Abstract
BackgroundGPs often report using clinical judgment to diagnose dementia.AimTo investigate the accuracy of GPs’ clinical judgment for the diagnosis of dementia.Design & settingDiagnostic test accuracy study, recruiting from 21 practices around Bristol, UK.MethodThe clinical judgment of the treating GP (index test) was based on the information immediately available at their initial consultation with a person aged ≥70 years who had cognitive symptoms. The reference standard was an assessment by a specialist clinician, based on a standardised clinical examination and made according to the 10th revision of the International Classification of Diseases (ICD-10) criteria for dementia.ResultsA total of 240 people were recruited, with a median age of 80 years (interquartile range [IQR] 75–84 years), of whom 126 (53%) were men and 132 (55%) had dementia. The median duration of symptoms was 24 months (IQR 12–36 months) and the median Addenbrooke's Cognitive Examination III (ACE-III) score was 75 (IQR 65–87). GP clinical judgment had sensitivity 56% (95% confidence interval [CI] = 47% to 65%) and specificity 89% (95% CI = 81% to 94%). Positive likelihood ratio was higher in people aged 70–79 years (6.5, 95% CI = 2.9 to 15) compared with people aged ≥80 years (3.6, 95% CI = 1.7 to 7.6), and in women (10.4, 95% CI = 3.4 to 31.7) compared with men (3.2, 95% CI = 1.7 to 6.2), whereas the negative likelihood ratio was similar in all groups.ConclusionA GP clinical judgment of dementia is specific, but confirmatory testing is needed to exclude dementia in symptomatic people whom GPs judge as not having dementia.
Highlights
The James Lind Alliance has identified the role of general practice in supporting a more effective route to diagnosis of dementia as a priority for health research.[1]
Positive likelihood ratio was higher in people aged 70–79 years (6.5, 95% CI = 2.9 to 15) compared with people aged ≥80 years (3.6, 95% CI = 1.7 to 7.6), and in women (10.4, 95% CI = 3.4 to 31.7) compared with men (3.2, 95% CI = 1.7 to 6.2), whereas the negative likelihood ratio was similar in all groups
This study shows that, in a symptomatic older adult, clinical judgment may be useful for helping to confirm a diagnosis of dementia, but GP judgment should not by itself be used to exclude dementia
Summary
The James Lind Alliance has identified the role of general practice in supporting a more effective route to diagnosis of dementia as a priority for health research.[1]. Research have historically faced long delays to get an assessment and an explanation for their symptoms.[2] Approaches to address waiting lists have included psychiatrists supporting primary care memory clinics,[3] integrated one-stop clinics,[4] and training GPs to make a diagnosis in uncomplicated cases,[5,6] which is supported by the National Institute for Health and Care Excellence (NICE).[7] Some GPs have in the past been hesitant about diagnosing dementia when there is no disease-m odifying treatment,[8] and disclosure of a diagnosis can still be problematic, especially if the affected person is not seeking help.[9] The situation has been complicated in the UK by controversial policies that have funded case- finding for dementia.[10,11,12] Formally evaluating cognition takes time and familiarity with tests. A GP could use a range of brief cognitive assessments[13] to evaluate a person with symptoms of dementia, and national guidelines differ on which test to use.[14,15] Instead, GPs report using non-standardised processes[16] such as clinical judgment[17] to diagnose dementia.
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