standard deviation age of 76.3 AE 6.6, screened using the Mini-Mental State Examination (MMSE); medical records reviewed. MEASUREMENTS: Demographics, MMSE, medical record information. Odds ratios (OR) with 95% confidence intervals (CI), adjusted for age, sex, and education. RESULTS: Thirty-one percent of the sample had MMSE scores of less than 25. Among these patients, physicians documented memory loss in only 23% which was significantly more often than in the higher scoring group (OR 5 1.9, 95% CI 5 1.3-2.8), basic activity of daily living (ADL) impairment in 7.9% (OR 5 2.4, 95% CI 5 1.3-4.4), instrumental ADL (IADL) impairment in 6.7% (OR 5 2.2, 95% CI 5 1.1 5 4.2), dementia in 12.2% (OR 5 3.7, 95% CI 5 2.0-6.8), and prescription of cholinesterase inhibitors in 7.6% (OR 5 4.4, 95% CI 5 1.9-10.2). Physicians recorded mental status testing largely in patients with research MMSE scores of 24 to 28, significantly more often when they also documented memory loss (OR 5 3.8, 95% CI 5 2.5-5.6) or impaired IADLs (OR 5 2.7, 95% CI 5 1.4-5.2), diagnosed dementia (OR 5 4.9, 95% CI 5 2.8-8.6), referred to specialists (OR 5 6.3, 95% CI 5 2.5 -16.2) or social services (OR 5 3.6, 95% CI 5 1.8-7.3), or prescribed cholinesterase inhibitors (OR 5 8.5, 95% CI 5 4.2-17.5). CONCLUSION: Physicians noted impairment in a minority of impaired patients. They tested mental status in those with documented cognitive and functional difficulties, in very mildly impaired patients, and in those for whom they intervened.
Diagnosing cognitive impairment and dementia in primary health care - a more active approach is needed
Age and Ageing, 2003
Objective: to determine the documentation rate of dementia in primary health care, the clinical characteristics of patients with documented and undocumented dementia, and the diagnostic evaluations made in cognitive impairment. Design: cross-sectional population-based study with a retrospective review of medical history. Setting: primary health care in the municipality of Lieto, Southwestern Finland. Subjects: all the inhabitants aged 64 and over in Lieto. Participation rate 82%, numbers = 1260. Measurements: assessment of dementia according to DSM-IV criteria, and severity according to Clinical Dementia Rating. Possible documentation of dementia and evaluations done were reviewed from primary health care medical records. Results: 112 patients with dementia were found. The sensitivity of the general practitioners' judgment of dementia was 48.2% and the speciWcity 99.6%. The documentation rate of dementia was 73% in severe, 46% in moderate and 33% in mild dementia. A greater proportion of the patients with undocumented dementia were male (P = 0.003), lived at home (P = 0.003), coped better with the instrumental activities of daily living (P = 0.006), had more depression (P = 0.029) and milder dementia (P = 0.005) than patients with documented dementia. Thyroid stimulating hormone was measured in 51% of the patients with suspected memory impairment or dementia, B12 vitamin in 20%, and serum calcium in 18%. Twenty-eight per cent of the patients had been tested for cognitive function, 68% for depressive symptoms, and 88% for social abilities. Forty-two per cent of patients were referred to a specialist, 32% of patients who were over 75 years. Conclusions: less than half of the patients with dementia had their diagnosis documented in primary care medical records. Documentation increased in more advanced dementia. The diagnostic evaluations for reversible causes of dementia were insufWcient in primary care, and they were done at a late phase of cognitive impairment.
Screening for Cognitive Impairment in Older Adults: A Systematic Review for the U.S. Preventive Services Task Force
Annals of Internal Medicine, 2013
Background: Earlier identification of cognitive impairment may reduce patient and caregiver morbidity. Purpose: To systematically review the diagnostic accuracy of brief cognitive screening instruments and the benefits and harms of pharmacologic and nonpharmacologic interventions for early cognitive impairment. Data Sources: MEDLINE, PsycINFO, and the Cochrane Central Register of Controlled Trials through December 2012; systematic reviews; clinical trial registries; and experts. Study Selection: English-language studies of fair to good quality, primary care-feasible screening instruments, and treatments aimed at persons with mild cognitive impairment or mild to moderate dementia. Data Extraction: Dual quality assessment and abstraction of relevant study details. Data Synthesis: The Mini-Mental State Examination (k ϭ 25) is the most thoroughly studied instrument but is not available for use without cost. Publicly available instruments with adequate test performance to detect dementia include the Clock Drawing Test (k ϭ 7), Mini-Cog (k ϭ 4), Memory Impairment Screen (k ϭ 5), Abbreviated Mental Test (k ϭ 4), Short Portable Mental Status Questionnaire (k ϭ 4), Free and Cued Selective Reminding Test (k ϭ 2), 7-Minute Screen (k ϭ 2), and Informant Questionnaire on Cogni-tive Decline in the Elderly (k ϭ 5). Medications approved by the U.S. Food and Drug Administration for Alzheimer disease (k ϭ 58) and caregiver interventions (k ϭ 59) show a small benefit of uncertain clinical importance for patients and their caregivers. Small benefits are also limited by common adverse effects of acetylcholinesterase inhibitors and limited availability of complex caregiver interventions. Although promising, cognitive stimulation (k ϭ 6) and exercise (k ϭ 10) have limited evidence to support their use in persons with mild to moderate dementia or mild cognitive impairment. Limitation: Limited studies in persons with dementia other than Alzheimer disease and sparse reporting of important health outcomes. Conclusion: Brief instruments to screen for cognitive impairment can adequately detect dementia, but there is no empirical evidence that screening improves decision making. Whether interventions for patients or their caregivers have a clinically significant effect in persons with earlier detected cognitive impairment is still unclear.
