DEMENTIA IN PRIMARY CARE:

What tools are being be used and are patients being screened and

diagnosed?

Maggie Heidenreich

DEMENTIA Defined as, “a general term that

describes a group of symptoms—such as loss of memory, judgment, language, complex motor skills, and other intellectual function—caused by the permanent damage or death of the brain's nerve cells, or neurons.” (Alzheimers Foundation

of America, 2013)

PREVALENCE

5.6 million people suffering from dementia in the U.S. (Alzheimer’s Association, 2012)

6th leading cause of death in the U.S. (Alzheimer’s Association, 2012)

Estimated 1 in 7 (Alzheimer’s Association, 2012)

No prevention, no cure Costs $200 billion (Alzheimer’s Association, 2012)

COST

Costs $20,000 per patient per year (Zhu, Scarmeas, Torgan, Albert, Brandt, Blacker, et al., 2006)

Increases as disease progresses (Zhu, et al., 2006)

Costs made as estimation of work time lost for caregivers (Zhu, et al., 2006)

Time spent for care giving ranges (Zhu, et al., 2006)

Long term care facilities are expensive (Duru, Callahan, Unverzagt, Weiner, Beck, et al., 2009).

OUTCOMES

Misdiagnosed (Boustani, et al., 2006)

Devastating to patient and family Diagnosis not made until later stages Goal is detection and planning

GUIDELINES

Alzheimer’s Association and NIH Guidelines (2011) Biomarkers for diagnosis in future Find MCI

Look for changes in cognition Diagnostic tests

American Academy of Neurology (2003) Recommends use of different diagnostic tools

not biomarkers Watch the MCI CT scan

(Jack, C.R., Albert, M.S., Knopman, D.S., McKhann, G.M., Sperling, R.A., Carillo, M.A., et al., 2011, AGS Clinical Practice Committee, 2003)

LITERATURE REVIEW Institutional reviews, cross-sectional

designs, experimental designs, meta analysis, and prospective designs were all reviewed

Results of review found some problems with dementia screening

LITERATURE REVIEW Problems:

Medical students receiving inadequate training on dementia management (Mitchell, A.J., Meader, N., Pentzek, M., 2011)

People refuse screening (Boustani, Perkins, Fox, Unverzagt, Austrom, et al.,

2008) (Justiss, Boustani, Fox, Katona, Perkins, Healey, et al., 2009)

Practitioners are not always able to recognize the disease and do not always document mental changes (Mitchell, A.J., Meader, N., Pentzek, M., 2011)

Many barriers to effective care of dementia in primary care offices (Hilton, Franz, Reddy, Flores, Kravtiz, et al., 2007)

LITERATURE REVIEW Tools

Review of research found that…

AD8 over MMSE (Kamenski, G., Dorner, T., Beng, K.T., Psota, G., Rieder, A., Schwarz, F., et al,

2009; Galvin, Fagan, Holtzman, Mintun, Morris, 2009)

MMSE and Mini-cog (Kamenski, Dorner, Beng, Psota, Rieder, et al., 2009; Holsinger, Plassman, Stechuchak, Burke, Coffman, et al., 2012, Crum, Anthony, Bassett & Folstein, 1993)

Comparing the Iqcode, FAQ, MMSE (Cruz-Orduna, Bellon, Torrero, Aparicio, Sanz, et al., 2011)

RESEARCH QUESTION

In a primary care office in Northeast Ohio, how many patients are screened for dementia, what tool is used, and is there correct documentation of the results?

METHODS Chart data review Primary care office in Northeast Ohio Only demographic, presence of test, and

diagnosis will be reported Sample

Inclusion 65 yrs and older Male and female

Exclusion Cognitive impairment Non-English speaking

DEMOGRAPHICSSex

FemaleMale

74%

26%

DEMOGRAPHICS

62-75 76-85 85-950

2

4

6

8

10

12

14

16

18

Ages of Subjects

Ages of Subjects

RESULTS

1 out of 35

MMSE

Documentation

DISCUSSION Dementia screening is not routinely

done Mini Cog and MMSE specific and

sensitive for picking up dementia characteristics in primary care settings

Healthcare professionals need more education regarding dementia management and resources for effective treatment

More education to patients regarding importance of screening

LIMITATIONS

There are several limitations to this study:small sample size convenience sampleonly one office usednot a representative sample

CONCLUSION The data shows that very few people are

being screened for dementia using any tool

Although guidelines exist, they do not outline an age or frequency of screening

Need further research

REFERENCES AGS Clinical Practice Committee. (2003). Guidelines abstracted

from the American academy of neurology’s dementia guidelines for early detection, Diagnosis, and management of dementia. The American Geriatrics Society. (51), 869-873

Albert, M.S., DeKosky, S.T., Dickson, D., Dubois, B., Feldman, H.H., Fox, N.C., et al., (2011). The diagnosis of mild cognitive impairment due to Alzheimer’s disease: Recommendations from the National Institute on aging-Alzheimer’s association workgroups on diagnostic guidelines for Alzheimer’s disease.

