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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 59:M621-M626 (2004)
© 2004 The Gerontological Society of America

Dementia Assessment in Primary Care: Results From a Study in Three Managed Care Systems

Linda Boise1,, Margaret B. Neal2 and Jeffrey Kaye1

1 Aging & Alzheimer Disease Center, Oregon Health & Science University, Portland.
2 Institute on Aging, Portland State University, Oregon.

Address correspondence to Linda Boise, PhD, MPH, Layton Aging & Alzheimer Disease Research Center, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd. (CR131), Portland, OR 97201. E-mail: boisel{at}ohsu.edu


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Background. Prior research has found that dementia is often undiagnosed in primary care, but there has been limited research on whether physicians respond to symptoms, behaviors, or other events that may be indicators of dementia.

Methods. A cross-sectional cohort study design was used to screen 553 patients aged 75 years or older for dementia in 3 managed health care systems in Portland, Oregon. For participants determined to be cognitively impaired, their medical charts were reviewed to determine if they had experienced adverse events, had been clinically evaluated for possible dementia, had received a diagnosis of dementia, or had been offered treatment.

Results. Nearly 43% of participants were identified as cognitively impaired: 29.7% were classified as mildly cognitively impaired (MI) and 13.7% as moderately to severely cognitively impaired (MSI). Eighteen percent of the MI group and 34.8% of the MSI group had evidence in their medical chart of having been clinically evaluated for dementia. None of the MI group and only 4.3% of the MSI group had been offered a cholinesterase inhibitor. Nearly two thirds (61.6%) of the MI and three fourths (75.4%) of the MSI participants had experienced 1 or more adverse events. Of those who had experienced adverse events, less than one quarter (23.7%) in the MI group and less than one half (44.2%) in the MSI group had received a clinical evaluation for dementia.

Conclusions. These findings suggest the need for greater attention by primary care physicians to the cognitive functioning of older patients, especially patients who experience adverse events that may be indicators of dementia.

THE prevalence of dementia has been estimated to be 10%–16% for people aged 75 years or older and up to 50% for those aged 85 years or older (1). Early diagnosis of dementing illness is important for identifying treatable causes of dementia (2–4), for effective management of the dementia and of coexisting illnesses (e.g., diabetes, heart disease), and to offer supportive services for the patient and family (5). Yet, a number of studies have found that cognitive impairment is frequently unrecognized and unevaluated in the clinical setting (6–8). One key barrier to diagnosis suggested in prior research is physicians' nonrecognition of symptoms, behavioral signs, or other events suggestive of dementia (9). Symptoms include difficulties in language, reasoning, or spatial ability, or signs of poor memory, including being repetitive (10). Behavioral signs such as the patient being a "poor historian," dressing inappropriately, failing to appear for scheduled appointments, or failing to follow instructions may also serve as triggers for dementia assessment (11). Physicians report that a dementia work-up is most often triggered when the family brings concerns about symptoms or behavioral signs to their attention (9). Other triggers for dementia assessment include falls and emergency room visits. Although falls may not directly result from dementia, persons with dementia have twice the risk of falls as those without dementia (12), due in part to changes in equilibrium and limb coordination in persons with mild cognitive impairment and Alzheimer's disease (13). Falling has also been associated with the use of psychotropic, cardiac, and analgesic drugs (14,15), and thus could be associated with inappropriate use of these types of medications. Persons with dementia are also twice as likely as age-matched controls to visit an emergency room. Although emergency room visits by older patients may be due primarily to physical illness, they also may be indicative of complications arising from cognitive deficits (16). In this study, cognitive symptoms, behavioral signs, emergency room visits, and falls were considered adverse events or indicators of the need for dementia assessment.

