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Dublin S, Greenwood-Hickman MA, Karliner L, Hsu C, Coley RY, Colemon L, Carrasco A, King D, Grace A, Lee SJ, Walsh JME, Barrett T, Broussard J, Singh U, Idu A, Yaffe K, Boustani M, Barnes DE. The electronic health record Risk of Alzheimer's and Dementia Assessment Rule (eRADAR) Brain Health Trial: Protocol for an embedded, pragmatic clinical trial of a low-cost dementia detection algorithm. Contemp Clin Trials 2023; 135:107356. [PMID: 37858616 DOI: 10.1016/j.cct.2023.107356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 09/26/2023] [Accepted: 10/15/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND About half of people living with dementia have not received a diagnosis, delaying access to treatment, education, and support. We previously developed a tool, eRADAR, which uses information in the electronic health record (EHR) to identify patients who may have undiagnosed dementia. This paper provides the protocol for an embedded, pragmatic clinical trial (ePCT) implementing eRADAR in two healthcare systems to determine whether an intervention using eRADAR increases dementia diagnosis rates and to examine the benefits and harms experienced by patients and other stakeholders. METHODS We will conduct an ePCT within an integrated healthcare system and replicate it in an urban academic medical center. At primary care clinics serving about 27,000 patients age 65 and above, we will randomize primary care providers (PCPs) to have their patients with high eRADAR scores receive targeted outreach (intervention) or usual care. Intervention patients will be offered a "brain health" assessment visit with a clinical research interventionist mirroring existing roles within the healthcare systems. The interventionist will make follow-up recommendations to PCPs and offer support to newly-diagnosed patients. Patients with high eRADAR scores in both study arms will be followed to identify new diagnoses of dementia in the EHR (primary outcome). Secondary outcomes include healthcare utilization from the EHR and patient, family member and clinician satisfaction assessed through surveys and interviews. CONCLUSION If this pragmatic trial is successful, the eRADAR tool and intervention could be adopted by other healthcare systems, potentially improving dementia detection, patient care and quality of life.
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Affiliation(s)
- Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Kaiser Permanente Bernard Tyson School of Medicine, Pasadena, CA, USA.
| | | | - Leah Karliner
- University of California, San Francisco, San Francisco, CA, USA
| | - Clarissa Hsu
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - R Yates Coley
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA; Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Leonardo Colemon
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Anna Carrasco
- University of California, San Francisco, San Francisco, CA, USA
| | - Deborah King
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Sei J Lee
- University of California, San Francisco, San Francisco, CA, USA
| | | | - Tyler Barrett
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Jia Broussard
- University of California, San Francisco, San Francisco, CA, USA
| | - Umesh Singh
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Abisola Idu
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Kristine Yaffe
- University of California, San Francisco, San Francisco, CA, USA
| | - Malaz Boustani
- Indiana University School of Medicine, Indianapolis, IN, USA
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Zolnoori M, Zolnour A, Topaz M. ADscreen: A speech processing-based screening system for automatic identification of patients with Alzheimer's disease and related dementia. Artif Intell Med 2023; 143:102624. [PMID: 37673583 PMCID: PMC10483114 DOI: 10.1016/j.artmed.2023.102624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 06/22/2023] [Accepted: 07/08/2023] [Indexed: 09/08/2023]
Abstract
Alzheimer's disease and related dementias (ADRD) present a looming public health crisis, affecting roughly 5 million people and 11 % of older adults in the United States. Despite nationwide efforts for timely diagnosis of patients with ADRD, >50 % of them are not diagnosed and unaware of their disease. To address this challenge, we developed ADscreen, an innovative speech-processing based ADRD screening algorithm for the protective identification of patients with ADRD. ADscreen consists of five major components: (i) noise reduction for reducing background noises from the audio-recorded patient speech, (ii) modeling the patient's ability in phonetic motor planning using acoustic parameters of the patient's voice, (iii) modeling the patient's ability in semantic and syntactic levels of language organization using linguistic parameters of the patient speech, (iv) extracting vocal and semantic psycholinguistic cues from the patient speech, and (v) building and evaluating the screening algorithm. To identify important speech parameters (features) associated with ADRD, we used the Joint Mutual Information Maximization (JMIM), an effective feature selection method for high dimensional, small sample size datasets. Modeling the relationship between speech parameters and the outcome variable (presence/absence of ADRD) was conducted using three different machine learning (ML) architectures with the capability of joining informative acoustic and linguistic with contextual word embedding vectors obtained from the DistilBERT (Bidirectional Encoder Representations from Transformers). We evaluated the performance of the ADscreen on an audio-recorded patients' speech (verbal description) for the Cookie-Theft picture description task, which is publicly available in the dementia databank. The joint fusion of acoustic and linguistic parameters with contextual word embedding vectors of DistilBERT achieved F1-score = 84.64 (standard deviation [std] = ±3.58) and AUC-ROC = 92.53 (std = ±3.34) for training dataset, and F1-score = 89.55 and AUC-ROC = 93.89 for the test dataset. In summary, ADscreen has a strong potential to be integrated with clinical workflow to address the need for an ADRD screening tool so that patients with cognitive impairment can receive appropriate and timely care.
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Affiliation(s)
- Maryam Zolnoori
- Columbia University Medical Center, New York, NY, United States of America; School of Nursing, Columbia University, New York, NY, United States of America.
| | - Ali Zolnour
- School of Electrical and Computer Engineering, University of Tehran, Tehran, Iran
| | - Maxim Topaz
- Columbia University Medical Center, New York, NY, United States of America; School of Nursing, Columbia University, New York, NY, United States of America
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Diaz-Asper C, Chandler C, Turner RS, Reynolds B, Elvevåg B. Increasing access to cognitive screening in the elderly: applying natural language processing methods to speech collected over the telephone. Cortex 2022; 156:26-38. [DOI: 10.1016/j.cortex.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/10/2022] [Accepted: 08/03/2022] [Indexed: 11/29/2022]
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Creavin ST, Noel-Storr AH, Langdon RJ, Richard E, Creavin AL, Cullum S, Purdy S, Ben-Shlomo Y. Clinical judgement by primary care physicians for the diagnosis of all-cause dementia or cognitive impairment in symptomatic people. Cochrane Database Syst Rev 2022; 6:CD012558. [PMID: 35709018 PMCID: PMC9202995 DOI: 10.1002/14651858.cd012558.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND In primary care, general practitioners (GPs) unavoidably reach a clinical judgement about a patient as part of their encounter with patients, and so clinical judgement can be an important part of the diagnostic evaluation. Typically clinical decision making about what to do next for a patient incorporates clinical judgement about the diagnosis with severity of symptoms and patient factors, such as their ideas and expectations for treatment. When evaluating patients for dementia, many GPs report using their own judgement to evaluate cognition, using information that is immediately available at the point of care, to decide whether someone has or does not have dementia, rather than more formal tests. OBJECTIVES To determine the diagnostic accuracy of GPs' clinical judgement for diagnosing cognitive impairment and dementia in symptomatic people presenting to primary care. To investigate the heterogeneity of test accuracy in the included studies. SEARCH METHODS We searched MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), Web of Science Core Collection (ISI Web of Science), and LILACs (BIREME) on 16 September 2021. SELECTION CRITERIA We selected cross-sectional and cohort studies from primary care where clinical judgement was determined by a GP either prospectively (after consulting with a patient who has presented to a specific encounter with the doctor) or retrospectively (based on knowledge of the patient and review of the medical notes, but not relating to a specific encounter with the patient). The target conditions were dementia and cognitive impairment (mild cognitive impairment and dementia) and we included studies with any appropriate reference standard such as the Diagnostic and Statistical Manual of Mental Disorders (DSM), International Classification of Diseases (ICD), aetiological definitions, or expert clinical diagnosis. DATA COLLECTION AND ANALYSIS Two review authors screened titles and abstracts for relevant articles and extracted data separately with differences resolved by consensus discussion. We used QUADAS-2 to evaluate the risk of bias and concerns about applicability in each study using anchoring statements. We performed meta-analysis using the bivariate method. MAIN RESULTS We identified 18,202 potentially relevant articles, of which 12,427 remained after de-duplication. We assessed 57 full-text articles and extracted data on 11 studies (17 papers), of which 10 studies had quantitative data. We included eight studies in the meta-analysis for the target condition dementia and four studies for the target condition cognitive impairment. Most studies were at low risk of bias as assessed with the QUADAS-2 tool, except for the flow and timing domain where four studies were at high risk of bias, and the reference standard domain where two studies were at high risk of bias. Most studies had low concern about applicability to the review question in all QUADAS-2 domains. Average age ranged from 73 years to 83 years (weighted average 77 years). The percentage of female participants in studies ranged from 47% to 100%. The percentage of people with a final diagnosis of dementia was between 2% and 56% across studies (a weighted average of 21%). For the target condition dementia, in individual studies sensitivity ranged from 34% to 91% and specificity ranged from 58% to 99%. In the meta-analysis for dementia as the target condition, in eight studies in which a total of 826 of 2790 participants had dementia, the summary diagnostic accuracy of clinical judgement of general practitioners was sensitivity 58% (95% confidence interval (CI) 43% to 72%), specificity 89% (95% CI 79% to 95%), positive likelihood ratio 5.3 (95% CI 2.4 to 8.2), and negative likelihood ratio 0.47 (95% CI 0.33 to 0.61). For the target condition cognitive impairment, in individual studies sensitivity ranged from 58% to 97% and specificity ranged from 40% to 88%. The summary diagnostic accuracy of clinical judgement of general practitioners in four studies in which a total of 594 of 1497 participants had cognitive impairment was sensitivity 84% (95% CI 60% to 95%), specificity 73% (95% CI 50% to 88%), positive likelihood ratio 3.1 (95% CI 1.4 to 4.7), and negative likelihood ratio 0.23 (95% CI 0.06 to 0.40). It was impossible to draw firm conclusions in the analysis of heterogeneity because there were small numbers of studies. For specificity we found the data were compatible with studies that used ICD-10, or applied retrospective judgement, had higher reported specificity compared to studies with DSM definitions or using prospective judgement. In contrast for sensitivity, we found studies that used a prospective index test may have had higher sensitivity than studies that used a retrospective index test. AUTHORS' CONCLUSIONS Clinical judgement of GPs is more specific than sensitive for the diagnosis of dementia. It would be necessary to use additional tests to confirm the diagnosis for either target condition, or to confirm the absence of the target conditions, but clinical judgement may inform the choice of further testing. Many people who a GP judges as having dementia will have the condition. People with false negative diagnoses are likely to have less severe disease and some could be identified by using more formal testing in people who GPs judge as not having dementia. Some false positives may require similar practical support to those with dementia, but some - such as some people with depression - may suffer delayed intervention for an alternative treatable pathology.
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Affiliation(s)
| | | | - Ryan J Langdon
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
| | - Edo Richard
- Department of Neurology, Donders Institute for Brain, Behaviour and Cognition, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands
| | | | - Sarah Cullum
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Sarah Purdy
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Yoav Ben-Shlomo
- Population Health Sciences, University of Bristol, Bristol, UK
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Midden AJ, Mast BT. Medical help-seeking intentions for cognitive impairment by the patient. Aging Ment Health 2022; 26:1078-1085. [PMID: 33860704 DOI: 10.1080/13607863.2021.1910791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objectives: Older adults represent one of the fastest growing population groups. As the aged population increases, incidence of Alzheimer's disease (AD) and other dementias will also increase. Professionals agree that early intervention is essential for therapeutic and quality of life purposes; however, many older adults wait several months or years to seek medical help after first noticing signs of cognitive impairment. The present study sought to identify the predictors of help-seeking for cognitive impairment by an individual for him/herself after the first detection of symptoms.Method: An online survey was administered to adults (N = 250) 50 years old and older. Individuals responded about their help-seeking intentions in response to a hypothetical vignette depicting symptoms of cognitive decline derived from a similar study with caregivers conducted by Qualls and colleagues. Additional standardized measures measuring constructs such as knowledge of Alzheimer's disease were completed.Results: The present study reveals that cognitive (i.e. symptom identification and disease attribution) and affective (i.e. symptom impact and threat appraisal) factors, as well as an interaction between the two, are predictive of help-seeking intentions with excellent model fit.Conclusion: Help-seeking intentions by individuals with possible cognitive impairment are comparable to those of potential caregivers. Contrary to hypotheses, high threat appraisal positively predicted help-seeking intentions despite the expectation that threat-induced fear would lead to avoidance. Recommendations are made for future research to further investigate both patients' help-seeking intentions and actions in response to signs of cognitive impairment.Supplemental data for this article is available online at https://doi.org/10.1080/13607863.2021.1910791 .
