How to prevent a delayed Alzheimer’s diagnosis

,

Applied Evidence

How to prevent a delayed Alzheimer’s diagnosis

J Fam Pract. 2009 January;58(1):9-15

By

Diana R. Kerwin, MD

Physicians fail to detect mild-to-moderate dementia more than half the time. Here’s when to screen and which tools to use

PDF Download

References

1. O’Connor DW, Pollitt PA, Hyde JB, et al. Do general practitioners miss dementia in elderly patients? BMJ. 1988;297:1107-1110.

2. Lagaay AM, van der Meij JC, Hijmans W. Validation of medical history taking as part of a population based survey in subjects aged 85 and over. BMJ. 1992;304:1091-1092.

3. Cooper B, Bickel H, Schaufele M. Early development and progression of dementing illness in the elderly: a general-practice based study. Psychol Med. 1996;26:411-419.

4. Olafsdottir M, Skoog I, Marcusson J. Detection of dementia in primary care: the Linkoping study. Dement Geriatr Cogn Disord. 2000;11:223-229.

5. Valcour VG, Masaki KH, Curb JD, et al. The detection of dementia in the primary care setting. Arch Intern Med. 2000;160:2964-2968.

6. Wilkinson D, Stave C, Keohane D, et al. The role of general practitioners in the diagnosis and treatment of Alzheimer’s disease: a multinational survey. J Int Med Res. 2004;32:149-159.

7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000.

8. Ritchie CW, Ames D, Clayton T, et al. Metaanalysis of randomized trials of the efficacy and safety of donepezil, galantamine, and rivastigmine for the treatment of Alzheimer disease. Am J Geriatr Psych. 2004;12:358-369.

9. Winblad B, Engedal K, Soinenen H, et al. A 1-year, randomized, placebo-controlled study of donepezil in patients with mild to moderate AD. Neurology. 2001;57:489-495.

10. Rogers SL, Farlow MR, Doody RS, et al. A 24-week, double-blind, placebo-controlled trial of donepezil in patients with Alzheimer’s disease. Donepezil Study Group. Neurology. 1998;50:136-145.

11. Doody RS, Geldmacher DS, Gordon B, et al. Open-label, multicenter, phase 3 extension study of the safety and efficacy of donepezil in patients with Alzheimer disease. Arch Neurol. 2001;58:427-433.

12. Ayalon L, Gum AM, Feliciano L, et al. Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia. Arch Intern Med. 2006;166:2182-2188.

13. Mittelman MS, Ferris SH, Shulman E, et al. A family intervention to delay nursing home placement of patients with Alzheimer’s disease. A randomized controlled trial. JAMA. 1996;276:1725-1731.

14. 2008 Alzheimer’s disease facts and figures. Available at: http://www.alz.org/alzheimers_disease_publications_reports.asp. Accessed March 19, 2008.

15. US Preventive Services Task Force. Screening for dementia: recommendations and rationale. June 2003. Available at: http://www.ahcpr.gov/clinic/3rduspstf/dementia/dementrr.htm. Accessed March 18, 2008.

16. AGS Clinical Practice Committee. Guidelines abstracted from the American Academy of Neurology’s Dementia Guidelines for early detection, diagnosis, and management of dementia. J Am Geriatr Soc. 2003;51:869-873.

17. Petersen RC, Stevens JC, Ganguli M, et al. Practice parameter: Mild Cognitive Impairment(an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001;56:1133-1142.

18. Wenger NS, Roth CP, Shekelle P. ACOVE Investigators. Introduction to the Assessing Care of Vulnerable Elders-3 Quality Indicator Measurement Set. J Am Geriatr Soc. 2007;55(suppl 2):s247-s251.

19. Feil DG, MacLean C, Sultzer D. Quality indicators for the care of dementia in vulnerable elders. J Am Geriatr Soc. 2007;55(suppl 2):s293-s301.

20. Adelman AM. Initial evaluation of the patient with suspected dementia. Am Fam Physician. 2005;71:1745-1750.

21. Folstein MF, Folstein SE, McHugh PR. Mini-mental state: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189-198.

22. Boustani M, Peterson B, Hanson L, et al. Screening for dementia in primary care: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2003;138:927-937.

23. Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the mini-mental state examination by age and educational level. JAMA. 1993;18:2386-2391.

24. Borson S, Scanlan J, Brush M, et al. The Mini-Cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry. 2000;15:1021-1027.

25. Borson S, Scanlan JM, Chen P, et al. The mini-cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc. 2003;51:1451-1454.

26. Steenland NK, Auman CM, Patel PM, et al. Development of a rapid screening instrument for mild cognitive impairment and undiagnosed dementia. J Alzheimers Dis. 2008;15:419-427.

27. Nasreddine ZS, Phillips NA, Bedirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53:695-699.

28. Galvin JE, Roe CM, Powlishta KK, et al. The AD8: a brief informant interview to detect dementia. Neurology. 2005;65:559-564.

