Dementia Screening and Surveillance

The prevalence of dementia, and in particular Alzheimer’s disease, is expected to increase dramatically in the elderly population over the next few decades. Because of the possibilities of pharmacological and psychosocial interventions, which aim to slow down or even prevent progress of the disease, early detection of dementia is of the utmost importance. The screening of patients at risk is the first step in the detection of dementia and should be undertaken at the primary healthcare level. A history and mental state examination is necessary for all patients, and in particular for elderly patients, who have had cognitive complaints and/or reports of cognitive decline. Useful screening tests for dementia are either the Mini-Mental State Examination (MMSE) or the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE); an MMSE score <27 and an IQCODE score >3.31 indicate a possible dementia and should be further investigated. However, neither MMSE nor IQCODE should be used as a diagnostic tool.Because of the heterogeneity of the deficits and the absence of a biological marker, the diagnosis of early degenerative dementias can be very complex and requires a multidisciplinary approach. Basic routine investigations carried out at the general practitioner (GP) level include physical and neurological examinations, a laboratory screen and a computerised tomography or magnetic resonance imaging examination. A neuropsychological examination is necessary to establish the diagnosis and there is promising evidence for the predictive value of some specific tests for Alzheimer’s disease. Complementary investigations such as functional neuroimaging, electroencephalogram and CSF investigations, may be indicated in some cases.Efficient management programmes can only be effective if they are implemented as early as possible and adapted regularly to the changing needs of patients with dementia and their caregivers. The creation of health teams working in the community under the supervision of a GP seems to be a promising model for the care of the patient with dementia living in the community.     

Relationship Between General Practitioners' Attitudes and Methods of Dealing with Psychosocial Problems

Braams FM, Duivenvoorden H J, Dokter H J, Trijsburg R W andVerhage F. Relationship between general practitioners' attitudesand methods of dealing with psychosocial problems. Family Practice1988; 5:5–11. The relationship between general practitioners' attitudes andthe methods they use when dealing with psychosocial problemswas investigated using a questionnaire that was answered bya group of 30 general practitioners. The results showed that:(1) the doctor's desire to help is in general associated withthe need to be appreciated; (2) when treating sexual problems,the giving of information is associated with a desire to changethe patient; (3) when dealing with problems associated withchronic illness, the giving of encouragement to the patientis accompanied by a desire to give advice. The findings suggestthat the way in which a general practitioner treats psychosocialproblems depends partly on the type of problem and partly onhis own attitude.     

Dementia and depression: two frequent disorders of the aged in primary health care in Greece

BACKGROUND: Dementia and depression are very common disorders among elderly people and their presence decreases the well-being of the aged. OBJECTIVES: The purpose of this study was to assess the magnitude of dementia and depression among elderly people living in different settings in the catchment area of the Chrisoupolis health centre (HCCh) in northern Greece. METHODS: A total of 536 patients aged 65 years and over, including 48 subjects living in an old people's home, 75 subjects who were taking part in the activities of the open centre for the elderly and 413 subjects randomly selected from those visiting the HCCh, were interviewed by the primary health care team of the HCCh. Medical and family history data were recorded, while cognitive and mood disorders were assessed by using the Mini Mental State Examination and Geriatric Depression Screening Scale. RESULTS: At the time of the examination, 37.6% of the men and 41.6% of the women showed various degrees of cognitive impairment, while 29.9% of the women and 19.6% of the men showed mild to moderate depression. Diabetes mellitus and hypertension frequently were found to co-exist with depression and dementia. CONCLUSION: The results reaffirm that there is a high prevalence of the studied mental disorders in older patients in the out-patient setting in Greece. A set of recommendations to Greek GPs has now been formulated, with specific emphasis on the use of different screening tools and the appropriate treatment of the most frequently co-existing chronic diseases.     