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Affiliation(s)
- Allison J Midden
- Department of Psychological and Brain Sciences, University of Louisville, Louisville, KY, USA
| | - Benjamin T Mast
- Department of Psychological and Brain Sciences, University of Louisville, Louisville, KY, USA
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de Arriba-Pérez F, García-Méndez S, González-Castaño FJ, Costa-Montenegro E. Automatic detection of cognitive impairment in elderly people using an entertainment chatbot with Natural Language Processing capabilities. JOURNAL OF AMBIENT INTELLIGENCE AND HUMANIZED COMPUTING 2022; 14:1-16. [PMID: 35529905 PMCID: PMC9053565 DOI: 10.1007/s12652-022-03849-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 04/04/2022] [Indexed: 06/14/2023]
Abstract
Previous researchers have proposed intelligent systems for therapeutic monitoring of cognitive impairments. However, most existing practical approaches for this purpose are based on manual tests. This raises issues such as excessive caretaking effort and the white-coat effect. To avoid these issues, we present an intelligent conversational system for entertaining elderly people with news of their interest that monitors cognitive impairment transparently. Automatic chatbot dialogue stages allow assessing content description skills and detecting cognitive impairment with Machine Learning algorithms. We create these dialogue flows automatically from updated news items using Natural Language Generation techniques. The system also infers the gold standard of the answers to the questions, so it can assess cognitive capabilities automatically by comparing these answers with the user responses. It employs a similarity metric with values in [0, 1], in increasing level of similarity. To evaluate the performance and usability of our approach, we have conducted field tests with a test group of 30 elderly people in the earliest stages of dementia, under the supervision of gerontologists. In the experiments, we have analysed the effect of stress and concentration in these users. Those without cognitive impairment performed up to five times better. In particular, the similarity metric varied between 0.03, for stressed and unfocused participants, and 0.36, for relaxed and focused users. Finally, we developed a Machine Learning algorithm based on textual analysis features for automatic cognitive impairment detection, which attained accuracy, F-measure and recall levels above 80%. We have thus validated the automatic approach to detect cognitive impairment in elderly people based on entertainment content. The results suggest that the solution has strong potential for long-term user-friendly therapeutic monitoring of elderly people.
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Affiliation(s)
- Francisco de Arriba-Pérez
- Information Technologies Group, atlanTTic, School of Telecommunications Engineering, University of Vigo, Campus Lagoas-Marcosende, 36310 Vigo, Spain
| | - Silvia García-Méndez
- Information Technologies Group, atlanTTic, School of Telecommunications Engineering, University of Vigo, Campus Lagoas-Marcosende, 36310 Vigo, Spain
| | - Francisco J. González-Castaño
- Information Technologies Group, atlanTTic, School of Telecommunications Engineering, University of Vigo, Campus Lagoas-Marcosende, 36310 Vigo, Spain
| | - Enrique Costa-Montenegro
- Information Technologies Group, atlanTTic, School of Telecommunications Engineering, University of Vigo, Campus Lagoas-Marcosende, 36310 Vigo, Spain
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Peters Settje KL, Yap TL, Chapman S, Brooks K, Sabol VK. Implementation of Nurse-Led Cognitive Screening During Medicare Annual Wellness Visits. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Simkins TJ, Bissig D, Moreno G, Kahlon NPK, Gorin F, Duffy A. A clinical decision rule predicting outcomes of emergency department patients with altered mental status. J Am Coll Emerg Physicians Open 2021; 2:e12522. [PMID: 34528023 PMCID: PMC8432088 DOI: 10.1002/emp2.12522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 03/07/2021] [Accepted: 07/07/2021] [Indexed: 12/19/2022] Open
Abstract
STUDY OBJECTIVE Approximately 5% of emergency department patients present with altered mental status (AMS). AMS is diagnostically challenging because of the wide range of causes and is associated with high mortality. We sought to develop a clinical decision rule predicting admission risk among emergency department (ED) patients with AMS. METHODS Using retrospective chart review of ED encounters for AMS over a 2-month period, we recorded causes of AMS and numerous clinical variables. Encounters were split into those admitted to the hospital ("cases") and those discharged from the ED ("controls"). Using the first month's data, variables correlated with hospital admission were identified and narrowed using univariate and multivariate statistics, including recursive partitioning. These variables were then organized into a clinical decision rule and validated on the second month's data. The decision rule results were also compared to 1-year mortality. RESULTS We identified 351 encounters for AMS over a 2-month period. Significant contributors to AMS included intoxication and chronic disorder decompensation. ED data predicting hospital admission included vital sign abnormalities, select lab studies, and psychiatric/intoxicant history. The decision rule sorted patients into low, moderate, or high risk of admission (11.1%, 44.3%, and 89.1% admitted, respectively) and was predictive of 1-year mortality (low-risk group 1.8%, high-risk group 34.3%). CONCLUSIONS We catalogued common causes for AMS among patients presenting to the ED, and our data-driven decision tool triaged these patients for risk of admission with good predictive accuracy. These methods for creating clinical decision rules might be further studied and improved to optimize ED patient care.
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Affiliation(s)
- Tyrell J Simkins
- Department of NeurologyUniversity of California, DavisSacramentoCaliforniaUSA
| | - David Bissig
- Department of NeurologyUniversity of California, DavisSacramentoCaliforniaUSA
| | - Gabriel Moreno
- Department of NeurologyUniversity of California, DavisSacramentoCaliforniaUSA
- Touro UniversityVallejoCaliforniaUSA
| | - Nimar Pal K Kahlon
- Department of NeurologyUniversity of California, DavisSacramentoCaliforniaUSA
| | - Fredric Gorin
- Department of NeurologyUniversity of California, DavisSacramentoCaliforniaUSA
| | - Alexandra Duffy
- Department of NeurologyUniversity of California, DavisSacramentoCaliforniaUSA
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Qian Y, Chen X, Tang D, Kelley AS, Li J. Prevalence of Memory-Related Diagnoses Among U.S. Older Adults With Early Symptoms of Cognitive Impairment. J Gerontol A Biol Sci Med Sci 2021; 76:1846-1853. [PMID: 33575783 DOI: 10.1093/gerona/glab043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Early diagnosis of cognitive impairment may confer important advantages. Yet the prevalence of memory-related diagnoses among older adults with early symptoms of cognitive impairment is unknown. METHODS A retrospective, longitudinal cohort design using 2000-2014 Health and Retirement Survey-Medicare linked data. We leveraged within-individual variation to examine the relationship between incident cognitive impairment and receipt of diagnosis among 1225 individuals aged 66 or older. Receipt of a memory-related diagnosis was determined by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Incident cognitive impairment was defined as the first assessment wherein the participant's modified Telephone Interview for Cognitive Status score was less than 12. RESULTS The unadjusted prevalence of memory-related diagnosis at cognitive impairment was 12.0%. Incident cognitive impairment was associated with a 7.3% (95% confidence interval [CI], 5.6% to 9.0%; p < .001) higher adjusted probability of any memory-related diagnosis overall, yielding 9.8% adjusted prevalence of diagnosis. The increase in likelihood of diagnosis associated with cognitive decline was significantly higher among non-Hispanic Whites than non-Hispanic Blacks (8.2% vs -0.7%), and among those with at least a college degree than those with a high school diploma or less (17.4% vs 6.8% vs 1.6%). Those who were younger, had below-median wealth, or without a partner had lower probability of diagnosis than their counterparts. CONCLUSIONS We found overall low prevalence of early diagnosis, or high rate of underdiagnosis, among older adults showing symptoms of cognitive impairment, especially among non-Whites and socioeconomically disadvantaged subgroups. Our findings call for targeted interventions to improve the rate of early diagnosis, especially among vulnerable populations.
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Affiliation(s)
- Yuting Qian
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, USA
| | - Xi Chen
- Department of Health Policy and management, Yale School of Public Health, New Haven, Connecticut, USA
| | - Diwen Tang
- Department of Health Economics, Shanghai Medical College, Fudan University, China
| | - Amy S Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, Mount Sinai, New York, USA.,James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
| | - Jing Li
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, USA
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Hollister BA, Yeh J, Ross L, Schlesinger J, Cherry D. Building an advocacy model to improve the dementia-capability of health plans in California. J Am Geriatr Soc 2021; 69:3641-3649. [PMID: 34476815 DOI: 10.1111/jgs.17429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 07/16/2021] [Accepted: 07/26/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Given the high and growing prevalence of Alzheimer's disease and related dementias, and the intensity of this population's care needs, it is imperative that healthcare systems increase their capacity to effectively serve people living with dementia (PLwD). The Dementia Cal MediConnect (Dementia CMC) project proposes an advocacy model that may foster dementia-capable systems change. METHODS The Dementia CMC project was a 5-year partnership (2013-2018) between local Alzheimer's organizations and 10 managed care health plans (HPs) in California's duals demonstration. It used an advocacy model with the following steps: (1) Identify dementia-capable best practices to set as systems change indicators; (2) Identify and leverage public policies in support of systems change indicators; (3) Identify and engage champions; (4) Develop and advocate for a business case to improve dementia care; (5) Identify gaps in dementia-capable practices; (6) Provide technical assistance, tools, and staff training to address the gaps in dementia-capable practices; and (7) Track systems change. Systems change data were collected through participant observation with HPs and interviews with key informants representing partnering organizations or government entities. RESULTS Participating HPs reported making systems changes toward more dementia-capable practices such as: better pathways for detection and diagnosis; better identification, assessment, support, and engagement of caregivers; and improved systems of referral to community-based organizations (CBOs), including Alzheimer's CBOs. Some indicators of systems change were inconclusive due to flawed assumptions around HP's care coordination, and the availability of common electronic health records between HPs and providers. CONCLUSION The application of this advocacy model in California has led to systems changes that can improve care for PLwD and their caregivers and should be replicated to expand the dementia-capability of other health systems. Continued efforts to refine indicators are needed to capture systems change in complex and changing health systems.
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Affiliation(s)
- Brooke A Hollister
- Institute for Health and Aging, University of California, San Francisco, California, USA.,Center for Care Research, University of Agder, Kristiansand, Norway
| | - Jarmin Yeh
- Institute for Health and Aging, University of California, San Francisco, California, USA
| | - Leslie Ross
- Institute for Health and Aging, University of California, San Francisco, California, USA
| | | | - Debra Cherry
- Alzheimer's Los Angeles, Los Angeles, California, USA
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Bissig D, Kaye J, Erten‐Lyons D. Validation of SATURN, a free, electronic, self-administered cognitive screening test. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2020; 6:e12116. [PMID: 33392382 PMCID: PMC7771179 DOI: 10.1002/trc2.12116] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/19/2020] [Accepted: 10/27/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cognitive screening is limited by clinician time and variability in administration and scoring. We therefore developed Self-Administered Tasks Uncovering Risk of Neurodegeneration (SATURN), a free, public-domain, self-administered, and automatically scored cognitive screening test, and validated it on inexpensive (<$100) computer tablets. METHODS SATURN is a 30-point test including orientation, word recall, and math items adapted from the Saint Louis University Mental Status test, modified versions of the Stroop and Trails tasks, and other assessments of visuospatial function and memory. English-speaking neurology clinic patients and their partners 50 to 89 years of age were given SATURN, the Montreal Cognitive Assessment (MoCA), and a brief survey about test preferences. For patients recruited from dementia clinics (n = 23), clinical status was quantified with the Clinical Dementia Rating (CDR) scale. Care partners (n = 37) were assigned CDR = 0. RESULTS SATURN and MoCA scores were highly correlated (P < .00001; r = 0.90). CDR sum-of-boxes scores were well-correlated with both tests (P < .00001) (r = -0.83 and -0.86, respectively). Statistically, neither test was superior. Most participants (83%) reported that SATURN was easy to use, and most either preferred SATURN over the MoCA (47%) or had no preference (32%). DISCUSSION Performance on SATURN-a fully self-administered and freely available (https://doi.org/10.5061/dryad.02v6wwpzr) cognitive screening test-is well-correlated with MoCA and CDR scores.
