A Program to Improve Detection of Undiagnosed Dementia in Primary Care and Its Association with Healthcare Utilization

Wray, Laura O.; Wade, Michael; Beehler, Gregory P.; Hershey, Linda A.; Vair, Christina L

doi:10.1016/j.jagp.2013.04.018

Cited by 19 publications

(31 citation statements)

References 43 publications

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“…Another limitation of prior studies is that most models were developed to predict diagnosed dementia and have assumed that results would apply to undiagnosed dementia. [43][44][45] However, our prior work suggests that patients with undiagnosed dementia often have values that fall in between patients with diagnosed dementia and those without dementia. 23 Thus models that are optimized to predict diagnosed dementia may be less accurate for identifying unrecognized dementia cases.…”

Section: Discussionmentioning

confidence: 99%

Development and Validation of eRADAR: A Tool Using EHR Data to Detect Unrecognized Dementia

Barnes

Zhou

Walker

et al. 2019

J American Geriatrics Society

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OBJECTIVES Early recognition of dementia would allow patients and their families to receive care earlier in the disease process, potentially improving care management and patient outcomes, yet nearly half of patients with dementia are undiagnosed. Our aim was to develop and validate an electronic health record (EHR)‐based tool to help detect patients with unrecognized dementia (EHR Risk of Alzheimer's and Dementia Assessment Rule [eRADAR]). DESIGN Retrospective cohort study. SETTING Kaiser Permanente Washington (KPWA), an integrated healthcare delivery system. PARTICIPANTS A total of 16 665 visits among 4330 participants in the Adult Changes in Thought (ACT) study, who undergo a comprehensive process to detect and diagnose dementia every 2 years and have linked KPWA EHR data, divided into development (70%) and validation (30%) samples. MEASUREMENTS EHR predictors included demographics, medical diagnoses, vital signs, healthcare utilization, and medications within the previous 2 years. Unrecognized dementia was defined as detection in ACT before documentation in the KPWA EHR (ie, lack of dementia or memory loss diagnosis codes or dementia medication fills). RESULTS Overall, 1015 ACT visits resulted in a diagnosis of incident dementia, of which 498 (49%) were unrecognized in the KPWA EHR. The final 31‐predictor model included markers of dementia‐related symptoms (eg, psychosis diagnoses, antidepressant fills), healthcare utilization pattern (eg, emergency department visits), and dementia risk factors (eg, cerebrovascular disease, diabetes). Discrimination was good in the development (C statistic = .78; 95% confidence interval [CI] = .76‐.81) and validation (C statistic = .81; 95% CI = .78‐.84) samples, and calibration was good based on plots of predicted vs observed risk. If patients with scores in the top 5% were flagged for additional evaluation, we estimate that 1 in 6 would have dementia. CONCLUSION The eRADAR tool uses existing EHR data to detect patients with good accuracy who may have unrecognized dementia. J Am Geriatr Soc 68:103–111, 2019

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Section: Discussionmentioning

confidence: 99%

Development and Validation of eRADAR: A Tool Using EHR Data to Detect Unrecognized Dementia

Barnes

Zhou

Walker

et al. 2019

J American Geriatrics Society

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“…If a woman scores>19 on the OMC test (indicative of dementia), the research team will discuss the case with the site principal investigator to make sure that her enrollment is appropriate. We do not plan to exclude women with capacity for informed consent but mild cognitive impairment (MCI) since: 1) ~20% of US women ≥ 75 years have MCI [32-34]; 2) many are screened without discussion of risks of mammography [35]; 3) MCI increases with age and is associated with comorbidity and shorter life expectancy [36]; and 4) women with MCI successfully participated in our pilot. Since on average women ≥ 90 years have <5 year life expectancy [1] and dementia is common (36%), we will exclude women ≥ 90 years [37].…”

Section: Methods and Analysismentioning

confidence: 99%

Evaluation of a Mammography Screening Decision Aid for Women Aged 75 and Older: Protocol for a Cluster-randomized Controlled Trial

et al. 2015

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Purpose There is insufficient evidence to recommend mammography for women >75 years. Guidelines recommend that older women be informed of the uncertainty of benefit and potential for harm, especially for women with short life expectancy. However, few older women are informed of harms of screening and many with short life expectancy are screened. Therefore, we aim to test whether a mammography screening decision aid (DA) for women >75 years affects their use of mammography, particularly for women with <10 year life expectancy. Methods/Design The DA is a self-administered pamphlet that includes information on screening outcomes, tailored information on breast cancer risk, health, life expectancy, and competing mortality risks, and includes a values clarification exercise. We are conducting a large cluster randomized controlled trial (RCT) of the DA with the primary care provider (PCP) as the unit of randomization to evaluate its efficacy. We plan to recruit 550 women 75-89 years from 100 PCPs to receive either the mammography DA or a pamphlet on home safety for older adults (control arm) before a visit with their PCP, depending on their PCP's randomization assignment. The primary outcome is receipt of mammography screening assessed through chart abstraction. Secondary outcomes include effect of the DA on older women's screening intentions, knowledge, and decisional conflict, and on documented discussions about mammography by their PCPs. We will recruit women from 5 Boston-based primary care practices (3 community-based internal medicine practices and 2 academic practices), and 2 North Carolina-based academic primary care practices. Discussion It is essential that we test the DA in a large RCT to determine if it is efficacious and to substantiate the need for broad translation into clinical practice. Our DA has the potential to improve health care utilization and care in a manner dictated by patient preferences.

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“…Further, there is evidence that undetected cognitive impairment and dementia contribute to increased healthcare utilization and costs of care, as evidenced in the study of Veterans Affairs Healthcare Network in Upstate New York. Veterans with undetected cognitive impairment had twice the number of hospitalizations with longer lengths of stay than those whose dementia had been diagnosed [11].…”

Section: Introductionmentioning

confidence: 96%

“…Several approaches are needed: training in medical schools and residences to focus on cognitive and other mental health disorders, geriatrics and complex multimorbidity; providing incentives for training in geriatric disciplines and rethinking continuing education and textbook presentations about dementia to include not only specific etiologies and treatments but also practical approaches to understanding and managing multimorbidity. Telemedicine and telepsychiatry models may offer ability to consult with specialists previously inaccessible in remote areas; a recent study was able to utilize electronic medical record and telephone-based brief cognitive screening to detect cognitive impairment and dementia [11].…”

Section: Introductionmentioning

confidence: 99%

Are we Providing the Best Possible Care for Dementia Patients?

Borisovskaya

Chen

Borson

2015

Neurodegener. Dis. Manag.

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Healthcare for patients with dementia is often reactive, poorly organized and fragmented. We discuss opportunities for improvements in the care of individuals living with dementia at home that can be implemented by physicians in their practices today. In particular, we argue that systematic identification and diagnosis of cognitive impairment and dementia in their early stages, coupled with a coherent, evidence-informed management framework, would benefit patients with dementia substantially and ease the burden of their caregivers. We emphasize that dementia influences all aspects of patient care, and each medical decision must be passed through the filter of knowledge that patients with dementia have special needs that can be identified and addressed.

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A Program to Improve Detection of Undiagnosed Dementia in Primary Care and Its Association with Healthcare Utilization

Cited by 19 publications

References 43 publications

Development and Validation of eRADAR: A Tool Using EHR Data to Detect Unrecognized Dementia

Development and Validation of eRADAR: A Tool Using EHR Data to Detect Unrecognized Dementia

Evaluation of a Mammography Screening Decision Aid for Women Aged 75 and Older: Protocol for a Cluster-randomized Controlled Trial

Are we Providing the Best Possible Care for Dementia Patients?

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