Dementia In Primary Care Research Articles

Two-stage screening for early dementia in primary care

ABSTRACTObjective: The objective was to compare two screening strategies for dementia in an urban primary care clinic, serving a low-education, minority community composed largely of Latino and African American patients. Method: Two hundred and fifty-seven patients underwent two-stage patient-based screening (PBS) and informant-based screening (IBS) followed by a diagnostic evaluation. In the first stage, PBS included brief tests of episodic memory (Memory Impairment Screen), semantic memory (Animal Fluency), and executive function (Reciting Months Backwards). For IBS, the first stage consisted of the short Informant Questionnaire on Cognitive Decline in the Elderly, administered to a family member or friend. Patients who screened positive in the first stage of either strategy underwent testing with the picture version of the Free and Cued Selective Reminding Test with Immediate Recall to identify memory impairment. Sensitivity, specificity, and positive and negative predictive values were computed for various cutoffs of each test and combination of tests. Dementia was diagnosed using Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition (DSM–IV) criteria without access to the screening test results. Results: We identified 66 patients (25.7%) with previously undiagnosed dementia. Sensitivity was the same (77%) for both strategies but specificity was higher for IBS than for PBS (92% versus 83%). IBS’s higher specificity makes it the preferred strategy if a knowledgeable informant is available. Conclusion: Unrecognized dementia is common in primary care. Case-finding can be improved using either PBS or IBS two-stage screening strategies.

Community-Dwelling People Screened Positive for Dementia in Primary Care: A Comprehensive, Multivariate Descriptive Analysis Using Data from the DelpHi-Study.

Efficient help and care for people with dementia (PWD) is dependent on knowledge about PWD in primary care. This analysis comprehensively describes community-dwelling PWD in primary care with respect to various dementia care specific variables. The analyses are based on baseline data of the ongoing general practitioner-based, randomized, controlled intervention trial DelpHi-MV (Dementia: life- and person-centered help). 6,838 patients were screened for dementia in 136 GP practices; 17.1% were screened positive, 54.4% of those agreed to participate and data could be assessed in n = 516 subjects. We assessed age, sex, living situation, cognitive status, functional status, level of impairment, comorbidities, formal diagnosis of dementia, depression, neuropsychiatric symptoms, quality of life, utilization of medical support, and pharmacological therapy. Concerning clinical-, dementia-, and health-related variables, the sample under examination was on average mildly cognitively and functionally impaired (MMSE, m = 22.2; BADL, m = 3.7). A level of care was assigned in 38.0%. Depression was identified in 15.4% and other frequent comorbidities were high blood pressure (83.3%), coronary heart diseases (37.1%), cerebrovascular diseases (22.3%), among others. In 48.6%, neuropsychiatric symptoms were present in a clinically relevant severity. Pharmacological treatment with antidementia medication was received by 25.8% and antidepressant medication by 14.0%. Utilization of services was generally low. The comprehensive description of people screened positive for dementia in primary care reveals a complex and unique population of patients. They are considerably underdiagnosed and in their majority mildly to moderately affected. More in-depth analyses are needed to study relations, associations and interactions between different variables.

Psychological distress in informal caregivers of patients with dementia in primary care: course and determinants.

The course of psychological distress in informal caregivers of patients with dementia has been investigated in longitudinal studies with conflicting outcomes. We investigated the course and determinants of psychological distress in informal caregivers of patients with dementia in primary care. In this prospective observational cohort study, data were collected at baseline, after 9 and 18 months. We assessed cognition and neuropsychiatric symptoms (NPS) of the patient (Mini-Mental State Examination and Neuropsychiatric Inventory) and psychological distress (Sense of Competence Questionnaire, Center for Epidemiological Studies Depression scale and General Health Questionnaire 12-tem version) of the informal caregivers. Determinants for the course of psychological distress were caregivers' age, gender and relationship with the patient, patients' cognition and NPS, participation in a care program and admission to long-term care facilities (LTCF). With linear mixed models, the course over time for psychological distress and its determinants were explored. We included 117 informal caregivers, of whom 23.1% had a high risk for depression and 41.0% were identified to be likely to have mental problems at baseline. We found a stable pattern of psychological distress over time. Higher frequency of NPS, informal caregivers' age between 50 and 70 years and being female or spouse were associated with higher psychological distress. For patients who were admitted to a LTCF during the study psychological distress of the informal caregivers improved. GPs should focus on NPS in patients with dementia and on caregivers' psychological distress and be aware of their risk for depression and mental problems, specifically to those who are spouse, female or between 50 and 70 years of age.