To gain an understanding of dementia assessment practices of primary care physicians working in managed care environments, the aims of this study were to:

  1. Assess cognitive functioning in a sample of community-dwelling patients aged 75 or older enrolled in 1 of 3 managed health care plans;
  2. In the subgroup of patients identified as having cognitive impairment:


   METHODS
Top
 Abstract
 Methods
Results
 Discussion
 References
 
Sample
The sample was drawn from patients of 34 primary care physicians affiliated with 3 managed health care plans, Kaiser Permanente NorthWest, Providence Health Plans, and Regence BlueCross BlueShield of Oregon, who approved the study. Physicians were recruited through informal methods (e.g., information meetings about the study or personal contacts by staff of their respective health plan). For physicians who agreed to have their patients contacted, the entire roster of patients who met the study criteria (i.e., were aged 75 years or older and residing in the community) was included in the sample pool. The age criterion of 75 years or older was stipulated for screening efficiency reasons, given the great prevalence of dementia in older age groups. A total of 1377 patients were randomly selected from the sample pool of 3700 patients and were mailed a letter from the patient's physician describing the study and advising them that someone would be contacting them by telephone to determine their willingness to participate. Of the 1377 letters mailed, 136 potential participants could not be contacted due to their having moved out of the area, or died, or not responding to three attempts of contact by phone.

Of the 1241 potential participants who were contacted, 21 were found to be ineligible due to being institutionalized or below the age of 75, and 13 were unable to participate in the cognitive testing protocol due to physical disability (blindness, deafness, or inability to speak) or being non-English speaking, leaving an eligible sample of 1207. Of these, 553 (45.8%) agreed to participate. The final study sample included from 1 to 75 participants per individual physician (mean 14 participants/physician, standard deviation [SD] 8.5). Nearly all participants (98%) were white, and 64% were female. Participants ranged in age from 75 to 100, with a mean age of 81 years. Approximately 85% had visited their primary care physician within the previous 6 months.

Data Collection, Determination of Cognitive Status, and Identification of Clinical Assessment, Diagnosis, and Treatment
Registered nurses and masters of social work trained in the study protocol contacted each person on the list by telephone, explained the study, requested the person's participation, collected demographic data, and conducted an initial screen for cognitive impairment. The screening tool used was the telephone version of the Blessed Orientation-Memory-Concentration Test (BOMCT), a 6-item screening tool with scores ranging from 0 (representing high cognitive functioning) to 28. Weighted scores greater than 10 are consistent with dementia (17). The BOMCT has been shown to have high sensitivity and specificity (18). Participants who scored "0" on the BOMCT, suggesting good cognitive functioning, received no further screening. For all other participants who agreed, a home interview was scheduled.

At the outset of the home interview, each participant's written consent was obtained for the researchers to administer the cognitive tests, to send results of the cognitive testing to the participant's primary care physician, and to contact a family member. Cognitive functioning was evaluated using the battery of neuropsychological tests developed by the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) (19). These tests included Verbal Fluency, Boston Naming, Constructional Praxis, 10-Word Recall (3 trials), and Delayed Recall. The Mini-Mental State Examination (MMSE) (20) was also administered during the home interview, and the patient's activities of daily living (Katz Instrumental Activities of Daily Living Scale [IADL]) (21), depressed mood (Center for Epidemiological Studies Depression Scale–Short Form [CES-D10]) (22), and self-reported memory and health were assessed. For each participant determined to be cognitively impaired (see below), a telephone interview with a family member was also conducted, and the participant's medical chart was reviewed. Family interviews were completed for 206 participants, and charts were reviewed for 221 participants.

Determination of cognitive status.-- Cognitive status was determined using age-, education-, and gender-based normative data from the CERAD study group (23). Participants who scored 2 or more standard deviations below the norms in a primary memory test (Trial 3 Word Recall or Delayed Word Recall) and at least 1 standard deviation below the norm in another cognitive domain (i.e., language, naming, construction) were classified in the moderately to severely impaired group (MSI). Participants who scored from 1 to 2 standard deviations below the age-gender-education norm in a primary memory test and at least 1 standard deviation below the norm in another cognitive domain (i.e., language, naming, construction) were classified in the mildly impaired group (MI). All others were classified as normal (N).