Assessment and management of patients with cognitive impairment and dementia in primary care
The journal of nutrition, health & aging, 2012
Objectives: To evaluate care provided by primary care physicians in community practice to older patients presenting with cognitive impairment and dementia. Design: Secondary analysis of an intervention study. Setting: Primary care clinics. Participants: 101 patients 75 years and older enrolled in the ACOVE-2 study who presented with a new cognitive problem, new dementia, or prevalent dementia. Measurements: Patients assessment and management were evaluated from medical record review and caregiver interviews. Results: Among 34 patients presenting with a new cognitive problem, half received a cognitive assessment comprising of a test of memory and one other cognitive task, 41% were screened for depression and 29% were referred to a consultant. Of the 27 patients with newly diagnosed dementia, 15% received the components of a basic neurological examination, one-fifth received basic laboratory testing and for one third the medical record reflected an attempt to classify the type of dementia. Counseling was under-reported in the medical record compared to the caregiver interview for the 101 patients with dementia, but even the interview revealed that about half or fewer patients received counseling about safety and accident prevention, caregiver support or managing conflicts. Less than 10% were referred to a social worker. Conclusion: This small but detailed evaluation suggests patients presenting with cognitive problems to primary care physicians do not consistently receive basic diagnosis and management.
Impairment Primary Care Screening for Dementia and Mild Cognitive
2008
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Assessment and diagnosis of dementia: a review for primary healthcare professionals
Hong Kong Medical Journal, 2019
Dementia is one of the most costly, disabling diseases associated with ageing, yet it remains underdiagnosed in primary care. In this article, we present the comprehensive approach illustrated with a classical case for diagnosing dementia which can be applied by healthcare professionals in primary care. This diagnostic approach includes history taking and physical examination, cognitive testing, informant interviews, neuropsychological testing, neuroimaging, and the utility of cerebrospinal fluid biomarkers. For the differential diagnosis of cognitive impairment, the differences and similarities among normal ageing, mild cognitive impairment, depression, and delirium are highlighted. As primary care physicians are playing an increasingly prominent role in the caring of elderly patients in an ageing population, their role in the diagnosis of
The Use Of The Cognitive Status Examination In Detecting Cognitive Impairment In Elderly People
2000
Dementia is a growing social problem in Australia because as the population ages, the incidence of dementia increases. While the prevalence rates are only about 1 % at age 65, they double every five years until by 85 years of age the rate is over 24%. It is expected that by the year 2030, the number of elderly people with dementia will increase by 200%. Dementia is easily recognized in its advanced stages but can be overlooked in the early phase. Family members, care-givers and even the treating medical practitioner may mistakenly attribute the early decline in mental function to the normal aging process. A diagnostic instrument that is easy to administer and score yet is sensitive and specific to the detection of cognitive impairment in the elderly may prove to be of significant benefit to clinicians and assist care-givers and family members in treatment decisions, accommodation requirements and the timely provision of a range of support services. This study investigates the use of...
Recommendations on screening for cognitive impairment in older adults
CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, 2015
Prevalence and Correlates of Cognitive Impairment among the Elderly in a General Hospital
Dementia and Geriatric Cognitive Disorders, 2009
Aging ؒ Cognitive reserve ؒ Daily functioning in dementia and mild cognitive impairment ؒ Early detection of mild cognitive impairment and dementia Abstract Ai ms: To e xamine the prevalence and correlates of cognitive impairment (CI) in adults over 50 years old attending primary care centres with complaints of memory failure. Methods: A sample of 580 individuals aged 50+ years with no previous diagnosis of dementia was assessed by use of the Mini Mental State Examination, the Cambridge Cognitive Assessment-Revised and the California Verbal Learning Test -to evaluate CI-dependent variables -and administration of a questionnaire on memory complaints and other instruments -to measure correlates. Results: The prevalence of CI was 46.20% and positive associations were found for age, gender, level of education, subjective memory complaints, instrumental activities of daily living, reading habits and frequency of leisure activities. In the logistic regression, modelled CI was associated with older age, gender (49.12% women, 39.66% men), instrumental activities of daily living, and reading habits. Conclusion: Almost half of the adults aged 50+ years attending primary care centres with subjective memory complaints were affected by CI. Early evaluation of cognitive functioning is essential to establish adequate preventive and intervention strategies.
