Prevalence and management of dementia in primary care practices with electronic medical records: a report from the Canadian Primary Care Sentinel Surveillance Network

Changes in the use of psychotropic drugs during the course of Alzheimer's disease: A large-scale longitudinal study of French medical records

INTRODUCTION

We aim to understand how patients with Alzheimer's disease (AD) are treated by identifying in a longitudinal fashion the late-life changes in patients' medical history that precede and follow AD diagnosis.

METHODS

We use prescription history of 34,782 patients followed between 1996 and 2019 by French general practitioners. We compare patients with an AD diagnosis, patients with mild cognitive impairment (MCI), and patients free of mental disorders. We use a generalized mixed-effects model to study the longitudinal changes in the prescription of eight drug types for a period 15 years before diagnosis and 10 years after.

RESULTS

In the decades preceding diagnosis, we find that future AD patients are treated significantly more than MCI patients with most psychotropic drugs and that most studied drugs are increasingly prescribed with age. At the time of diagnosis, all psychotropic drugs except benzodiazepines show a significant increase in prescription, while other drugs are significantly less prescribed. In the 10 years after diagnosis, nearly all categories of drugs are less and less prescribed including antidementia drugs.

DISCUSSION

Pre-diagnosis differences between future AD patients and MCI patients may indicate that subtle cognitive changes are recognized and treated as psychiatric symptoms. The disclosure of AD diagnosis drastically changes patients' care, priority being given to the management of psychiatric symptoms. The decrease of all prescriptions in the late stages may reflect treatment discontinuation and simplification of therapeutic procedures. This study therefore provides new insights into the medical practices for management of AD.

Characteristics and Real-Life Outcomes of Dementia and Cognitive Impairment at a Geriatric Clinic

BACKGROUND

Various patterns of dementia care have been developed in different settings, depending on the availability of healthcare resources and facilities. The purpose of this study was to examine the epidemiology and characteristics of dementia care at a geriatric clinic, a field that has been subject to little prior evaluation.

METHODS

A retrospective chart review was undertaken of cohort patients with cognitive impairment who had received a diagnosis and were still on active follow-up at a geriatric clinic. A total of 892 patients were included. In addition, 203 geriatric patients with no cognitive impairment who attended the clinic during the study period were sampled as a control.

RESULTS

The main diagnoses of dementia were Alzheimer's disease (AD) (40.1%), vascular dementia (16.9%), unspecified dementia (16.3%), mixed dementia (9.0%), AD with cerebrovascular disease (8.7%), and Parkinson's disease dementia (6.1%). Atypical dementia was presented in 3.0% of cases. There were 178 patients with mild cognitive impairment, 20 with vascular cognitive impairment, and 18 with subjective cognitive decline. Other comorbidities were found in 97% of the subjects. Patients with cognitive impairment had a higher total number of other geriatric syndromes and higher percentages for delirium, falls, immobility, loss of appetite, and incontinence. Potentially reversible causes of dementia were found in 11.3% of the cases. Acetylcholinesterase inhibitors were administered to 61%, whereas 23.5% received an NMDA receptor antagonist. The need for a change in the antidementia medication was identified for 10.7% of the subjects; the major cause was adverse drug side effects. Nonpharmacological therapy only was administered to 52.4% of the people with dementia who had behavioral and psychological symptoms.

CONCLUSIONS

Mixed brain pathologies, comorbidities, and the coexistence of other geriatric syndromes are common at geriatric clinics. Holistic, integrated, and continuous care are needed to improve the outcomes of patients with more complicated comorbidities.

Cognitive changes and neural correlates after oral rehabilitation procedures in older adults: a protocol for an interventional study

BACKGROUND

Epidemiological studies show an association between masticatory function and cognitive impairment. This has further strengthened the notion that tooth loss and impaired masticatory function may be risk factors for dementia and cognitive decline. Animal experiments have indicated a causal relationship and several possible mechanisms have been discussed. This evidence is, however, lacking in humans. Therefore, in the current interventional study, we aim to investigate the effect of rehabilitation of masticatory function on cognition in older adults.

METHODS

Eighty patients indicated for prosthodontic rehabilitation will be randomly assigned to an experimental or a control group. Participants will conduct neuropsychological assessments, masticatory performance tests, saliva tests, optional magnetic resonance imaging, and answer questionnaires on oral health impact profiles and hospital anxiety and depression scale before, 3 months, and 1 year after oral rehabilitation. The difference between the two groups is that the control group will be tested an additional time, (at an interval of about 3 months) before the onset of the oral rehabilitation procedure. The primary outcome is a change in measures of episodic memory performance.