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Affiliation(s)
- David Bissig
- Department of NeurologyUniversity of California–DavisSacramentoCaliforniaUSA
| | - Jeffrey Kaye
- Department of NeurologyOregon Health and Science UniversityPortlandOregonUSA
| | - Deniz Erten‐Lyons
- Department of NeurologyVeterans Affairs Medical CenterPortlandOregonUSA
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Shadid AM, Aldayel AY, Shadid A, Alqaraishi AM, Gholah MM, Almughiseeb FA, Alessa YA, Alani HF, Khan SUD, Algarni S. Extent of and influences on knowledge of Alzheimer's disease among undergraduate medical students. J Family Med Prim Care 2020; 9:3707-3711. [PMID: 33102354 PMCID: PMC7567219 DOI: 10.4103/jfmpc.jfmpc_113_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 03/12/2020] [Accepted: 04/02/2020] [Indexed: 12/30/2022] Open
Abstract
Background: Alzheimer's disease (AD) is a major health problem, which is of increasing concern because of rising yearly incidence and estimated cost. Early diagnosis and treatment is essential to manage AD effectively and improve the outcomes. Inadequate knowledge can delay the diagnosis. General practitioners should play a more effective role in the identification and diagnosis of AD, and medical education is key to solving this issue. Objectives: This study aimed to assess the knowledge of undergraduate medical students and to identify the factors that influenced their knowledge. Methods: This study used a quantitative cross-sectional evaluation of 327 Saudi Arabian medical students from the first and final years in Riyadh, Saudi Arabia, who participated in an online survey via email between March and May 2018. Knowledge of AD was assessed using the 12-item AD Knowledge Test for Health Professionals from the University of Alabama at Birmingham (UAB ADKT). General linear models were used to identify the most significant influence on AD knowledge scores. Results: Only 10.73% of first-year and 33.33% of final-year students scored ≥ 50% on the UAB ADKT. Students pursuing specialties related to AD (adult neurology, geriatrics, or psychiatry) and students aged ≥ 27 years had higher scores (P < 0.05). Conclusion: Undergraduate medical students lacked proper knowledge of AD, suggesting that improvements in education programs can help. Future studies are needed to assess the quality and effectiveness of AD education in the curriculum of Saudi medical schools.
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Affiliation(s)
| | | | - Asem Shadid
- College of Medicine, Al Imam Mohammad ibn Saud Islamic University, Kingdom of Saudi Arabia
| | - Ali M Alqaraishi
- College of Medicine, Al Imam Mohammad ibn Saud Islamic University, Kingdom of Saudi Arabia
| | - Maha M Gholah
- College of Medicine, Al Imam Mohammad ibn Saud Islamic University, Kingdom of Saudi Arabia
| | - Fay A Almughiseeb
- College of Medicine, Al Imam Mohammad ibn Saud Islamic University, Kingdom of Saudi Arabia
| | - Yara Abdullah Alessa
- College of Medicine, Al Imam Mohammad ibn Saud Islamic University, Kingdom of Saudi Arabia
| | - Haima F Alani
- College of Medicine, Near East University, Kingdom of Saudi Arabia
| | - Salah Ud Din Khan
- Department of Biochemistry, College of Medicine, Al Imam Mohammad Ibn Saud Islamic University, Kingdom of Saudi Arabia
| | - Saleh Algarni
- Department of Clinical Neurosciences, College of Medicine, Al Imam Mohammad Ibn Saud Islamic University, Kingdom of Saudi Arabia
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13
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Casey AN, Islam MM, Schütze H, Parkinson A, Yen L, Shell A, Winbolt M, Brodaty H. GP awareness, practice, knowledge and confidence: evaluation of the first nation-wide dementia-focused continuing medical education program in Australia. BMC FAMILY PRACTICE 2020; 21:104. [PMID: 32522153 PMCID: PMC7285709 DOI: 10.1186/s12875-020-01178-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/28/2020] [Indexed: 01/04/2023]
Abstract
Background Dementia is under-diagnosed in primary care. Timely diagnosis and care management improve outcomes for patients and caregivers. This research evaluated the effectiveness of a nationwide Continuing Medical Education (CME) program to enhance dementia-related awareness, practice, knowledge and confidence of general practitioners (GPs) in Australia. Methods Data were collected from self-report surveys by GPs who participated in an accredited CME program face-to-face or online; program evaluations from GPs; and process evaluations from workshop facilitators. CME participants completed surveys at one or more time-points (pre-, post-program, six to 9 months follow-up) between 2015 and 2017. Paired samples t-test was used to determine difference in mean outcome scores (self-reported change in awareness, knowledge, confidence, practice) between time-points. Multivariable regression analyses were used to investigate associations between respondent characteristics and key variables. Qualitative feedback was analysed thematically. Results Of 1352 GPs who completed a survey at one or more time-points (pre: 1303; post: 1017; follow-up: 138), mean scores increased between pre-CME and post-program for awareness (Mpost-pre = 0.9, p < 0.0005), practice-related items (Mpost-pre = 1.3, p < 0.0005), knowledge (Mpost-pre = 2.2, p < 0.0005), confidence (Mpost-pre = 2.1, p < 0.0005). Significant increases were seen in all four outcomes for GPs who completed these surveys at both pre- and follow-up time-points. Male participants and those who had practised for five or more years showed greater change in knowledge and confidence. Age, years in practice, and education delivery method significantly predicted post-program knowledge and confidence. Most respondents who completed additional program evaluations (> 90%) rated the training as relevant to their practice. These participants, and facilitators who completed process evaluations, suggested adding more content addressing patient capacity and legal issues, locality-specific specialist and support services, case studies and videos to illustrate concepts. Conclusions The sustainability of change in key elements relating to health professionals’ dementia awareness, knowledge and confidence indicated that dementia CME programs may contribute to improving capacity to provide timely dementia diagnosis and management in general practice. Low follow-up response rates warrant cautious interpretation of results. Dementia CME should be adopted in other contexts and updated as more research becomes available.
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Affiliation(s)
- Anne-Nicole Casey
- Dementia Centre for Research Collaboration, University of New South Wales (UNSW) Sydney, AGSM Building, Sydney, NSW, 2052, Australia.,Centre for Healthy Brain Ageing, School of Psychiatry, UNSW Sydney, Sydney, NSW, 2052, Australia
| | - M Mofizul Islam
- Department of Public Health, School of Psychology and Public Health, La Trobe University, Melbourne, VIC, 3086, Australia
| | - Heike Schütze
- School of Health and Society, University of Wollongong, Wollongong, NSW, 2522, Australia.,School of Public Health and Community Medicine, UNSW Sydney, Sydney, NSW, 2052, Australia
| | - Anne Parkinson
- Department of Health Services Research & Policy, Research School of Population Health, Australian National University, Canberra, NSW, 2601, Australia
| | - Laurann Yen
- Department of Health Services Research & Policy, Research School of Population Health, Australian National University, Canberra, NSW, 2601, Australia
| | - Allan Shell
- Dementia Centre for Research Collaboration, University of New South Wales (UNSW) Sydney, AGSM Building, Sydney, NSW, 2052, Australia
| | - Margaret Winbolt
- Dementia Training Australia, La Trobe University, Melbourne, VIC, 3086, Australia
| | - Henry Brodaty
- Dementia Centre for Research Collaboration, University of New South Wales (UNSW) Sydney, AGSM Building, Sydney, NSW, 2052, Australia. .,Centre for Healthy Brain Ageing, School of Psychiatry, UNSW Sydney, Sydney, NSW, 2052, Australia. .,Academic Department for Old Age Psychiatry, Prince of Wales Hospital, Randwick, NSW, 2031, Australia.
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14
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Fowler NR, Head KJ, Perkins AJ, Gao S, Callahan CM, Bakas T, Suarez SD, Boustani MA. Examining the benefits and harms of Alzheimer's disease screening for family members of older adults: study protocol for a randomized controlled trial. Trials 2020; 21:202. [PMID: 32075686 PMCID: PMC7031904 DOI: 10.1186/s13063-019-4029-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 12/23/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Multiple national expert panels have identified early detection of Alzheimer's disease and related dementias (ADRD) as a national priority. However, the United States Preventive Services Task Force (USPSTF) does not currently support screening for ADRD in primary care given that the risks and benefits are unknown. The USPSTF stresses the need for research examining the impact of ADRD screening on family caregiver outcomes. METHODS The Caregiver Outcomes of Alzheimer's Disease Screening (COADS) is a randomized controlled trial that will examine the potential benefits or harms of ADRD screening on family caregivers. It will also compare the effectiveness of two strategies for diagnostic evaluation and management after ADRD screening. COADS will enroll 1800 dyads who will be randomized into three groups (n = 600/group): the 'Screening Only' group will receive ADRD screening at baseline and disclosure of the screening results, with positive-screen participants receiving a list of local resources for diagnostic follow-up; the 'Screening Plus' group will receive ADRD screening at baseline coupled with disclosure of the screening results, with positive-screen participants referred to a dementia collaborative care program for diagnostic evaluation and potential care; and the control group will receive no screening. The COADS trial will measure the quality of life of the family member (the primary outcome) and family member mood, anxiety, preparedness and self-efficacy (the secondary outcomes) at baseline and at 6, 12, 18 and 24 months. Additionally, the trial will examine the congruence of depressive and anxiety symptoms between older adults and family members at 6, 12, 18 and 24 months and compare the effectiveness of two strategies for diagnostic evaluation and management after ADRD screening between the two groups randomized to screening (Screening Only versus Screening Plus). DISCUSSION We hypothesize that caregivers in the screening arms will express higher levels of health-related quality of life, lower depressive and anxiety symptoms, and better preparation for caregiving with higher self-efficacy at 24 months. Results from this study will directly inform the National Plan to Address Alzheimer's Disease, the USPSTF and other organizations regarding ADRD screening and early detection policies. TRIAL REGISTRATION ClinicalTrials.gov, NCT03300180. Registered on 3 October.
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Affiliation(s)
- Nicole R. Fowler
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202 USA
- Indiana University Center for Aging Research, Indianapolis, IN 46202 USA
- Regenstrief Institute, Inc., Indianapolis, IN 46202 USA
- Center for Health Innovation and Implementation Science, Indiana Clinical and Translational Science Institute, Indianapolis, IN 46202 USA
| | - Katharine J. Head
- Department of Communication Studies, Indiana University-Purdue University Indianapolis, Indianapolis, IN 46202 USA
| | - Anthony J. Perkins
- Department of Biostatistics, Indiana University School of Medicine & Richard M. Fairbanks School of Public Health, Indianapolis, IN 46202 USA
| | - Sujuan Gao
- Department of Biostatistics, Indiana University School of Medicine & Richard M. Fairbanks School of Public Health, Indianapolis, IN 46202 USA
| | - Christopher M. Callahan
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202 USA
- Indiana University Center for Aging Research, Indianapolis, IN 46202 USA
- Regenstrief Institute, Inc., Indianapolis, IN 46202 USA
- Eskenazi Health, Indianapolis, IN 46202 USA
| | - Tamilyn Bakas
- College of Nursing, University of Cincinnati, Cincinnati, OH 45219 USA
| | - Shelley D. Suarez
- Indiana University Center for Aging Research, Indianapolis, IN 46202 USA
- Regenstrief Institute, Inc., Indianapolis, IN 46202 USA
| | - Malaz A. Boustani
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202 USA
- Indiana University Center for Aging Research, Indianapolis, IN 46202 USA
- Regenstrief Institute, Inc., Indianapolis, IN 46202 USA
- Center for Health Innovation and Implementation Science, Indiana Clinical and Translational Science Institute, Indianapolis, IN 46202 USA
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15
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Bernstein A, Rogers KM, Possin KL, Steele NZR, Ritchie CS, Kramer JH, Geschwind M, Higgins JJ, Wohlgemuth J, Pesano R, Miller BL, Rankin KP. Dementia assessment and management in primary care settings: a survey of current provider practices in the United States. BMC Health Serv Res 2019; 19:919. [PMID: 31783848 PMCID: PMC6884754 DOI: 10.1186/s12913-019-4603-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 10/03/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Primary 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. METHODS A 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. RESULTS PCPs 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. CONCLUSIONS This 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.
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Affiliation(s)
- Alissa Bernstein
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, USA. .,Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, USA.
| | - Kirsten M Rogers
- Department of Neurology, University of California San Francisco, San Francisco, USA
| | - Katherine L Possin
- Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, USA.,Department of Neurology, University of California San Francisco, San Francisco, USA
| | | | - Christine S Ritchie
- Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, USA.,Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Joel H Kramer
- Department of Neurology, University of California San Francisco, San Francisco, USA
| | - Michael Geschwind
- Department of Neurology, University of California San Francisco, San Francisco, USA
| | | | | | | | - Bruce L Miller
- Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, USA.,Department of Neurology, University of California San Francisco, San Francisco, USA
| | - Katherine P Rankin
- Department of Neurology, University of California San Francisco, San Francisco, USA
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Abstract
Computerized cognitive assessment tools may facilitate early identification of dementia in the primary care setting. We investigated primary care physicians' (PCPs') views on advantages and disadvantages of computerized testing based on their experience with the Computer Assessment of Mild Cognitive Impairment (CAMCI). Over a 2-month period, 259 patients, 65 years and older, from the family practice of 13 PCPs completed the CAMCI. Twelve PCPs participated in an individual interview. Generally, PCPs felt that the relationship between them and their patients helped facilitate cognitive testing; however, they thought available paper tests were time consuming and not sufficiently informative. Despite concerns regarding elderly patients' computer literacy, PCPs noticed high completion rates and that their patients had generally positive experiences completing the CAMCI. PCPs appreciated the time-saving advantage of the CAMCI and the immediately generated report, but thought the report should be shortened to 1 page and that PCPs should receive training in its interpretation. Our results suggest that computerized cognitive tools such as the CAMCI can address PCPs' concerns with cognitive testing in their offices. Recommendations to improve the practicality of computerized testing in primary care were suggested.