Alzheimer’s Association. (2012). Alzheimer's facts and figures. Retrieved from http://www.alz.org/alzheimers_disease_facts_and_figures.asp.

Alzheimer’s Foundation of America. (2013). About Dementia. Retrieved from http://www.alzfdn.org/AboutDementia/definition.html.

Boustani, M., Perkins, A. J., Fox, C., Unverzagt, F., Austrom, M. G., & Fultz, B., et al. (2006). Who refuses the diagnostic assessment for dementia in primary care?. International Journal of Geriatric Psychiatry, (21), 556-563. doi: 10.1002/gps.1524

REFERENCES Crum, R.M., Anthony, J.C., Basset, B.B., & Folstein, M.F. (1993).

Population-based norms for the mini-mental state examination by age and education level. Journal of the American Medication Association. 269(18). Retrieved From http://faculty.pepperdine.edu/shimels/Courses/Files/MMSE.pdf.

Cruz-Orduna, I., Bellon, J.M., Torrero, P., Aparicio, E., Sanz, A., et al. (2011). Detecting mci and dementia in primary care: Efficiency of the MMS the FAQ and the IQCODE. Family Practice. 29, 401-406. DOI: 10.1093/fampra/cmr114.

Galvin, J.E., Fagan, A.E., Holtzman, D.M., Mintun, M.A., & Morris, J.C. (2010). Relationship of dementia screening tests with biomarkers of alzheimer’s disease. Brain. 133, 3290-3300. DOI: 10.1093/brain/awq204.

Hilton, L., Franz, C.E., Reddy, G., Flores, Y., Kravitz, R.L., et al. (2007). Practice constraints, behavioral problems, and dementia care: Primary care physicians’’ perspectives. Journal of General Internal Medicine. 22(11), 1487-1492. Retrieved from http://ezproxy.uakron.edu:3130/ehost/pdfviewer/pdfviewer?sid=97b96b0a-b5bc-41ad-80b8-126f079256da%40sessionmgr11&vid=37&hid=27.

REFERENCES Holsinger, T., Plassman, B.L., Stechuchak, K.M., Burke, J.R.,

Coffman, C.J., et al. (2012). Screening for cognitive impairment: Comparing the performance of four instruments in primary care. The American Geriatrics Society. 60, 1027-1036.

Jack, C.R., Albert, M.S., Knopman, D.S., McKhann, G.M., Sperling, R.A., Carillo, M.A., et al., (2011). Introduction to the recommendations from the National Institute on aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. The Alzheimer’s Association.

Justiss, M.D., Boustani, M., Fox, C., Katona, C., Perkins, A.J., Healey, P.J., et al., 2009. Patients’ attitudes of dementia screening across the Atlantic. International Journal of Geriatric Psychiatry. 24. 632-637.

Kamenski, G., Dorner, T., Beng, K.T., Psota, G., Rieder, A., Schwarz, F., et al. (2009). Mini-Cog assessment with the mental state examination. Mental Health in Family Practice. 6(4), 209-217. Retrieved from http://ezproxy.uakron.edu:3130/ehost/pdfviewer/pdfviewer?sid=97b96b0a-b5bc-41ad-80b8-126f079256da%40sessionmgr11&vid=33&hid=109.

REFERENCES Mitchell, A.J., Meader, N., Pentzek, M., (2011). Clinical

recognition of dementia and cognitive impairment in primary care: a meta-analysis of physician accuracy. Acta Psyhiatr Scand. 124, 165-183. DOI: 10.1111/j.1600-0447.2011.01730.x.

Saira, B., Moss, S.B., Nair, R., & Tingle, L. (2010). Practice patterns in the evaluation and management of dementia by primary care residents, primary care physicians, and geriatricians. Baylor University Medical Center. 23(2). 121-125.

Zhu, C.W., Scarmeas, N., Torgan, R., Albert. M., Brandt, J., Blacker, D., et al., (2006). Clinical characteristics and longitudinal changes of informal cost of alzheimer’s disease in the community. The American Geriatrics Society. 54, 1596-1602.