29. Solomon PR, Hirschoff A, Kelly B, et al. A 7 minute neurocognitive screening battery highly sensitive to Alzheimer’s disease. Arch Neurol. 1998;55:349-355.

30. Lyketsos CG, DelCampo L, Steinberg M, et al. Treating depression in Alzheimer’s disease: efficacy and safety of sertraline therapy, and the benefits of depression reduction. The DIADS. Arch Gen Psychol. 2003;60:737-746.

31. Artero S, Ancelin ML, Portet F, et al. Risk profiles for mild cognitive impairment and progression to dementia are gender specific. J Neurol Neurosurg Psychiatry. 2008;79:979-984.

32. Rinaldi P, Mecocci P, Benedetti C, et al. Validation of the five-item geriatric depression scale in elderly subjects in three different settings. J Am Geriatr Soc. 2003;51:694-698.

33. Sheikh JL, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol. 1986;5:165-173.

Practice recommendations

Avoid cognitive screening solely on the basis of age (SOR A).
Screen vulnerable elderly patients at their initial visit and annually thereafter (SOR A).
Ensure that all patients who undergo cognitive screening are tested for depression (SOR A).

Strength of recommendation (SOR)

Good-quality patient-oriented evidence
Inconsistent or limited-quality patient-oriented evidence
Consensus, usual practice, opinion, disease-oriented

Janet M, a 69-year-old woman with a history of hypertension, comes for a visit because she thinks she has Alzheimer’s disease (AD). She recently had an episode of acute confusion while shopping at the mall; when she returned to her car, she couldn’t remember how to get home. The episode cleared within minutes and hasn’t recurred.

Jack S, an 84-year-old man, seeks medical care for pain in his right shoulder. He injured the rotator cuff several years ago, but it’s been fine since he completed physical therapy—until he tripped and fell while walking outside about a week ago. His daughter is concerned about his “forgetfulness” and increasing inability to remember certain words, but the patient thinks this is a natural consequence of age.

Fran B, a 72-year-old, presents with complaints of memory problems that began about 6 months ago. She’s worried about her son and has had increasing difficulty concentrating, sleeping, and keeping track of her things.

If these were your patients, whom would you screen for dementia? Would you decide whether to screen based on your “gut,” or a defined set of criteria? Would you have several screening tools on hand, and know enough about them to determine which one might be best suited for a particular patient?

If you make decisions about screening based on your gut or aren’t sure which tools are best for which patients, you’re far from alone. Cognitive impairment, particularly in the early stages, can be difficult and time-consuming to detect, and community physicians fail to diagnose mild-to-moderate dementia more than 50% of the time.^1-5

Family members and caregivers often overlook declines in cognitive function, as well. In a study of 741 caregivers of patients with AD, an average of 4 months went by between the time symptoms were first noticed and the patient was seen by a physician—and 22% of the caregivers waited more than a year.⁶

Cognitive decline can be slowed with early Dx

Early diagnosis of AD or any dementia is important for a number of reasons. In some cases, cognitive impairment may be related to medical conditions—head trauma, Parkinson’s disease, human immunodeficiency virus, thyroid disorder, among others—that can be modified or reversed with treatment.⁷ There is evidence, too, that medical, behavioral, and social interventions can delay the cognitive and functional decline associated with AD, thereby helping to prolong the time the patient can remain at home. Early diagnosis also facilitates legal and financial family planning, and makes it possible to take appropriate safety measures.^8-13

AD affects approximately 5 million US residents.¹⁴ With an aging population, that number is expected to surge in the decades ahead. To help you provide optimal care for your geriatric patients, this review will detail when to screen, which tools to use, and how best to care for the 3 elderly patients in the opener.

FAST TRACK

Cognitive screening based on age alone is not recommended

When and whether to screen

Despite the benefits of early detection, population-based screening based on age alone is not recommended. Guidelines recommend focused screening of patients in high-risk groups and on a case-by-case basis.¹⁵

US Preventive Services Task Force (USPSTF) guidelines recommend that physicians evaluate older patients for dementia whenever there is a suggestion of cognitive impairment, based on clinical observation or concern expressed by the individuals themselves or by family members, caretakers, or friends.¹⁵

However, cognitive screening generally provides better results in populations at higher risk of dementia.^16,17 With that in mind, the Assessing Care of Vulnerable Elders (ACOVE), a collaborative project to develop a set of quality indicators for care of the elderly, recently recommended cognitive and functional screening of all “vulnerable elderly.”^18,19

Who are the vulnerable elderly?

ACOVE defines the vulnerable elderly as individuals who are 65 years of age and older who live in the community and are at high risk of death or functional decline over the next 2 years. You can use a screening tool to identify members of this high-risk group. Or you can simply ask a few questions and classify any noninstitutionalized older person who reports being in poor health and/or acknowledges difficulty with activities of daily living—eg, money or medication management, dressing, grooming, or preparing simple meals—as a vulnerable elderly patient.