Dos and don’ts for PCPs when discussing dementia with patients

Peter Boling

NEW ORLEANS — Discussions between primary care physicians and patients about dementia are challenging, particularly when patients begin to worry they have the disease, according to a presenter here at the American College of Physicians Internal Medicine meeting.

Creating an atmosphere to facilitate those conversations begins when patients ask during office visits about products that can stave off dementia, Peter A. Boling, MD, of the division of general internal medicine at Virginia Commonwealth University told Healio Family Medicine. He said physicians should not encourage patients to take medicines and over-the-counter products for dementia treatment for which there is no good evidence of benefit.

“Patients want to tell you they should take product like statins to keep themselves from getting dementia,” he told attendees. “But there has been no evidence to support that vitamins D or vitamin E or statins can prevent dementia. In addition, there is no documented value that indicates patients should take these substances when their memory is not as good as it used to be.”

Also critical is making sure that the diagnosis is thoroughly considered, he said.

“There are a fair number of patients who have been assigned the diagnosis without a careful evaluation,” Boling said. “Sometimes the diagnosis is based on anecdotal information that comes from family members, such as the person is being forgetful when all the person has is delirium or depression. But dementia is neither of these last two conditions, nor is it altered consciousness, attention deficit disorder and/or being medically ill.”

Previously published data suggest misdiagnosing dementia is not a new phenomenon.

A 1981 study in the Journal of the American Geriatrics Society found that of 100 patients referred to a specialized outpatient dementia clinic, at least 26 did not have dementia. Another study in Dementia and Geriatric Cognitive Disorders randomly selected nearly 900 patients in Denmark aged 65 and younger diagnosed with dementia in 2008. Their medical records were reviewed to see if they met the DSM-IV and ICD-10 criteria for the disease. In only 59% of cases was the initial diagnosis was correct, these researchers reported.

“Some patients who are incorrectly diagnosed do not get the benefit of other medical procedures that should be done because the provider thinks the dementia is going to limit the patient’s life,” Boling said in the interview. “We need to be careful and be as accurate as possible when diagnosing dementia.”

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To accomplish a reasonable level of accuracy in making such a diagnosis, Boling suggested a thorough medical history be conducted by talking to the patient and getting a third party who knows the patient well, such as a family member to validate or discredit the patient’s claims.

He also recommended that the DSM-IV 4 test, DSM-5 test, Geriatric Depression Scale or Cornell Scale for Depression in Dementia be administered. In addition, patients suspected of having dementia should also have white blood cell counts taken, renal and hepatic functions assessed, thyroid glands examined and undergo urinalysis.

Boling also told attendees that CT scans can help in the diagnosis of dementia, but that too presents another round of dos and don’ts.

“A person who would benefit most from a CT head scan usually has had recent onset and rapid progression,” he said. “They may have also had a history of head trauma and features of normal pressure hydrocephalus. If a radiologist tells you a patient has atrophy after reading the CT, do not make any dementia determinations based on that.” – by Janel Miller

Reference:

Boling, PA. Dementia: diagnosis and management. Presented at: American College of Physicians Internal Medicine Meeting; April 17-21, 2018; New Orleans.

Garcia CA, et al. J Am Geriatr Soc. 1981; Sep;29(9):407-10.

Salem LC, et al. Dement Geriatr Cogn Disord. 2012;doi:10.1159/00034548.

Disclosure: Boling reports no relevant financial disclosures. Healio Family Medicine was unable to determine the other authors’ relevant financial disclosures prior to publication.