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Memory impairment among primary care veterans
- Authors:
- CHODOSH Joshua, et al
- Journal article citation:
- Aging and Mental Health, 11(4), July 2007, pp.444-450.
- Publisher:
- Taylor and Francis
Memory impairment is the most frequent cognitive dysfunction for older patients. Though studies have shown that dementia is often overlooked in primary care settings, there has been minimal focus specifically on memory impairment, on patients' concerns about memory, or their desire to address these concerns. The objectives of this study were to (1) investigate the prevalence of memory impairment among patients without dementia diagnoses, (2) determine the degree of patients' concern about memory impairment and (3) identify other patient characteristics associated with memory impairment among older primary care patients. Using telephone versions of a four-item memory test and proxy-reported cognitive decline for patients unable to complete interviews, a memory assessment of randomly selected patients, 75 years and older, without dementia diagnoses who see primary care physicians at least twice every six months was performed. Among 260 patients and 20 proxies, 19.8% had memory impairment at a level indicative of probable dementia. Adjusting for age, ethnicity, and education, subjects who were more concerned about memory impairment were more likely to be impaired. (Adjusted odds ratio [AOR]: 1.4 (for each additional level of concern); 95% confidence interval [CI]: (1.0-2.0)). Similarly, subjects wanting their physician to discuss with them their memory concerns were more likely to be impaired (AOR: 1.4; 95% CI: 1.0-1.9). Memory impairment is common among older primary care patients without diagnosed dementia. Knowing patients' concerns about memory impairment and their desire to discuss these concerns may facilitate cognitive screening in this setting.
Cost effectiveness of using cognitive screening tests for detecting dementia and mild cognitive impairment in primary care
- Authors:
- TONG Thaison, et al
- Journal article citation:
- International Journal of Geriatric Psychiatry, 32(12), 2017, pp.1392-1400.
- Publisher:
- Wiley
Introduction: The authors estimated the cost effectiveness of different cognitive screening tests for use by General Practitioners (GPs) to detect cognitive impairment in England. Methods: A patient-level cost-effectiveness model was developed using a simulated cohort that represents the elderly population in England (65 years and older). Each patient was followed over a lifetime period. Data from published sources were used to populate the model. The costs include government funded health and social care, private social care and informal care. Patient health benefit was measured and valued in Quality Adjusted Life Years (QALYs). Results: Base-case analyses found that adopting any of the three cognitive tests (Mini-Mental State Examination, 6-Item Cognitive Impairment Test or GPCOG (General Practitioner Assessment of Cognition)) delivered more QALYs for patients over their lifetime and made savings across sectors including healthcare, social care and informal care compared with GP unassisted judgement. The benefits were due to early access to medications. Among the three cognitive tests, adopting the GPCOG was considered the most cost-effective option with the highest Incremental Net Benefit (INB) at the threshold of £30 000 per QALY from both the National Health Service and Personal Social Service (NHS PSS) perspective (£195 034 per 1000 patients) and the broader perspective that includes private social care and informal care (£196 251 per 1000 patients). Uncertainty was assessed in both deterministic and probabilistic sensitivity analyses. Conclusions: The analyses indicate that the use of any of the three cognitive tests could be considered a cost-effective strategy compared with GP unassisted judgement. The most cost-effective option in the base-case was the GPCOG. (Edited publisher abstract)
Do subjective memory complaints predict falls, fractures and healthcare utilization? A two-year prospective study based on a cohort of older women recruited from primary care
- Authors:
- AL-SARI Usama A., et al
- Journal article citation:
- International Journal of Geriatric Psychiatry, 32(9), 2017, pp.968-976.
