- Activities of daily living dependency and a longer time since the onset of symptoms are associated with a diagnosis of dementia, whereas somatic comorbidity is associated with the absence of dementia.
- Family physicians should be aware of diagnostic difficulties in patients with somatic comorbidity.
- We were unable to confirm the diagnostic value of the recommended dementia guidelines.
Some authors have hypothesized that the continuity of care typical of family practice is an important tool for family physicians to recognize cognitive and behavioral changes in their patients.8 The finding of a positive association between the number of previous contacts with the patient and the family physician’s diagnostic accuracy supports this assertion.1 The family physicians’ accuracy is also positively associated with the severity of the dementia.1,3,9 However, 2 intervention studies that tried to improve the family physicians’ diagnostic accuracy were inconclusive.10,11 Although family physicians may be hesitant to communicate a diagnosis of dementia to patients and their relatives,12 an early and accurate diagnosis is important for a number of reasons. First, explaining the diagnosis enables the patient and relatives to better understand and deal with changed behavior.13,14 Second, realizing the progressive nature of the condition permits patients and relatives to prepare for future care planning and allows support for the often severely burdened caregivers.15,16 Third, dementia patients with Alzheimer’s disease may benefit from anti-Alzheimer drugs.17,18 Therefore, the aim of this study was to quantify the relative contribution of guideline recommendations and other diagnostic determinants in the family physicians’ work-up of patients suspected of having dementia.
Subjects and design
All 250 family physicians from an eastern district in the Netherlands (Nijmegen) were approached by mail to participate in a prospective dementia case-finding study. Of these, 64 family physicians participated. The main reasons for not participating were limited time, having a young practice population, or having no interest in the subject. During consultations or home visits the family physicians assessed patients newly suspected of having dementia using the dementia guideline of the Dutch College of General Practice (DCGP).5,19 Suspicion of dementia was defined by 2 criteria: age 55 years or older and presence of signs of cognitive impairment that had not yet been evaluated. These signs included memory complaints, worsening orientation, or behavioral changes and could be reported by patients or family members or observed by the family physician. After the family physicians’ assessment using the Dutch guideline, all patients with suspected dementia were referred to the outpatient memory clinic of the Academic Medical Center of Nijmegen. Their evaluation served as the diagnostic reference standard. The Medical Ethics Committee of the University Medical Center St Radboud in Nijmegen approved of the study and informed consent of patients was sought by the family physician. A few patients were not able to reproduce basic information about the study, in which case informed consent was sought from their principal caregiver.
The DCGP dementia guideline is a national, evidence-based guideline for the diagnosis of dementia (Table 1). It contains diagnostic criteria of the Diagnostic Statistical Manual, 3rd edition, revised (DSM-III-R)20 and includes assessment of cognitive, physical, and activities of daily living (ADL) functioning. A cognitive screening test such as the Mini-Mental State Examination (MMSE) is optional. Instead, the dementia guideline includes a brief assessment of 11 cognitive functions that correspond to the DSM-III-R criteria (long- and short-term memory; orientation to time, place, and person; gnosis; praxis; language ability; judgment; personality changes; and abstraction), and indications on how to assess these functions. In Table 1 the recommendations of the DCGP guideline are compared with the dementia guideline of the Veterans Affairs (VA) and of the Agency for Health Care Policy and Research (AHCPR). These 2 guidelines are constructed for use in primary care as well. The DCGP guideline closely resembles the VA and AHCPR guidelines with some exceptions.21 Results about the applicability of the Dutch dementia guideline to practice were recently published.22
Comparison of recommendations in 3 dementia guidelines