Routine Check-Ups and Other Factors Affecting Discussions With a Health Care Provider About Subjective Memory Complaints, Behavioral Risk Factor Surveillance System, 21 States, 2011

Self-administered gerocognitive examination (SAGE) aids early detection of cognitive impairment at primary care provider visits

Introduction

Current estimates indicate that up to 50-75% of dementia cases are undiagnosed at an early stage when treatments are most effective. Conducting robust accurate cognitive assessments can be time-consuming for providers and difficult to incorporate into a time-limited Primary Care Provider (PCP) visit. We wanted to compare PCP visits with and without using the self-administered SAGE to determine differences in identification rates of new cognitive disorders.

Methods

Three hundred patients aged 65-89 without diagnosed cognitive disorders completing a non-acute office visit were enrolled (ClinicalTrials.gov identifier: NCT04063371). Two PCP offices conducted routine visits for 100 consecutive eligible patients each. One office used the SAGE in an additional 100 subjects and asked available informants about cognitive changes over the previous year. Chart reviews were conducted 60 days later. One-way analysis of variance and Fisher exact tests were used to compare the groups and outcomes.

Results

When SAGE was utilized, the PCP documented the detection of new cognitive conditions/concerns six times (9% versus 1.5%) as often (p = 0.003). The detection rate was nearly 4-fold for those with cognitively impaired SAGE scores (p = 0.034). Patients having impaired SAGE score and informant concerns were 15-fold as likely to have new cognitive conditions/concerns documented (p = 0.0007). Among providers using SAGE, 86% would recommend SAGE to colleagues.

Discussion

SAGE was easily incorporated into PCP visits and significantly increased identification of new cognitive conditions/concerns leading to new diagnoses, treatment, or management changes. The detection rate increased 15-fold for those with impaired SAGE scores combined with informant reports.

Subjective Memory Complaints Predict Decline in Memory, Instrumental Activities of Daily Living, and Social Participation in Older Adults: A Fixed-Effects Model

IMPORTANCE

Although subjective memory complaints (SMCs) have been suggested to be associated with future memory impairment, limitations in instrumental activities of daily living (IADLs), and social participation restriction, these associations are still inconclusive.

OBJECTIVE

To determine whether changes in SMCs over time predict decline in memory, IADLs, and social participation in older adults.

DESIGN

Longitudinal study.

SETTING

Community.

PARTICIPANTS

Sample 1 included 2,493 community-dwelling older adults drawn from the Health and Retirement Study (HRS) data collected between 2004 and 2018. Sample 2 included 1,644 community-dwelling older adults drawn from the HRS data collected between 2008 and 2018.

OUTCOMES AND MEASURES

Self-reported SMCs, memory function, self-reported IADL performance, and self-reported social participation.

RESULTS

The mean age of Sample 1 at baseline was 70.16 yr; 1,468 (58.88%) were female. In Sample 1, immediate and delayed memory (all ps < .001) and IADL performance (p < .01) declined over time. Increases in SMCs over time significantly predicted future immediate and delayed memory declines (p < .01 and p < .001, respectively) and future IADL performance decline (p < .001), after controlling for depressive symptoms. The mean age of Sample 2 at baseline was 71.52 yr; 928 (56.45%) were female. In Sample 2, social participation declined over time (all ps < .001). Increases in SMCs over time significantly predicted future social participation decline (p < .05), after controlling for depressive symptoms.

CONCLUSIONS AND RELEVANCE

Increases in SMCs predict future decline in memory, IADL performance, and social participation after accounting for depressive symptoms. What This Article Adds: SMCs can be used as an early indicator of future memory impairment, IADL limitations, and social participation restrictions in older adults. Furthermore, interventions that minimize SMCs may help older adults achieve successful aging.

Barriers to seeking care for memory problems: A vignette study

INTRODUCTION

This study compares how older adults judge the need for follow-up care for memory-related problems when they are responding about themselves versus someone of the same age.

METHODS

Adults ages 65 and over in the Understanding America Study, a nationally representative internet panel, were invited to participate in a short survey with three vignettes describing memory-related problems associated with normal aging, mild cognitive impairment, and mild dementia. Respondents were randomly assigned to vignettes about themselves or about an individual of the same age and asked whether the problems warranted follow-up discussion with a health-care provider. Unadjusted and covariate-adjusted differences in the percent of affirmative responses to follow-up discussion and an index, ranging from 0 to 3, that summed affirmative responses, were compared across respondents randomly assigned to self- versus other-framed vignettes.

RESULTS

One thousand six hundred twenty-eight panel members (81.6%) completed the survey (mean age, 72.3 [range, 65-102], 801 female [49.2%] and 827 male [50.8%]) with 796 (48.9%) randomly assigned to vignettes about themselves and 832 (51.1%) to vignettes about individuals of the same age. Percent affirming need for follow-up ranged from 66.9% to 90.5% and was systematically lower for those randomized to vignettes about themselves. The differences ranged from -10.8 percentage points (95% confidence interval [CI], -13.6 to -7.9 percentage points) for the most severe to -13.9 percentage points (95% CI, -18.1 to -9.7 percentage points) for the mildest memory-related problem vignettes. The summary index was -0.444 points (95% CI, 0.563 to -0.326) or 0.491 of a standard deviation (95% CI, 0.622σ to -0.362σ) lower for scenarios about participants themselves relative to others.