Determination of diagnosis or treatment.-- The medical charts of cognitively impaired participants were reviewed for the previous 3 years by a trained nurse research assistant to determine if the participant had received a clinical work-up for dementia, a diagnosis, and/or been offered treatment. If any notations related to possible dementia or dementia symptoms were found within the past 3 years, further review of the entire chart was carried out. Specific data obtained from the chart included notations of dementia-related symptoms, work-up for dementia, dementia-related diagnoses, discussion with the patient or family about the patient's cognitive difficulties, referrals for community resources, and discussion or prescribing of medications to treat dementia or dementia-related problems (e.g., cognitive symptoms, depression, anxiety). Criteria for determining clinical work-up for dementia were defined using published guidelines (24–26). A participant was determined to have received a clinical work-up for dementia if he or she had received any of the following within 6 months of noted dementia symptoms: one or more recommended laboratory tests (complete blood count, electrolytes, blood urea nitrogen/creatinine, thyroid-stimulating hormone, urinalysis), mental status assessment (e.g., MMSE) (20), other standard mental status test, or notation of testing for "orientation"), patient or family interview to assess cognitive problems, imaging tests (computed tomography scan or magnetic resonance imaging), or consultation with or referral to a specialist.

Medical records were also examined for adverse events noted within the past 3 years. These included medication use errors, problems in compliance with treatment recommendations, falls, emergency room visits, family contacts with the doctor (as recorded in the chart) related to concerns about the patient's memory or functioning, symptoms of cognitive deficits (i.e., memory problems, "poor historian" or "confusion"), and inappropriate patient contacts (i.e., presenting at the wrong time or day for an appointment, frequent phone calls to the doctor's office).

Analysis
The 3 cognitive status groups (N, MI, and MSI) were first compared on their demographic and health characteristics using one-way analysis of variance and the chi-square test, as appropriate. For variables analyzed using one-way analysis of variance, the Scheffé significance test (27) was used for post hoc comparisons to determine pair-wise differences between the groups. Just the 2 cognitively impaired groups then were compared, using chi-square analysis, on (a) their medical chart notations related to identification and assessment of dementia symptoms, and (b) the proportions of participants experiencing adverse events and, of those participants with adverse events, the proportions who had received a work-up for dementia.


   RESULTS
Top
 Abstract
 Methods
 Results
Discussion
 References
 
Rates of Cognitive Impairment
Of the 553 participants, 313 (56.6%) were found to have normal cognitive functioning: 93 (16.8%) scored "0" on the telephone BOMCT (and thus received no home assessment) and an additional 220 participants (39.8%) were subsequently determined from the CERAD battery to test within the normal range. A total of 164 participants (29.7%) were determined to be mildly cognitively impaired, and 76 (13.7%) were found to be moderately to severely impaired, for a total of 240 cognitively impaired participants.

Comparisons on demographic characteristics, mental state (MMSE), depressive symptoms (CES-D10), and self-reported health and memory for the 3 cognitive status groups are shown in Table 1. For the 3 variables analyzed using chi-square, i.e., gender, percent married, and whether or not participants lived alone, no significant group differences were found. For the other variables reported in Table 1, there were no significant group differences in depressive symptoms or self-reported health, but, as expected, the 3 groups differed in mental status (MMSE) and self-reported memory.


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  		Table 1. Comparison of Normal, Mildly, and More Severely Cognitively Impaired Groups on Demographic Characteristics, Self-Reported Health and Memory, and Depression.

