Clinical recognition of dementia and cognitive impairment in primary care: a meta-analysis of physician accuracy

Mitchell AJ, Meader N, Pentzek M. Clinical recognition of dementia and cognitive impairment in primary care: a meta‐analysis of physician accuracy. Objective: We aimed to examine the ability of the general practitioners (GPs) to recognize a spectrum of cognitive impairment from mild cognitive impairment (MCI) to severe dementia in routine practice using their own clinical judgment. Method: Using PRISMA criteria, a meta‐analysis of studies testing clinical judgment and clinical documentation was conducted against semi‐structured interviews (for dementia) and cognitive tests (for cognitive impairment). We located 15 studies reporting on dementia, seven studies that examined recognition of broadly defined cognitive impairment, and eight regarding MCI. Results: By clinical judgment, clinicians were able to identify 73.4% of people with dementia and 75.5% of those without dementia but they made correct annotations in medical records in only 37.9% of cases (and 90.5% of non‐cases). For cognitive impairment, detection sensitivity was 62.8% by clinician judgment but 33.1% according to medical records. Specificity was 92.6% for those without cognitive impairment by clinical judgment. Regarding MCI, GPs recognized 44.7% of people with MCI, although this was recorded in medical notes only 10.9% of the time. Their ability to identify healthy individuals without MCI was between 87.3% and 95.5% (detection specificity). Conclusion: GPs have considerable difficulty identifying those with MCI and those with mild dementia and are generally poor at recording such diagnoses in medical records.     

Prevalence of cognitive impairment: data from the Indianapolis Study of Health and Aging.

BACKGROUND: The epidemiology and natural history of cognitive impairment that is not dementia is important to the understanding of normal aging and dementia. OBJECTIVE: To determine the prevalence and outcome of cognitive impairment that is not dementia in an elderly African American population. METHOD: A two-phase, longitudinal study of aging and dementia. A total of 2212 community-dwelling African American residents of Indianapolis, IN, aged 65 and older were screened, and a subset (n = 351) received full clinical assessment and diagnosis. Subsets of the clinically assessed were seen again for clinical assessment and rediagnosis at 18 and 48 months. Weighted logistic regression was used to generate age-specific prevalence estimates. RESULTS: The overall rate of cognitive impairment among community-dwelling elderly was 23.4%. Age-specific rates indicate increasing prevalence with increasing age: 19.2% for ages 65 to 74 years, 27.6% for ages 75 to 84 years, and 38.0% for ages 85+ years. The most frequent cause of cognitive impairment was medically unexplained memory loss with a community prevalence of 12.5%, followed by medical illness-associated cognitive impairment (4.0% prevalence), stroke (3.6% prevalence), and alcohol abuse (1.5% prevalence). At 18-month follow-up, 26% (17/66) of the subjects had become demented. CONCLUSIONS: Cognitive impairment short of dementia affects nearly one in four community-dwelling elders and is a major risk factor for later development of dementia.     

Detection and documentation of dementia and delirium in acute geriatric wards

Detection of cognitive impairment among hospitalized older individuals has shown to be insufficient. A point prevalence study in two geriatric hospitals in Helsinki, Finland, was performed among 219 acutely ill individuals over 70 years to assess the detection of dementia and delirium. Documentation of dementia and delirium in medical records, and recordings of confusional symptoms in nurses' notes were compared with the researchers' diagnosis made after a detailed assessment of cognitive status. The cognitive decline was mentioned in medical records in 70/88 (79.5%) of the cases. Cognitive testing was performed on 42/88 (47.7%) of the dementia patients, and the diagnosis of dementia was recorded in 47/88 (53.4%) of them. A specific etiological diagnosis was recorded in only 4/88 (4.5%) cases. Cognitive impairment in at least one of these four means was recorded in 80/88 (90.9%) of cases (sensitivity 0.93). Eight patients had a false-positive diagnosis of dementia (specificity 0.94). Delirium was diagnosed in 77 (35.2%) patients by the researchers, but it was recorded in only 31/77 (40.3%) in medical records. In 64/77 (83.1%) cases signs of confusion were recorded in nurses' notes. Poor detection and documentation may lead to undertreatment of both disorders.     

