Früherkennung und Frühbehandlung von kognitiven Funktionseinbußen: eine Studie über eine geriatrische Vorsorgeuntersuchung im unausgelesenen Patientengut der Allgemeinpraxis

Abstract

To investigate the feasibility of early assessment of preventable disabilities in primary care, we developed a geriatric preventive screening examination with various indicators of physical, emotional, and social functions as well as laboratory exams. Cognitive impairment was measured by the modified MMSE. Severe cases of dementia, who would deserve home visits were excluded. Results of the assessment procedure in 446 patients aged 70 and over (71.5% females) were compared to ratings of general practitioners (n = 67). In these patients we found 4250 medical, 374 psychiatric, and 528 social problems. 45.4% of medical, 61.8% of psychiatric, and 56.8% of social problems where hitherto unknown to the GPs. The prevalence of cognitive impairment was 4.6% according to GPs diagnosis and 21% according to the MMSE. The sensitivity of GPs diagnosis was 14%, the specificity 98%, and the overall agreement measured by kappa was 0.17. There were significant (p < 0.05) associations of cognitive impairment with poor health, vascular disease, syncope, weight loss, previous hospitalization, depression, and ADL and IADL-items. Hypertension, or pathological thyroid function, occurred more frequently in the cognitively impaired (p > 0.05). Only 19.5% of dementia cases had severe functional loss, which substantiates our hypothesis that mild dementia was studied. Of all cases with newly identified cognitive impairment (n = 83 of 446 patients), three (3.6%) had reversible disorder such as depression (n = 1), drug toxicity (n = 2) 3 (3.6%) received counseling, and 5 (6%) further diagnostic assessment or treatment. One (1.2%) patient did not accept any treatment. In the remainder of 71 patients (85.5%), the GPs adopted a wait and see strategy with no intervention. In conclusion, memory deficits seem to be underdiagnosed in general practice despite much treatable comorbidity or social problems, and some reversible conditions such as depression and drug adverse effects.

Rates of formal diagnosis of dementia in primary care: The effect of screening

“…For German primary care patients, Sandholzer et al [5] showed that the prevalence of cognitive impairment in patients aged 70 years or older was 4.6% according to the GP diagnosis but 21% according to the MMSE score.…”

“…To the best of our knowledge, this study is the first to demonstrate such a profound effect of screening, although previous studies reported substantially smaller effects. Sandholzer et al [5] found that only 6% of the German primary care patients who had screened positive for dementia had received any diagnostic assessment or treatment. Borson et al [4] showed that relevant physician behavior (i.e., a formal diagnosis of dementia, specialist referral, or cognitive enhancing medication) occurred for only 17% of the positively screened patients.…”

“…The screening of older patients for cognitive impairment could be a method to improve the recognition of dementia. Previous studies have shown that screening for dementia in general practitioners' (GPs) practices did increase the diagnosis rates [4], [5]. Nevertheless, routine screening for dementia has been controversial and is not presently recommended in the dementia guidelines owing to the lack of evidence that patients benefit from it [6], [7], [8].…”

“…Nevertheless, routine screening for dementia has been controversial and is not presently recommended in the dementia guidelines owing to the lack of evidence that patients benefit from it [6], [7], [8]. In addition, patients with positive screening results often undergo no additional diagnostic assessment and do not receive specific treatment [4], [5]. For the benefit of patients, a positive screening outcome should initiate an adequate diagnostic assessment and, depending on the results, state of the art treatment and care.…”

“…Boustani et al [13] showed that the probability of false-positive screening results is relatively high: about 20% of patients who screened positive for dementia did not have dementia at all and another 30% had mild cognitive impairment. Sandholzer et al [5] examined the acceptance of screening among German primary care patients and found that 89% of the screened patients considered the screening to be useful. Only 1.5% of the patients reported that they worried more about their health after the screening.…”