Search

Introduction This study examined the operating characteristics of two-stage case finding to identify memory impairment and very mild dementia. Methods Primary care patients underwent two-stage testing and a subsequent diagnostic assessment to assess outcomes. Patients who screen positive for subjective cognitive decline on the Informant Questionnaire on Cognitive Decline in the Elderly undergo memory testing with the Free and Cued Selective Reminding Test with Immediate Recall. Outcomes were determined without access to these data. A split-half design with discovery and confirmatory samples was used. Results One hundred seventeen of 563 (21%) patients had dementia and 68 (12%) had memory impairment but not dementia. Operating characteristics were similar in the discovery and confirmatory samples. In the pooled sample, combined, patients with memory impairment or dementia were identified with good sensitivity (72%) and high specificity (90%). Differences in ethnicity, educational level, or age (≤75, >75) did not affect classification accuracy. Discussion Two-stage screening facilitates the efficient identification of older adults with memory impairment or dementia.

The objective was to compare two screening strategies for dementia in an urban primary care clinic, serving a low-education, minority community composed largely of Latino and African American patients.Two hundred and fifty-seven patients underwent two-stage patient-based screening (PBS) and informant-based screening (IBS) followed by a diagnostic evaluation. In the first stage, PBS included brief tests of episodic memory (Memory Impairment Screen), semantic memory (Animal Fluency), and executive function (Reciting Months Backwards). For IBS, the first stage consisted of the short Informant Questionnaire on Cognitive Decline in the Elderly, administered to a family member or friend. Patients who screened positive in the first stage of either strategy underwent testing with the picture version of the Free and Cued Selective Reminding Test with Immediate Recall to identify memory impairment. Sensitivity, specificity, and positive and negative predictive values were computed for various cutoffs of each test and combination of tests. Dementia was diagnosed using Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) criteria without access to the screening test results.We identified 66 patients (25.7%) with previously undiagnosed dementia. Sensitivity was the same (77%) for both strategies but specificity was higher for IBS than for PBS (92% versus 83%). IBS's higher specificity makes it the preferred strategy if a knowledgeable informant is available.Unrecognized dementia is common in primary care. Case-finding can be improved using either PBS or IBS two-stage screening strategies.

A randomized controlled trial examined whether the diagnostic process for Alzheimer’s disease and other dementias may be influenced by knowledge of the patient’s education and/or self-reported race. Four conditions were implemented: diagnostic team knows (a) race and education, (b) education only, (c) race only, or (d) neither. Diagnosis and clinical staging was established at baseline, at Wave 2, and for a random sample of Wave 3 respondents by a consensus panel. At study end, a longitudinal, “gold standard” diagnosis was made for patients with follow-up data (71%). Group differences in Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) diagnosis were estimated using logistic regression and generalized estimating equations. Sensitivity and specificity were examined for baseline diagnosis in relation to the gold standard, longitudinal diagnosis. Despite equivalent status on all measured variables across waves, members of the “knows race only” group were less likely than those of other groups to receive a diagnosis of dementia. At final diagnosis, 19% of the “knows race only” group was diagnosed with dementia versus 38% to 40% in the other 3 conditions (p = .038). Examination of sensitivities and specificities of baseline diagnosis in relation to the gold standard diagnosis showed a nonsignificant trend for lower sensitivities in the knowing race conditions (0.3846), as contrasted with knowing education only (0.480) or neither (0.600). The finding that knowledge of race may influence the diagnostic process in some unknown way is timely, given the recent State-of-the-Science conference on Alzheimer’s disease prevention, the authors of which called for information about and standardization of the diagnostic process.

As new and more effective treatments for Alzheimer's disease (AD) emerge, the development of efficient screening strategies in educationally and racially diverse primary care settings has increased in importance. A set of candidate screening tests and an independent diagnostic assessment were administered to a sample of 318 patients treated at a geriatric primary care center. Fifty-six subjects met criteria for dementia. Exploratory analysis led to the development of three two-stage screening strategies that differed in the composition of the first stage or Rapid Dementia Screen, which is applied to all patients over the age of 65. The second stage, applied to those patients who screen positively for dementia, is accomplished with the Free and Cued Selective Reminding Test to detect memory impairment. Using clinical diagnosis as a gold standard, the strategies had high sensitivity and specificity for identifying dementia and performed better for identifying AD than non-AD dementias. Sensitivity and specificity did not differ by race or education. The strategies provide an efficient approach to screening for early dementia. (JINS, 2008,14, 130–142.)

Objectives To examine how often hospitalized older adults with a diagnosis of heel ulcers are evaluated with noninvasive vascular tests and to determine the impact of invasive vascular or surgical procedures on 1-year mortality. Design Retrospective review using an electronic database and chart review of all patients discharged with a diagnosis of heel ulcer between 2006 and 2009. Setting Urban teaching hospital. Participants A total of 506 participants aged 65 years and older. Measurements Data collected included resident characteristics (demographics, medical history, and severity of illness using the Charlson comorbidity index), staging of heel ulcers, rates of noninvasive vascular assessments, vascular and surgical procedures, length of stay, and 1-year mortality. Results Thirty-one percent (155/506) of patients with a heel ulcer underwent noninvasive vascular testing and of these 83% (129/155) were found to have underlying ischemia. Twenty-six percent (130/506) of patients underwent at least 1 vascular or surgical procedure. The 1-year mortality rate for patients with stage 1 or 2 disease was 55%; this rose to 70% for patients with stage 3 or 4 ulcers (P = .01), and could not be explained by differences in the Charlson comorbidity index. Patients who underwent a vascular or surgical procedure had a significantly lower mortality compared with those who did not (59% vs 68% P = .04). Conclusion Older adults with a heel ulcer in the acute care setting are frequently not assessed for underlying ischemia of the lower extremities. The diagnosis carries high 1-year mortality rates. Evidence-based protocols need to be developed to determine which older adults should have a vascular assessment and then undergo an invasive procedure.