Disturbed behaviour in dementia sufferers: A comparison of three nursing home settings

In order to determine whether a specialist psychogeriatric nursing home was fulfilling its intended role of caring for the most behaviourally disturbed dementia sufferers, 24 of its demented residents were compared with 28 demented individuals discharged from a psychiatric unit to ordinary nursing homes and 30 mobile dementia sufferers in nursing home wards of a geriatric centre. Those in the psychogeriatric nursing home showed more disturbed behaviours than those in the other two settings. Scores on the Rating Scale for Aggressive Behaviour in the Elderly were compared with degree of cognitive impairment for the first time in the literature and showed no correlation with degree of cognitive impairment for the first time in the literature and showed no correlation with congnitive performance.     

Werden Demenzkranke bei der Feststellung der Pflegebedürftigkeit nach dem Pflegeversicherungsgesetz benachteiligt?

Fifty-eight recipients of long-term care insurance benefits were interviewed during home visits by a research team. Fourty-eight percent of the interviewees achieved less than 22 points in the Mini-Mental State Examination (MMSE), clearly indicating cognitive impairment. Comparison of the authorized examination on the one hand and the findings of the research team on the other showed: neither CNS-specific diagnoses (77.8% sensitivity) nor CNS malfunction adequately recognised cognitive impairment. In 41% of the cognitively impaired, authorised examination found only minor or no functional CNS disorders. A comparison of the 'recognised' and 'not recognised' cognitively impaired and physically handicapped applicants found that a higher stage of care was allocated to the group with recognised dementia but that, in all MDK parameters, there was no judgmental difference in medical expert records between patients with unrecognised cognitive impairment and physically handicapped persons.     

Characteristics and outcomes of dementia residents in an assisted living facility

BACKGROUND: Assisted living (AL) is the fastest growing segment of residential long-term care in the US. At least half of the estimated 1 million AL residents have dementia or cognitive impairment, with many AL facilities offering specialized dementia services. Little research has been done on the demographics, outcomes, or clinical variables of this population.METHODS: Participants were a cohort of 144 residents admitted to the AL unit of Copper Ridge, a specialized dementia-care facility. Comparison samples included 737 patients with dementia residing in other locations (home, nursing home, and other assisted living facilities). Selected measures of cognition, behavior, medical health, and function were taken at admission to AL and at 6-month intervals.RESULTS: When compared with residents of the dementia-specialized AL facility, dementia patients at home were younger, less cognitively impaired, and less likely to exhibit wandering, delusions, or aggression. Residents of a dementia-specialized nursing home had more cognitive impairment, greater medical comorbidity, and were more dependent on caregivers. The 2-year mortality rate in the dementia-specialized AL was 23%, significantly lower than rates reported for nursing homes. Primarily due to increasing care needs, most residents in the specialized AL relocated to a nursing home after a median stay of 10.9 months. Depression, falling, and wandering were significant predictors of the transition.CONCLUSION: Dementia-specialized AL facilities occupy a unique position in the long-term care continuum that is distinct from home-care and nursing home facilities. This research is the first step toward understanding the significant dementia population residing in assisted living.     

Depressed mood, cognitive impairment, and survival in older people admitted to care homes in England.

OBJECTIVE: To investigate psychiatric morbidity, cognitive impairment, dependency, and survival in residents newly admitted to care homes. METHODS: A total of 308 older people were assessed using measures of cognitive impairment and depressive symptomatology, and interviewable residents completed a quality-of-life interview. Dependency levels were assessed by interviews with staff and medication data were collected from home records. Follow-up assessments were carried out at five and nine months. A telephone follow-up approximately 12 months later augmented the survival data. RESULTS: Of residents whose outcomes were known, 73% survived throughout the nine-month study period. Residents who died before the five-month follow-up had higher scores on the depression measure than those surviving longer. Reduced survival was predicted by greater dependency at baseline. Of 188 surviving residents, 63 (38%) were classified as depressed at baseline. Twenty-seven (43%) of the latter were still classed as depressed at five and nine months. Just 19% of residents rated as depressed at baseline were prescribed antidepressant medication, increasing to 26% at each follow-up. There was significant coexistence of cognitive impairment and depressive symptomatology. CONCLUSION: High levels of mortality, psychiatric morbidity, and chronicity of depressed mood among residents requires care homes to improve access to specialist resources such as geriatric consultation, old-age psychiatry, occupational therapy, and physiotherapy. Findings suggest that future care standards should include external factors, such as the extent of access to relevant specialist services for vulnerable older people.     