DISCUSSION

Seniors were more likely to recognize and recommend follow-up for memory-related problems affecting someone else than the same problems affecting themselves, suggesting symptom education alone may not improve rates of cognitive assessment for detection of impairment and dementia.

Cognitive Impairment and Cardiovascular Disease: A Comparison of Risk Factors, Disability, Quality of Life, and Access to Health Care

OBJECTIVES

Cognitive difficulties or impairment may be an early step in the development of dementia. Several modifiable risk factors for cardiovascular disease (CVD) may also increase the risk of dementia. The objective of our study was to compare adults with subjective cognitive impairment (SCI), using the Behavioral Risk Factor Surveillance System (BRFSS) cognitive disability measure, with adults who reported CVD.

METHODS

We examined data on 3 key outcomes among 302 008 adult respondents aged ≥45 in the 2017 BRFSS: respondents with SCI only, respondents with CVD only, and respondents with both conditions. We compared measures of disability, quality of life, access to health care, and a composite measure of the following 7 risk factors: current smoking, diabetes, high cholesterol, hypertension, inadequate fruit and vegetable consumption, obesity, and sedentary lifestyle. We also estimated population-attributable risk (PAR).

RESULTS

Among respondents, 7.9% reported SCI only, 11.1% reported CVD only, and 3.2% reported both conditions, with differences by age and sex. Adults with SCI only were more likely than adults with CVD only to report other disability, worse access to health care, and poorer quality of life, even though adults with CVD were older. Compared with adults with neither condition, adults with any of the 3 outcomes were more likely to report having each of the 7 risk factors; we found a linear association with an increasing number of risk factors. Five or 6 risk factors contributed to PARs for each of the 3 key outcomes. PARs for SCI only were highest for ever smoking (17.2%) and sedentary lifestyle (12.8%), whereas for CVD only, PARs were highest for hypertension (35.5%) and high cholesterol (22.9%).

CONCLUSION

Despite differences between adults with SCI and adults with CVD in several demographic and health-related measures, the overall similarity in PARs for SCI and CVD suggests potential benefits from using effective CVD interventions to address SCI.

Diagnosis and Management of Dementia: Review

Importance

Worldwide, 47 million people live with dementia and, by 2050, the number is expected to increase to 131 million.

Observations

Dementia is an acquired loss of cognition in multiple cognitive domains sufficiently severe to affect social or occupational function. In the United States, Alzheimer disease, one cause of dementia, affects 5.8 million people. Dementia is commonly associated with more than 1 neuropathology, usually Alzheimer disease with cerebrovascular pathology. Diagnosing dementia requires a history evaluating for cognitive decline and impairment in daily activities, with corroboration from a close friend or family member, in addition to a thorough mental status examination by a clinician to delineate impairments in memory, language, attention, visuospatial cognition such as spatial orientation, executive function, and mood. Brief cognitive impairment screening questionnaires can assist in initiating and organizing the cognitive assessment. However, if the assessment is inconclusive (eg, symptoms present, but normal examination findings), neuropsychological testing can help determine whether dementia is present. Physical examination may help identify the etiology of dementia. For example, focal neurologic abnormalities suggest stroke. Brain neuroimaging may demonstrate structural changes including, but not limited to, focal atrophy, infarcts, and tumor, that may not be identified on physical examination. Additional evaluation with cerebrospinal fluid assays or genetic testing may be considered in atypical dementia cases, such as age of onset younger than 65 years, rapid symptom onset, and/or impairment in multiple cognitive domains but not episodic memory. For treatment, patients may benefit from nonpharmacologic approaches, including cognitively engaging activities such as reading, physical exercise such as walking, and socialization such as family gatherings. Pharmacologic approaches can provide modest symptomatic relief. For Alzheimer disease, this includes an acetylcholinesterase inhibitor such as donepezil for mild to severe dementia, and memantine (used alone or as an add-on therapy) for moderate to severe dementia. Rivastigmine can be used to treat symptomatic Parkinson disease dementia.

Conclusions and Relevance

Alzheimer disease currently affects 5.8 million persons in the United States and is a common cause of dementia, which is usually accompanied by other neuropathology, often cerebrovascular disease such as brain infarcts. Causes of dementia can be diagnosed by medical history, cognitive and physical examination, laboratory testing, and brain imaging. Management should include both nonpharmacologic and pharmacologic approaches, although efficacy of available treatments remains limited.

Memory complaints, dementia, and neuropathology in older blacks and whites

OBJECTIVE

To determine relationships of memory complaints to cognitive function and decline, incident dementia, and neurodegenerative and other neuropathologies, as well as the population-attributable risk for dementia in older black and white persons.