 
Clinical Evaluation for Possible Dementia
As shown in Table 2, among participants in the MSI group, 70.6% had at least 1 reference in their medical chart to dementia-related symptoms, referral for assessment, work-up, or diagnosis. Of the MSI group, 34.8% had received actual assessment for dementia (based on data in the chart), 14.5% had received a diagnosis of dementia, 4.3% had been offered or prescribed donepezil (the only cholinesterase inhibitor approved by the Food and Drug Administration as a treatment for Alzheimer's disease at the time of the study), 10.1% had been prescribed an antidepressant, and 10.1% had been prescribed an anxiolytic. Among the MI group, 45.3% had a reference in their medical chart to dementia-related symptoms, referrals, work-up, or diagnosis; 18.4% had received a dementia assessment; and 13.3% had received a dementia diagnosis. None had been prescribed or offered donepezil, but 15.8% had been prescribed antidepressants, and 16.6% had been prescribed an anxiolytic. The medical charts for both groups of cognitively impaired participants had very few mentions of nonpharmacological management of dementia or of referrals for community services. Thus, these data are not reported in the Tables.


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  		Table 2. Comparison of Medical Chart Notations on Dementia-Related Symptoms, Assessments, Diagnosis, and Treatments for the Two Cognitively Impaired Groups.

 
Table 3 provides data for each impairment group on the frequencies of adverse events reported in the participants' medical charts and whether or not participants who had that event received clinical assessment for dementia. Among the MI group, 61.6% had experienced 1 or more adverse events, with the frequencies of adverse events ranging from 7.9% for family communication of concerns about the patient's cognitive functioning to 36.8% for falls. The participants in this group who experienced adverse events had rates of clinical assessment ranging from a low of 23. 2%, for those who had a medically recorded fall, to a high of 43.8%, for those who had inappropriate contacts with the clinic.


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  		Table 3. Frequencies of Adverse Events Reported in Medical Chart and Portion of Patients Experiencing Adverse Events Who Received Clinical Work-up for Dementia.

 
Among the MSI group, 75.4% had 1 or more adverse events, with the frequencies of adverse events ranging from 23.2%, for family contacts related to possible dementia, to 46.4%, for falls. The participants in this group who experienced adverse events had rates of clinical assessment ranging from 33.3%, for those with inappropriate contacts with the clinic, to 61.5% for participants who had memory-related symptoms noted in their chart. Of those with recorded medication or treatment noncompliance, 38% had received clinical assessment for dementia.


   DISCUSSION
Top
 Abstract
 Methods
 Results
 Discussion
References
 
This study confirms the findings of earlier studies with respect to low rates of clinical assessment and diagnosis for patients with cognitive impairment and further demonstrates a lack of dementia assessment for patients experiencing adverse events. One possible explanation for these findings is the subtlety of dementia symptoms combined with the constraints physicians face in their clinical practice, especially limited time available to evaluate patients. Alternative explanations are that physicians: (a) considered, but then discounted, whether the events were indicators of a need for dementia assessment, (b) failed to see the usefulness of assessment for dementia given the inevitable progression of Alzheimer's disease, or (c) felt that they could manage the dementia without assessing or identifying the cause. Qualitative research by the primary author of this article suggests that two key factors result in low assessment and diagnosis rates: first, the busy pace of today's health care environment makes it challenging to recognize dementia symptoms, and, second, the perception of many primary care physicians is that dementia assessment is not warranted, since little can be done to improve Alzheimer's disease or other progressive dementias (9).

Further research is needed to understand the potential harm to the patient with cognitive impairment that may result from nonidentification of and/or treatment for dementia. For example, inappropriate medication use is a common and potentially serious problem in elderly people (28) that may cause cognitive impairment. Medication noncompliance may also be an early sign of dementia (29). In either case, cognitive assessment should be a component of medication review, especially if continued use of prescription medicines is needed.