A Prospective Study of Cognitive Function and Onset of Dementia in Cognitively Healthy Elders
Archives of Neurology, 1998
To examine the earliest cognitive changes associated with the onset of dementia as well as changes associated with normal aging. Design: Longitudinal evaluation of participants with annual clinical and psychometric examinations for up to 15 1 ⁄2 years. Setting and Participants: Elderly volunteers (n=82) enrolled with a Clinical Dementia Rating of 0 (cognitively intact) in longitudinal studies. Interventions: None. Main Outcome Measures: Clinical Dementia Rating and results of a 1 1 ⁄2-hour psychometric battery. Results: As estimated with survival analysis, 40% of participants had a Clinical Dementia Rating greater than 0 (cognitive decline) within 12 years of enrollment; 59% of these were judged to have dementia of the Alzheimer type or incipient dementia. Participants with poorer performance on psychometric testing at enrollment were at higher risk for cognitive decline subsequently. The rate of change in psychometric performance before clinically detectable cognitive change occurred was not significantly different between those who eventually developed dementia and those who remained stable, except for performance on the Logical Memory subtest of the Wechsler Memory Scale. When subtle cognitive decline was clinically detected, however, an abrupt deterioration in performance on independently administered psychometric tests was observed. Conclusions: Cognitively healthy elderly people maintain stable cognitive performance when measured longitudinally by both careful clinical evaluation and repeated psychometric testing. This stability is maintained unless and until they develop a dementing illness, at which time a sharp decline in performance is observed.
Dementia Assessment in Primary Care: Results From a Study in Three Managed Care Systems
The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 2004
Background. Prior research has found that dementia is often undiagnosed in primary care, but there has been limited research on whether physicians respond to symptoms, behaviors, or other events that may be indicators of dementia.
Finding Dementia in Primary Care: The Results of a Clinical Demonstration Project
Journal of the American Geriatrics Society, 2012
To assess the effect of screening on diagnosing cognitive impairment. Quality improvement initiative. Seven Veterans Affairs Medical Centers. Veterans aged 70 or older without a prior diagnosis of cognitive impairment. Veterans failing a brief cognitive screen (Mini-Cog score <4/5) at a routine primary care visit were offered a further, comprehensive evaluation with an advance practice registered nurse trained in dementia care and integrated into the primary care clinic. Veterans completing the evaluation were reviewed in a consensus conference and assigned a diagnosis of dementia; cognitive impairment, no dementia; or no cognitive impairment. Total numbers of screens, associated scores (0-5), and the consensus diagnoses were tallied. New cognitive impairment diagnoses were also tracked for veterans who passed the screen but requested further evaluation, failed but declined further evaluation, or were not screened. Primary care provider satisfaction with the program also was assessed. Of 8,342 veterans offered screening, 8,063 (97%) accepted, 2,081 (26%) failed the screen, 580 (28%) agreed to further evaluation, and 540 (93%) were diagnosed with cognitive impairment, including 432 (75%) with dementia. For screen passes requesting further evaluation, 87% (103/118) had cognitive impairment, including 70% (82/118) with dementia. Screen failures declining further evaluation had 17% (259/1,501) incident cognitive impairment diagnosed through standard care, bringing the total newly documented cognitive impairment in all screens to 11% (902/8,063), versus 4% (1,242/28,349) in similar clinics without this program. Eighty-two percent of primary care providers in clinics with this program agreed that it provided a useful service. Screening combined with offering further evaluation increased new diagnoses of cognitive impairment in older veterans two to three times. Veterans accepted screening well, and providers found the program useful.