- Publisher:
- Wiley
Objective: A proportion of older individuals report subjective memory complaints (SMCs), which can predict the development of cognitive impairment and dementia. Previous studies based on secondary care suggest that SMC is also associated with other adverse health consequences, including falls, fractures and increased healthcare utilization. In this study, the authors aimed to establish whether similar findings are observed in the wider population. Methods: Prospective analysis of the Cohort for Skeletal Health in Bristol and Avon, a population-based cohort recruited from primary care, was carried out. Data were collected by self-completion questionnaire at baseline and 2 years. SMC was assessed at baseline. Fractures, measures of falls, mobility and healthcare utilization were assessed 2 years later. A random 5% subsample of data was validated against electronic general practitioner records. Logistic regression was used to identify independent associations, following adjustment for a range of confounders assessed at baseline. Results: Data were available on 3184 women. Three hundred and fifty participants (11.0%) reported SMC. They were older (73.3 ± 4.5 vs 72.0 ± 4.2 years) and less mobile compared with those not reporting SMC. SMCs at baseline were associated with an increased risk of upper limb fractures over the following 2 years (OR 1.72, 95% CI 1.02–2.90). SMCs were also associated with an increased risk of falls (OR 1.83, 95% CI 1.41–2.38) and increased healthcare utilization (OR for hospital appointments 2.20, 95% CI 1.26–3.86). No association was observed with bone mineral density at any site. Conclusions: Subjective memory complaints are important markers of adverse health outcomes and should prompt interventions to reduce fractures such as physiotherapy-led fall reduction programmes. (Edited publisher abstract)
Suitability of the 6CIT as a screening test for dementia in primary care patients
- Authors:
- HESSLER Johannes, et al
- Journal article citation:
- Aging and Mental Health, 18,(4) 2014, pp.515-520.
- Publisher:
- Taylor and Francis
Objectives: To map the suitability of the Six Item Cognitive Impairment Test's (6CIT) as a screening instrument for dementia in primary care and to assess its feasibility, reliability, and validity in a real-world setting.Method: The present study was part of a population-based prospective trial aimed at reducing the incidence of stroke and dementia. The 6CIT was administered by general practitioners (GPs) at routine examinations every two years. Incidence of dementia was obtained from health insurance records. Psychometric qualities of the 6CIT were evaluated for two different cut-offs.Results: At baseline, 72 GPs examined 3908 patients. In total, 528 patients were diagnosed with new dementia. Less than 1% of the tests were not completed. Internal consistency (Cronbach's alpha), stability over time (Pearson's r), and the agreement between successive tests (Cohen's kappa) reached values of 0.58, 0.62, and 0.45, respectively. Sensitivity and specificity reached values of 0.49 and 0.92 at the 7/8 cut-off and of 0.32 and 0.98 at the 10/11 cut-off, respectively. Patients with dementia had significantly higher mean error scores than patients without dementia. High scores at baseline posed a more than fourfold risk of being diagnosed with dementia.Conclusion: The 6CIT's psychometric properties in a real-world setting suggest that the test is not suited as a routine screening instrument. Factors inherent to screening in primary care likely contributed to its low reliability and validity. This highlights the need for training GPs in the conduct of cognitive screening before such procedures can be implemented on a routine basis. (Publisher abstract)
Association between subjective memory complaints and nursing home placement: a four-year follow-up
- Authors:
- BOCH WALDORFF Frans, SIERSMA Volkert, WALDEMAR Gunhild
- Journal article citation:
- International Journal of Geriatric Psychiatry, 24(6), June 2009, pp.602-609.
- Publisher:
- Wiley
In order to evaluate whether elderly persons with subjective memory complaints may be regarded as a group of potentially vulnerable patients who need close follow-up, the authors investigated the risk of nursing home placement during a 4-year follow-up period. A prospective cohort survey was carried out. Cox proportional hazard models were used to examine the influence of risk factors on nursing home placement. Results showed that a total of 758 non-nursing home residents aged 65 years and older consulted the General Practitioners in October and November 2002, of whom 50 nursing home placements were observed. Subjective memory complaints were associated with an adjusted Hazard Ratio (HR) of 2.59 for nursing home placement. Other statistical significant covariates were MMSE < 24 (HR = 3.95), age and extreme anxiety/depression. The effect of subjective memory complaints is seen to moderate when subjects are older. The authors conclude that the data of this study indicated that in an elderly primary care population the presence of subjective memory complaints was a significant independent predictor for nursing home placement together with other known risk factors.
Screening for amnestic mild cognitive impairment and early Alzheimer's disease with M@T (Memory Alteration Test) in the primary care population
- Authors:
- RAMI L., et al
- Journal article citation:
- International Journal of Geriatric Psychiatry, 22(4), April 2007, pp.294-304.