DISCUSSION

Although tooth loss and masticatory function are widespread in older people, it is still an underexplored modifiable risk factor potentially contributing to the development of cognitive impairment. If rehabilitation of masticatory function shows positive effects on the neurocognitive function, this will have great implications on future health care for patients with impaired masticatory status. The present project may provide a new avenue for the prevention of cognitive decline in older individuals.

TRIAL REGISTRATION

The protocol for the study was retrospectively registered in ClinicalTrials.gov Identifier: NCT04458207, dated 02-07-2020.

Detection and Prediction of Incident Alzheimer Dementia over a 10-Year or Longer Medical History: A Population-Based Study in Primary Care

BACKGROUND

Despite the crucial role played by general practitioners in the identification and care of people with cognitive impairment, few data are available on how they may improve the early recognition of patients with Alzheimer dementia (AD), especially those with long (i.e., 10 years and longer) medical history.

AIMS

To investigate the occurrence and the predictors of AD during a 10-year or longer period prior AD diagnosis in primary care patients aged 60 years or older.

MATERIALS AND METHODS

A cohort study with a nested case-control analysis has been conducted. Data were extracted from the Italian Health Search Database (HSD), an Italian database with primary care data. AD cases have been defined in accordance with the International Classification of Diseases, ninth edition (ICD-9-CM) codes and coupled with the use of anti-dementia drugs. Prevalence and incidence rates of AD have been calculated. To test the association between candidate predictors, being identified in a minimum period of 10 years, and incident cases of AD, we used a multivariate conditional logistic regression model.

RESULTS

As recorded in the primary care database, AD prevalence among patients aged 60 years or older was 0.8% during 2016, reaching 2.4% among nonagenarians. Overall, 1,889 incident cases of AD have been identified, with an incidence rate as high as 0.09% person-year. Compared with 18,890 matched controls, history of hallucinations, agitation, anxiety, aberrant motor behavior, and memory deficits were positively associated with higher odds of AD (p < 0.001 for all) diagnosis. A previous diagnosis of depression and diabetes and the use of low-dose aspirin and non-steroidal anti-inflammatory drugs were associated with higher odds of AD (p < 0.05 for all).

CONCLUSION

Our findings show that, in accordance with primary care records, 1% of patients aged 60 years and older have a diagnosis of AD, with an incident AD diagnosis of 0.1% per year. AD is often under-reported in primary care settings; yet, several predictors identified in this study may support general practitioners to early identify patients at risk of AD.

A data quality assessment to inform hypertension surveillance using primary care electronic medical record data from Alberta, Canada

BACKGROUND

Hypertension is a common chronic condition affecting nearly a quarter of Canadians. Hypertension surveillance in Canada typically relies on administrative data and/or national surveys. Routinely-captured data from primary care electronic medical records (EMRs) are a complementary source for chronic disease surveillance, with longitudinal patient-level details such as sociodemographics, blood pressure, weight, prescribed medications, and behavioural risk factors. As EMR data are generated from patient care and administrative tasks, assessing data quality is essential before using for secondary purposes. This study evaluated the quality of primary care EMR data from one province in Canada within the context of hypertension surveillance.

METHODS

We conducted a cross-sectional, descriptive study using primary care EMR data collected by two practice-based research networks in Alberta, Canada. There were 48,377 adults identified with hypertension from 53 clinics as of June 2018. Summary statistics were used to examine the quality of data elements considered relevant for hypertension surveillance.

RESULTS

Patient year of birth and sex were complete, but other sociodemographic information (ethnicity, occupation, education) was largely incomplete and highly variable. Height, weight, body mass index and blood pressure were complete for most patients (over 90%), but a small proportion of outlying values indicate data inaccuracies were present. Most patients had a relevant laboratory test present (e.g. blood glucose/glycated hemoglobin, lipid profile), though a very small proportion of values were outside a biologically plausible range. Details of prescribed antihypertensive medication, such as start date, strength, dose, frequency, were mostly complete. Nearly 80% of patients had a smoking status recorded, though only 66% had useful information (i.e. categorized as current, past, or never), and less than half had their alcohol use described; information related to amount, frequency or duration was not available.

CONCLUSIONS

Blood pressure and prescribed medications in primary care EMR data demonstrated good completeness and plausibility, and contribute valuable information for hypertension epidemiology and surveillance. The use of other clinical, laboratory, and sociodemographic variables should be used carefully due to variable completeness and suspected data errors. Additional strategies to improve these data at the point of entry and after data extraction (e.g. statistical methods) are required.

