Does MRI Increase the Diagnostic Confidence of Physicians in an Outpatient Memory Clinic?

Background and Aim: Data showing the usefulness of MRI to improve the accuracy of the diagnostic process in cognitive disorders were derived from studies in tertiary referral centers. MRI is widely used as a diagnostic tool in everyday practice, but it is unknown what the actual added value of MRI is. We studied the usefulness of MRI in the diagnostic process by measuring the change of confidence of the physician. Methods: Physicians indicated confidence in their diagnosis before and after presentation of MR images using a visual analogue scale from 0-100%. Results: Use of MRI increased the level of confidence by 3% in experienced clinicians and by 9% in inexperienced physicians. In 2/125 cases, MRI showed an unexpected finding. Conclusion: MRI is a useful diagnostic tool in everyday practice of diagnosing cognitive disorders

Diagnostic Impact of CSF Biomarkers in a Local Hospital Memory Clinic Revisited

Background/Aims: Research guidelines on predicting and diagnosing Alzheimer's disease (AD) acknowledge cerebrospinal fluid (CSF) levels as pivotal biomarkers. We studied the usefulness of CSF biomarkers in the diagnostic workup of patients in a geriatric outpatient memory clinic of a community-based hospital, attempted to determine a cutoff age for the use of CSF biomarkers in this group of patients, and compared the total τ/Aβ ratio as an alternative CSF diagnostic rule with the usual rules for interpreting CSF levels. Methods: This was a prospective study of consecutively referred patients. Inclusion criteria were described on the basis of previous study results in the same setting. The CSF tool was applied either to differentiate between AD and no AD or to increase certainty having made the diagnosis of AD. Clinicians were asked to judge whether the CSF results were helpful to them or not. Results: The reasons to use the CSF tool in the diagnostic workup were in 78/106 patients to decide between the diagnosis "AD" and "no AD" and in 28/106 patients to increase the certainty regarding the diagnosis. In 75% of cases the CSF levels were considered diagnostically helpful to the clinicians. Results in the present setting suggest 65 years as the cutoff age to use CSF as a diagnostic tool. The sensitivity and specificity of the total τ/Aβ ratio using the clinical diagnosis as the gold standard were at least as good as the usual categorization rule. Conclusions: Our study results corroborate earlier findings that the CSF tool is of added value to the diagnostic workup in daily clinical practice outside tertiary referral centers. CSF levels can best be used in patients under 66 years of age. Given the limited use of this tool in settings outside research facilities, we recommend that the usefulness of CSF biomarkers is studied in a multicenter study. When in the future CSF levels can be reliably measured in plasma, this may become even more relevant

Zelfverwaarlozing bij ouderen, een complex probleem

A 76-year-old man presented at the emergency department with functional decline and extreme self-neglect. He died after a few days. The probable cause of death was pneumonia. His family consented to autopsy. Surprisingly, the neuropathological findings showed a tauopathy consistent with fronto-temporal dementia. Self-neglect in the elderly is a common and complex problem associated with high mortality and morbidity. This syndrome requires a thorough workup to detect possible causes. The most common etiologies are neurodegenerative disorders, psychiatric illness and alcohol abuse. It is important to elucidate the cause of self-neglect in order to give the proper treatment and support to the patient and family

Self-neglect in older adults--a complex problem

A 76-year-old man presented at the emergency department with functional decline and extreme self-neglect. He died after a few days. The probable cause of death was pneumonia. His family consented to autopsy. Surprisingly, the neuropathological findings showed a tauopathy consistent with fronto-temporal dementia. Self-neglect in the elderly is a common and complex problem associated with high mortality and morbidity. This syndrome requires a thorough workup to detect possible causes. The most common etiologies are neurodegenerative disorders, psychiatric illness and alcohol abuse. It is important to elucidate the cause of self-neglect in order to give the proper treatment and support to the patient and family.</p

Testing Episodic Memory in Elderly Subjects:Not as Simple as It Looks

Background/Aims: The available episodic memory tests are not specifically constructed to examine older subjects. Their use in outpatient memory clinics may result in aborted test administration. We used a strict adherence to the test protocol in cognitively healthy, amnestic mild cognitive impairment (aMCI), and Alzheimer's disease dementia subjects to assess the possibility of preventing this. Methods: This is a cross-sectional study in memory outpatient subjects with a mean age of 74.5 years. Primary study outcomes were: number of missing values and test results in the Visual Association Test (VAT) and the 15 Word Test (15WT). Results: A strict adherence to the test protocol resulted in a 10-fold decrease in the number of missing values in the VAT. For the 15WT this could not be realized mostly because the test was deemed too demanding for 1 in 6 patients. Conclusions: This study is one of the few examining the applicability of well-known episodic memory tests in older subjects. A strict adherence to the test protocol reduced the number of missing values. Floor effects were stronger for the 15WT than for the VAT. Results favor the use of the VAT in senior subjects and show the unsuitability of the 15WT in this group

Clinicians’ communication with patients receiving a MCI diagnosis: The ABIDE project

Background We aimed to explore clinicians’ communication, including the discussion of diagnosis, cause, prognosis and care planning, in routine post-diagnostic testing consultations with patients with Mild Cognitive Impairment (MCI). Methods Thematic content analysis was used to analyze audiotaped consultations in which 10 clinicians (eight neurologists and two geriatricians) from 7 memory clinics, disclosed diagnostic information to 13 MCI patients and their care partners. We assessed clinician-patient communication regarding diagnostic label, cause, prognosis and care planning to identify core findings. Results Core findings were: clinicians 1) differed in how they informed about the MCI label; 2) tentatively addressed cause of symptoms; 3) (implicitly) steered against further biomarker testing; 4) rarely informed about the patient’s risk of developing dementia; 5) often informed about the expected course of symptoms emphasizing potential symptom stabilization and/ or improvement, and; 6) did not engage in a conversation on long-term (care) planning. Discussion Clinicians’ information provision about the underlying cause, prognosis and implications for long-term (care) planning in MCI could be more specific. Since most patients and care partners have a strong need to understand the patient’s symptoms, and for information on the prognosis and implications for the future, clinicians’ current approach may not match with those needs

What patients want to know, and what we actually tell them: The ABIDE project

Background:We studied to what degree and at whose initiative 25 informational topics, formerly identified as important, are discussed in diagnostic consultations. Methods: Audio recordings of clinician–patient consultations of 71 patients and 32 clinicians, collected in eight Dutch memory clinics, were independently contentcoded by two coders. The coding scheme encompassed 25 informational topics. Results: Approximately half (Mdn = 12) of the 25 topics were discussed per patient during the diagnostic process, with a higher frequency among individuals receiving a dementia diagnosis (Mdn = 14) compared to others (Mdn = 11). Individual topics ranged from being discussed with 2/71 (3%) to 70/71 (99%) of patients. Patients and/or care partners rarely initiated topic discussion (10%). When they did, they often enquired about one of the least frequently addressed topics. Conclusion: Most patients received information on approximately half of the important informational topics. Providing the topic list to patients and care partners beforehand could allow consultation preparation and stimulate participation