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Abstract
BACKGROUND Dementia in the elderly constitutes a growing challenge in healthcare worldwide, including Hungary. There is no previous report on the role of general practitioners in the management of dementia. AIM The purpose of the present study was to investigate the Hungarian general practitioners' attitude toward their patients living with dementia as well as dementia care. Our goal was also to assess their willingness and habits in assessing dementia. Additionally we wanted to explore the role of education about dementia, and its impact on their attitude in dementia management. METHODS As part of a large survey, a self-administered questionnaire was filled out voluntarily by 402 of general practitioners. According to our preset criteria, 277 surveys were selected for evaluation. Descriptive statistical analysis and Likert-scale analysis were performed. FINDINGS Half of the doctors (49.8%) indicated that they conducted a test to assess cognitive functions in case of suspicion. Among the respondents who did not assess, 50.0% of physicians cited lack of time as the main reason for not doing so and 14.4% of them had not proper knowledge of testing methods. The respondents most often mentioned feelings toward their patients with dementia, were regret (Likert-scale mean: 3.33), helplessness (3.28) and sadness (3.07). The majority of physicians thought the treatment of dementia was difficult (4.46). Most of the respondents (81.2%) indicated that in the past 2 years they had not participated in any training about dementia. Those practitioners who had participated in some form of education were less likely to feel helpless facing a patient with dementia, and education also determined their approach to dementia care.
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18
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Bissig D, DeCarli CS. Global & Community Health: Brief in-hospital cognitive screening anticipates complex admissions and may detect dementia. Neurology 2019; 92:631-634. [PMID: 30910941 PMCID: PMC6453772 DOI: 10.1212/wnl.0000000000007176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE With the long-term goal of improving community health by screening for dementia, we tested the utility of integrating the Six-Item Screener (SIS) into our emergency department neurology consultations. METHODS In this cross-sectional observational study, we measured SIS performance within 24 hours of hospital arrival in 100 consecutive English-speaking patients aged ≥45 years. Performance was compared to patient age, previously charted cognitive impairment, and proxies for in-hospital complexity: whether or not a patient was admitted to the hospital and the number of medical studies ordered. RESULTS Those with poor SIS performance were older (p = 0.02) and more likely to have previously charted cognitive impairment (p < 0.01; sensitivity 86%, specificity 77%). Poor performers were more likely to be admitted to the hospital (p = 0.04; odds ratio 3.6) and were subjected to more tests once admitted (p < 0.01), relationships that persisted after accounting for age and history of cognitive impairment. CONCLUSIONS Poor performance on the SIS was associated with previously charted cognitive impairment, justifying future study of its ability to detect unrecognized dementia cases. Until then, its ability to inexpensively anticipate medically complex hospital admissions motivates broader emergency department use of the SIS.
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Affiliation(s)
- David Bissig
- From the Department of Neurology (D.B.), Oregon Health & Science University, Portland; and Department of Neurology (C.S.D.), University of California-Davis.
| | - Charles S DeCarli
- From the Department of Neurology (D.B.), Oregon Health & Science University, Portland; and Department of Neurology (C.S.D.), University of California-Davis
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19
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Schütze H, Shell A, Brodaty H. Development, implementation and evaluation of Australia's first national continuing medical education program for the timely diagnosis and management of dementia in general practice. BMC MEDICAL EDUCATION 2018; 18:194. [PMID: 30097036 PMCID: PMC6086051 DOI: 10.1186/s12909-018-1295-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 07/25/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Dementia is the second leading cause of death in Australia. Over half of patients with dementia are undiagnosed in primary care. This paper describes the development, implementation and initial evaluation of the first national continuing medical education program on the timely diagnosis and management of dementia in general practice in Australia. METHODS Continuing medical education workshops were developed and run in 16 urban and rural locations across Australia (12 were delivered as small group workshops, four as large groups), and via online modules. Two train-the-trainer workshops were held. The target audience was general practitioners, however, international medical graduates, GP registrars, other doctors, primary care nurses and other health professionals were also welcome. Self-complete questionnaires were used for the evaluation. RESULTS Of 1236 people (GPs, other doctors, nurses and other health professionals) who participated in the program, 609 completed the full program (small group workshops (282), large group workshops (75), online modules (252)); and 627 elected to undertake one or more individual submodules (large group workshops (444), online program (183)). Of those who completed the full program as a small group workshop, 14 undertook the additional Train-the-trainer program. 76% of participants felt that their learning needs were entirely met and 78% felt the program was entirely relevant to their practice. CONCLUSION Continuing medical education programs are an effective method to deliver education to GPs. A combination of face-to-face and online delivery modes increases reach to primary care providers. Train-the-trainer sessions and online continuing medical education programs promote long-term delivery sustainability. Further research is required to determine the long-term knowledge translation effects of the program.
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Affiliation(s)
- Heike Schütze
- School of Health and Society, University of Wollongong, Wollongong, NSW 2522 Australia
| | - Allan Shell
- Dementia Centre for Research Collaboration, UNSW Australia, Level 3, AGSM Building, Sydney, 2052 Australia
| | - Henry Brodaty
- Dementia Centre for Research Collaboration, UNSW Australia, Level 3, AGSM Building, Sydney, 2052 Australia
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20
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Maslow K, Fortinsky RH. Nonphysician Care Providers Can Help to Increase Detection of Cognitive Impairment and Encourage Diagnostic Evaluation for Dementia in Community and Residential Care Settings. THE GERONTOLOGIST 2018; 58:S20-S31. [DOI: 10.1093/geront/gnx171] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Indexed: 11/13/2022] Open
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21
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Tóth L, Hoffmann I, Gosztolya G, Vincze V, Szatlóczki G, Bánréti Z, Pákáski M, Kálmán J. A Speech Recognition-based Solution for the Automatic Detection of Mild Cognitive Impairment from Spontaneous Speech. Curr Alzheimer Res 2018; 15:130-138. [PMID: 29165085 PMCID: PMC5815089 DOI: 10.2174/1567205014666171121114930] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 09/10/2017] [Accepted: 11/15/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Even today the reliable diagnosis of the prodromal stages of Alzheimer's disease (AD) remains a great challenge. Our research focuses on the earliest detectable indicators of cognitive decline in mild cognitive impairment (MCI). Since the presence of language impairment has been reported even in the mild stage of AD, the aim of this study is to develop a sensitive neuropsychological screening method which is based on the analysis of spontaneous speech production during performing a memory task. In the future, this can form the basis of an Internet-based interactive screening software for the recognition of MCI. METHODS Participants were 38 healthy controls and 48 clinically diagnosed MCI patients. The provoked spontaneous speech by asking the patients to recall the content of 2 short black and white films (one direct, one delayed), and by answering one question. Acoustic parameters (hesitation ratio, speech tempo, length and number of silent and filled pauses, length of utterance) were extracted from the recorded speech signals, first manually (using the Praat software), and then automatically, with an automatic speech recognition (ASR) based tool. First, the extracted parameters were statistically analyzed. Then we applied machine learning algorithms to see whether the MCI and the control group can be discriminated automatically based on the acoustic features. RESULTS The statistical analysis showed significant differences for most of the acoustic parameters (speech tempo, articulation rate, silent pause, hesitation ratio, length of utterance, pause-per-utterance ratio). The most significant differences between the two groups were found in the speech tempo in the delayed recall task, and in the number of pauses for the question-answering task. The fully automated version of the analysis process - that is, using the ASR-based features in combination with machine learning - was able to separate the two classes with an F1-score of 78.8%. CONCLUSION The temporal analysis of spontaneous speech can be exploited in implementing a new, automatic detection-based tool for screening MCI for the community.
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Affiliation(s)
- László Tóth
- MTA-SZTE Research Group on Artificial Intelligence, Szeged, Hungary
| | - Ildikó Hoffmann
- Linguistics Department, University of Szeged, Szeged, Hungary
- Research Institute for Linguistics, Hungarian Academy of Sciences, Budapest, Hungary
| | - Gábor Gosztolya
- MTA-SZTE Research Group on Artificial Intelligence, Szeged, Hungary
| | - Veronika Vincze
- MTA-SZTE Research Group on Artificial Intelligence, Szeged, Hungary
| | | | - Zoltán Bánréti
- Research Institute for Linguistics, Hungarian Academy of Sciences, Budapest, Hungary
| | | | - János Kálmán
- Department of Psychiatry, University of Szeged, Szeged, Hungary
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22
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Mehta HB, Mehta V, Goodwin JS. Association of Hypoglycemia With Subsequent Dementia in Older Patients With Type 2 Diabetes Mellitus. J Gerontol A Biol Sci Med Sci 2017; 72:1110-1116. [PMID: 27784724 DOI: 10.1093/gerona/glw217] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 10/12/2016] [Indexed: 12/18/2022] Open
Abstract
Background Studies have found conflicting evidence regarding the association of hypoglycemia with dementia. We evaluated an association of hypoglycemia with subsequent dementia in patients with type 2 diabetes. Methods This retrospective longitudinal cohort study used the Clinical Practice Research Datalink, an electronic medical records data from the United Kingdom, from 2003 to 2012. We included patients aged >65 years diagnosed with type 2 diabetes, with no prior diagnosis of dementia. Dementia was defined using diagnosis codes from medical records. All patients were followed from the date of initial diabetes diagnosis. To account for competing risk of death, we used Fine and Gray's competing risk model to determine the association of hypoglycemia with dementia while adjusting for potential confounders. Hypoglycemia was modeled as a time-dependent covariate. Results Of 53,055 patients, 5.7% (n = 3,018) had at least one hypoglycemia episodes. The overall incidence rate of dementia was 12.7 per 1,000 person-years. In the fully adjusted model that controlled for all confounders, the occurrence of at least one hypoglycemia episode was associated with 27% higher odds of subsequent dementia (hazard ratio = 1.27; 95% confidence interval = 1.06-1.51). The risk increased with the number of hypoglycemia episodes: one episode (hazard ratio = 1.26; 95% confidence interval = 1.03-1.54); two or more episodes (hazard ratio = 1.50; 95% confidence interval = 1.09-2.08). Conclusions Hypoglycemia is associated with a higher risk of dementia and may be responsible in part for the higher risk of dementia in patients with diabetes. Alternatively, hypoglycemia may be a marker for undiagnosed cognitive impairment, and we cannot rule out the possibility of reverse causation between hypoglycemia and dementia.
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Affiliation(s)
| | | | - James S Goodwin
- Department of Internal Medicine, University of Texas Medical Branch, Galveston
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23
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Singleton D, Mukadam N, Livingston G, Sommerlad A. How people with dementia and carers understand and react to social functioning changes in mild dementia: a UK-based qualitative study. BMJ Open 2017; 7:e016740. [PMID: 28706105 PMCID: PMC5541577 DOI: 10.1136/bmjopen-2017-016740] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To analyse people with dementia and their family carers' attribution of social changes in dementia and the consequences of these attributions. DESIGN Qualitative study, using a semi-structured interview guide. Individual interviews continued to theoretical saturation. Two researchers independently analysed interview transcripts. SETTING AND PARTICIPANTS People with mild dementia and family carers purposively selected from London-based memory services for diverse demographic characteristics to encompass a range of experiences. PRIMARY AND SECONDARY OUTCOMES Attribution of social changes experienced by the person with dementia and the consequences of these attributions. RESULTS We interviewed nine people with dementia and nine carers, encompassing a range of age, ethnicity and educational backgrounds.Both groups reported that the person with dementia had changed socially. People with dementia tended to give one or two explanations for social change, but carers usually suggested several. People with dementia were often socially embarrassed or less interested in going out, and they or their relatives' physical illness or fear of falls led to reduced social activity. Carers often attributed not going out to a choice or premorbid personality. Carers found that their relative needed more support to go out than they could give and carers needed time to themselves because of carer stress or other problems from which they shielded the person with dementia. Additionally, there was decreased opportunity to socialise, as people were bereaved of friends and family. Participants acknowledged the direct impact of dementia symptoms on their ability to socially engage but sometimes decided to give up socialising when they knew they had dementia. There were negative consequences from social changes being attributed to factors such as choice, rather than dementia. CONCLUSION Clinicians should ask about social changes in people with dementia. Explaining that these may be due to dementia and considering strategies to overcome them may be beneficial.