Behavioral and psychological symptoms of dementia in older residents in long-term care facilities in Japan: a cross-sectional study

Objective: To investigate the prevalence of the behavioral and psychological symptoms of dementia (BPSD) and associated factors in residents in long-term care (LTC) facilities.

Method: We conducted a cross-sectional survey of older residents with dementia or similar symptoms (n = 312) using a questionnaire for care staff in 10 selected LTC facilities in Hokkaido, Japan. The questionnaire included sociodemographic characteristics, health conditions, living environments, and a brief questionnaire form of the Neuropsychiatric Inventory for assessing BPSD.

Results: We revealed that the prevalence of BPSD in LTC facilities (percentage of people exhibiting at least one BPSD) in residents with dementia or similar symptoms was 64%. Having Alzheimer's disease, an imbalance between activities of daily living and cognitive function, poor relationships with other residents, and persistent requests in daily life were significantly associated with having BPSD.

Conclusion: The prevalence of BPSD in LTC facilities was relatively low compared with other countries. The factors found to relate to BPSD may provide useful information for developing care methods to address BPSD in LTC residents.     

Dementia and depression in italian geriatric institutions

A random sample of 368 elderly residents in nine geriatric institutions in Milan was selected, and interviewed using the Intervista Psicogeriatrica, the modified Italian version of the OBS scale (82.1 % successfully completed) and the Depression scale (75.5 % successfully completed) of the Comprehensive Assessment and Referral Evaluation (CARE). The estimated prevalence rates of dementia and depression were 36 % and 30 % respectively, and 50 % for either or both diagnoses. Correlates of dementia were characteristics of the institutions (size, ownership, and admission criteria), age (for women), age at admission, female sex, and poor education. Correlates of depression were disability, length of stay in men (negative association), and marital status. Correlates of dementia and depression were also examined using multivariate analysis. The only significant independent effects on dementia were admission criteria of the institutions and age, while on depression were sex and marital status.     

Prevalence of dementia in a Japanese elderly population

The geriatric community study was conducted by the Aichi Prefecture (Japan) Project. The psychiatric epidemiological survey was conducted using a stratified random sampling method. 3106 community residents over the age of 65 years, randomly selected from the whole Aichi Prefecture of Japan, were interviewed; 476 had suspected dementia. The second interviews and the neurologic examinations were carried out by psychiatrists. The prevalence of dementia was estimated to be 5.8% (moderate and severe, 2.2%; mild 3.6%) of the aged population in the community. Cerebrovascular dementia (CVD) or multi-infarct dementia (MID) was found in 2.8%, senile dementia of the Alzheimer type (SDAT) in 2.4%, and dementia due to other causes in 0.6%. CVD (MID) was diagnosed more frequently in men, and SDAT in women.     

Cognitive impairment in the elderly medically ill: How often is it missed?

One hundred and sixty-three patients over 65 years of age admitted to the acute medical wards of a district teaching hospital were studied for prevalence and type of cognitive impairment. Findings from research assessments, where possible using a cognitive rating scale, were compared with detection of impairment by medical and nursing staff involved in patients' clinical management. 30.7% of patients were judged by us to show definite or probable cognitive impairment, a figure substantially higher than that detected by hospital staff. Outcomes in terms of death, duration of admission and discharge location were related to the presence or absence of cognitive impairment and whether impairment was due to delirium, dementia or a mixed syndrome. The low rate of detection of cognitive impairment is discussed, and suggestions made to improve detection in acute elderly medical inpatients.     