Cognitive impairment in old people living in the community
Archives of Gerontology and Geriatrics, 2010
Improving identification of cognitive impairment in primary care
International Journal of Geriatric Psychiatry, 2006
To compare the relative level and predictors of accuracy of a brief cognitive screen, the Mini-Cog, with spontaneous detection of cognitive impairment by subjects' primary care physicians. Participants A heterogeneous community sample (n ¼ 371) of predominantly ethnic minority elderly assessed by standardized research protocol, 231 of whom met criteria for dementia or mild cognitive impairment (MCI). Results The Mini-Cog detected cognitively impaired subjects much more effectively than did subject's own physicians (p < 0.0001), correctly classifying 83% of the sample and 84% of cognitively impaired subjects. Physicians correctly classified 59% of all subjects but identified only 41% of cognitively impaired subjects. The Mini-Cog's advantage over physicians was greatest when impairment was mildest (screen vs physician recognition at CDR 0.5, 58% vs 6%; at CDR 1, 92% vs 41%). Additional subject variables associated with missed detection by physicians were non-Alzheimer type dementia and low education, low literacy, and non-English speaking, factors that had little or no effect on the performance of the Mini-Cog. Ethnic differences, also observed for physician recognition, were not significant in final regression equations. The number and recency of primary care visits, and duration of the primary care relationship, were not associated with physicians' recognition of cognitive impairment. Conclusion This study demonstrates that recognition of cognitive impairment by primary care physicians is adversely influenced by important patient and disease characteristics. Results also show that use of the Mini-Cog would improve recognition of cognitive impairment in primary care, particularly in milder stages and in older adults subject to disparities in health care quality due to sociodemographic factors.
Should older adults be screened for dementia? It is important to screen for evidence of dementia
Alzheimers & Dementia, 2007
Multiple arguments for considering routine dementia screening have been presented. Furthermore, dementia diagnoses are widely unrecognized. As a result, persons with dementia are missing important clinical care and treatment interventions. By distinction, the problems of defining, diagnosing, and treating mild cognitive impairment (MCI) are not yet resolved, and MCI is not ready for a screening recommendation. Dementia screening approaches, including cognitive testing and functional assessment, must be evaluated on their scientific merits, including sensitivity and specificity for recognizing affected individuals in at-risk populations. Screening tests must be "cost-worthy", with the benefits of true-positive test results justifying the costs of testing and resolving false-positive cases, with due consideration for proper diagnostic evaluation and potential harms. With the tremendous number of new cases projected in the near future and the expected emergence of beneficial therapies, considerably more research is needed to develop more efficient screening systems.
Should we screen for cognitive decline and dementia?
Maturitas, 2015
Due to increased life expectancy, the prevalence of cognitive decline related to neurodegenerative diseases and to non-neurological conditions is increasing in western countries. As with other diseases, the burden might be reduced through personalized interventions delivered at early stages of the disease. Thus, there is an increasing demand, from both social and healthcare systems, for instruments and strategies to recognize cognitive decline, and possibly distinguish the precursor of serious neurodegeneration from "benign senile forgetfulness" or the temporary consequences of illness or trauma. However, this goal faces both technical and ethical issues. In this article we deal with the following: (i) re-definition of cognitive decline and its relationship with frailty definitions, starting from the recent work of international consensus groups for presymptomatic Alzheimer disease recognition; (ii) ethical problems concerning anonymous and personalized cognitive screening and the need for appropriate counselling; (iii) the need for more sensitive and specific tools to detect and distinguish pathological levels of cognitive decline and delineate the contribution of non-pathological decline to accumulated frailty impacts and (iv) the potential of the language domain and spontaneous speech analyses.
Screening for cognitive impairment in the elderly
Canadian family physician Médecin de famille canadien, 1997
To evaluate the extent and type of screening for cognitive impairment primary care physicians use for their elderly patients, to identify perceived barriers to screening, and to explore whether physicians would be willing to use the clock drawing test as a cognitive screening tool. Mailed questionnaire. Primary care practices in the Ottawa-Carleton region. Family physicians and general practitioners culled from the Yellow Pages and Canadian Medical Directory; 368 of 568 questionnaires were returned for a response rate of 70%. Six respondents had fewer than 30 patients weekly and two responded too late to be included in the analysis; 360 cases were included in the analysis. Responses to 10 questions on cognitive screening and five on demographics and the nature of respondents' practices. About 80% of respondents reported doing at least one mental status examination during the past year. Only 24% routinely screened patients, although 82% believed screening was needed. Major barrie...
Diagnosing dementia and cognitive dysfunction in the elderly in primary health care: A systematic review
Dementia & Neuropsychologia, 2019
Dementia is a public health issue making the screening and diagnosing of dementia and its prodromal phases in all health settings imperative. Objective: using PRISMA, this systematic review aimed to identify how low-, middle-, and high-income countries establish dementia and cognitive dysfunction diagnoses in primary health care. Methods: studies from the past five years in English, Spanish, and Portuguese were retrieved from Scopus, PubMed, Embase, Lilacs, Scielo, and Web of Science. Of 1987 articles, 33 were selected for analysis. Results: only three articles were from middle-income countries and there were no studies from low-income countries. The most used instrument was the Mini-Mental State Examination (MMSE). Mild Cognitive Impairment (MCI) and dementia criteria were based on experts' recommendation as well as on the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD-10), respectively. Conclusion: differences between these criteria among high-and middle-income countries were observed.
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