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Affiliation(s)
- David Singleton
- Division of Psychiatry, University College London, London, UK
| | - Naaheed Mukadam
- Division of Psychiatry, University College London, London, UK
- Camden and Islington NHS Foundation Trust, St Pancras Hospital, London, UK
| | - Gill Livingston
- Division of Psychiatry, University College London, London, UK
- Camden and Islington NHS Foundation Trust, St Pancras Hospital, London, UK
| | - Andrew Sommerlad
- Division of Psychiatry, University College London, London, UK
- Camden and Islington NHS Foundation Trust, St Pancras Hospital, London, UK
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Bentvelzen A, Aerts L, Seeher K, Wesson J, Brodaty H. A Comprehensive Review of the Quality and Feasibility of Dementia Assessment Measures: The Dementia Outcomes Measurement Suite. J Am Med Dir Assoc 2017; 18:826-837. [PMID: 28283381 DOI: 10.1016/j.jamda.2017.01.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 01/11/2017] [Indexed: 12/19/2022]
Abstract
The diagnosis of dementia and the management of its associated symptoms are aided by high-quality assessment tools. However, there is disagreement on the optimal tools among abundant alternatives and lack of consistent quality standards across the different domains of dementia-related change (ie, cognition, severity, function, behavioral and psychological symptoms, delirium, quality of life). Standardization is difficult because the relevance of a measurement tool for health professionals may depend on the clinical setting and on the dementia type and severity. To address this need, we conducted a comprehensive and clinically relevant evidence-based review of dementia-related tools and present a set of recommended tools, the Dementia Outcomes Measurement Suite. The review revealed that considerable development has occurred in terms of assessment of persons with mild cognitive impairment, executive dysfunction, cognitively mediated functional change, and apathy. More research is needed to develop and validate tools to assess health-related quality of life and specific symptoms of dementia including anxiety, wandering, and repetitive vocalizations. This extensive overview of the quality of different measures may serve as a guide for health professionals clinically and for researchers developing new or improved dementia assessment tools.
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Affiliation(s)
- Adam Bentvelzen
- Dementia Collaborative Research Center (DCRC) Network, University of New South Wales Australia, Sydney, Australia
| | - Liesbeth Aerts
- Dementia Collaborative Research Center (DCRC) Network, University of New South Wales Australia, Sydney, Australia
| | - Katrin Seeher
- Dementia Collaborative Research Center (DCRC) Network, University of New South Wales Australia, Sydney, Australia
| | - Jacqueline Wesson
- Aging Work and Health Research Unit, Faculty of Health Sciences, University of Sydney, Sydney, Australia
| | - Henry Brodaty
- Dementia Collaborative Research Center (DCRC) Network, University of New South Wales Australia, Sydney, Australia; Center for Healthy Brain Aging (CHeBA), University of New South Wales Australia, Sydney, Australia.
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Lang L, Clifford A, Wei L, Zhang D, Leung D, Augustine G, Danat IM, Zhou W, Copeland JR, Anstey KJ, Chen R. Prevalence and determinants of undetected dementia in the community: a systematic literature review and a meta-analysis. BMJ Open 2017; 7:e011146. [PMID: 28159845 PMCID: PMC5293981 DOI: 10.1136/bmjopen-2016-011146] [Citation(s) in RCA: 278] [Impact Index Per Article: 39.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Detection of dementia is essential for improving the lives of patients but the extent of underdetection worldwide and its causes are not known. This study aimed to quantify the prevalence of undetected dementia and to examine its correlates. METHODS/SETTING/PARTICIPANTS A systematic search was conducted until October 2016 for studies reporting the proportion of undetected dementia and/or its determinants in either the community or in residential care settings worldwide. Random-effects models calculated the pooled rate of undetected dementia and subgroup analyses were conducted to identify determinants of the variation. PRIMARY AND SECONDARY OUTCOME MEASURES The outcome measures of interest were the prevalence and determinants of undetected dementia. RESULTS 23 studies were eligible for inclusion in this review. The pooled rate of undetected dementia was 61.7% (95% CI 55.0% to 68.0%). The rate of underdetection was higher in China and India (vs Europe and North America), in the community setting (vs residential/nursing care), age of <70 years, male gender and diagnosis by general practitioner. However, it was lower in the studies using Mini-Mental State Examination (MMSE) diagnosis criteria. CONCLUSIONS The prevalence of undetected dementia is high globally. Wide variations in detecting dementia need to be urgently examined, particularly in populations with low socioeconomic status. Efforts are required to reduce diagnostic inequality and to improve early diagnosis in the community.
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Affiliation(s)
- Linda Lang
- Faculty of Education, Health and Wellbeing University of Wolverhampton, Wolverhampton, UK
- Post Graduate Academic Institute of Medicine, University of Wolverhampton, Wolverhampton, UK
| | - Angela Clifford
- Faculty of Education, Health and Wellbeing University of Wolverhampton, Wolverhampton, UK
| | - Li Wei
- Department of Practice and Policy, University College London, London, UK
| | - Dongmei Zhang
- School of Health Administration, Anhui Medical University, China
| | - Daryl Leung
- New Cross Hospital, The Royal Wolverhampton NHS Trust, UK
| | - Glenda Augustine
- Department of Public Health, Wolverhampton City Council, Wolverhampton, UK
| | - Isaac M Danat
- Faculty of Education, Health and Wellbeing University of Wolverhampton, Wolverhampton, UK
| | - Weiju Zhou
- Faculty of Education, Health and Wellbeing University of Wolverhampton, Wolverhampton, UK
| | - John R Copeland
- Department of Psychiatry, University of Liverpool, Liverpool, UK
| | - Kaarin J Anstey
- Dementia Collaborative Research Centre-Early Diagnosis and Prevention, Centre for Research on Ageing, Health and Wellbeing, Research School of Population Health, The Australian National University, Canberra, Australia
| | - Ruoling Chen
- Faculty of Education, Health and Wellbeing University of Wolverhampton, Wolverhampton, UK
- Post Graduate Academic Institute of Medicine, University of Wolverhampton, Wolverhampton, UK
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Sivananthan SN, McGrail KM. Diagnosis and Disruption: Population-Level Analysis Identifying Points of Care at Which Transitions Are Highest for People with Dementia and Factors That Contribute to Them. J Am Geriatr Soc 2016; 64:569-77. [PMID: 27000330 DOI: 10.1111/jgs.14033] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To examine transitions that individuals with dementia experience longitudinally and to identify points of care when transitions are highest and the factors that contribute to those transitions. DESIGN Population-based 10-year retrospective cohort study from 2000 to 2011. SETTING General community. PARTICIPANTS All individuals aged 65 and older newly diagnosed with dementia in British Columbia, Canada. MEASUREMENTS The frequency and timing of transitions over 10 years, participant characteristics associated with greater number of transitions, and the influence of recommended dementia care and high-quality primary care on number of transitions. RESULTS Individuals experience a spike in transitions during the year of diagnosis, driven primarily by hospitalizations, despite accounting for end of life or newly moving to a long-term care facility (LTCF). This occurs regardless of survival time or care location. Regardless of survival time, individuals not in LTCFs experience a marked increase in hospitalizations in the year before and the year of death, often exceeding hospitalizations in the year of diagnosis. Receipt of recommended dementia care and receipt of high-quality primary care were independently associated with fewer transitions across care settings. CONCLUSION The spike in transitions in the year of diagnosis highlights a distressing period for individuals with dementia during which unwanted or unnecessary transitions might occur and suggests a useful target for interventions. There is an association between recommended dementia care and outcomes and evidence of the continued value of high-quality primary care in a complex population at a critical point when gaps in continuity are especially likely.
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Affiliation(s)
- Saskia N Sivananthan
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kimberlyn M McGrail
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
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Khodabakhsh A, Demiroglu C. Analysis of speech-based measures for detecting and monitoring Alzheimer's disease. Methods Mol Biol 2016; 1246:159-73. [PMID: 25417086 DOI: 10.1007/978-1-4939-1985-7_11] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Automatic diagnosis of the Alzheimer's disease as well as monitoring of the diagnosed patients can make significant economic impact on societies. We investigated an automatic diagnosis approach through the use of speech based features. As opposed to standard tests, spontaneous conversations are carried and recorded with the subjects. Speech features could discriminate between healthy people and the patients with high reliability. Although the patients were in later stages of Alzheimer's disease, results indicate the potential of speech-based automated solutions for Alzheimer's disease diagnosis. Moreover, the data collection process employed here can be done inexpensively by call center agents in a real-life application. Thus, the investigated techniques hold the potential to significantly reduce the financial burden on governments and Alzheimer's patients.
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Kasper JD, Freedman VA, Spillman BC, Wolff JL. The Disproportionate Impact Of Dementia On Family And Unpaid Caregiving To Older Adults. Health Aff (Millwood) 2015; 34:1642-9. [PMID: 26438739 PMCID: PMC4635557 DOI: 10.1377/hlthaff.2015.0536] [Citation(s) in RCA: 211] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The number of US adults ages sixty-five and older who are living with dementia is substantial and expected to grow, raising concerns about the demands that will be placed on family members and other unpaid caregivers. We used data from the 2011 National Health and Aging Trends Study and its companion study, the National Study of Caregiving, to investigate the role of dementia in caregiving. We found that among family and unpaid caregivers to older noninstitutionalized adults, one-third of caregivers, and 41 percent of the hours of help they provide, help people with dementia, who account for about 10 percent of older noninstitutionalized adults. Among older adults who receive help, the vast majority in both community and residential care settings other than nursing homes rely on family or unpaid caregivers (more than 90 percent and more than 80 percent, respectively), regardless of their dementia status. Caregiving is most intense, however, to older adults with dementia in community settings and from caregivers who are spouses or daughters or who live with the care recipient.
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Affiliation(s)
- Judith D Kasper
- Judith D. Kasper is a professor of health policy and management in the Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland
| | - Vicki A Freedman
- Vicki A. Freedman is a research professor in the Institute for Social Research at the University of Michigan, in Ann Arbor
| | - Brenda C Spillman
- Brenda C. Spillman is a senior fellow in the Health Policy Center at the Urban Institute, in Washington, D.C
| | - Jennifer L Wolff
- Jennifer L. Wolff is an associate professor of health policy and management in the Johns Hopkins Bloomberg School of Public Health
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Yu X, Chen S, Chen X, Jia J, Li C, Liu C, Toumi M, Milea D. Clinical management and associated costs for moderate and severe Alzheimer's disease in urban China: a Delphi panel study. Transl Neurodegener 2015; 4:15. [PMID: 26301090 PMCID: PMC4546035 DOI: 10.1186/s40035-015-0038-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 08/09/2015] [Indexed: 11/10/2022] Open
Abstract
Background Healthcare resource utilisation for Alzheimer’s disease (AD) in China is not well understood. This Delphi panel study aimed to describe the clinical management pathways for moderate and severe AD patients in urban China and to define the amount and cost of healthcare resources used. Methods A panel of 11 experts was recruited from urban China to participate in two rounds of preparatory interviews. In the first round, 9 physicians specialised in dementia gave a qualitative description of the clinical management of AD patients. In the second round, 2 hospital administrators were asked about the cost of AD management and care. Results from the interviews were discussed by the experts in a Delphi panel meeting, where consensus was reached on quantitative aspects of AD management, including the rate of healthcare resource utilisation, the respective unit costs and caregiving time. Results Interviewees reported that mild AD is under-recognised in China; most patients are diagnosed with moderate to severe AD. Loss of independence and agitation/aggression are the main drivers for healthcare resource utilisation and contribute to a heavier caregiver burden. It was estimated that 70 % moderate AD patients are independent/non-aggressive at the time of diagnosis, 15 % are independent/aggressive, 10 % are dependent/non-aggressive, and 5 % are dependent/aggressive. Dependent/aggressive AD patients are more likely to be hospitalised (70–90 %) than accepted in a nursing home (0–20 %), while the opposite is true for dependent/non-aggressive patients (5–35 % for hospitalisation vs. 80 % for nursing home). Independent AD patients require 1–3 hours/day of caregiver time, while dependent patients can require up to 12–15 hours/day. Experts agreed that AD complicates the management of age-related comorbidities, found in 70–80 % of all AD patients, increasing the frequency and cost of hospitalisation. Conclusions The Delphi panel approach was an efficient method of gathering data about the amount of healthcare resources used and associated costs for moderate and severe AD patients in urban China. The results of this study provide a useful source of information for decision makers to improve future healthcare policies and resource planning, as well as to perform economic evaluations of AD therapies.