PREVALENCE OF COGNITIVE IMPAIRMENT IN THE HOSPITALIZED ELDERLY

Surveys of older populations reveal rates of senile dementia varying from 5.2% to 25%. The specialist branch of psychiatry dealing with the elderly advocates that services for these patients and their carers should predominantly be based outside hospital. The following study was conducted in Limerick, Ireland before the arrival of a consultant in old age psychiatry and associated services. Its aim was to assess the extent to which the patients with dementing disorders were using hospital facilities other than those in psychiatric wards. The study assessed 371 patients aged 65 years and over in various medical and surgical units. The Mini Mental State Examination was performed on all patients. Patients with scores of 23/31 or less were considered to have significant cognitive impairment and those with 16 or less to have severe impairment. As mental performance can be impaired by acute illness, methods were used to avoid such patients being wrongly labelled as suffering from dementia. In the acute hospital 112 patients with an average age of 74.7 years were examined and 22.3% of these had significant cognitive impairment. These patients were predominantly sited on medical wards. On acute medical wards 31% of older patients had significant impairment compared to only 7.3% on the surgical wards. In the orthopaedic unit 15.8% of the elderly had evidence of cognitive impairment. In hospitals specializing in continuing care of the elderly the proportion was 70.6% and of these 46% were severely impaired. We conclude that in the absence of specialized dementia services for the elderly, medical beds both in the acute and long-stay sector will be used for these patients more than their medical needs might otherwise require. © 1997 by John Wiley & Sons, Ltd.     

The recognition of dementia in "non-EMI" nursing home residents in South East England

OBJECTIVES: To estimate the agreement between nursing staff's recognition of dementia and results of MMSE assessment in a probability sample of non-specialist nursing home residents in South East England, and to identify correlates of disagreement. METHODS: Prospective survey. The most senior nurse on duty was interviewed about each resident sampled, and optionally about their own training and experience. Residents were interviewed using the MMSE, and assessed using the Cornell Scale for Depression in Dementia, the Barthel ADL index, and the Behave-AD scale for behavioural problems. RESULTS: 135 nurses were interviewed about 445 residents-116 reported on of the 291 residents scoring 23 or less on the MMSE-34% of these were acknowledged to have dementia. 46.4% of those with MMSE scores of 15 or less were acknowledged to have dementia. "Missed dementia" was associated with higher MMSE and lower Behave-AD scores, and inversely associated with RMN training and private home ownership for profit. It was not associated with training or duration of staff employment. CONCLUSIONS: Most cognitive impairment in non-specialist nursing homes appeared to be unrecognised. This has implications for the prospects of good dementia care in these homes.     

Cognitive impairment in public housing residents living in Western New York

Purpose

Many older adults in the USA live in public housing facilities and have characteristics that may place them at risk for cognitive impairment. Cognitive impairment has been largely unexamined in this socioeconomically disadvantaged population, however. We therefore aim to characterize its prevalence and correlates, which may help determine which residents could benefit from additional assistance to optimize their ability to function independently.

Methods

We interviewed 190 English-speaking public housing residents aged 60 years and older in Rochester, a city in Western New York, to assess socio-demographics, mental health, physical health and disability, coping strategies and social support, and service utilization. The Mini-Cog dementia screen evaluated cognitive status.

Results

Twenty-seven percent of residents screened positive for cognitive impairment. In bivariate analyses, older age, less education, greater duration of residence, worse health, less reliance on adaptive coping strategies, and greater utilization of health services were associated with cognitive impairment; age and worse health remained correlated with cognitive impairment in multivariable analyses. Anxiety, depression, and history of substance misuse were not associated with cognitive impairment.

Conclusions

The high level of cognitive impairment in public housing could threaten residents’ continued ability to live independently. Further examination is needed on how such threats to their independence are best accommodated so that public housing residents at risk for needing higher levels of care can successfully age in place.     

Attitudes to dementia and dementia care held by nursing staff in U.K. "non-EMI" care homes: what difference do they make?