What is the potential for improving care and lowering cost for persons with dementia?

The increasing prevalence of dementia with population aging has heightened interest in understanding patterns of utilization and health expenditures in persons with dementia (PWD) among policy officials, practicing physicians, and health system. While a substantial part of this interest is concerned with the high costs of care for people diagnosed with dementia (Kelley et al., 2015), less attention has been focused on the costs and consequences of missed or delayed diagnosis in those who screen positive for dementia. The article on "Healthcare resource utilization and cost in dementia: are there differences between patients screened positive for dementia with and those without a formal diagnosis of dementia in primary care in Germany?" by Michalowsky and colleagues (Michalowsky et al., 2015) in this issue makes a particularly important contribution in this regard.

Examination of level of knowledge in Italian general practitioners attending an education session on diagnosis and management of the early stage of Alzheimer's disease: pass or fail?

We detected the general level of knowledge about the early diagnosis of Alzheimer's disease (AD) and subsequent care in general practitioners (GPs) from Southern Italy. We explored also the GP perception about their knowledge and training on diagnosis and management of AD. On a sample of 131 GPs, we administered two questionnaires: the GP-Knowledge, evaluating GPs' expertise about AD epidemiology, differential diagnosis, and available treatments, and the GP-QUestionnaire on Awareness of Dementia (GP-QUAD), assessing the GPs' attitudes, awareness, and practice regarding early diagnosis of dementia. Specific screening tests or protocols to diagnose and manage dementia were not used by 53% of our GPs. The training on the recognition of early AD signs and symptoms was considered inadequate by 55% of the participants. Females were more likely to consider their training insufficient (58%) compared to males (53%). Female GPs were less likely to prescribe antipsychotic drugs to control neuropsychiatric symptoms (NPS) and suggest specialist advice in late stage of cognitive impairment. Multiple Correspondence Analysis (MCA) performed only on GP-QUAD suggested two dimensions explaining 26.1% ("GP attitude") and 20.1% ("GP knowledge") of the inertia for a total of 46.2%, In our survey on GP clinical practice, several problems in properly recognizing early AD symptoms and subsequently screening patients to be referred to secondary/tertiary care centers for diagnosis confirmation have emerged. In the future, specific training programs and educational projects for GPs should be implemented also in Italy to improve detection rates and management of dementia in primary care.

Predicting dementia risk in primary care: development and validation of the Dementia Risk Score using routinely collected data.

BackgroundExisting dementia risk scores require collection of additional data from patients, limiting their use in practice. Routinely collected healthcare data have the potential to assess dementia risk without the need to collect further information. Our objective was to develop and validate a 5-year dementia risk score derived from primary healthcare data.MethodsWe used data from general practices in The Health Improvement Network (THIN) database from across the UK, randomly selecting 377 practices for a development cohort and identifying 930,395 patients aged 60–95 years without a recording of dementia, cognitive impairment or memory symptoms at baseline. We developed risk algorithm models for two age groups (60–79 and 80–95 years). An external validation was conducted by validating the model on a separate cohort of 264,224 patients from 95 randomly chosen THIN practices that did not contribute to the development cohort. Our main outcome was 5-year risk of first recorded dementia diagnosis. Potential predictors included sociodemographic, cardiovascular, lifestyle and mental health variables.ResultsDementia incidence was 1.88 (95 % CI, 1.83–1.93) and 16.53 (95 % CI, 16.15–16.92) per 1000 PYAR for those aged 60–79 (n = 6017) and 80–95 years (n = 7104), respectively. Predictors for those aged 60–79 included age, sex, social deprivation, smoking, BMI, heavy alcohol use, anti-hypertensive drugs, diabetes, stroke/TIA, atrial fibrillation, aspirin, depression. The discrimination and calibration of the risk algorithm were good for the 60–79 years model; D statistic 2.03 (95 % CI, 1.95–2.11), C index 0.84 (95 % CI, 0.81–0.87), and calibration slope 0.98 (95 % CI, 0.93–1.02). The algorithm had a high negative predictive value, but lower positive predictive value at most risk thresholds. Discrimination and calibration were poor for the 80–95 years model.ConclusionsRoutinely collected data predicts 5-year risk of recorded diagnosis of dementia for those aged 60–79, but not those aged 80+. This algorithm can identify higher risk populations for dementia in primary care. The risk score has a high negative predictive value and may be most helpful in ‘ruling out’ those at very low risk from further testing or intensive preventative activities.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-016-0549-y) contains supplementary material, which is available to authorized users.