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Affiliation(s)
- Xin Yu
- Institute of Mental Health, Peking University Sixth Hospital, Huayuanbeilu 51, Haidian District, Beijing, 100191 China
| | - Shengdi Chen
- Department of Neurology, Ruijin Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaochun Chen
- Fujian Institute of Geriatrics, Union Hospital of Fujian Medical University, Fuzhou, China
| | - Jianjun Jia
- Department of Geriatric Neurology, Chinese PLA General Hospital, Beijing, China
| | - Chunhou Li
- Medical Services Department, Peking Union Medical College Hospital, Beijing, China
| | - Cong Liu
- Beijing Tongren Hospital, Capital Medical University, Beijing, China
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Feasibility and validity of the self-administered computerized assessment of mild cognitive impairment with older primary care patients. Alzheimer Dis Assoc Disord 2015; 28:311-9. [PMID: 24614274 DOI: 10.1097/wad.0000000000000036] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
We investigated whether a validated computerized cognitive test, the Computerized Assessment of Mild Cognitive Impairment (CAMCI), could be independently completed by older primary care patients. We also determined the optimal cut-off for the CAMCI global risk score for mild cognitive impairment against an independent neuropsychological reference standard. All eligible patients aged 65 years and older, seen consecutively over 2 months by 1 family practice of 13 primary care physicians, were invited to participate. Patients with a diagnosis or previous work-up for dementia were excluded. Primary care physicians indicated whether they, the patient, or family had concerns about each patient's cognition. A total of 130 patients with cognitive concerns and a matched sample of 133 without cognitive concerns were enrolled. The CAMCI was individually administered after instructions to work independently. Comments were recorded verbatim. A total of 259 (98.5%) completed the entire CAMCI. Two hundred and forty-one (91.6%) completed it without any questions or after simple acknowledgment of their question. Lack of computer experience was the only patient characteristic that decreased the odds of independent CAMCI completion. These results support the feasibility of using self-administered computerized cognitive tests with older primary care patients, given the increasing reliance on computers by people of all ages. The optimal cut-off score had a sensitivity of 80% and specificity of 74%.
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Fowler NR, Morrow L, Chiappetta L, Snitz B, Huber K, Rodriguez E, Saxton J. Cognitive testing in older primary care patients: A cluster-randomized trial. ALZHEIMER'S & DEMENTIA: DIAGNOSIS, ASSESSMENT & DISEASE MONITORING 2015; 1:349-357. [PMID: 26380844 PMCID: PMC4568843 DOI: 10.1016/j.dadm.2015.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction This study investigated whether neuropsychological testing in primary care (PC) offices altered physician-initiated interventions related to cognitive impairment (CI) or slowed the rate of CI progression. Methods This 24-month, cluster-randomized study included 11 community-based PC practices randomized to either treatment as usual (5 practices) or cognitive report (CR; 6 practices) arms. From 2005 to 2008, 533 patients aged ≥65 years and without a diagnosis of CI were recruited; 423 were retested 24 months after baseline. Results CR physicians were significantly more likely to order cognitive-related interventions (P = .02), document discussions about cognition (P = .003), and order blood tests to rule out reversible CI (P = .002). At follow-up, significantly more CR patients had a medication for cognition listed in their chart (P = .02). There was no difference in the rate of cognitive decline between the groups. Discussion Providing cognitive information to physicians resulted in higher rates of physician-initiated interventions for patients with CI.
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Affiliation(s)
- Nicole R Fowler
- Department of Medicine, School of Medicine, Regenstrief Institute, Indiana University, Indianapolis, IN, USA
| | - Lisa Morrow
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Beth Snitz
- Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kimberly Huber
- Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Eric Rodriguez
- Department of Medicine, School of Medicine, Regenstrief Institute, Indiana University, Indianapolis, IN, USA
| | - Judith Saxton
- Department of Medicine, School of Medicine, Regenstrief Institute, Indiana University, Indianapolis, IN, USA ; Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Savva GM, Arthur A. Who has undiagnosed dementia? A cross-sectional analysis of participants of the Aging, Demographics and Memory Study. Age Ageing 2015; 44:642-7. [PMID: 25758406 DOI: 10.1093/ageing/afv020] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 01/07/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND delays in diagnosing dementia may lead to suboptimal care, yet around half of those with dementia are undiagnosed. Any strategy for case finding should be informed by understanding the characteristics of the undiagnosed population. We used cross-sectional data from a population-based sample with dementia aged 71 years and older in the United States to describe the undiagnosed population and identify factors associated with non-diagnosis. METHODS the Aging, Demographics and Memory Study (ADAMS) Wave A participants (N = 856) each underwent a detailed neuropsychiatric investigation. Informants were asked whether the participant had ever received a doctor's diagnosis of dementia. We used multiple logistic regression to identify factors associated with informant report of a prior dementia diagnosis among those with a study diagnosis of dementia. RESULTS of those with a study diagnosis of dementia (n = 307), a prior diagnosis of dementia was reported by 121 informants (weighted proportion = 42%). Prior diagnosis was associated with greater clinical dementia rating (CDR), from 26% (CDR = 1) to 83% (CDR = 5). In multivariate analysis, those aged 90 years or older were less likely to be diagnosed (P = 0.008), but prior diagnosis was more common among married women (P = 0.038) and those who had spent more than 9 years in full-time education (P = 0.043). CONCLUSIONS people with dementia who are undiagnosed are older, have fewer years in education, are more likely to be unmarried, male and have less severe dementia than those with a diagnosis. Policymakers and clinicians should be mindful of the variation in diagnosis rates among subgroups of the population with dementia.
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Affiliation(s)
- George M Savva
- School of Health Sciences, University of East Anglia, Edith Cavell Building, Norwich Research Park, Norwich NR4 7TJ, UK
| | - Antony Arthur
- School of Health Sciences, University of East Anglia, Edith Cavell Building, Norwich Research Park, Norwich NR4 7TJ, UK
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Lyons BE, Austin D, Seelye A, Petersen J, Yeargers J, Riley T, Sharma N, Mattek N, Wild K, Dodge H, Kaye JA. Pervasive Computing Technologies to Continuously Assess Alzheimer's Disease Progression and Intervention Efficacy. Front Aging Neurosci 2015; 7:102. [PMID: 26113819 PMCID: PMC4462097 DOI: 10.3389/fnagi.2015.00102] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 05/13/2015] [Indexed: 11/24/2022] Open
Abstract
Traditionally, assessment of functional and cognitive status of individuals with dementia occurs in brief clinic visits during which time clinicians extract a snapshot of recent changes in individuals’ health. Conventionally, this is done using various clinical assessment tools applied at the point of care and relies on patients’ and caregivers’ ability to accurately recall daily activity and trends in personal health. These practices suffer from the infrequency and generally short durations of visits. Since 2004, researchers at the Oregon Center for Aging and Technology (ORCATECH) at the Oregon Health and Science University have been working on developing technologies to transform this model. ORCATECH researchers have developed a system of continuous in-home monitoring using pervasive computing technologies that make it possible to more accurately track activities and behaviors and measure relevant intra-individual changes. We have installed a system of strategically placed sensors in over 480 homes and have been collecting data for up to 8 years. Using this continuous in-home monitoring system, ORCATECH researchers have collected data on multiple behaviors such as gait and mobility, sleep and activity patterns, medication adherence, and computer use. Patterns of intra-individual variation detected in each of these areas are used to predict outcomes such as low mood, loneliness, and cognitive function. These methods have the potential to improve the quality of patient health data and in turn patient care especially related to cognitive decline. Furthermore, the continuous real-world nature of the data may improve the efficiency and ecological validity of clinical intervention studies.
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Affiliation(s)
- Bayard E Lyons
- Oregon Center for Aging and Technology, Oregon Health and Science University , Portland, OR , USA ; Department of Neurology, Oregon Health and Science University , Portland, OR , USA
| | - Daniel Austin
- Oregon Center for Aging and Technology, Oregon Health and Science University , Portland, OR , USA ; Department of Biomedical Engineering, Oregon Health and Science University , Portland, OR , USA
| | - Adriana Seelye
- Oregon Center for Aging and Technology, Oregon Health and Science University , Portland, OR , USA ; Department of Neurology, Oregon Health and Science University , Portland, OR , USA
| | - Johanna Petersen
- Oregon Center for Aging and Technology, Oregon Health and Science University , Portland, OR , USA ; Department of Biomedical Engineering, Oregon Health and Science University , Portland, OR , USA
| | - Jonathan Yeargers
- Oregon Center for Aging and Technology, Oregon Health and Science University , Portland, OR , USA
| | - Thomas Riley
- Oregon Center for Aging and Technology, Oregon Health and Science University , Portland, OR , USA
| | - Nicole Sharma
- Oregon Center for Aging and Technology, Oregon Health and Science University , Portland, OR , USA
| | - Nora Mattek
- Oregon Center for Aging and Technology, Oregon Health and Science University , Portland, OR , USA ; Department of Neurology, Oregon Health and Science University , Portland, OR , USA
| | - Katherine Wild
- Oregon Center for Aging and Technology, Oregon Health and Science University , Portland, OR , USA ; Department of Neurology, Oregon Health and Science University , Portland, OR , USA
| | - Hiroko Dodge
- Oregon Center for Aging and Technology, Oregon Health and Science University , Portland, OR , USA ; Department of Neurology, Oregon Health and Science University , Portland, OR , USA
| | - Jeffrey A Kaye
- Oregon Center for Aging and Technology, Oregon Health and Science University , Portland, OR , USA ; Department of Neurology, Oregon Health and Science University , Portland, OR , USA ; Department of Biomedical Engineering, Oregon Health and Science University , Portland, OR , USA ; Neurology Service, Portland Veteran Affairs Medical Center , Portland, OR , USA
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Dixon J, Ferdinand M, D'Amico F, Knapp M. Exploring the cost-effectiveness of a one-off screen for dementia (for people aged 75 years in England and Wales). Int J Geriatr Psychiatry 2015; 30:446-52. [PMID: 25043227 DOI: 10.1002/gps.4158] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 05/07/2014] [Accepted: 05/23/2014] [Indexed: 11/10/2022]
Abstract
OBJECTIVE This paper examines the numbers of people with dementia who could be diagnosed and the likely cost-effectiveness of a one-off screen for dementia for people aged 75 years in England and Wales. METHODS The study uses static decision modelling to compare a one-off screen for dementia with a no-screen scenario. Estimates for the model were drawn from systematic reviews, high-quality studies and government and administrative sources. A panel of experts also advised the study. RESULTS An estimated 3514 people could be diagnosed as a result of screening, 2152 of whom would otherwise never receive a diagnosis. The study identified societal economic impact of between £3,649,794 (net costs) and £4,685,768 (net savings), depending on assumptions. CONCLUSIONS Our analysis suggests that screening could be cost-effective, especially as treatments and social care interventions become more effective and if diagnosis by current routes remains low or occurs later than is optimal. This study was, however, limited by available evidence and a range of quality of life benefits, cost savings and potential harms could not be quantified. It was also beyond the scope of this study to consider dynamic factors such as repeat screening, mortality, disease trajectories or trends in the numbers of people with dementia. A larger study would be needed for this, involving more complex and innovative approaches to generating estimates for modelling. We did not compare population screening for people aged 75 years to other methods for increasing diagnosis rates.
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Affiliation(s)
- Josie Dixon
- Personal Social Services Research Unit, London School of Economics, London, UK
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Dodd E, Cheston R, Fear T, Brown E, Fox C, Morley C, Jefferies R, Gray R. An evaluation of primary care led dementia diagnostic services in Bristol. BMC Health Serv Res 2014; 14:592. [PMID: 25432385 PMCID: PMC4264325 DOI: 10.1186/s12913-014-0592-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 11/10/2014] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Typically people who go to see their GP with a memory problem will be initially assessed and those patients who seem to be at risk will be referred onto a memory clinic. The demographic forces mean that memory services will need to expand to meet demand. An alternative may be to expand the role of primary care in dementia diagnosis and care. The aim of this study was to contrast patient, family member and professional experience of primary and secondary (usual) care led memory services. METHODS A qualitative, participatory study. A topic guide was developed by the peer and professional panels. Data were collected through peer led interviews of people with dementia, their family members and health professionals. RESULTS Eleven (21%) of the 53 GP practices in Bristol offered primary care led dementia services. Three professional panels were held and were attended by 9 professionals; nine carers but no patients were involved in the three peer panels. These panels identified four main themes: GPs rarely make independent dementia diagnosis; GPs and memory nurses work together; patients and carers generally experience a high quality diagnostic service; an absence of post diagnostic support. Evidence relating to these themes was collected through a total of 46 participants took part; 23 (50%) in primary care and 23 (50%) in the memory service. CONCLUSIONS Patients and carers were generally satisfied with either primary or secondary care led approaches to dementia diagnosis. Their major concern, shared with many health care professionals, was a lack of post diagnostic support.