- Publisher:
- Wiley
This Spanish study aimed to design and validate a new screening test for amnestic Mild Cognitive Impairment (A-MCI) and early stage Alzheimer's disease (AD). The authors develop a verbal episodic and semantic memory test: the Memory Alteration Test. Discriminative validity was assessed in a population sample of 400 aged individuals from primary care population centres in Barcelona, Spain, 50 patients with A-MCI according to Petersen et al. criteria, and 66 with early AD (Global Deterioration Scale - 4 stage) according to the NINCDS-ADRDA criteria. The Memory Alteration Test is a quick, 5-minute, and easy to administer and to score. The results found that the Memory Alteration Test provides efficient and valid screening for A-MCI and early stage AD, and discriminates between A-MCI and early AD patients.
Health risk appraisal in older people 2: the implications for clinicians and commissioners of social isolation risk in older people
- Authors:
- ILIFFE Steve, et al
- Journal article citation:
- British Journal of General Practice, 57(537), April 2007, pp.277-282.
- Publisher:
- Royal College of General Practitioners
This study aimed to explore the significance of social isolation in the older population for GPs and for service commissioners. Secondary analysis of baseline data from a randomised controlled trial of health risk appraisal. The study used secondary analysis of baseline data from a randomised controlled trial of health risk appraisal. Participants were a total of 2641 community-dwelling, non-disabled people aged 65 years and over in suburban London. Analysis included demographic details, social network and risk for social isolation based on the 6-item Lubben Social Network Scale, measures of depressed mood, memory problems, numbers of chronic conditions, medication use, functional ability, self-reported use of medical services. The results found more than 15% of the older age group were at risk of social isolation, and this risk increased with advancing age. In bivariate analyses risk of social isolation was associated with older age, education up to 16 years only, depressed mood and impaired memory, perceived fair or poor health, perceived difficulty with both basic and instrumental activities of daily living, diminishing functional ability, and fear of falling. Despite poorer health status, those at risk of social isolation did not appear to make greater use of medical services, nor were they at greater risk of hospital admission. Half of those who scored as at risk of social isolation lived with others. Multivariate analysis showed significant independent associations between risk of social isolation and depressed mood and living alone, and weak associations with male sex, impaired memory and perceived poor health. The risk of social isolation is elevated in older men, older persons who live alone, persons with mood or cognitive problems, but is not associated with greater use of services. These findings would not support population screening for individuals at risk of social isolation with a view to averting service use by timely intervention. Awareness of social isolation should trigger further assessment, and consideration of interventions to alleviate social isolation, treat depression or ameliorate cognitive impairment.
Improving identification of cognitive impairment in primary care
- Authors:
- BORSON Soo, et al
- Journal article citation:
- International Journal of Geriatric Psychiatry, 21(4), April 2006, pp.349-355.
- Publisher:
- Wiley
The objectives of this study were to compare the relative level and predictors of accuracy of a brief cognitive screen, the Mini-Cog, with spontaneous detection of cognitive impairment by subjects' primary care physicians. A heterogeneous community sample of 371 predominantly ethnic minority elderly assessed by standardized research protocol, 231 of whom met criteria for dementia or mild cognitive impairment (MCI). The Mini-Cog detected cognitively impaired subjects much more effectively than did subject's own physician, correctly classifying 83% of the sample and 84% of cognitively impaired subjects. Physicians correctly classified 59% of all subjects but identified only 41% of cognitively impaired subjects. The Mini-Cog's advantage over physicians was greatest when impairment was mildest. Additional subject variables associated with missed detection by physicians were non-Alzheimer type dementia and low education, low literacy, and non-English speaking, factors that had little or no effect on the performance of the Mini-Cog. Ethnic differences, also observed for physician recognition, were not significant in final regression equations. The number and recency of primary care visits, and duration of the primary care relationship, were not associated with physicians' recognition of cognitive impairment. This study demonstrates that recognition of cognitive impairment by primary care physicians is adversely influenced by important patient and disease characteristics. Results also show that use of the Mini-Cog would improve recognition of cognitive impairment in primary care, particularly in milder stages and in older adults subject to disparities in health care quality due to sociodemographic factors.
Poor mental and physical health differentially contributes to disability in hospitalized geriatric patients of different ages
- Authors:
- MARENGONI Alessandra, et al
- Journal article citation:
- International Journal of Geriatric Psychiatry, 19(1), January 2004, pp.27-34.
