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Implementing Routine Cognitive Screening of Older Adults in Primary Care: Process and Impact on Physician Behavior

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An Erratum to this article was published on 31 May 2007

An Erratum to this article was published on 31 May 2007

Abstract

Background

Early detection of cognitive impairment is a goal of high-quality geriatric medical care, but new approaches are needed to reduce rates of missed cases.

Objective

To evaluate whether adding routine cognitive screening to primary care visits for older adults increases rates of dementia diagnosis, specialist referral, or prescribing of antidementia medications.

Setting

Four primary care clinics in a university-affiliated primary care network.

Design

A quality improvement screening project and quasiexperimental comparison of 2 intervention clinics and 2 control clinics. The Mini-Cog was administered by medical assistants to intervention clinic patients aged 65+ years. Rates of dementia diagnoses, referrals, and medication prescribing were tracked over time using computerized administrative data.

Results

Twenty-six medical assistants successfully screened 70% (n = 524) of all eligible patients who made at least 1 clinic visit during the intervention period; 18% screened positive. There were no complaints about workflow interruption. Relative to baseline rates and control clinics, Mini-Cog screening was associated with increased dementia diagnoses, specialist referrals, and prescribing of cognitive enhancing medications. Patients without previous dementia indicators who had a positive Mini-Cog were more likely than all other patients to receive a new dementia diagnosis, specialty referral, or cognitive enhancing medication. However, relevant physician action occurred in only 17% of screen-positive patients. Responses were most related to the lowest Mini-Cog score level (0/5) and advanced age.

Conclusion

Mini-Cog screening by office staff is feasible in primary care practice and has measurable effects on physician behavior. However, new physician action relevant to dementia was likely to occur only when impairment was severe, and additional efforts are needed to help primary care physicians follow up appropriately on information suggesting cognitive impairment in older patients.

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REFERENCES

  1. Borson S, Scanlan JM, Watanabe J, Tu SP, Lessig M. Improving identification of cognitive impairment in primary care. Int J Geriatr Psychiatry. 2006;21:349–55.

    Article  PubMed  Google Scholar 

  2. Bush C, Kozak J, Elmslie T. Screening for cognitive impairment in the elderly. Can Fam Physician. 1997;43:1763–8.

    PubMed  CAS  Google Scholar 

  3. Callahan CM, Hendrie HC, Tierney WM. Documentation and evaluation of cognitive impairment in elderly primary care patients. Ann Intern Med. 1995;122:422–9.

    PubMed  CAS  Google Scholar 

  4. Evans DA, Funkenstein HH, Albert MS, et al. Prevalence of Alzheimer’s disease in a community population of older persons. Higher than previously reported. JAMA. 1989;262:2551–6.

    Article  PubMed  CAS  Google Scholar 

  5. Valcour V, Masaki K, Curb J, Blanchette P. The detection of dementia in the primary care setting. Arch Intern Med. 2000;160:2964–8.

    Article  PubMed  CAS  Google Scholar 

  6. Ashford JW, Borson S, O’Hara R, et al. Should older adults be screened for dementia? Alzheimers Dement. 2006;2:76–85.

    Article  Google Scholar 

  7. Boustani M, Peterson B, Hanson L, Harris R, Lohr KN. US Preventive Task Force. Screening for dementia in primary care: a summary of the evidence for the USPSTF. Ann Intern Med. 2003;138:927–37.

    PubMed  Google Scholar 

  8. Boustani M, Callahan CM, Unverzagt FW, et al. Implementing a screening and diagnosis program for dementia in primary care. J Gen Intern Med. 2005;20:572–7.

    Article  PubMed  Google Scholar 

  9. Harvan JR, Cotter V. An evaluation of dementia screening in the primary care setting. J Am Acad Nurse Pract. 2006;18:351–60.

    Article  PubMed  Google Scholar 

  10. Boise L, Camicioli R, Morgan DL, Rose JH, Congelton L. Diagnosing dementia: perspectives of primary care physicians. Gerontologist. 1999;39:457–64.

    PubMed  CAS  Google Scholar 

  11. Boise L, Neall MB, Kaye J. Dementia assessment in primary care: results from a study in three managed care systems. J Gerontol A Biol Sci Med Sci. 2004;59:M621–6.

