Active case finding of dementia in ambulatory care settings: a comparison of three strategies

Abstract

Background and purpose To reduce the diagnostic gap of dementia, three strategies can be employed for case finding of cognitive impairment in ambulatory care settings, namely using informant report, brief cognitive test or a combination of informant report and brief cognitive test. The right strategy to adopt across different healthcare settings remains unclear. This diagnostic study compared the performance of the three strategies for detecting dementia (primary aim), as well as for detecting both mild cognitive impairment (MCI) and dementia (secondary aim). Methods Participants aged ≥65 years (n = 11 057) were recruited from Alzheimer’s Disease Centers across the USA. Participants provided data on an informant report (Functional Activities Questionnaire), brief cognitive test (four‐item short variant of Montreal Cognitive Assessment) and a combined measure with informant report and brief cognitive test (sum of Functional Activities Questionnaire and Montreal Cognitive Assessment short variant). They also received standardized assessments (clinical history, physical examination and neuropsychological testing) to diagnose MCI and dementia. Areas under the receiver operating characteristic curve (AUCs) of the three strategies were compared using the DeLong method, with AUC > 90% indicating excellent performance. Results All three strategies had excellent performance in detecting dementia, although informant report [AUC, 95.9%; 95% confidence intervals (CI), 95.4–96.3%] was significantly better than brief cognitive test (AUC, 93.0%; 95% CI, 92.4–93.6%) and the combined measure had the best performance (AUC, 97.0%; 95% CI, 96.7–97.4%). However, to detect both MCI and dementia, only the combined measure had excellent performance (AUC, 93.0%; 95% CI, 92.5–93.4%), whereas stand‐alone informant report or brief cognitive test performed suboptimally (AUC < 90%). Performance of the three strategies was not affected by participants’ age, educational attainment or underlying prevalence of MCI and dementia. Conclusions For case finding of dementia in ambulatory care settings, informant reports would suffice as first‐line measures and brief cognitive tests may optionally be added on, in services with available resources, to further improve the accuracy of detection. For case finding of both MCI and dementia, a combination of informant reports and brief cognitive tests remains the most appropriate strategy.

Subjective cognitive decline, anxiety symptoms, and the risk of mild cognitive impairment and dementia

“…Vice versa, among older patients with known SCD, the additional complaints of anxiety symptoms should also not be dismissed as merely a psychological reaction to their concerns about the SCD. On the contrary, anxiety and SCD should be seen as independent predictors of neurocognitive disorders, and the cooccurrence of both should alert clinicians to the much higher risk of neurocognitive disorders, which may then prompt more intensive interventions to prevent cognitive decline (such as those related to risk-factor modification, physical exercise, and cognitive training) [12,13], enrolment into preventive trials for dementia [3,32], and closer monitoring of cognitive function over time to allow timely diagnosis of cognitive impairment [40][41][42][43].…”

Subjective cognitive decline, APOE e4 allele, and the risk of neurocognitive disorders: Age- and sex-stratified cohort study

“…Such risk stratification can allow clinicians to employ more personalized approaches in patient counseling and management (Liew, 2020c, 2020d), whereby those at imminent risk of neurocognitive disorders may be identified for more intensive interventions (e.g. risk factor modification, physical exercise and cognitive training) (Jessen et al, 2020; Livingston et al, 2020; Ngandu et al, 2015), enrolment into preventive trials (Liew, 2019e, 2020b), as well as closer monitoring of cognitive function over time to allow timely diagnosis of cognitive impairment (Liew, 2019a, 2019c, 2019d, 2020a).…”

The impact of active community-based survey on dementia detection ratio in Taiwan: A cohort study with historical control

“…Besides, previous reports showed that passive screening can lead to a false positive and incorrect diagnosis of some psychiatric disorders with dementia (7). Therefore, several scientific bodies have advocated active case-finding in the elderly population using validated cognitive tests and functional questionnaires (8). Despite the potential advantages of active case-finding, there is a lack of population-based studies comparing the effectiveness of active case-finding with passive screening.…”