BACKGROUND: There is doubt about the value of training in dementia care in U.K. nursing homes. We decided to estimate the association between nursing staff's attitudes to dementia and dementia care and their recognition of cognitive impairment in residents and other indicators of care practice in nonspecialist nursing homes derived from a probability sample of 445 residents in South-East England, and to relate this to previous training. METHODS: Prospective survey. The most senior nurse on duty was interviewed about each resident sampled, about their own training and experience, their attitude to restriction of egress and covert medication use, and asked to complete the Attitudes to Dementia Questionnaire (ADQ) and the dementia Care Styles Questionnaire (CSQ). Nurses were also asked about care practices in relation to restriction of egress and covert medication use in the home. Residents were interviewed using the Mini-mental State Examination (MMSE). RESULTS: One hundred and fifty-eight nurses were interviewed. Increased person-centered attitudes seem to be associated with better recognition of cognitive impairment independent of training and experience. The espousal of restrictive practices was also associated with better recognition, but only when analysis included nurses reporting on only one impaired resident. CONCLUSIONS: More person-centered attitudes are associated with better recognition of cognitive impairment, despite perverse U.K. regulatory incentives; the need for training and support in developing person-centered dementia care for staff in "non-Elderly Mentally Infirm" ("non-EMI") care homes is supported by these results.     

The prevalence and causes of dementia in people under the age of 65 years

OBJECTIVES: To determine the prevalence of dementia in people under the age of 65 in a large catchment area, and use these figures to estimate the number of younger people affected by dementia in the UK. DESIGN: Epidemiological catchment area prevalence survey. SETTING: The London boroughs of Kensington and Chelsea, Westminster, and Hillingdon with a total population of 567500 people. PARTICIPANTS: All residents of the catchment area with dementia, where the illness began before the age of 65 years. Participants were notified to the study by medical and care professionals. The diagnosis and age of onset was established from all available health and social care records. In total, 227 people were identified, of whom 185 fulfilled the inclusion criteria of having a dementia which started before their 65th birthday. MAIN OUTCOME MEASURES: Diagnosis of dementia and differential diagnosis of the cause of the dementia. RESULTS: The prevalence of dementia in those aged 30-64 was 54.0 per 100000 (95% CI 45.1 to 64.1 per 100000). For those aged 45-64 years, the prevalence was 98.1 per 100000 (95% CI 81.1 to 118.0 per 100000). From the age of 35 onwards, the prevalence of dementia approximately doubled with each 5 year increase in age. Extrapolating these figures nationally suggests that there are 18319 (15296-21758) people with dementia under the age of 65 in the UK. CONCLUSIONS: The study confirms previous "guestimates" of the number of younger people affected by dementia in UK. The prevalence figures generated are robust, and are supported by other smaller and targeted prevalence surveys. The prevalence figures provided by this study will allow health planners to accurately estimate need and plan services.     

Comparison of the diagnostic accuracy of the Cognitive Performance Scale (Minimum Data Set) and the Mini-Mental State Exam for the detection of cognitive impairment in nursing home residents

OBJECTIVE: To compare the diagnostic accuracy of an outcome measurement scale of the Minimum Data Set of the Resident Assessment Instrument for nursing homes (MDS/RAI-NH), the Cognitive Performance Scale (CPS) and the Mini-Mental State Exam (MMSE) for the detection of cognitive impairment. The Cambridge Examination for Mental Disorders of the Elderly--Revised (CAMDEX-R) was used as the reference standard. STUDY DESIGN AND SETTING: This study was part of a larger prospective study (QUALIDEM) involving a diagnostic procedure and two-year follow-up on the quality of primary care for demented patients. CAMDEX-R and MDS/RAI-NH were administered to 198 residents, aged 65 or more, living in 42 low and high care institutions for aged people. MAIN OUTCOME MEASURES: Indicators of diagnostic accuracy: sensitivity, specificity, predictive values, likelihood ratios, odds ratio and area under receiver operating characteristics curve (AUC). RESULTS: The CAMDEX-based prevalence of cognitive impairment was 75%. The diagnostic values of a CPS score of two or more for the detection of cognitive impairment were: sensitivity = 0.81; specificity = 0.80; PPV = 0.92; NPV = 0.57. The diagnostic values of a MMSE score of less than or equal 23 were: sensitivity = 0.97; specificity = 0.59; PPV = 0.88; NPV = 0.85. For CPS, the area under the receiver operating characteristic (ROC) curve was 0.87 (95% CI, 0.81-0.91), and not significantly different (p = 0.63) from the MMSE score, 0.88 (0.83-0.93). CONCLUSIONS: CPS and MMSE demonstrated similar performance to detect cognitive impairment in nursing home residents.