Does Mild Traumatic Brain Injury Increase the Risk for Dementia? A Systematic Review and Meta-Analysis

Background: Mild traumatic brain injury (mTBI) is a putative risk factor for dementia; however, despite having apparent face validity, the evidence supporting this hypothesis remains inconclusive. Understanding the role of mTBI as a risk factor is becoming increasingly important given the high prevalence of mTBI, and the increasing societal burden of dementia. Objective: Our objective was to use the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) format to determine if an association exists between mTBI and dementia and related factors, and to quantify the degree of risk. Methods: In this format, two authors conducted independent database searches of PubMed, PsycInfo, and CINAHL using three search blocks to find relevant papers published between 2000 and 2020. Relevant studies were selected using pre-defined inclusion/exclusion criteria, and bias scoring was performed independently by the two authors before a subset of studies was selected for meta-analysis. Twenty-one studies met the inclusion criteria for this systematic review. Results: The meta-analysis yielded a pooled odds ratio of 1.96 (95% CI 1.698–2.263), meaning individuals were 1.96 times more likely to be diagnosed with dementia if they had a prior mTBI. Most studies examining neuropsychiatric and neuroimaging correlates of dementia found subtle, persistent changes after mTBI. Conclusion: These results indicate that mTBI is a risk factor for the development of dementia and causes subtle changes in performance on neuropsychiatric testing and brain structure in some patients.

Achieving quality primary care data: a description of the Canadian Primary Care Sentinel Surveillance Network data capture, extraction, and processing in Alberta

Introduction

Electronic medical record (EMR) databases have become increasingly popular for secondary purposes, such as health research. The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) is the first and only pan-Canadian primary care EMR data repository, with de-identified health information for almost two million Canadians. Comprehensive and freely available documentation describing the data ‘lifecycle’ is important for assessing potential data quality issues and appropriate interpretation of research findings. Here, we describe the flow and transformation of CPCSSN data in the province of Alberta.

Approach

In Alberta, the data originate from 54 publicly-funded primary care settings, including one community pediatric clinic, with 318 providers contributing de-identified EMR data for 410,951 patients (as of December 2018). Data extraction methods have been developed for five different EMR systems, and include both backend and automated frontend extractions. The raw EMR data are transformed according to specific rules, including trimming implausible values, converting values and free text to standard terminologies or classification systems, and structuring the data into a common CPCSSN format. Following local data extraction and processing, the data are transferred to a central repository and made available for research and disease surveillance.

Conclusion

This paper aims to provide important contextual information to future CPCSSN data users.

How well can electronic health records from primary care identify Alzheimer's disease cases?

Background

Electronic health records (EHR) from primary care are emerging in Alzheimer’s disease (AD) research, but their accuracy is a concern. We aimed to validate AD diagnoses from primary care using additional information provided by general practitioners (GPs), and a register of dementias.

Patients and methods

This retrospective observational study obtained data from the System for the Development of Research in Primary Care (SIDIAP). Three algorithms combined International Statistical Classification of Diseases (ICD-10) and Anatomical Therapeutic Chemical codes to identify AD cases in SIDIAP. GPs evaluated dementia diagnoses by means of an online survey. We linked data from the Register of Dementias of Girona and from SIDIAP. We estimated the positive predictive value (PPV) and sensitivity and provided results stratified by age, sex and severity.

Results

Using survey data from the GPs, PPV of AD diagnosis was 89.8% (95% CI: 84.7–94.9). Using the dataset linkage, PPV was 74.8 (95% CI: 73.1–76.4) for algorithm A1 (AD diagnoses), and 72.3 (95% CI: 70.7–73.9) for algorithm A3 (diagnosed or treated patients without previous conditions); sensitivity was 71.4 (95% CI: 69.6–73.0) and 83.3 (95% CI: 81.8–84.6) for algorithms A1 (AD diagnoses) and A3, respectively. Stratified results did not differ by age, but PPV and sensitivity estimates decreased amongst men and severe patients, respectively.

Conclusions

PPV estimates differed depending on the gold standard. The development of algorithms integrating diagnoses and treatment of dementia improved the AD case ascertainment. PPV and sensitivity estimates were high and indicated that AD codes recorded in a large primary care database were sufficiently accurate for research purposes.

Epidemiology of dementia: prevalence and incidence estimates using validated electronic health records from primary care

Purpose

Updated estimates of incidence and prevalence of dementia are crucial to ensure adequate public health policy. However, most of the epidemiological studies in the population in Spain were conducted before 2010. This study assessed the validity of dementia diagnoses recorded in electronic health records contained in a large primary-care database to determine if they could be used for research purposes. Then, to update the epidemiology of dementia in Catalonia (Spain), we estimated crude and standardized prevalence and incidence rates of dementia in Catalonia in 2016.