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Affiliation(s)
- Emily Dodd
- UWE Bristol, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK.
| | - Richard Cheston
- UWE Bristol, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK.
| | - Tina Fear
- UWE Bristol, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK.
| | - Ellie Brown
- UWE Bristol, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK.
| | - Chris Fox
- The University of East Anglia and Norfolk and Suffolk NHS Foundation Trust, Norwich, UK.
| | - Clare Morley
- Bristol Memory Service, Callington Road Hospital, Devon Partnership NHS Trust, Bristol, BS4 5PJ, UK.
| | - Rosalyn Jefferies
- Bristol Community Health, South Plaza, Marlborough Street, Bristol, BS1 3NX, UK.
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Barnes DE, Beiser AS, Lee A, Langa KM, Koyama A, Preis SR, Neuhaus J, McCammon RJ, Yaffe K, Seshadri S, Haan MN, Weir DR. Development and validation of a brief dementia screening indicator for primary care. Alzheimers Dement 2014; 10:656-665.e1. [PMID: 24491321 PMCID: PMC4119094 DOI: 10.1016/j.jalz.2013.11.006] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 10/29/2013] [Accepted: 11/07/2013] [Indexed: 01/30/2023]
Abstract
BACKGROUND Detection of "any cognitive impairment" is mandated as part of the Medicare annual wellness visit, but screening all patients may result in excessive false positives. METHODS We developed and validated a brief Dementia Screening Indicator using data from four large, ongoing cohort studies (the Cardiovascular Health Study [CHS]; the Framingham Heart Study [FHS]; the Health and Retirement Study [HRS]; the Sacramento Area Latino Study on Aging [SALSA]) to help clinicians identify a subgroup of high-risk patients to target for cognitive screening. RESULTS The final Dementia Screening Indicator included age (1 point/year; ages, 65-79 years), less than 12 years of education (9 points), stroke (6 points), diabetes mellitus (3 points), body mass index less than 18.5 kg/m(2) (8 points), requiring assistance with money or medications (10 points), and depressive symptoms (6 points). Accuracy was good across the cohorts (Harrell's C statistic: CHS, 0.68; FHS, 0.77; HRS, 0.76; SALSA, 0.78). CONCLUSIONS The Dementia Screening Indicator is a simple tool that may be useful in primary care settings to identify high-risk patients to target for cognitive screening.
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Affiliation(s)
- Deborah E Barnes
- Department of Psychiatry, University of California, San Francisco, CA, USA; Department of Epidemiology & Biostatistics, University of California, San Francisco, CA, USA; Veterans Affairs Medical Center, San Francisco, CA, USA.
| | - Alexa S Beiser
- Department of Neurology, Boston University, Boston, MA, USA; Department of Biostatistics, Boston University, Boston, MA, USA
| | - Anne Lee
- Department of Epidemiology & Biostatistics, University of California, San Francisco, CA, USA
| | - Kenneth M Langa
- Institute for Social Research, University of Michigan, Ann Arbor, MI, USA; Department of Medicine, University of Michigan, Ann Arbor, MI, USA; Veterans Affairs Center for Practice Management and Outcomes Research, Ann Arbor, MI, USA
| | - Alain Koyama
- Northern California Institute for Research and Education, San Francisco, CA, USA
| | - Sarah R Preis
- Department of Neurology, Boston University, Boston, MA, USA
| | - John Neuhaus
- Department of Epidemiology & Biostatistics, University of California, San Francisco, CA, USA
| | - Ryan J McCammon
- Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | - Kristine Yaffe
- Department of Psychiatry, University of California, San Francisco, CA, USA; Department of Neurology, University of California, San Francisco, CA, USA; Department of Epidemiology & Biostatistics, University of California, San Francisco, CA, USA; Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Sudha Seshadri
- Department of Neurology, Boston University, Boston, MA, USA; Department of Biostatistics, Boston University, Boston, MA, USA
| | - Mary N Haan
- Department of Epidemiology & Biostatistics, University of California, San Francisco, CA, USA
| | - David R Weir
- Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
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Min L, Kerr EA, Blaum CS, Reuben D, Cigolle C, Wenger N. Contrasting effects of geriatric versus general medical multimorbidity on quality of ambulatory care. J Am Geriatr Soc 2014; 62:1714-21. [PMID: 25123154 DOI: 10.1111/jgs.12989] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine whether greater burden of geriatric conditions would have contrasting effects on quality of care (QOC) than nongeriatric, general medical conditions. DESIGN Cross-sectional observation over 1 year of ambulatory care. SETTING The Assessing Care of Vulnerable Elders-2 study. PARTICIPANTS Older adults prospectively screened for falls, incontinence, and dementia (N = 644). MEASUREMENTS Participant-level QOC in absolute percentage points calculated using 65 ambulatory care care-process quality indicators (QIs) for 13 general medical and geriatric conditions (#QIs provided/#QIs eligible). Secondary outcomes were geriatric QOC (a subset of 38 geriatric care QIs) and medical QOC (the 27 remaining nongeriatric QIs). Exposure variables were number of six medical conditions (medical comorbidity) and six geriatric conditions (geriatric comorbidity), controlling for age, sex, number of primary care visits, and site. RESULTS Medical and geriatric comorbidity were unrelated to each other (correlation coefficient = 0.04, P = .27) yet had opposite effects on QOC. Each additional medical condition was associated with a 3.2-percentage point (95% confidence interval (CI) = 2.3-4.2 percentage point) increment in QOC, and each additional geriatric condition was associated with 4.9-percentage point (95% CI = 3.5-6.5 percentage point) decrement in QOC. Participants with greater geriatric comorbidity received poorer medical and geriatric QOC. CONCLUSION Greater burden of geriatric conditions, or geriatric multimorbidity, is associated with poorer QOC. Geriatric multimorbidity should be targeted for better care using a comprehensive approach.
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Affiliation(s)
- Lillian Min
- Division of Geriatrics, Department of Medicine, University of Michigan, Ann Arbor, Michigan; Geriatrics Research, Education and Clinical Care Center, Ann Arbor Veterans Affairs Healthcare System, Ann Arbor, Michigan
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George NR, Steffen AM. Promoting medication adherence in older adults through early diagnosis of neurocognitive disorders. Prim Care Companion CNS Disord 2014; 16:14m01686. [PMID: 25834766 DOI: 10.4088/pcc.14m01686] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 07/30/2014] [Indexed: 09/29/2022] Open
Abstract
OBJECTIVE Community-dwelling older adults with neurocognitive disorders experience high risk of and often suffer severe consequences from medication nonadherence. Due to the important role of informal caregivers in the care of patients with neurocognitive disorders, medication management involves both patients and families. A formal diagnosis of a neurocognitive disorder may improve both provider-patient and provider-family communications and resulting regimen adherence, yet many with signs of neurocognitive disorders remain undiagnosed. The goal of this study was to examine the differences in medication management behaviors for family caregivers of mildly impaired older adults with or without a formal neurocognitive disorder diagnosis. METHOD The study included 112 women who provided at least 2 forms of medication assistance for a mildly cognitively impaired older adult with (n = 38, 34%) or without (n = 75, 66%) a reported neurocognitive disorder diagnosis and who completed online self-assessments of medication adherence and self-efficacy for medication management from May 2012 to May 2013. Cases were selected for analyses based on analog Clinical Dementia Rating scores between 0.5 and 1, indicating mild cognitive impairment in the older adult. RESULTS Compared to families unaware of a neurocognitive disorder diagnosis, caregivers reporting knowledge of a neurocognitive disorder diagnosis in their older family member endorsed higher medication management self-efficacy and increased levels of adherence-related behaviors. Step-wise logistic regression analyses demonstrated statistical significance in using these adherence and self-efficacy variables to differentiate between the presence or absence of a known neurocognitive disorder diagnosis (N = 112, χ (2) 6 = 22.84, P < .05). CONCLUSIONS A formally charted and communicated neurocognitive disorder diagnosis is associated with improved medication management behaviors and medication-related self-efficacy in neurocognitive disorder family caregivers.
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Affiliation(s)
- Nika R George
- Department of Psychology, University of Missouri, St Louis
| | - Ann M Steffen
- Department of Psychology, University of Missouri, St Louis
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Improving dementia diagnosis and management in primary care: a cohort study of the impact of a training and support program on physician competency, practice patterns, and community linkages. BMC Geriatr 2013; 13:134. [PMID: 24325194 PMCID: PMC3878895 DOI: 10.1186/1471-2318-13-134] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 12/03/2013] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Primary care physicians routinely provide dementia care, but may lack the clinical skills and awareness of available resources to provide optimal care. We conducted a community-based pilot dementia training intervention designed to both improve clinical competency and increase utilization of local dementia care services. METHODS Physicians (N = 29) and affiliated staff (N = 24) participated in a one-day training program on dementia screening, diagnosis and management that included direct engagement with local support service providers. Questionnaires about their dementia care competency and referral patterns were completed before and 6 months after the training intervention. RESULTS Physicians reported significantly higher overall confidence in their dementia care competency 6 months post-training compared to pre-training. The largest reported improvements were in their ability to educate patients and caregivers about dementia and making appropriate referrals to community care services. Participants also reported markedly increased use of cognitive screening tools in providing care. Community service providers recorded approximately 160 physician-initiated referrals over a 2 year-period post-training, compared to few beforehand. CONCLUSIONS Combining a targeted physician practice-based educational intervention with community service engagement improves dementia care competency in clinicians and promotes linkages between clinical and community dementia care providers.
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Meuser TM, Carr DB, Berg-Weger M, Irmiter C, Peters KE, Schwartzberg JG. The instructional impact of the American Medical Association's Older Drivers Project online curriculum. GERONTOLOGY & GERIATRICS EDUCATION 2013; 35:64-85. [PMID: 24266732 DOI: 10.1080/02701960.2013.823603] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The Older Drivers Project (ODP) of the American Medical Association has provided evidence-based training for clinicians since 2003. More than 10,000 physicians and other professionals have been trained via an authoritative manual, the Physician's Guide to Assessing & Counseling Older Drivers, and an associated continuing medical education five-module curriculum offered formally by multidisciplinary teams from 12 U.S. States from 2003 to 2008. An hour-long, online version was piloted with medical residents and physicians (N = 259) from six academic and physician office sites from 2010 to 2011. Pre/postsurveys were completed. Most rated the curriculum of high quality and relevant to their practice. A majority (88%) reported learning a new technique or tool, and 89% stated an intention to incorporate new learning into their daily clinical practice. More than one half (62%) reported increased confidence in addressing driving. This transition from in-person to online instruction will allow the ODP to reach many more clinicians, at all levels of training, in the years to come.
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Affiliation(s)
- Thomas M Meuser
- a Gerontology Graduate Program, School of Social Work, University of Missouri-St. Louis , St. Louis , Missouri , USA
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Helmer C, Malet F, Rougier MB, Schweitzer C, Colin J, Delyfer MN, Korobelnik JF, Barberger-Gateau P, Dartigues JF, Delcourt C. Is there a link between open-angle glaucoma and dementia? The Three-City-Alienor cohort. Ann Neurol 2013; 74:171-9. [PMID: 23686609 DOI: 10.1002/ana.23926] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 04/12/2013] [Accepted: 04/19/2013] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Previous research has suggested an association between dementia and glaucoma through common risk factors or mechanisms. Our aim was to evaluate the longitudinal relationship between open-angle glaucoma (OAG) and incident dementia. METHODS The Three-City-Bordeaux-Alienor study is a population-based cohort of 812 participants with a 3-year follow-up period. All participants were aged 72 years or older. An eye examination was performed on all subjects. An OAG was determined based on optic nerve damage and visual field loss. Incident dementia was actively screened for and confirmed by a neurologist. RESULTS A total of 41 participants developed dementia over the 3-year follow-up period. Future incident dementia cases had an increased prevalence of OAG (17.5% vs 4.5% for nondemented participants, p = 0.003). After adjustment for age, gender, education, family history of glaucoma, vascular comorbidities, and apolipoprotein ε4, our results showed that participants with an OAG were four times more likely to develop dementia during the 3-year follow-up period (odds ratio = 3.9, 95% confidence interval = 1.5-10.4, p = 0.0054). An increased risk of dementia was also associated with 2 markers of optic nerve degeneration (vertical cup:disk ratio and minimal rim:disk ratio). However, no association was found between a high intraocular pressure and/or the use of intraocular pressure-lowering medications and incident dementia. INTERPRETATION If the association between OAG and dementia is confirmed, direct and noninvasive quantification of the amount of retinal ganglion cell axonal loss may be a useful biomarker of cerebral axonal loss in the future. It may also offer new breakthroughs in understanding the underlying pathophysiological mechanisms of both diseases.
