Case finding of mild cognitive impairment and dementia and subsequent care; results of a cluster RCT in primary care

Purpose Despite a call for earlier diagnosis of dementia, the diagnostic yield of case finding and its impact on the mental health of patients and relatives are unclear. This study assessed the effect of a two-component intervention of case finding and subsequent care on these outcomes. Methods In a cluster RCT we assessed whether education of family physicians (FPs; trial stage 1) resulted in more mild cognitive impairment (MCI) and dementia diagnoses among older persons in whom FPs suspected cognitive decline and whether case finding by a practice nurse and the FP (trial stage 2) added to this number of diagnoses. In addition, we assessed mental health effects of case finding and subsequent care (trial stage 2). FPs of 15 primary care practices (PCPs = clusters) judged the cognitive status of all persons ≤ 65 years. The primary outcome, new MCI and dementia diagnoses by FPs after 12 months as indicated on a list, was assessed among all persons in whom FPs suspected cognitive impairment but without a formal diagnosis of dementia. The secondary outcome, mental health of patients and their relatives, was assessed among persons consenting to participate in trial stage 2. Trial stage 1 consisted of either intervention component 1: training FPs to diagnose MCI and dementia, or control: no training. Trial stage 2 consisted of either intervention component 2: case finding of MCI and dementia and care by a trained nurse and the FP, or control: care as usual. Results Seven PCPs were randomized to the intervention; eight to the control condition. MCI or dementia was diagnosed in 42.3 (138/326) of persons in the intervention, and in 30.5 (98/321) in the control group (estimated difference GEE: 10.8, OR: 1.51, 95-CI 0.60-3.76). Among patients and relatives who consented to stage 2 of the trial (n = 145; 25), there were no differences in mental health between the intervention and control group. Conclusions We found a non-significant increase in the number of new MCI diagnoses. As we cannot exclude a clinically relevant effect, a larger study is warranted to replicate ours. Trial Registration Nederlands Trial Register NTR3389 © 2016 van den Dungen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Case-finding of dementia in general practice and effects of subsequent collaborative care; design of a cluster RCT

<p>Abstract</p> <p>Background</p> <p>In the primary care setting, dementia is often diagnosed relatively late in the disease process. Case finding and proactive collaborative care may have beneficial effects on both patient and informal caregiver by clarifying the cause of cognitive decline and changed behaviour and by enabling support, care planning and access to services.</p> <p>We aim to improve the recognition and diagnosis of individuals with dementia in general practice. In addition to this diagnostic aim, the effects of case finding and subsequent care on the mental health of individuals with dementia and the mental health of their informal carers are explored.</p> <p>Methods and design</p> <p>Design: cluster randomised controlled trial with process evaluation.</p> <p>Participants: 162 individuals ≥ 65 years, in 15 primary care practices, in whom GPs suspect cognitive impairment, but without a dementia diagnosis.</p> <p>Intervention; case finding and collaborative care: 2 trained practice nurses (PNs) invite all patients with suspected cognitive impairment for a brief functional and cognitive screening. If the cognitive tests are supportive of cognitive impairment, individuals are referred to their GP for further evaluation. If dementia is diagnosed, a comprehensive geriatric assessment takes place to identify other relevant geriatric problems that need to be addressed. Furthermore, the team of GP and PN provide information and support.</p> <p>Control: GPs provide care and diagnosis as usual.</p> <p>Main study parameters: after 12 months both groups are compared on: 1) incident dementia (and MCI) diagnoses and 2) patient and caregiver quality of life (QoL-AD; EQ5D) and mental health (MH5; GHQ 12) and caregiver competence to care (SSCQ). The process evaluation concerns facilitating and impeding factors to the implementation of this intervention. These factors are assessed on the care provider level, the care recipient level and on the organisational level.</p> <p>Discussion</p> <p>This study will provide insight into the diagnostic yield and the clinical effects of case finding and collaborative care for individuals with suspected cognitive impairment, compared to usual care. A process evaluation will give insight into the feasibility of this intervention.</p> <p>The first results are expected in the course of 2013.</p> <p>Trial registration</p> <p>NTR3389</p

Preferences regarding disclosure of a diagnosis of dementia: a systematic review.

Studies in memory clinics suggest that the majority of patients would like to know of a diagnosis of dementia. It is less clear what preferences are in the community. Our objective was to review the literature on preferences regarding disclosure of a diagnosis of dementia and to assess key arguments in favor of and against disclosure. Systematic search of empirical studies was performed in Pubmed, Embase, and Psycinfo. We extracted preferences of individuals without cognitive impairment (general population; relatives of dementia patients; and physicians) and preferences of individuals referred to a memory clinic or already diagnosed with dementia. A meta-analysis was done using a random effects model. Our main conclusions are based on studies with a response rate ≥75%. We included 23 articles (9.065 respondents). In studies with individuals without cognitive impairment, the pooled percentage in favor of disclosure was 90.7% (95%CI: 83.8%-97.5%). In studies with patients who were referred to a memory clinic or already diagnosed with dementia, the pooled percentage that considered disclosure favorable was 84.8% (95%CI: 75.6%-94.0%). The central arguments in favor of disclosure pertained to autonomy and the possibility to plan one's future. Arguments against disclosure were fear of getting upset and that knowing has no use. The vast majority of individuals without and with cognitive impairment prefers to be informed about a diagnosis of dementia for reasons pertaining to autonom

