White‐coat effect among older patients with suspected cognitive impairment: prevalence and clinical implications

Abstract

ObjectivesTo evaluate the prevalence of white‐coat effect (WCE), and its association with individual anxiety and insight of disease, among older patients evaluated for suspected cognitive impairment.MethodsThis prospective cohort study, conducted in an Alzheimer Evaluation Unit, involved patients aged 55 years or older with suspected cognitive impairment. WCE was defined as a difference of at least 20 mmHg in systolic or 10 mmHg in diastolic blood pressure (BP) measured either by a physician during the visit or by a nurse (before and after the visit), compared with home self‐blood pressure measurement (SBPM). Severity of cognitive impairment was evaluated through the Mini‐Mental State Examination (MMSE); the Clinical Insight Rating Scale (CIR) and the Guidelines for the Rating for Awareness Deficits (GRAD) were used to evaluate the subject's insight; anxiety disorder was evaluated using the seven‐question Generalized Anxiety Disorder scale (GAD‐7).ResultsAmong 273 subjects, prevalence of WCE was 52%, 32.6% and 30.4%, according to physician and nurse BP measurements, respectively (p = 0.000). Prevalence of WCE did not differ between patients diagnosed with and without dementia, but was higher among patients with than in those without anxiety disorder (70.7% vs 38.2%, p = 0.000). Positive relations were observed between severity of anxiety and insight of disease, which were both inversely related with severity of coginitive impairment.ConclusionsWCE is extremely common and is correlated to individual anxiety and insight of disease among older outpatients with suspected cognitive impairment; overestimation of hypertension severity might lead to unnecessary drug treatment and greater health costs in this setting. Copyright © 2008 John Wiley & Sons, Ltd.

Predictors of the community pharmacy white-coat effect in treated hypertensive patients. The MEPAFAR study

“…Therefore, the WCE in the clinical or pharmacy setting introduces an error in the BP measurement, which can lead to mistakes in clinical evaluations and therapeutic decision-making, including overdiagnosis of hypertension, underestimation of the effectiveness of treatment, or the use of unnecessary medication. This may result in the increased risk of undesirable effects of the medication and/or health care spending [2,3]. To avoid the possible consequences of the WCE, the optimal solution is to use BP measurement methods that, as they are applied outside a clinical setting, are exempt from that effect [4], such as home BP (HBP) monitoring (HBPM) and ambulatory BP (ABP) monitoring (ABPM).…”

“Do it-yourself”: Home blood pressure as a predictor of traditional and everyday cognition in older adults

“…Using paired sample t-tests, mean hSBP was slightly lower than mean oSBP (t (132) = -2.2, p < .05 two-tailed), though this difference was not as pronounced as typically found in previous studies [20, 23]. Mean hPP was slightly lower than mean oPP (M = 52.7, SD = 9.5, t (132) = -2.0, p < .05 two-tailed).…”

“…Over 50% of older outpatients attending their first visit for a cognitive evaluation are estimated to have substantial white coat hypertension [23], which could lead to overestimations of hypertensive severity [18]. Home readings also identify individuals with masked hypertension and prehypertension who are at increased risk for cognitive dysfunction and stroke [8].…”

Episodix: a serious game to detect cognitive impairment in senior adults. A psychometric study

“…However, classical tests have some relevant limitations, such as being perceived as intrusive ( Chaytor & Schmitter-Edgecombe, 2003 ), being influenced by the white-coat effect ( Mario et al, 2009 ), providing a late diagnosis ( Holtzman, Morris & Goate, 2011 ), lacking ecological validity ( Farias et al, 2003 ; Knight & Titov, 2009 ); being strongly dependent on confounding factors (e.g., age, educational level ( Cordell et al, 2013 ), practice effect ( Hawkins, Dean & Pearlson, 2004 ; Lezak, 2004 )), or being prone to processing errors due to their manual processing.…”