Dementia assessment and management in primary care settings: a survey of current provider practices in the United States

Abstract

BackgroundPrimary care providers (PCPs) are typically the first to screen and evaluate patients for neurocognitive disorders (NCDs), including mild cognitive impairment and dementia. However, data on PCP attitudes and evaluation and management practices are sparse. Our objective was to quantify perspectives and behaviors of PCPs and neurologists with respect to NCD evaluation and management.MethodsA cross-sectional survey with 150 PCPs and 50 neurologists in the United States who evaluated more than 10 patients over age 55 per month. The 51-item survey assessed clinical practice characteristics, and confidence, perceived barriers, and typical practices when diagnosing and managing patients with NCDs.ResultsPCPs and neurologists reported similar confidence and approaches to general medical care and laboratory testing. Though over half of PCPs performed cognitive screening or referred patients for cognitive testing in over 50% of their patients, only 20% reported high confidence in interpreting results of cognitive tests. PCPs were more likely to order CT scans than MRIs, and only 14% of PCPs reported high confidence interpreting brain imaging findings, compared to 70% of specialists. Only 21% of PCPs were highly confident that they correctly recognized when a patient had an NCD, and only 13% were highly confident in making a specific NCD diagnosis (compared to 72 and 44% for neurologists, both p < 0.001). A quarter of all providers identified lack of familiarity with diagnostic criteria for NCD syndromes as a barrier to clinical practice.ConclusionsThis study demonstrates how PCPs approach diagnosis and management of patients with NCDs, and identified areas for improvement in regards to cognitive testing and neuroimaging. This study also identified all providers’ lack of familiarity with published diagnostic criteria for NCD syndromes. These findings may inform the development of new policies and interventions to help providers improve the efficacy of their decision processes and deliver better quality care to patients with NCDs.

Current State of Self-Administered Brief Computerized Cognitive Assessments for Detection of Cognitive Disorders in Older Adults: A Systematic Review

“…While almost all reviewed measures reported data on concurrent validity, the estimates for several individual domain subtests within some tools were low. These findings are concerning, particularly when considering the need for a battery to distinguish among different types of MCI and dementia and inform differential diagnoses in non-specialty settings ( 16 ). On the other hand, we found that most measures required minimal involvement of an examiner in test administration and scoring of results and were available as standalone applications on several device types (e.g., PC, tablet computer, etc.).…”

“…An additional and important limitation of these conventional tools is that administration, scoring, interpretation, and documentation require substantial clinical staff time. Indeed, among the commonly reported reasons to not conduct the screening were insufficient time during visits and lack of confidence in performing the evaluation ( 7 , 16 ).…”

Cognitive Impairment and Dementia in Primary Care: Current Knowledge and Future Directions Based on Findings From a Large Cross-Sectional Study in Crete, Greece

“…Despite that, the diagnosis of dementia can be delayed by the insidiousness of the symptoms and the perceptions by both patients and GPs/FPs that it may be just a sign of normal aging (7). As many as two-thirds of people with dementia may be misdiagnosed and there is often a significant delay between symptom onset and diagnosis (8). Even in highincome countries with advanced health-care systems, more than half of dementia cases are not formally diagnosed (9)(10)(11).…”

Detecting Alzheimer’s disease biomarkers with a brief tablet-based cognitive battery: sensitivity to Aβ and tau PET

“…Second, our sample included a substantial number of participants with less typical dementia syndromes, including earlier onset and atypical variants of AD. At the same time, this limitation may also be regarded as a strength of the study given a shift towards biological definition of AD and the importance and challenges of identifying its atypical variants in clinical practice [ 3 , 43 ]. Finally, there was a trend for greater CDR Sum of Boxes scores in Aβ+ versus Aβ− participants, and although all analyses controlled for this variable, it is possible that our findings may in part be related to an overall greater a disease severity effect not captured by the CDR.…”