Assessment and Management of Patients with Cognitive Impairment and Dementia in Primary Care

Published In: The Journal of Nutrition, Health & Aging, v. 16, no. 5, May 2012, p. 462-467

Posted on RAND.org on January 01, 2012

by J Belmin, Lillian Min, Carol P. Roth, David Reuben, Neil S. Wenger

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Research Question

  1. How good is the quality of care provided by primary care physicians to patients with newly discovered cognitive impairment and dementia?

OBJECTIVES: To evaluate care provided by primary care physicians in community practice to older patients presenting with cognitive impairment and dementia. DESIGN: Secondary analysis of an intervention study. SETTING: Primary care clinics. PARTICIPANTS: 101 patients 75 years and older enrolled in the ACOVE-2 study who presented with a new cognitive problem, new dementia, or prevalent dementia. MEASUREMENTS: Patients assessment and management were evaluated from medical record review and caregiver interviews. RESULTS: Among 34 patients presenting with a new cognitive problem, half received a cognitive assessment comprising of a test of memory and one other cognitive task, 41% were screened for depression and 29% were referred to a consultant. Of the 27 patients with newly diagnosed dementia, 15% received the components of a basic neurological examination, one-fifth received basic laboratory testing and for one third the medical record reflected an attempt to classify the type of dementia. Counseling was under-reported in the medical record compared to the caregiver interview for the 101 patients with dementia, but even the interview revealed that about half or fewer patients received counseling about safety and accident prevention, caregiver support or managing conflicts. Less than 10% were referred to a social worker. CONCLUSION: This small but detailed evaluation suggests patients presenting with cognitive problems to primary care physicians do not consistently receive basic diagnosis and management.

Key Findings

  • Few patients received appropriate cognitive testing, laboratory screening, referral to a social worker, and counseling about safety and accident prevention.
  • In only one-third of the cases was there documentation of an attempt to determine the type of dementia.
  • With only one-third of the patients was there an effort to complete advance care directives.

Recommendation

  • Findings from this small study should be replicated in larger studies to stimulate interventions that will improve the initial and ongoing treatment of older persons with cognitive impairment.

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