Falls also have serious health consequences for older adults (30). While cognitive impairment is only one of the risk factors for falling, identifying cognitive deficits as a potential contributing factor may alert the clinician and family caregivers to the need for more general supportive care as well as for home safety measures. Similarly, whether or not emergency room visits are directly related to dementia, effective recovery from illness episodes often depends on the ability of the patient to follow through on treatment recommendations and medication protocols. Given the many cognitively impaired participants living alone (45% in the MSI group) and the small proportion of participants in this group whose family had contacted the physician with concerns about the participant (23.2%), an important question is who, if anyone, is monitoring these patients' health and well-being? Other indicators of possible dementia not investigated in this study, e.g., unexplained weight loss (31) or urinary incontinence, could also be explored as potential triggers. Further research is needed to establish which triggers are most sensitive and specific for dementia.

The results of this study should be treated with caution for several reasons. First, the identification of cognitive impairment through cognitive testing alone may overestimate the prevalence of dementing illness. However, the high reliability of the CERAD test measures (19) supports the conclusions of this study. Second, the lack of randomization among physician patient pools, as well as the relatively low participant response rate, may have introduced bias in the proportions of participants that had and had not been clinically evaluated. Unfortunately, for reasons of confidentiality, we were unable to obtain data for those individuals who refused to participate. However, because the participants were drawn from panels of physicians who voluntarily agreed to have their patients contacted, and because the patients themselves may have refused to participate if they had concerns about their cognitive functioning, it is likely that these two sources of potential bias resulted in overestimates rather than underestimates of cognitively impaired participants who received clinical evaluation. In addition, it should be noted that the criteria used to define clinical assessment for dementia were quite generous. This may also have led us to overestimate the proportion of cognitively impaired participants who received dementia assessment. For example, the notation of "oriented" or of ordering complete blood counts within 6 months of noting problems with cognition were considered evidence of dementia assessment. Such tests may have been carried out for reasons other than dementia assessment, however.

A third study limitation is that since the sample was limited to patients in managed care settings in a single Pacific Northwest city, the findings cannot be generalized to other regions of the country, nor can conclusions be drawn about differences in assessment practices between managed and nonmanaged health care settings. A fourth limitation is the almost exclusively Caucasian sample. There is a need for replication of this study with nonwhite elders, where the rates of nondiagnosed conditions are likely to be even higher. Finally, although participants classified in this study as more severely cognitively impaired had evidence of substantial deficits in cognition, whether participants in the mildly impaired group had symptoms that were serious enough to warrant clinical evaluation is debatable. At the same time, current research indicates that persons with mild symptoms are at high risk of transitioning to full dementia (32,33), and a number of clinical trials are currently evaluating the benefits of early treatment to prevent or delay the onset of dementia.

In general, the results of this study suggest that significant numbers of older adults experiencing cognitive impairment fail to be assessed for dementia. Evaluating cognitive functioning is important not only to identify treatable causes of cognitive deficits and to effectively manage nonreversible dementias, but also because treating physical illness and managing patients' overall health may more successfully be achieved.


   Acknowledgments
 
This study was funded and conducted under the auspice of a local partnership organization, The Alzheimer's Research Alliance of Oregon, which included the 5 major health care systems in the Portland metropolitan area. Additional support was provided by the Oregon Alzheimer Disease Center under National Institute on Aging grant P30 AGO8017. The authors thank the participating organizations (Regence BlueCross Blue Shield of Oregon, Legacy Health System, Providence Health Plans, Providence Health System, and Kaiser Permanente NorthWest) and the members of the project team who were of immense help in planning the project and in facilitating access to physicians and patients: Elizabeth Baxter, Legacy Clinics and Chronic Care Initiatives, Legacy Health Systems; Lucy Nonnenkamp and Clyde Pope, PhD, Kaiser Center for Health Research; Tom Harburg, MD, Kaiser Permanente NorthWest; Richard M. Rytting, MD, Providence Health Plans; Cindy Klug, Providence Health System. We also thank Kenneth Brummel-Smith, MD, for advice and consultation on medical records review and the components of clinical assessment, and Diane Howieson, PhD, and Gary Sexton, PhD, for their consultation and advice on interpretation of CERAD test scores.

Received August 29, 2002

Accepted March 7, 2003


   References
Top
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 Methods
 Results
 Discussion
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