The accuracy of family physicians' dementia diagnoses at different stages of dementia: a systematic review

Objective: Optimising care for dementia patients and their informal carers is imperative in light of the impending dementia epidemic. An important aspect of care is accurate recognition and diagnosis of dementia. The aim of this review was to estimate family physicians' diagnostic accuracy at the different stages of dementia. Methods: Pubmed, Embase, CINAHL, PsycINFO and the Cochrane Library were searched for articles comparing family physicians' 'dementia' and 'cognitive impairment' diagnoses in the primary care setting to reference standard dementia diagnoses. Results: Data from six cross-sectional studies of moderate to reasonable methodological quality were extracted for the analysis. One study considered the accuracy of family physicians' recollected diagnoses, and three studies focussed on documented diagnoses. In these four studies, the sensitivity of family physicians' combined diagnostic categories of 'cognitive impairment' together with 'dementia' was 0.48-0.67 for mild dementia and 0.76-0.85 for moderate to severe dementia. The sensitivity of their diagnostic category 'dementia' alone was 0.14-0.33 for mild and 0.28-0.61 for moderate to severe dementia. Specificity was excellent for all severity stages in both comparisons. Three studies examined the accuracy of family physicians' judgement of cognition during consultation. Compared with the studies on recollection and documentation, these studies reported higher sensitivity and lower specificity. Conclusion: Many individuals with dementia are not recognised or not diagnosed as such; particularly mild dementia is under-diagnosed. Collaboration within primary care and education focussing both on knowledge and attitude are recommended to improve the accuracy of family physicians' dementia diagnosis. Copyright (C) 2011 John Wiley & Sons, Lt

Additional file 2: Appendix 2. of Dutch family physicians’ awareness of cognitive impairment among the elderly

Number of respondents per CAMCOG outcome category at baseline and 1-year follow-up. (DOC 47 kb

Additional file 1: Appendix 1. of Dutch family physicians’ awareness of cognitive impairment among the elderly

Graph of cognitive classification per practice. Legend: Primary Care Practice 12 and 16 were the outliers. (DOC 50 kb

CONSORT Flowdiagram.

<p>CONSORT Flowdiagram.</p

Dutch family physicians' awareness of cognitive impairment among the elderly

Dementia is often not formally diagnosed in primary care. To what extent this is due to family physicians' (FPs) watchful waiting, reluctance to diagnose or to their unawareness of the presence of cognitive impairment is unclear. The objective of this study was to assess FPs' awareness of cognitive impairment by comparing their evaluation of the absence or presence of cognitive impairment in older patients without an established diagnosis of dementia, with a reference test of cognitive functioning. In addition, we assessed which patient characteristics were associated with con- and discordance between FPs' evaluation of cognition and results of the reference test. The design was a nested diagnostic study. FPs (n = 29) of 15 primary care practices classified the cognitive status of all their patients ≥ 65 years of age (n = 7865) into four categories, based on recollection and medical records. All patients categorized as 'possible cognitive impairment or dementia' and a sample of patients categorized as 'no signs of cognitive impairment' randomly selected to match age and gender were offered to receive a reference test of cognitive function (the CAMCOG) to verify the FPs' label. This reference test could yield three outcomes: no cognitive impairment, amnestic mild cognitive impairment (aMCI) or dementia. Reference test results were weighted back to the original samples to provide estimates for the correct categorization of elderly as 'possible cognitive impairment or dementia' (positive predictive value [PPV]) and 'no signs of cognitive impairment' (negative predictive value [NPV]). Cognitive functioning was not assessed for patients evaluated by FPs as 'probable dementia' and 'unknown or no recent contact'. Characteristics associated with the con- or discordance of the FPs' classification and the reference test were assessed using logistic regression. Complete reference test results were obtained from 318 elderly. FPs labeled 8.3 % of elderly 'possible cognitive impairment or dementia'. The PPV of this label for a CAMCOG score suggestive of dementia or aMCI was 47.1 % (95 %-confidence interval: 43.5 - 62.4 %). FPs labeled 83.7 % 'no signs of cognitive impairment'. The 1-NPV of this label for a CAMCOG score suggestive of dementia or aMCI was 12.5 % (95 %-CI 8.2 - 16.8 %). FPs labeled 3.6 % as 'probable dementia' and 4.5 % as 'unknown or no recent contact'. The odds that FPs' suspicion of cognitive impairment were confirmed by the CAMCOG were higher if persons were ADL dependent (OR 2.24 [95 %-CI 1.16 - 4.35]). The odds of FPs being unaware of the presence of cognitive impairment were higher in the older elderly (OR 1.15 [95 %-CI 1.09 - 1.23] per year). Evaluation of FPs' classification of the global cognitive function of elderly without a firm diagnosis of dementia showed both over- and unawareness of the presence of cognitive impairment. FPs were more often unaware of cognitive impairment in the older elderl