Depressive symptoms and depression in people screened positive for dementia in primary care - results of the DelpHi-study.

Dementia and depression are common syndromes in the elderly. There is lack of knowledge concerning the frequency of depressive symptoms in people with dementia (PWD) and factors associated with depression. The aim of this analysis is to (a) describe the frequency of depressive symptoms in people screened positive for dementia, (b) describe differences between PWD with and without depressive symptoms, and (c) analyze associations between depressive symptoms and other dementia-related variables. Analyses are based on data of the GP-based intervention trial DelpHi-MV. A sample of 430 (6.29%) people screened positive for dementia in primary care was analyzed regarding depression according to the German version of the Geriatric Depression Scale (GDS, 15-items), demographic variables, and dementia/depression-related variables. Multivariate analyses were conducted to identify factors associated with depressive symptoms. The mean GDS-score of depressive symptoms in n = 430 PWD was m = 3.21 (SD 2.45) with 67 PWD (15.55%) showing clinically relevant depression (GDS < 5) m = 7.71 (SD = 1.92). A total of n = 72 (16.74%) received a formal diagnosis of depression and n = 62 (14.42%) received antidepressive drug treatment. Depressive symptoms are significantly associated with age (OR = 0.93), functional impairment (OR = 1.36), and quality of life (OR = 0.01, CI: 0.00-0.06). Our results support previous findings that clinically relevant depressive symptoms are more common in people screened positive for dementia than in the general population and are often missed or mismanaged. Our findings underline the importance of managing quality of life, functional status, or depressive symptoms. Also, the results highlight the benefit of including the partner (and probably other carers) for adequate treatment of PWD.

Primary Care Dementia Clinic Reduces Societal Cost of Dementia: A Cost-Utility Analysis

The prevalence of dementia in Singapore is expected to increase with an ageing population. With the inclusion of dementia as part of Chronic Disease Management Program, more primary care consultations are expected in the polyclinic. A Primary Care Dementia Clinic (PCDC) was set up in Ang Mo Kio Polyclinic to manage stable patients. The objective of this study is to evaluate the cost-utility of dementia care at PCDC compared with specialists’ care at the Memory Clinic (MC) and care at other polyclinics. Stable dementia patients with a Clinical Dementia Rating of 1.0 – 3.0 were recruited for the programme. Costs were measured from the societal viewpoint, including both direct and indirect costs. To establish cost-utility, EQ-5D was used to calculate QALYs. Cost and utility were measured at six-months and one-year. The incremental cost-effectiveness ratio was calculated by dividing the difference in costs by the difference in QALYs. A total of 168 dementia patients were recruited for this study. 55 for the PCDC arm and 113 from the two comparator groups (MC = 82 & Other Polyclinics = 31). Compared with care at the Memory Clinic and standard polyclinic care, PCDC was $2,110 (vs. MC) and $2,335 (vs. Other Polyclinics) lower respectively at six-months. There were no statistical differences in one-year costs and QALYs across both comparisons. Our analysis found that dedicated dementia care for stable patients at the primary care setting reduces societal cost. Expansion of PCDC could greatly reduce societal resources without impacting patients’ quality of life.

Healthcare resource utilization and cost in dementia: are there differences between patients screened positive for dementia with and those without a formal diagnosis of dementia in primary care in Germany? - ERRATUM.