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Affiliation(s)
- Catherine Helmer
- National Institute of Health and Medical Research (INSERM) Center U897-Biostatistical Epidemiology, Institute of Public Health and Development (ISPED), Bordeaux, France; University of Bordeaux Segalen 2, Bordeaux, France; National Institute of Health and Medical Research Clinical Investigation Center Clinical Epidemiology 7 (CIC-EC7), Bordeaux, France
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Duane FM, Goeman DP, Beanland CJ, Koch SH. The role of a clinical nurse consultant dementia specialist: A qualitative evaluation. DEMENTIA 2013; 14:436-49. [PMID: 24339107 DOI: 10.1177/1471301213498759] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Delay in diagnosis and difficulties in accessing appropriate health care services plague dementia care delivery in the community setting, potentiating the risk for misdiagnosis, inappropriate management, poor psychological adjustment and reduced coping capacity and ability to forward plan. We evaluated a clinical nurse consultant role with a speciality in dementia to provide person-centred pre-diagnosis support in the community. Clients, with a six-month history of cognitive and functional decline in the absence of delirium but no formal diagnosis of dementia, were recruited from a Home Care Nursing Service and an Aged Care Assessment Service located in the Western Suburbs of Melbourne, Victoria, Australia. The role of a clinical nurse consultant was highly regarded by clients and other health professionals. This paper discussing the CNC role and the outcomes of the role suggests it was successful in providing timely assistance and support for consumers and support for other health professionals.
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Affiliation(s)
- Fleur M Duane
- Royal District Nursing Service, Altona, Victoria, Australia
| | - Dianne P Goeman
- Royal District Nursing Service, RDNS Institute, St Kilda, Victoria, Australia
| | - Chris J Beanland
- Royal District Nursing Service, RDNS Institute, St Kilda, Victoria, Australia
| | - Susan H Koch
- Royal District Nursing Service, RDNS Institute, St Kilda, Victoria, Australia
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Geldmacher DS, Kirson NY, Birnbaum HG, Eapen S, Kantor E, Cummings AK, Joish VN. Pre-diagnosis excess acute care costs in Alzheimer's patients among a US Medicaid population. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2013; 11:407-413. [PMID: 23700254 DOI: 10.1007/s40258-013-0038-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND AND OBJECTIVES Prior research has documented that Alzheimer's disease (AD) is associated with increased costs from comorbid conditions. However, little is known about medical resource utilization and costs among AD patients prior to the onset of cognitive symptoms. This study estimates excess acute care costs among Medicaid AD patients in the year prior to diagnosis. STUDY DESIGN Administrative claims data for New Jersey Medicaid patients over the period 1997-2010 were retrospectively analyzed. The study focused on non-institutionalized AD patients and examined their medical costs compared with matched controls with no dementia over the 12 months prior to their preliminary diagnosis. Costs reflect amounts reimbursed by Medicaid to medical service providers, reported in 2010 US dollars. RESULTS The study sample included 11,536 AD patients who were matched to controls. Average age was 76 years, and 76.2 % were female. Compared with matched controls, total medical costs over the 12-month pre-index period were US$ 5,549 higher among AD patients (US$ 14,977 vs. US$ 9,428, p < 0.001), of which US$ 3,321 (p < 0.001) was due to outpatient services. Home care and medical daycare services accounted for US $1,442 (p < 0.001) of the difference. Emergency department visits and inpatient care accounted for only a small fraction of the excess costs. CONCLUSIONS Compared with controls, Medicaid AD patients incurred higher acute care costs in the 12 months prior to their preliminary diagnosis, suggesting room for beneficial interventions and better disease management should earlier diagnosis become possible. These findings may be especially relevant in light of new criteria facilitating earlier diagnosis of AD.
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Affiliation(s)
- David S Geldmacher
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Nagle BJ, Usita PM, Edland SD. United States medical students' knowledge of Alzheimer disease. JOURNAL OF EDUCATIONAL EVALUATION FOR HEALTH PROFESSIONS 2013; 10:4. [PMID: 23750313 PMCID: PMC3674970 DOI: 10.3352/jeehp.2013.10.4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 05/21/2013] [Indexed: 05/25/2023]
Abstract
PURPOSE A knowledge gap exists between general physicians and specialists in diagnosing and managing Alzheimer disease (AD). This gap is concerning due to the estimated rise in prevalence of AD and cost to the health care system. Medical school is a viable avenue to decrease the gap, educating future physicians before they specialize. The purpose of this study was to assess the knowledge level of students in their first and final years of medical school. METHODS Fourteen participating United States medical schools used e-mail student rosters to distribute an online survey of a quantitative cross-sectional assessment of knowledge about AD; 343 students participated. Knowledge was measured using the 12-item University of Alabama at Birmingham AD Knowledge Test for Health Professionals. General linear models were used to examine the effect of demographic variables and previous experience with AD on knowledge scores. RESULTS Only 2.5% of first year and 68.0% of final year students correctly scored ten or more items on the knowledge scale. Personal experience with AD predicted higher knowledge scores in final year students (P= 0.027). CONCLUSION Knowledge deficiencies were common in final year medical students. Future studies to identify and evaluate the efficacy of AD education programs in medical schools are warranted. Identifying and disseminating effective programs may help close the knowledge gap.
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Affiliation(s)
- Brian J. Nagle
- Graduate School of Public Health, San Diego State University, San Diego, CA,
USA
| | - Paula M. Usita
- Graduate School of Public Health, San Diego State University, San Diego, CA,
USA
| | - Steven D. Edland
- Departments of Family and Preventive Medicine and Neurosciences, University of California, San Diego, CA,
USA
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Abstract
This article reviews the current recommendations in early diagnosis and the desires of the patients and their relatives, put in perspective with the reality of the clinical practices. More specific situations covered are: (1) the issue of young diseased patients, taking into account the psychological implications of the early occurrence of the disease in life and of the longer delay for these patients between the first observable signs and the diagnosis and (2) the issue of genetic testing, taking into account the implications of this extremely early form of bad news on the individual's existence and on the family structure.
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Pond CD, Brodaty H, Stocks NP, Gunn J, Marley J, Disler P, Magin P, Paterson N, Horton G, Goode S, Paine B, Mate KE. Ageing in general practice (AGP) trial: a cluster randomised trial to examine the effectiveness of peer education on GP diagnostic assessment and management of dementia. BMC FAMILY PRACTICE 2012; 13:12. [PMID: 22397614 PMCID: PMC3323889 DOI: 10.1186/1471-2296-13-12] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 03/07/2012] [Indexed: 11/24/2022]
Abstract
Background Dementia is increasing in prevalence as the population ages. An earlier rather than later diagnosis allows persons with dementia and their families to plan ahead and access appropriate management. However, most diagnoses are made by general practitioners (GPs) later in the course of the disease and are associated with management that is poorly adherent to recommended guidelines. This trial examines the effectiveness of a peer led dementia educational intervention for GPs. Methods The study is a cluster randomised trial, conducted across three states and five sites. All GPs will complete an audit of their consenting patients aged 75 years or more at three time points - baseline, 12 and 24 months. GPs allocated to the intervention group will receive two educational sessions from a peer GP or nurse, and will administer the GPCOG to consenting patients at baseline and 12 months. The first education session will provide information about dementia and the second will provide individualised feedback on audit results. GPs in the waitlist group will receive the RACGP Guidelines by post following the 12 month audit Outcomes: Primary outcomes are carer and consumer quality of life and depression. Secondary outcomes include: rates of GP identification of dementia compared to a more detailed gold standard assessment conducted in the patient's home; GP identification of differential diagnoses including reversible causes of cognitive impairment; and GP referral to specialists, Alzheimers' Australia and support services. A "case finding" and a "screening" group will be compared and the psychometrics of the GPCOG will be examined. Sample size: Approximately 2,000 subjects aged 75 years and over will be recruited through approximately 160 GPs, to yield approximately 200 subjects with dementia (reducing to 168 by 24 months). Discussion The trial outlined in this paper has been peer reviewed and supported by the Australian National Health and Medical Research Council. At the time of submission of this paper 2,034 subjects have been recruited and the intervention delivered to 114 GPs. Trial registration Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12607000117415.
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Affiliation(s)
- Constance D Pond
- School of Medicine and Population Health, University of Newcastle, Newcastle, Australia 2308
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Maximizing the value of diagnostics in Alzheimer's disease drug development. Nat Rev Drug Discov 2012; 11:183-4. [PMID: 22378261 DOI: 10.1038/nrd3535] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Mitchell AJ, Meader N, Pentzek M. Clinical recognition of dementia and cognitive impairment in primary care: a meta-analysis of physician accuracy. Acta Psychiatr Scand 2011; 124:165-83. [PMID: 21668424 DOI: 10.1111/j.1600-0447.2011.01730.x] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We aimed to examine the ability of the general practitioners (GPs) to recognize a spectrum of cognitive impairment from mild cognitive impairment (MCI) to severe dementia in routine practice using their own clinical judgment. METHOD Using PRISMA criteria, a meta-analysis of studies testing clinical judgment and clinical documentation was conducted against semi-structured interviews (for dementia) and cognitive tests (for cognitive impairment). We located 15 studies reporting on dementia, seven studies that examined recognition of broadly defined cognitive impairment, and eight regarding MCI. RESULTS By clinical judgment, clinicians were able to identify 73.4% of people with dementia and 75.5% of those without dementia but they made correct annotations in medical records in only 37.9% of cases (and 90.5% of non-cases). For cognitive impairment, detection sensitivity was 62.8% by clinician judgment but 33.1% according to medical records. Specificity was 92.6% for those without cognitive impairment by clinical judgment. Regarding MCI, GPs recognized 44.7% of people with MCI, although this was recorded in medical notes only 10.9% of the time. Their ability to identify healthy individuals without MCI was between 87.3% and 95.5% (detection specificity). CONCLUSION GPs have considerable difficulty identifying those with MCI and those with mild dementia and are generally poor at recording such diagnoses in medical records.
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Affiliation(s)
- Alex J Mitchell
- Leicester General Hospital, Leicestershire Partnership Trust, UK.
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Roark B, Mitchell M, Hosom JP, Hollingshead K, Kaye J. Spoken Language Derived Measures for Detecting Mild Cognitive Impairment. IEEE TRANSACTIONS ON AUDIO, SPEECH, AND LANGUAGE PROCESSING 2011; 19:2081-2090. [PMID: 22199464 PMCID: PMC3244269 DOI: 10.1109/tasl.2011.2112351] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Spoken responses produced by subjects during neuropsychological exams can provide diagnostic markers beyond exam performance. In particular, characteristics of the spoken language itself can discriminate between subject groups. We present results on the utility of such markers in discriminating between healthy elderly subjects and subjects with mild cognitive impairment (MCI). Given the audio and transcript of a spoken narrative recall task, a range of markers are automatically derived. These markers include speech features such as pause frequency and duration, and many linguistic complexity measures. We examine measures calculated from manually annotated time alignments (of the transcript with the audio) and syntactic parse trees, as well as the same measures calculated from automatic (forced) time alignments and automatic parses. We show statistically significant differences between clinical subject groups for a number of measures. These differences are largely preserved with automation. We then present classification results, and demonstrate a statistically significant improvement in the area under the ROC curve (AUC) when using automatic spoken language derived features in addition to the neuropsychological test scores. Our results indicate that using multiple, complementary measures can aid in automatic detection of MCI.
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Affiliation(s)
- Brian Roark
- Center for Spoken Language Understanding, Department of Biomedical Engineering, Oregon Health and Science University, Portland, OR 97239 USA
| | - Margaret Mitchell
- Department of Computing Science, University of Aberdeen, Aberdeen AB24 3UE, U.K
| | - John-Paul Hosom
- Center for Spoken Language Understanding, Department of Biomedical Engineering, Oregon Health and Science University, Portland, OR 97239 USA
| | - Kristy Hollingshead
- Center for Spoken Language Understanding, Oregon Health and Science University, Portland, OR 97239 USA. She is now with the Institute for Advanced Computer Studies, University of Maryland, College Park, MD, USA
| | - Jeffrey Kaye
- Departments of Neurology and Biomedical Engineering, and Layton Aging and Alzheimer’s Disease Center, Oregon Health and Science University, Portland, OR 97239 USA, and also with the Portland Veterans Affairs Medical Center, Portland, OR, USA
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