- Publisher:
- Wiley
This article seeks to evaluate the relationship between depressive symptoms, cognition and somatic diseases on functional status of geriatric patients at hospital discharge. Patients 65+ years consecutively admitted to the acute care geriatric ward of the Internal Medicine Department I, Civil Hospital of Brescia, Italy, from February 1998 to December 2000 (n = 830) were examined. Functional disability was defined as need of physical assistance in at least one of the basic Activities of Daily Living (ADL). The Greenfield Index of Disease Severity (IDS) and the Geriatric Index of Comorbidity (GIC) were used to measure number and severity of diseases. The Mini-Mental State Examination (MMSE) assessed cognitive status and the Geriatric Depression Scale (GDS) measured depressive symptoms. Prevalence of functional disability at discharge was 29.3% in the younger age group (65-74 years) and 55.2% in the older age group (75+ years). Using logistic regression models, older age, poorer cognitive status, and depressive symptoms were independently associated with functional disability in the younger and older age group, respectively. Additionally cognitive impairment and depressive symptoms showed an additive association with disability, especially in younger patients, while comorbidity was correlated with functional status only in the oldest old, in particular among those who were cognitively impaired. Functional disability after acute hospitalization is highly prevalent in geriatric patients. Depressive symptoms, comorbidity, and cognitive impairment often coexist, interact and are differentially associated with function depending on age. Considering that depressive symptoms are a modifiable problem, their detection in hospital settings may help clinicians in targeting subjects at high risk of functional disability.
Assessment and management pathways of older adults with mild cognitive impairment: descriptive review and critical interpretive synthesis
- Authors:
- CHAMBERS Duncan, et al
- Journal article citation:
- Health and Social Care Delivery Research, 10(10), 2022, p.180. Online only
- Publisher:
- National Institute for Health Research
- Place of publication:
- London
Background: Mild cognitive impairment in older adults is a risk factor for dementia. Mild cognitive impairment is a result of a diverse range of underlying causes and may progress to dementia, remain stable or improve over time. Objectives: We aimed to assess the evidence base around the assessment and management pathway of older adults with mild cognitive impairment in community/primary care, hospital and residential settings. Data sources: In January 2021, we searched MEDLINE, EMBASE, PsycInfo, Scopus, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library (i.e. Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials), Science Citation Index and Social Science Citation Index. The search was limited to studies published in English between 2010 and 2020. Grey literature and citation searches were also performed. Methods: We performed two separate evidence reviews: (1) a descriptive review with narrative synthesis focusing on diagnosis, service provision and patient experience; and (2) a critical interpretive synthesis of evidence on the advantages and disadvantages of 'mild cognitive impairment' as a diagnostic label. Results: A total of 122 studies were included in the descriptive review, of which 29 were also included in the critical interpretive synthesis. Study participants were most commonly recruited from populations of community-living older adults or those who had sought medical help from their general practitioner for memory problems. Follow-up searching identified a further 11 studies for the critical interpretive synthesis. The descriptive review identified multiple barriers to efficient diagnosis, starting with patient reluctance to seek help. General practitioners have a variety of cognitive tests available, but substantial numbers of patients meeting criteria for dementia do not have a diagnosis recorded. Patients may be referred to a memory clinic, but these clinics are mainly intended to identify and support people with dementia, and people with mild cognitive impairment may be discharged back to their general practitioner until symptoms worsen. Availability of scanning and biomarker tests is patchy. Qualitative studies show that patients with mild cognitive impairment and their carers find the process of investigation and diagnosis difficult and frustrating to negotiate. The key finding from the critical interpretive synthesis was that the need for a 'timely' diagnosis outweighs the ongoing debate about the value, or otherwise, of early investigation and labelling of memory problems. Determining what is a timely diagnosis involves balancing the perspectives of the patient, the health system and the clinician. Conclusions: The two reviews reported here have applied different 'lenses' to the same body of evidence. Taken together, the reviews highlight the importance of a timely diagnosis for memory problems and identify barriers to obtaining such a diagnosis, from reluctance to seek help through to patchy availability of advanced diagnostic tests. Limitations: The review was primarily descriptive, reflecting the prespecified review questions. Study selection was complicated by lack of a consistent definition of mild cognitive impairment and its overlap with other memory disorders. It was not possible to employ double study selection, data extraction or quality assessment, although processes of checking and verification were used throughout the review. Future work: Priorities include evaluating remote methods of memory assessment and preparing for the likely future availability of disease-modifying treatments for early dementia. Research is needed on the investigation of memory problems in hospital and social care settings. (Edited publisher abstract)