In the above mentioned article by Michalowsky et al., Johannes Hertel was mistakenly omitted from the authorship list. This error has been corrected in the print, PDF and HTML versions of the original article.

The assessment of dementia in primary care.

Dementia is an irreversible and progressive condition characterized by a global deterioration of a person’s cognitive abilities. With an ageing population, the number of people diagnosed with dementia is expected to rise both in the UK and abroad. Consequently, government policies across the world have stressed the need to improve early diagnosis of dementia in the hope that this will facilitate adjustment to the illness and thus to prolong independence. Arguably, one way of achieving this aim is to strengthen the role of primary care in the assessment, diagnosis and subsequent support of people affected by dementia. The purpose of this commentary is to explore the role of mental health and memory nurses in this process drawing on examples from the UK and Australia. Although there are a number of risks about increasing the role of primary care, pressures from limited budgets and resources at a time when the numbers of people affected by dementia are set to increase, means that it is inevitable that primary care will have a more influential role in dementia care than before. Consequently, it is important that the implications of these policy changes for mental health and specialist memory nurses are clearly understood.

AAIC: Exercise Program Improved Mild Cognitive Impairment

WASHINGTON — A 7-minute screening tool nearly doubled the rate at which primary care physicians could identify elderly patients in their practices with dementia in a German study involving more than 6,800 community-dwelling people. “Screening can considerably improve the recognition of dementia in primary care,” Tilly Eichler, PhD, said at the Alzheimer’s Association International Conference 2015. But she cautioned that further research is needed to determine the best ways to identify the specific type of dementia a patient has, and it must also follow patients long term to assess the benefits and risks from a more aggressive approach to dementia diagnosis in community-dwelling primary care patients. The majority of patients identified with dementia in primary care practices had an unspecified cause for their dementia, noted Dr. Eichler, a researcher with the German Center for Neurodegenerative Diseases in Greifswald, Germany. Dr. Eichler and her associates arranged for 136 German primary care physicians to administer the DemTect screening tool (Int J Geriatr Psychiatry 2004;19:136– 43) — a five-part test that takes about 7 minutes to administer — to screen 6,838 community dwellers 70 years or older as part of the DelpHi-MV (Dementia: Lifeand Person-Centered Help in Mecklenburg–Western Pomerania) study. The DemTect test identified 1,166 people (17%) with potential dementia based on scoring 8 or less on the screening tool. After obtaining informed consent, the researchers performed a detailed assessment of 468 of that population. The 468 people flagged by screening as possibly having dementia were all 70–79 years old, 60% were women, and half of them lived alone. Medical records for this subgroup showed that 179 (38%) had already been diagnosed with dementia prior to screening based on their scores on the Mini Mental State Examination (MMSE). Among the remaining 289 people identified by their DemTect score as potentially having dementia, MMSE testing identified another 171 people with dementia, increasing the total of this subgroup diagnosed with dementia by a relative 96%, compared with the 179 patients who had been identified with dementia prior to screening. Two-thirds of the patients with newly diagnosed dementia had an unspecified form, whereas 18% had Alzheimer’s disease, 14% had vascular dementia, and the remainder had other forms of dementia, Dr. Eichler said. Combining the newly identified 171 people with dementia and the 179 people previously diagnosed resulted in a total of 350 people diagnosed with definite dementia by the MMSE, 75% of the 468 identified as potentially having dementia based on their scores with the DemTect screening tool. Dr. Eichler had no relevant financial disclosures. CfA — Mitchel L. Zoler

Healthcare resource utilization and cost in dementia: are there differences between patients screened positive for dementia with and those without a formal diagnosis of dementia in primary care in Germany?

