How physicians evaluate patients with dementia who present with shortness of breath

Abstract

Background: Whether the presence of dementia in patients makes it difficult for physicians to assess the risk such patients might have for serious conditions such as pulmonary embolism (PE) is unknown. Our objective was to examine the differential association of four clinical factors (deep venous thrombosis (DVT)/PE, malignancy, recent surgery, and tachycardia) with PE testing for patients with dementia compared to patients without dementia. Methods: We performed a cross-sectional study of emergency department (ED) visits to 104 Veterans Affairs (VA) hospitals from 2011 to 2018 by patients aged 60 years and over presenting with shortness of breath (SOB). Our outcomes were PE testing (CT scan and/or D-dimer) and subsequently diagnosed acute PE. Results:The sample included 593,001 patient visits for SOB across 7124 ED physicians; 5.6% of the sample had dementia, and 10.6% received PE testing. Three of the four clinical factors examined had a lower association with PE testing for patients with dementia. For example, after taking into account that at baseline, physicians were 0.9 percentage points less likely to test patients with dementia than patients without dementia for PE, physicians were an additional 2.6 percentage points less likely to test patients with dementia who had tachycardia than patients without dementia who had tachycardia. We failed to find evidence that any clinical factor examined had a differentially lower association with a subsequently diagnosed acute PE for patients with dementia. Conclusions: Clinical factors known to be predictive of PE risk had a lower association with PE testing for patients with dementia compared to patients without dementia. These results may be consistent with physicians missing these clinical factors more often when evaluating patients with dementia, but also with physicians recognizing such factors but not using them in the decision-making process. Further understanding how physicians evaluate patients with dementia presenting with common acute symptoms may help improve the care delivered to such patients.

Comment on: How physicians evaluate patients with dementia who present with shortness of breath

“…Takashi Yoshioka MD, MPH, PhD 1 Atsushi Takayama MD, MPH, PhD 1 Hiroaki Nakagawa MD 1,2 Akihiro Ozaka MD 1 Taro Takeshima MD, DrPH, PhD 1,3…”

“…In a recently published paper by Ly et al, 1 the authors presented interesting findings stating that older adults with dementia who experienced shortness of breath were less likely to undergo diagnostic testing for pulmonary embolism (PE) than those without dementia. The authors' challenge to clarify the differences in both physicians' behavior and testing for PE in the presence of dementia using a widely used clinical prediction model for PE, Well's criteria, 2 is quite impressive.…”

“…However, we believe that some additional important factors may exist that need to be adjusted for in this study. Since Well's criteria weigh the most on the factors based on the physician's subjective assessment (e.g., "clinical signs and symptoms of deep venous thrombosis" and "pulmonary embolism is #1 or equally likely"), 1 the physicians' impressions associated with the intention of PE tests should be adjusted for. Following this viewpoint, "physician's frailty impression" indicators may be an important residual adjustment variable.…”

Reply to: Comment on: How physicians evaluate patients with dementia who present with shortness of breath

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We agree with the comments by Yoshioka and colleagues 1 about the limitations of studies using large databases, such as ours. 2 We want to note that the focus of our study was not on differences in level of testing for pulmonary embolism (PE) between patients with and without dementia, but on differences in the association of clinical factors with PE testing between these two groups of patients.Although we wanted to use reference standards for diagnosing dementia as suggested by Yoshioka and colleagues such as the Mini Mental State Examination, such data were not available. We instead used diagnosis codes, which are subject to the limitations mentioned by Yoshioka and colleagues.

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“…We agree with the comments by Yoshioka and colleagues 1 about the limitations of studies using large databases, such as ours. 2 We want to note that the focus of our study was not on differences in level of testing for pulmonary embolism (PE) between patients with and without dementia, but on differences in the association of clinical factors with PE testing between these two groups of patients.…”