Studies that assess health care use in older adults with and without dementia face several major challenges. These include ascertaining dementia status, measuring health care use, and adjusting for comorbidities. Most studies rely either on patient and informant reports or on medical claims data. Claims-based studies show that older adults with dementia use more medical care and incur higher medical costs than older adults without dementia.1–3 In these studies, the use of medical claims data to establish dementia cases creates at least two methodological issues. First, use of claims data likely underestimates true dementia-related utilization, as such data cannot capture undiagnosed dementia or the prodromal states preceding frank dementia. Second, because the same data are used to capture dementia cases and to measure outcomes, persons with higher costs may be preferentially ascertained, resulting in ascertainment bias.4 Studies using claims-based data are therefore vulnerable to the twin problems of underestimating total utilization and cost, while overestimating the health care costs per person. Studies that rely on patient and informant reports often use research quality evaluations to determine dementia status, which generally provide more consistent ascertainment of dementia status.5,6 However, these studies may need to rely on informants to obtain medical history and determine patterns of health care use. Abundant evidence suggests that such informant-based reporting is subject to bias, often failing to report utilization.7,8 Assessing the role of comorbidities is a third challenge. Serious medical conditions that are common in people with dementia increase the use and cost of health care services.9 If comorbidites increase utilization independent of dementia status, any estimate of dementia burden should adjust for them. On the other hand, if comorbid disease is mediated by dementia status, then adjusting may lead to underestimates of dementia-attributable utilization. To address these challenges, we systematically screened and diagnosed dementia in older adults participating in a longitudinal cohort study of dementia screening strategies in an urban geriatrics practice. To capture the range in severity of comorbidities, we then used the Cumulative Illness Rating Scale-Geriatrics (CIRS-G) a well validated measure of chronic medical burden for geriatric patients that indicates number and severity of comorbid disease.10,11 We avoided reliance on informant reports by reviewing medical charts to compile the CIRS-G. Finally, we used hospital-based claims data to assess utilization, focusing on emergency department (ED) visits and hospital admissions for 5 years following our initial assessment. We expected that patients with very mild dementia would have more ED visits and hospitalizations than patients without dementia. This is because very mild dementia, which often goes unrecognized in primary care,12–14 may lead to poor adherence to medication and lifestyle management and a failure to optimally manage medical comorbidities.15 This, in turn, may increase the use of acute care services and exacerbate cognitive impairment.1,5,16 Medical burden was expected to be a powerful predictor of both ED visits and hospital admissions as it is in most studies of dementia. 9 Finally, we sought to determine whether dementia status and medical burden were independent predictors of ED visits and hospitalizations.

Geriatric psychosocial problems are prevalent and significantly affect the physical health and overall well-being of older adults. Geriatrics fellows require psychosocial education, and yet to date, geriatrics fellowship programs have not developed a comprehensive geriatric psychosocial curriculum. Fellowship programs in the New York tristate area collaboratively created the New York Metropolitan Area Consortium to Strengthen Psychosocial Programming in Geriatrics Fellowships in 2007 to address this shortfall. The goal of the Consortium is to develop model educational programs for geriatrics fellows that highlight psychosocial issues affecting elder care, share interinstitutional resources, and energize fellowship program directors and faculty. In 2008, 2009, and 2010, Consortium faculty collaboratively designed and implemented a psychosocial educational conference for geriatrics fellows. Cumulative participation at the conferences included 146 geriatrics fellows from 20 academic institutions taught by interdisciplinary Consortium faculty. Formal evaluations from the participants indicated that the conference: a) positively affected fellows' knowledge of, interest in, and comfort with psychosocial issues; b) would have a positive impact on the quality of care provided to older patients; and c) encouraged valuable interactions with fellows and faculty from other institutions. The Consortium, as an educational model for psychosocial learning, has a positive impact on geriatrics fellowship training and may be replicable in other localities.

This study examines the prevalence of risk factors for fires and burns in, homebound urban elderly. A home safety assessment was performed on 83 patients enrolled in a physician home visiting program. Information was collected on the presence and functioning of smoke alarms, the presence of fire extinguishers and the maximum temperature of hot tap water. Functional smoke alarms were not present in 37% of households, 82% of households had no access to a fire extinguisher, 46% of households had hot tap water temperature greater than the recommended 120 degrees F. Multiple risk factors for burns and fires exist in the homes of elderly homebound patients that are well known to the medical community. Further attention to burn and fire prevention should be incorporated into the medical and geriatrics curriculum. Language: en

Objectives: To describe the risk factors, etiology and referral patterns of elderly patients treated for minor burns in an urban emergency department (ED). Methods: A retrospective chart review was conducted of persons aged 65 years and older who were treated for a minor burn and discharged home from the ED. Medical records were reviewed for 77 burn patients that presented over a 6-year period. Results: Burn patients had significant co-morbid medical illness. The etiology of the burns was scalds (58%), contact (27%) and flame (12%). Sixty-eight percent of the burns were cooking related. Heating pads, curling irons or hot pipes accounted for the majority of contact burns. Three percent of burn patients were referred to a home care agency for a home safety evaluation at the time of discharge from the ED. Conclusion: Cooking-related activities accounted for the majority of minor burns in this series. Common consumer items or environmental hazards were responsible for most contact burns. Elderly patients seen in the ED with minor burns were rarely referred to a home care agency.