It is well-known that dementia is undiagnosed, resulting in the exclusion of patients without a formal diagnosis of dementia in many studies. Objectives of the present analyses were (1) to determine healthcare resource utilization and (2) costs of patients screened positive for dementia with a formal diagnosis and those without a formal diagnosis of dementia, and (3) to analyze the association between having received a formal dementia diagnosis and healthcare costs. This analysis is based on 240 primary care patients who screened positive for dementia. Within the baseline assessment, individual data about the utilization of healthcare services were assessed. Costs were assessed from the perspective of insurance, solely including direct costs. Associations between dementia diagnosis and costs were evaluated using multiple linear regression models. Patients formally diagnosed with dementia were treated significantly more often by a neurologist, but less often by all other outpatient specialists, and received anti-dementia drugs and day care more often. Diagnosed patients underwent shorter and less frequent planned in-hospital treatments. Dementia diagnosis was significantly associated with higher costs of anti-dementia drug treatment, but significantly associated with less total medical care costs, which valuated to be € 5,123 compared, to € 5,565 for undiagnosed patients. We found no association between dementia diagnosis and costs of evidence-based non-medication treatment or total healthcare cost (€ 7,346 for diagnosed vs. € 6,838 for undiagnosed patients). There are no significant differences in total healthcare cost between diagnosed and undiagnosed patients. Dementia diagnosis is beneficial for receiving cost-intensive anti-dementia drug treatments, but is currently insufficient to ensure adequate non-medication treatment for community-dwelling patients.

P-088: Recruitment of people with dementia in primary care –experiences from the HIND study

OBJECTIVES: A purpose of the Hypertension in Dementia feasibility study was to explore recruitment of people with dementia and essential hypertension in primary care practices to prepare a withdrawal study of their antihypertensive medication. METHODS: Primary care practices were invited by phone to support the study, which would entail screening their databases to identify people with diagnoses of both dementia and essential hypertension, and sending out letters to these people asking them to indicate their willingness participate in the feasibility withdrawal study. Practice managers or GPs from practices that declined to support the study were asked to give their reasons. RESULTS: All primary care practices in Nottingham and Nottinghamshire were contacted (n=145). Of those, 12 (8%) practices agreed to support the study. Between them they identified and sent out a total of 249 letters to potential participants. Of these 19 (7%) people responded and only 6 (2%) met the eligibility criteria for withdrawing antihypertensive medication. 80/133 (60%) non responding practices gave reasons for why they did not support the study: the most common responses were that 31 (39%) were ‘too busy’, staff changes or short staffed were cited in 11 (14%) and “too time consuming” was cited in 7 (9%). CONCLUSIONS: Recruitment of a sufficiently large and representative population for a larger trial would not be feasible in primary care practices using these methods, due to the high workload in UK primary care.

Diagnosis of dementia in primary care: The effect of screening

Diagnosis of dementia in primary care: The effect of screening

Burden of Behavioral and Psychiatric Symptoms in People Screened Positive for Dementia in Primary Care: Results of the DelpHi-Study.

There is limited knowledge about the range and effects of neuropsychiatric symptoms shown by persons with dementia (PWD) living in the community and their related caregiver burden. To examine neuropsychiatric symptoms in PWD in primary care with regard to frequency, severity, and burden to caregiver; to compare PWD with and without symptoms with regard to sociodemographics, care-related, and disease-related variables; and to identify variables associated with symptoms. A general physician-based epidemiological cohort of 248 people screened positive for dementia over the age of 70 (living at home) and their caregivers, was assessed using the Neuropsychiatric Interview (NPI), sociodemographics, and disease-related variables. In preliminary analyses, neuropsychiatric symptoms were frequent in PWD. Prevalence numbers ofdysphoria/depression, apathy, and agitation/aggression were each more than 30% . The severity of neuropsychiatric symptoms in people screened positive for dementia in primary care is moderate with a mean NPI score of m = 11.91 (SD = 16.0). Overall, caregiver distress is low, indicated by a total distress score of m = 5.94 (SD = 7.2, range 0-39). Common or frequent symptoms are not necessarily the most distressing symptoms. Neuropsychiatric symptoms are common in people screened positive for dementia in primary care. While frequency, severity, and perceived distress might be low in the total sample, we identified the dimensions delusions, aggression, anxiety, disinhibition, and depression to be perceived "severely" to "extremely" distressing in more than 30% of the caregivers affected. The association between activities of daily living and symptoms needs further attention.