Methods

The System for the Development of Research in Primary Care (SIDIAP) database contains anonymized information for >80% of the Catalan population. Validity of dementia codes in SIDIAP was assessed in patients at least 40 years old by asking general practitioners for additional evidence to support the diagnosis. Crude and standardized incidence and prevalence (95% CI) in people aged ≥65 years were estimated assuming a Poisson distribution.

Results

The positive predictive value of dementia diagnoses recorded in SIDIAP was estimated as 91.0% (95% CI 87.5%–94.5%). Age-and sex-standardized incidence and prevalence of dementia were 8.6/1,000 person-years (95% CI 8.0–9.3) and 5.1% (95% CI 4.5%–5.7%), respectively.

Conclusion

SIDIAP contains valid dementia records. We observed incidence and prevalence estimations similar to recent face-to-face studies conducted in Spain and higher than studies using electronic health data from other European populations.

Antidepressant and antipsychotic prescribing in primary care for people with dementia

OBJECTIVE

To use data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) to evaluate the prevalence of antidepressant and antipsychotic prescriptions among patients with no previous depression or psychosis diagnoses, and to identify the factors associated with the use of these drugs in this population.

DESIGN

Retrospective cohort study using data derived from CPCSSN.

SETTING

Primary care practices associated with CPCSSN.

PARTICIPANTS

Patients who were born before 1949; who were associated with a CPCSSN primary care practitioner between October 1, 2007, and September 30, 2013; and whose electronic medical records contained data from at least 6 months before and 12 months after the date of dementia diagnosis.

MAIN OUTCOME MEASURES

Prescription for an antidepressant or antipsychotic medication in the absence of a depression or psychosis diagnosis. Multivariable models were fitted to determine estimated odds ratios (ORs) and were adjusted for age and sex.

RESULTS

Of the 3252 patients without a depression diagnosis, 8.5% received a new prescription for an antidepressant in the 12 months following their diagnosis of dementia. Prescribing was reduced in association with older age (OR of 0.86 per 5-year age increase, P=.001) and male sex (OR=0.77, P=.056), and prescribing increased in association with prescription of cholinesterase inhibitor medications (OR=1.57, P=.003). Of the 4262 patients without a diagnosis of psychosis, 6.1% received a new prescription for an antipsychotic in the 12 months following their diagnosis of dementia. Higher rates of antipsychotic prescriptions were reported in men (OR=1.31, P=.046), those receiving a prescription for steroids (OR=1.90, P=.037), and those diagnosed with Parkinson disease (OR 1.58, P=.051).

CONCLUSION

A substantial number of patients with dementia are being prescribed antidepressant or antipsychotic medications by their primary care practitioners without evidence of depression or psychosis in their electronic medical records.

Using Canadian Primary Care Sentinel Surveillance Network data to examine depression in patients with a diagnosis of Parkinson disease: a retrospective cohort study

BACKGROUND

Parkinson disease is a complex neurodegenerative disorder, and a comorbidity of depression is common. We aimed to describe demographic and health characteristics of patients with Parkinson disease and examine sex differences in antidepressant prescriptions for those with comorbid depression using electronic medical records.

METHODS

We analyzed Canadian Primary Care Sentinel Surveillance Network data for patients 18 years and older with a diagnosis of Parkinson disease who had at least 1 primary care encounter between Sep. 30, 2012, and Sep. 30, 2014. We used regression modelling to determine sex differences in antidepressant prescriptions. An advisory group of clinicians helped determine the common list of medications and interpreted the results.

RESULTS

We identified a total of 1815 patients (54.9% male) with Parkinson disease during the study period. The mean age of patients was 74.6 years. Most (82.0%) lived in urban areas. Patients had a mean number of 15.5 primary care encouters over the 2-year study period. Almost 40% of patients had a concurrent diagnosis of depression. More than half of the patients had received a depression diagnosis within 1 year of their Parkinson diagnosis. Eight out of every 10 patients had a prescription for at least 1 medication for depression, the most frequently prescribed being selective serotonin reuptake inhibitors (SSRIs). No sex differences were found in the number or type of medications.

INTERPRETATION

Our findings support Canadian Parkinson Guidelines for Routine Screening of Comorbid Depression, but more evidence and decision-support tools are needed to examine the efficacy of antidepressants and assist clinicians in evaluating the frequent SSRI prescriptions in this population.