General Practitioners' Opinions About Their Responsibility for Medical Tasks: Comparison Between England and the Netherlands

Whitfield M, Grol R and Mokkink H. General practitioners' opinionsabout their responsibility for medical tasks: comparison betweenEngland and the Netherlands. Family Practice 1989; 6: 274–278. A questionnaire survey compared a sample of 371 general practitionersin the Avon region of England with 74 general practitionersin the east of the Netherlands. A list of 14 medical tasks —six technical tasks and eight chronic disease management tasks— was presented and the doctors indicated whether eachtask was totally, often, sometimes, seldom or not at all theresponsibility of the general practitioner. The results showthat English general practitioners felt more responsibilityfor chronic problems than the Dutch doctors whereas Dutch generalpractitioners felt more responsibility for technical tasks thanthe English. Fewer general practitioners in both countries feltresponsible for technical tasks than for chronic disease. Reasonsfor the differences in terms of the structure of general practiceand training are discussed.     

Referral to Hospital: Perceptions of Patients, General Practitioners and Consultants About Necessity and Suitability of Referral

A sample of new referrals from general practitioners to hospitalspecialists was examined from the points of view of the patient,general practitioner and consultant concerned with regard tothe adequacy of the general practitioners' performance beforereferral, his ability to have managed without referral and thesuitability of the specialist seen. Little agreement was foundbetween the opinions expressed by the three groups, althoughsome of the opinions expressed within the groups were foundto be associated with characteristics of the groups.     

General practitioners' views about the need for a stress support service

OBJECTIVES: We wished to determine general practitioners' (GPS') views regardingthe need for a stress support service. METHOD: A postal questionnaire survey of GPs' views (n = 274) aboutthe need for a stress support service, and what form such aservice might take, was undertaken on Tyneside. RESULTS: A response rate of 79.5% was achieved with one reminder. A majority(78.8%) were in favour of a stress support service for GPs,the most popular options for the service being independentlyaccessed counsellors and stress management groups. Over 90%of respondents thought that support should be available to anydoctor, and 65% that it should be available to all primary healthcare team members. The five most commonly mentioned causes ofstress were: time and workload problems; on call; expectationsand demands of patients; administration and paperwork; and complaintsand fear of litigation. CONCLUSIONS: The survey demonstrated widespread concern amongst GPs on Tynesideabout stress levels and considerable interest in the idea ofstress support. However, a variety of approaches would be requiredto meet the range of perceived needs, and any such servicesshould be made accessible to all practitioners regardless ofwhether they are actually suffering from stress, as well asto other members of the primary health care team. Keywords. General practitioners, stress support, counselling, primary health care teams.     

Dementia as risk factor for severe bone fractures among the elderly

INTRODUCTION: Falls among elderly represent an important public health concern due to its high incidence, health implications, and medical care costs. The study aims to assess the association between dementia and bone fracture risk after falls among the elderly. METHODS: A case-control of 404 subjects aged 60 years old or more living in Rio de Janeiro, Brazil, was carried out. Cases and controls were matched by age, sex, and hospital. Data were collected using structured interviews. Elderly people who scored 2 or more points in the BOAS (Brazil Old Age Schedule) scale were considered as having dementia. Odds ratios (OR) adjusted for potential confoundings were calculated using conditional logistic regression. RESULTS: Falls occurred at the same frequency in the morning, afternoon and night, but they were less common at dawn. Among those who fell at home, 78% had dementia against 55% with no dementia. The crude OR for the association between dementia and severe bone fracture was 2.0 (95% CI: 1.23-3.25). After adjustment for confounders there was a small reduction in the strength of this association (OR=1.82; 1.03-3.23). CONCLUSIONS: Dementia elderly people showed a higher risk of falling and being hospitalized due to bone fracture. This stresses the importance of special care for those individuals to reduce the occurrence of these accidents.     

Validity of the Portuguese version of Clinical Dementia Rating

OBJECTIVE: To evaluate the validity of the Portuguese version of the Clinical Dementia Rating for classifying the cognitive function among the elderly. METHODS: The Mini Mental State Examination was utilized as a screening method for cognitive deficit among a cohort of 424 elderly. All those who scored <26 points (108 elderly) and 48 elderly with scores > or =26 were included in the study. The 156 subjects selected were submitted to clinical evaluation and neuropsychological tests for the diagnosis of dementia. Afterwards, both cases and non-cases were classified, according to the Portuguese version of the Clinical Dementia Rating, in the categories normal, borderline, mild, moderate and severe dementia. RESULTS: Among the 156 subjects selected, 122 were non-cases, 62 (51%) were classified as normal (CDR=0) and 60 (49%) as borderline (CDR=0.5). Among the 34 cases of dementia, 17 (50%) were classified as mild dementia (CDR=1), eight (23%) as moderate (CDR=2) and six (18%) as severe dementia (CDR=3). Only three (9%) of the cases were considered borderline cases by the Clinical Dementia Rating. Its sensibility was 91.2% and the specificity was 100%. The positive predictive value was 100% and the negative predictive value was 97.6%. The Mini Mental State Examination scores declined significantly according to the degree of dementia. CONCLUSIONS: The Portuguese version of the Clinical Dementia Rating is a valid instrument for classifying the dementia status of the elderly. Almost half the cases considered normal by the diagnostic criteria of the Mini Mental State Examination were borderline cases according to the Clinical Dementia Rating and might correspond to cases of mild cognitive impairment, with an increased risk of conversion to dementia cases.     