Subjective memory impairment: No suitable criteria for case-finding of dementia in primary care

IntroductionSubjective memory impairment (SMI) might be used for the case-finding of dementia. Present analyses aim to determine the diagnostic value and the predictive ability of SMI and related worries for the discrimination of patients screened positive or negative for dementia. MethodsThe analyses are based on data derived from the ongoing German general practioner (GP)-based, randomized controlled trial DelpHi-MV. A total of 5106 patients (age ≥ 70, living at home) were first asked for SMI and related worries and then screened for dementia in 110 participating GP practices (November 2011 to August 2014; preliminary data) using the DemTect. ResultsA total number of 2556 patients (50%) stated that they experience SMI and 892 patients (17%) screened positive for dementia. The sensitivity of SMI for the correct classification of positively screened patients was 54%, the positive predictive value (PPV) 19%. The specificity of SMI was 51%; the negative predictive value (NPV) 84%. Among 2480 patients with SMI, 45% reported SMI-related worries (sensitivity 52%; specificity 57%; PPV 22%; NPV 84%). Receiver operating characteristics analyses showed no statistically significant improvement in the area under the curves when using SMI or related worries as predictors (additional to age and sex) for the discrimination between positively and negatively screened patients. DiscussionThe analyses showed that the risk of overlooking cognitive impairment in the subgroup of patients who state that they do not experience SMI would be unreasonable high. Thus, the results provide clear evidence that neither SMI nor related worries can be used as a valid criteria to decide whether an elderly primary care patient should be tested for dementia.Trials registration: ClinicalTrials.gov Identifier: NCT01401582.

Depression, vascular factors, and risk of dementia in primary care: a retrospective cohort study.

To study the interaction between and timing effects of depression and vascular disorders on dementia risk. Retrospective cohort study. Primary care practices in the south of the Netherlands. Individuals in primary care aged 50 to 100 followed for 13 years (N = 35,791). Medical diagnoses of incident depression, hypertension, obesity, type 2 diabetes mellitus, stroke, and dementia were extracted from a research database. Cox proportional hazards regression was used to test whether incident depression predicted dementia and its putative interactions with vascular factors. In total, 1,680 participants developed dementia. Individuals with depression (n = 978) had a higher risk of dementia (adjusted hazard ratio (HR) = 2.03, 95% confidence interval (CI) = 1.56-2.64). Depression exerted most effect in participants with incident stroke (HR = 5.29, 95% CI = 2.52-11.14) or newly diagnosed hypertension (HR = 3.09, 95% CI = 1.54-6.20). Depression in later life increases the risk of dementia. The effect is particularly high in individuals with depression and vascular disorders. Targeting late-onset depression in individuals with vascular disorders might lower dementia risk by preventing cerebrovascular changes.

GPs’ and nurses’ views about a primary care dementia service

GPs’ and nurses’ views about a primary care dementia service

Rates of formal diagnosis of dementia in primary care: The effect of screening

BackgroundScreening could improve recognition of dementia in primary care. We sought to determine the effect of screening for dementia in primary care practices on the formal diagnosis rate; the distribution of differential diagnoses; and the factors associated with receiving a formal diagnosis. MethodsThe “Dementia: life- and person-centered help in Mecklenburg-Western Pomerania” is an ongoing general practitioner (GP)-based, randomized, controlled intervention trial. A total of 4064 community dwelling patients (aged ≥70 years) were screened for dementia in 108 GP practices. Of these patients, 692 (17%) had positive screening results (DemTect score <9). Of these 692 patients, 406 (59%) provided informed consent. The analyses included the data from 243 patients with a complete baseline assessment (preliminary data; January 2014). ResultsOf 146 patients without a formal diagnosis of dementia, 72 (49%) received a formal diagnosis after a positive screening outcome (69% with “unspecified dementia”). Female sex was significantly associated with receiving a formal diagnosis (multivariate analyses). ConclusionScreening improved the identification of dementia considerably. Because of the risk of receiving a false-positive diagnosis, additional diagnostic assessment should be mandatory.

New Tool Offers Quick, Reliable Dementia Assessment

New Tool Offers Quick, Reliable Dementia Assessment