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Aging Population Calls for FPs' Expertise
Caring for Patients With Dementia Demands Special Skills
By Matt Brown
Although the burgeoning need for dementia care may be self-evident, making the diagnosis -- or even the decision to screen at all -- is not quite as clear-cut. The U.S. Preventive Services Task Force currently concludes that the evidence is insufficient to recommend for or against routine screening for dementia in older adults. The task force does, however, recommend assessing cognitive function if cognitive impairment or deterioration is suspected.
Individualize the Decision to Screen
"When a patient presents with a change in functional status -- usually instrumental activities of daily living (IADLs) first, such as the ability to pay bills, go shopping, etc. -- or if a patient or family member expresses concern about functional or memory impairment, I will perform a cognitive screening test," DeJoseph told AAFP News Now.
- Family physicians are being called on to diagnose and treat dementia in their older patients on an increasingly regular basis.
- The U.S. Preventive Services Task Force does not recommend for or against routine screening for dementia in older adults, but says cognitive function should be assessed if cognitive impairment or deterioration is suspected.
- Family members often serve as the best source of information regarding potential dementia symptoms.
"Currently, I use the animal naming test, which has good sensitivity (88 percent) and specificity (96 percent) when the cut-off for normal is 15 animals named in a minute, and the Mini-Cog, with scores of 0-2 (a positive screen for dementia) having 76 percent sensitivity and 89 percent specificity for dementia," he said. "If these tests are abnormal, I proceed to a full cognitive assessment."
Barry Brent Simmons, M.D., a family physician practicing in Philadelphia, said he also follows the AGS recommendations.
"I will do a cognitive assessment on any patient in whom I suspect memory problems if the family has concerns about memory or if the patient has any concerns about memory," Simmons said. "The AGS recommendations give good guidance on lab and imaging studies to order as an addition to the cognitive testing, such as when and when not to get an MRI."
Family Members' Input Can Be Vital
"Oftentimes, (family members) are going to be your best source of information on what is going on with the patient," he said. "I have been fooled many times by patients who come in alone for an office visit. They do not volunteer any cognitive issues and can carry on a conversation, but then you talk to family members and what they tell you is happening at home is hard to believe. That just doesn't always show up in a normal office visit."
FamilyDoctor.org Adds New Information on Elderly Care
Simmons shrugged off that concern, however, saying that although the revision might cause problems for some in the medical community, it should not be an issue for FPs who work with these patients.
"Essentially, with the new diagnostic guidelines, the lines between mild cognitive impairment (MCI) and early Alzheimer's are blurred," he said.
"This does have an impact on research activities focusing on MCI, but in clinical practice, it doesn't have as much impact. The drugs we use for Alzheimer's, such as donepezil, are used by many clinicians for MCI, as well, and I think most clinicians make the decision to do a drug trial based on the level of impairment and patient preferences more than the label put on the cognitive impairment."
DeJoseph agreed, emphasizing that family physicians' focus should be on pursuing --rather than labeling -- any evidence of cognitive impairment in their patients, with the goal of initiating treatment and other support at the appropriate time.
"It is important to keep in mind that dementia is categorized by a gradual onset of symptoms and a continuing decline of function," he said. "The patient's functional status declines as the disease progresses.
"This progression is delineated on the FAST (functional assessment staging) scale, with which I would encourage all FPs and residents to become familiar. On this scale, mild cognitive impairment corresponds to a FAST 3, and the AGS quotes an annual conversion rate to dementia syndrome of 6 percent to 15 percent."
Patients with dementia generally become eligible for hospice by the time they reach the FAST 7 stage, DeJoseph added, and may benefit from palliative care services in stage 6.
Look Beyond the Illness
"Since dementia is usually a disease of the elderly, patients with dementia can have many medical comorbidities," he explained. "It is the FP's job to transition care from disease-centered to patient-centered. Specifically, there are different, more relaxed, treatment goals for chronic diseases, such as diabetes, in patients with dementia. Patients with dementia are at a greater risk for adverse drug events, polypharmacy and other iatrogenic morbidities."
And when it comes to ensuring that patients -- and their caregivers -- receive the support and services they need, practicing as part of an interdisciplinary team can be essential, DeJoseph noted.
"I would encourage all FPs to strive for an interdisciplinary care model, including a clinical pharmacist, psychologist, and social work, to assist and support the patient and family/caretakers," he said. "The FP needs to help the patient get as much support as possible."
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