Aluminum and Silica in Drinking Water and the Risk of Alzheimer's Disease or Cognitive Decline: Findings From 15-Year Follow-up of the PAQUID Cohort

The authors examined associations between exposure to aluminumor silica from drinking water and risk of cognitive decline,dementia, and Alzheimer's disease among elderly subjects followedfor 15 years (1988–2003). They actively searched for incidentcases of dementia among persons aged 65 years or over livingin 91 civil drinking-water areas in southern France. Two measuresof exposure to aluminum were assessed: geographic exposure andindividual exposure, taking into account daily consumption oftap water and bottled water. A total of 1,925 subjects who werefree of dementia at baseline and had reliable water assessmentdata were analyzed. Using random-effects models, the authorsfound that cognitive decline with time was greater in subjectswith a higher daily intake of aluminum from drinking water (0.1mg/day, P = 0.005) or higher geographic exposure to aluminum.Using a Cox model, a high daily intake of aluminum was significantlyassociated with increased risk of dementia. Conversely, an increaseof 10 mg/day in silica intake was associated with a reducedrisk of dementia (adjusted relative risk = 0.89, P = 0.036).However, geographic exposure to aluminum or silica from tapwater was not associated with dementia. High consumption ofaluminum from drinking water may be a risk factor for Alzheimer'sdisease. aluminum; Alzheimer disease; cognition; dementia; silicon dioxide; water; water supply     

上海城乡老年期痴呆患者死亡率和生存预示因素研究

目的研究老年期痴呆的死亡率和影响患者生存的因素。方法在上海地区基线患病率调查的基础上随机选择5个居委会和4个村委会的居民为研究对象。通过简易精神筛查量表,按文化程度划分的分界值进行初筛。分界值以下和正常人的4%进入第二阶段细查。细查项目包括详细病史记录、体格检查和神经心理学检查。6个月后对所有进入细查的对象进行上述内容的复查。根据NINCDSADRDA和NINDAAIREN标准诊断阿尔茨海默病(AD)和血管性痴呆(VaD)。结果老年期痴呆患者的死亡率是6.06/1000人年。与非痴呆组相比,在随访40个月后,痴呆组的生存概率急剧下降57%,两者相比差异有统计学意义(P<0.05)。但AD和VaD间的生存率无统计学差异(P>0.05)。由痴呆、AD和VaD导致的死亡相对危险度(RR)值分别为1.63(95%CI:1.42～1.86)、1.71(95%CI:1.44～2.03)和1.45(95%CI:1.16～1.82)。增加患者死亡危险性的因素有年龄(RR=1.0685)、疾病程度(RR=1.5733)、高社会生活功能量表(ADL)值(RR=1.0368)。结论上海地区老年期痴呆的死亡率为6.06/1000人年。AD和VaD患者的生存概率没有明显差别。增加患者死亡危险性的因素有年龄、疾病程度和高ADL值。     