METHODS

A total of 4,015 community-based persons (28% black; 74% women; mean baseline age = 78 years) were enrolled in 1 of 4 longitudinal cohort studies, and another 2,937 in a population-based cohort. Memory scores, assessed using 2 questions (5-point Likert scales) were categorized as complaints present or absent. Global cognition and 5 cognitive domains were derived from annual neuropsychological tests. Dementia was assessed from these tests and additional data. Neuropathologic data were available for 1,350 deceased subjects with brain autopsies. Regression and mixed effects models were used to examine relationships of memory complaints to cognition and neuropathology.

RESULTS

Baseline memory complaints (n = 1,310; 33% of 4,015) were associated with lower cognition and faster decline in all domains (global score estimate = -0.032, standard error = 0.004, p < 0.0001), during a mean follow-up of 6 (standard deviation = 2) years. Persons with memory complaints had higher dementia risk (hazard ratio = 1.64, 95% confidence interval [CI] = 1.42-1.89) and odds of pathologic Alzheimer disease (odds ratio [OR] = 1.96, 95% CI = 1.51-2.54), neocortical Lewy bodies (OR = 2.47, 95% CI = 1.54-3.96), and other neurodegenerative pathologies. Results for dementia risk were similar among blacks and whites. Among 2,937 older persons in a population-based cohort with similar data, the population-attributable risk for incident dementia due to memory complaints was 14.0% (95% CI = 2.6-23.0), and did not vary between the black and white groups.

INTERPRETATION

Memory complaints are common in older black and white persons, and relate to cognitive decline, dementia risk, and neurodegenerative pathologies. Ann Neurol 2018;83:718-729.

Digitally translated Self-Administered Gerocognitive Examination (eSAGE): relationship with its validated paper version, neuropsychological evaluations, and clinical assessments

BACKGROUND

The original paper Self-Administered Gerocognitive Examination (SAGE) is a valid and reliable cognitive assessment tool used to identify individuals with mild cognitive impairment (MCI) or early dementia. We evaluated identical test questions in a digital format (eSAGE) made for tablet use with the goals of calibrating it against SAGE and establishing its association with other neuropsychological tests and clinical assessments of cognitive impairment.

METHODS

Subjects aged 50 and over who had taken SAGE were recruited from community and clinic settings. Subjects were randomly selected to participate in a clinical evaluation including neuropsychological evaluations. SAGE and eSAGE were administered using a crossover design. Subjects were identified as dementia, MCI, or normal based on standard clinical criteria. Associations were investigated using Spearman correlations, linear regression, and sensitivity and specificity measures.

RESULTS

Of the 426 subjects screened, 66 completed the evaluation. eSAGE score correlation to a battery of neuropsychological tests was 0.73 (p < 0.0001) with no significant difference between the paper and digital format. Spearman correlation of SAGE versus eSAGE was 0.88 (p < 0.0001), and they are related by the formula: eSAGE score = -1.05 + 0.99 × SAGE score. Since the slope is very close to 1 (p = 0.86) there is strong evidence that the scaling is identical between eSAGE and SAGE, with no scale bias. Overall, eSAGE scores are lower by an average of 1.21 and the decrease is statistically significant (p < 0.0001). For those subjects familiar with smartphones or tablets (one measure of digital proficiency), eSAGE scores are lower by an average of 0.83 points (p = 0.029). With a score 16 and higher being classified as normal, eSAGE had 90% specificity and 71% sensitivity in detecting those with cognitive impairment from normal subjects.

CONCLUSIONS

Tablet-based eSAGE shows a strong association with the validated paper SAGE and a neuropsychological battery. It shows no scale bias compared to SAGE. Both have the advantage of self-administration, brevity, four interchangeable forms, and high sensitivity and specificity in detecting cognitive impairment from normal subjects. Their potential widespread availability will be a major factor in overcoming the many obstacles in identifying early cognitive changes.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02544074 . Registered on 18 March 2015.

Estimating Dementia and Receipt of Informal Care Using Behavioral Risk Factor Surveillance System Data

INTRODUCTION

Estimates of US adults with dementia differ widely and don't distinguish adults living in the community.

METHODS

Behavioral Risk Factor Surveillance System data from 120 485 households in 21 states that used a cognitive decline module in 2011 were used. Data for both respondents and other adults with subjective cognitive decline (SCD) were included through proxy responses. Using responses to questions about the receipt of informal care for their SCD and diagnosed dementia, estimates were made for each state.

RESULTS

Overall, 2.9% (range: 1.5% in Tennessee to 5.3% in Arkansas) of all noninstitutionalized adults in these states received informal care for their SCD and 0.9% (range: 0.5% in Tennessee to 2.0% in Arkansas) were estimated to have dementia. Limiting results to respondents reduced estimates significantly.

DISCUSSION

Combined results for respondents and nonrespondents from a representative telephone survey provide varying estimates of SCD-related measures across states, highlighting the need for state-specific estimates.