    PubMed  Google Scholar 

  12. Borson S, Scanlan J, Brush M, Vitaliano PP, Dokmak A. The Mini-Cog: A cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry. 2000;15:1021–7.

    Article  PubMed  CAS  Google Scholar 

  13. Borson S, Scanlan JM, Chen P, Ganguli M. The Mini-Cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc. 2003;51:1451–4.

    Article  PubMed  Google Scholar 

  14. Sandholzer H, Breull A, Fischer GC. Early diagnosis and early treatment of cognitive disorders: a study of geriatric screening of an unselected patient population in general practice. Z Gerontol Geriatr. 1999;32:172–8.

    Article  PubMed  CAS  Google Scholar 

  15. Brodaty H, Howarth GC, Mant A, et al. General practice and dementia. A national survey of Australian GPs. Med J Aust. 2004;160:10–4.

    Google Scholar 

  16. Ganguli M, Rodriguez E, Mulsant B, et al. Detection and management of cognitive impairment in primary care: The Steel Valley Seniors Survey. J Am Geriatr Soc. 2004;52:1668–75.

    Article  PubMed  Google Scholar 

  17. Sinclair AJ, Girlin AJ, Bayer AJ. Cognitive dysfunction in older subjects with diabetes mellitus: impact on diabetes self-management and use of care services. Diabetes Res Clin Pract. 2000;50:203–12.

    Article  PubMed  CAS  Google Scholar 

  18. Allen SC, Jain M, Ragab S, Malik N. Acquisition and short-term retention of inhaler techniques require intact executive function in elderly subjects. Age Ageing. 2003;32:299–302.

    Article  PubMed  Google Scholar 

  19. Salas M, In’t Veld BA, van der Linden PD, Hofman A, Breteler M, Stricker BH. Impaired cognitive function and compliance with antihypertensive drugs in elderly: the Rotterdam study. Clin Pharmacol Ther. 2001;70:561–6.

    Article  PubMed  CAS  Google Scholar 

  20. Royall DR, Cordes J, Polk M. Executive control and the comprehension of medical information by elderly retirees. Exp Aging Res. 1997;23:301–13.

    Article  PubMed  CAS  Google Scholar 

  21. Barat I, Andreasen F, Damsgaard EMS. Drug therapy in the elderly: what doctors believe and patients actually do. Br J Clin Pharmacol. 2001;51:615–22.

    Article  PubMed  CAS  Google Scholar 

  22. Tinetti ME, Doucette J, Claus E, Marottoli R. Risk factors for serious injury during falls by older persons in the community. J Am Geriatr Soc. 1995;43:1214–21.

    PubMed  CAS  Google Scholar 

  23. US Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med. 2002;136:760–4.

    Google Scholar 

  24. Callahan CM, Boustani MA, Unverzagt FW, et al. Effectiveness of collaborative care for older adults with Alzheimer’s disease in primary care: a randomized controlled trial. JAMA. 2006;295:2148–57.

    Article  PubMed  CAS  Google Scholar 

  25. Vickrey B, Mittman BS, Connor KI, et al. The effect of a disease management intervention on quality and outcomes of dementia care: a randomized, controlled trial. Ann Intern Med. 2006;145:713–26.

    PubMed  Google Scholar 

  26. Lessig M, Farrell J, Madhavan E, et al. Cooperative dementia care clinics: a new model for managing cognitively impaired patients. J Am Geriatr Soc. 2006;54:1937–42.

    Article  PubMed  Google Scholar 

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Acknowledgements

This study was funded by an investigator-initiated grant from Ortho McNeil (GAL-ALZ-419). Jürgen Unutzer MD, MPH, made valuable comments on the draft. Sherry Neher assisted with manuscript preparation.

Conflict of Interest

None disclosed.

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Correspondence to Soo Borson MD.

Additional information

An erratum to this article can be found at http://dx.doi.org/10.1007/s11606-007-0242-0

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Borson, S., Scanlan, J., Hummel, J. et al. Implementing Routine Cognitive Screening of Older Adults in Primary Care: Process and Impact on Physician Behavior. J GEN INTERN MED 22, 811–817 (2007). https://doi.org/10.1007/s11606-007-0202-8

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  • DOI: https://doi.org/10.1007/s11606-007-0202-8

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