北京部分城乡社区老年人和痴呆患者神经精神症状的调查

目的 研究社区老年人和轻中度痴呆患者神经精神症状的表现及其患病率。方法 采用国际通用的神经精神科问卷(NPI)对北京市城乡1540名认知功能正常的65岁及其以上老年人和373名痴呆患者的神经精神症状进行了调查。结果 痴呆患者中49.33％在近一个月内出现过至少一种神经精神症状(35.66％为临床显著性症状),其中80.4％出现2种以上的神经精神症状。痴呆患者最常见的症状包括抑郁/心境恶劣(23.86％),情感淡漠/漠不关心(21.72％),焦虑(20.38％)。正常老年人中有18.25％在近一个月内出现过至少一种神经精神症状(6.49％为临床显著性症状),其中53％出现2种以上的神经精神症状。老年人中最常见的症状有睡眠障碍(10％),抑郁/心境恶劣(8.9％),焦虑(6.97％)。结论 研究结果显示,痴呆患者神经精神症状患病率较高,程度上也更为严重,更具临床意义,认知功能正常的社区老年人神经精神症状也不容忽视,因此在痴呆的临床诊断过程中要特别关注老年人的精神行为异常。     

Beliefs about Menopause of General Practitioners and Mid-aged Women

Recent general population studies suggest that experience ofthe normal menopause transition is relatively unremarkable forthe majority of women, but negative stereotyped beliefs aboutmenopause remain pervasive. This study explored GPs' beliefsand opinions about menopause in general, and compared the GPs'beliefs with those of their mid-aged female patients. All GPsat five general practices (n = 24) and 101 45-year-old womenregistered at the same practices took part. Large proportionsof both groups believed that most women experience somatic andpsychological difficulties during menopause. GPs expressed morenegative beliefs than patients but were also more likely toexpress positive/neutral beliefs. Some causal attributions ofmenopausal problems were shared by the two groups, but theydiffered on others. When both GPs and patients hold negativesocial stereotypes about menopause, problems of mid-aged womenmay be misattributed to menopause. Health information on menopausemay be biased towards negative images of menopause and of agingwomen.     

How do General Practitioners Diagnose Dementia?

By means of a qualitative study, we set out to generate hypothesesabout the way general practitioners (GPs) diagnosed dementia.We looked for triggers for the diagnosis of dementia. Ten GPswere interviewed about four dementia cases taken from theirown practices. GPs are more concerned with treatment than withthe diagnosis of dementia as such, as diagnosis is performedin relation to treatment. The most important aid was the evolutionof the clinical tables based on the information of caregivers.Important triggers were changes of activities of daily lifefunction, behaviour and cognition. Acute illness and loss ofthe key caregiver were relevatory moments. Recommendations aremade for the improvement of the diagnostic abilities of GPs.     

全身麻醉和硬膜外麻醉对老年骨折患者的作用

目的探讨全身麻醉和硬膜外麻醉对老年骨折患者的作用。方法选取2018年3月-2019年9月98例老年骨折患者,按数字随机抽取分成观察组(n=49)与对照组(n=49),对照组采取全身麻醉,观察组采取硬膜外麻醉,观察两组简易精神状况检测量表(mini-mental state examination,MMSE)评分、认知功能障碍及血流动力学。结果观察组术后24 h的MMSE评分高于对照组,P<0.05;观察组术后6 h、12 h认知功能障碍发生率明显低于对照组,P<0.05;观察组T1、T2时的心率、舒张压、收缩压均低于对照组,P<0.05。结论对比全身麻醉,硬膜外麻醉可减少老年骨折患者认知功能障碍,对血流动力学影响更小。     

Risk Factors and Hospitalization Costs of Dementia Patients: Examining Race and Gender Variations

Aims:

To examine the variation in risk factors and hospitalization costs among four elderly dementia cohorts by race and gender.

Materials and Methods:

The 2008 Tennessee Hospital Discharged database was examined. The prevalence, risk factors and cost of inpatient care of dementia were examined for individuals aged 65 years and above, across the four race gender cohorts - white males (WM), black males (BM), white females (WF), and black females (BF).

Results:

3.6% of patients hospitalized in 2008 had dementia. Dementia was higher among females than males, and higher among blacks than whites. Further, BF had higher prevalence of dementia than WF; similarly, BM had a higher prevalence of dementia than WM. Overall, six risk factors were associated with dementia for the entire sample including HTN, DM, CKD, CHF, COPD, and stroke. These risk factors varied slightly in predicting dementia by race and gender. Hospital costs were 14% higher among dementia patients compared to non-dementia patients.

Conclusions:

There exist significant race and gender disparities in prevalence of dementia. A greater degree of co-morbidity, increased duration of hospital stay, and more frequent hospitalizations, may result in a higher cost of inpatient dementia care. Aggressive management of risk factors may subsequently reduce stroke and cost of dementia care, especially in the black population. Race and gender dependent milestones for management of these risk factors should be considered.     

