Applied Evidence

How to prevent a delayed Alzheimer’s diagnosis

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Physicians fail to detect mild-to-moderate dementia more than half the time. Here’s when to screen and which tools to use


 

References

Practice recommendations
  • Avoid cognitive screening solely on the basis of age (SOR A).
  • Screen vulnerable elderly patients at their initial visit and annually thereafter (SOR A).
  • Ensure that all patients who undergo cognitive screening are tested for depression (SOR A).

Strength of recommendation (SOR)

  1. Good-quality patient-oriented evidence
  2. Inconsistent or limited-quality patient-oriented evidence
  3. Consensus, usual practice, opinion, disease-oriented

Janet M, a 69-year-old woman with a history of hypertension, comes for a visit because she thinks she has Alzheimer’s disease (AD). She recently had an episode of acute confusion while shopping at the mall; when she returned to her car, she couldn’t remember how to get home. The episode cleared within minutes and hasn’t recurred.

Jack S, an 84-year-old man, seeks medical care for pain in his right shoulder. He injured the rotator cuff several years ago, but it’s been fine since he completed physical therapy—until he tripped and fell while walking outside about a week ago. His daughter is concerned about his “forgetfulness” and increasing inability to remember certain words, but the patient thinks this is a natural consequence of age.

Fran B, a 72-year-old, presents with complaints of memory problems that began about 6 months ago. She’s worried about her son and has had increasing difficulty concentrating, sleeping, and keeping track of her things.

If these were your patients, whom would you screen for dementia? Would you decide whether to screen based on your “gut,” or a defined set of criteria? Would you have several screening tools on hand, and know enough about them to determine which one might be best suited for a particular patient?

If you make decisions about screening based on your gut or aren’t sure which tools are best for which patients, you’re far from alone. Cognitive impairment, particularly in the early stages, can be difficult and time-consuming to detect, and community physicians fail to diagnose mild-to-moderate dementia more than 50% of the time.1-5

Family members and caregivers often overlook declines in cognitive function, as well. In a study of 741 caregivers of patients with AD, an average of 4 months went by between the time symptoms were first noticed and the patient was seen by a physician—and 22% of the caregivers waited more than a year.6

Cognitive decline can be slowed with early Dx

Early diagnosis of AD or any dementia is important for a number of reasons. In some cases, cognitive impairment may be related to medical conditions—head trauma, Parkinson’s disease, human immunodeficiency virus, thyroid disorder, among others—that can be modified or reversed with treatment.7 There is evidence, too, that medical, behavioral, and social interventions can delay the cognitive and functional decline associated with AD, thereby helping to prolong the time the patient can remain at home. Early diagnosis also facilitates legal and financial family planning, and makes it possible to take appropriate safety measures.8-13

AD affects approximately 5 million US residents.14 With an aging population, that number is expected to surge in the decades ahead. To help you provide optimal care for your geriatric patients, this review will detail when to screen, which tools to use, and how best to care for the 3 elderly patients in the opener.

When and whether to screen

Despite the benefits of early detection, population-based screening based on age alone is not recommended. Guidelines recommend focused screening of patients in high-risk groups and on a case-by-case basis.15

US Preventive Services Task Force (USPSTF) guidelines recommend that physicians evaluate older patients for dementia whenever there is a suggestion of cognitive impairment, based on clinical observation or concern expressed by the individuals themselves or by family members, caretakers, or friends.15

However, cognitive screening generally provides better results in populations at higher risk of dementia.16,17 With that in mind, the Assessing Care of Vulnerable Elders (ACOVE), a collaborative project to develop a set of quality indicators for care of the elderly, recently recommended cognitive and functional screening of all “vulnerable elderly.”18,19

Who are the vulnerable elderly?

ACOVE defines the vulnerable elderly as individuals who are 65 years of age and older who live in the community and are at high risk of death or functional decline over the next 2 years. You can use a screening tool to identify members of this high-risk group. Or you can simply ask a few questions and classify any noninstitutionalized older person who reports being in poor health and/or acknowledges difficulty with activities of daily living—eg, money or medication management, dressing, grooming, or preparing simple meals—as a vulnerable elderly patient.

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