The Phadiatop In Vitro Test for Allergy in General Practice: Is it Useful?

Dekker F W, Mulder Dzn J D, Kramps J A, Kaptein A A, VandenbrouckeJ P and Dijkman J H. The Phadiatop in vitro test for allergyin general practice: is it useful? Family Practice 1990: 7:144–14.8. A study was performed in order to assess the value of the Phadiatop,a new in vitro allergy test, in general practice. A total of248 patients were screened for bronchial allergy with PRIST,RAST and the Phadiatop. Information about the patient historyand the results of the PRIST, Phadiatop and RAST tests werepresented consecutively to the general practitioner and hisdiagnoses based on and evolving from these were evaluated andcompared with the diagnosis of a specialist. The general practitioner'sdiagnosis based on the resu Its of the Phadiatop was the closestof all the tests to the specialist diagnosis. It is concludedthat Phadiatop is of great use in diagnosing bronchial allergyin general practice.     

Dementia and driving.

Many European countries test cars, but not their drivers, as they age. There is evidence to suggest that human factors are more important than vehicular factors as causes of motor crashes. The elderly also are involved in more accidents per distance travelled than middle-aged drivers. As the UK relies on self-certification of health by drivers over the age of 70 years, we examined the driving practices of patients with dementia attending a Memory Clinic. Nearly one-fifth of 329 patients with documented dementia continued to drive after the onset of dementia, and impaired driving ability was noted in two-thirds of these. Their families experienced great difficulty in persuading patients to stop driving, and had to invoke outside help in many cases. Neuropsychological tests did not help to identify those who drove badly while activity of daily living scores were related to driving ability. These findings suggest that many patients with dementia drive in an unsafe fashion after the onset of the illness. The present system of self-certification of health by the elderly for driver-licensing purposes needs to be reassessed.     

Economics of the Iceberg: Informal Care Provided to French Elderly with Dementia

ObjectivesDementia has a substantial effect on patients and their relatives, who have to cope with medical, social, and economic changes. In France, most elderly people with dementia live in the community and receive informal care, which has not been well characterized.MethodsUsing a sample of 4680 people aged 75 years and older collected in 2008 through a national comprehensive survey on health and disability, we compared the economic value of the care received by 513 elderly people with dementia to that received by a propensity score– matched set of older people without dementia.ResultsMore than 85% of elderly people with dementia receive informal care; the estimation of its economic value ranges from €4.9 billion (proxy good method) to €6.7 billion (opportunity cost method) per year.ConclusionsThe informal care provided to people with dementia has substantial annual costs; further work should be done to examine the social and economic roles foregone as a result of this care.     

Appropriateness of laboratory testing in nursing home elderly with advanced dementia: an opinion poll among physicians

OBJECTIVE: Dilemmas regarding selection of appropriate laboratory tests in older frail nursing home patients with advanced dementia are commonly encountered by physicians. Our objective was to study physician opinions about evaluating the appropriateness of laboratory testing in older hospitalized patients in nursing homes based on a real case. SETTING: A 750-bed university teaching hospital in the Bronx that regularly receives acutely ill older residents from long-term care facilities, with medical care provided by residents, fellows, and teaching faculty. DESIGN: An opinion poll was conducted among 53 physicians. Information was provided on the history, physical examination, and laboratory findings of a 92-year-old woman with advanced Alzheimer's dementia admitted for gastrointestinal bleeding to the acute care Geriatrics unit. A questionnaire sought opinions on selection of laboratory tests (emphasizing Troponin I) and management in this patient. Chi-square analysis was performed to analyze the data RESULTS: The majority of polled physicians (37/53, P = 0.01) felt that ordering Troponin I in the setting described hindered patient care and stated they would not have ordered the test. The opinion on overall management was divided (P = 0.861). CONCLUSION: Dilemmas regarding choosing appropriate laboratory tests, including their implications for care, are found frequently in the setting of frail, demented elderly from nursing homes hospitalized for acute care. We suggest that the choice of tests in these subjects with advanced dementia be individualized based on due consideration for life expectancy, quality of life, and surrogate opinion.