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‘Room for improvement’ in diagnosing dementia in primary care
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Dementia was misclassified in 35.7% of cases in primary care, despite the use of at least one of the most frequently recommended tests to assess for dementia, according to findings recently published in Neurology: Clinical Practice.
“False negatives may prevent or delay diagnosis, meaning missed opportunities for planning and timely access to treatment and services. False positives may cause unnecessary referrals and investigations, affecting patients, families and health services," Janice M. Ranson, MSc, of the College of Medicine and Health at the University of Exeter Medical School in England, and colleagues wrote.
“Predictors of dementia misclassification by brief cognitive assessments have not been studied in-depth. ... There is a lack of evidence for factors predicting misclassification across a variety of assessments. This knowledge may assist clinical decision-making and inform dementia identification strategies,” they added.
Researchers reviewed assessments by the Mini-Mental State Examination (cut-point 24 or less), Animal Naming (cut-point nine or less) and Memory Impairment Screen (cut-point five or less) in 824 adults aged 70 to 110 years from a U.S. cohort.
Ranson and colleagues found 35.7% of participants were misclassified by at least one of the assessments; 1.7% of participants were misclassified by all three assessments. When the Mini-Mental State Examination was used, patients’ years of education predicted higher false-negatives (OR = 1.23; 95% CI, 1.07-1.4) and lower false-positives (OR = 0.77; 95% CI, 0.7-0.83). When Animal Naming was used, nursing home residency predicted lower false-negatives (OR = 0.15; 95% CI, 0.03-0.63) and higher false-positives (OR = 4.85; 95% CI, 1.27-18.45).
In addition, false-negatives were most consistently predicted when a spouse or close family member interviewed could not rate the study participant’s memory as “fair,” “good,” “very good” or “excellent” memory. Predictors of false-positives included age, non-Caucasian ethnicity and nursing home residency (all P < 0.05 in at least two models) across all assessments studied.
“These findings suggest there is definitely room for improvement in this initial stage of the diagnostic pathway for dementia. There is no strong evidence to suggest one particular test is best for everyone,” Ranson told Healio Family Medicine.
She discussed how she and her colleagues are trying to help more clinicians correctly diagnose dementia in primary care.
“We are developing new technology using data science and artificial intelligence to help clinicians get the best outcome for their patients by combining patient characteristics with brief test scores to indicate the probability of dementia for a given patient. This is currently being trialed,” Ranson said.
In the meantime, she offered ways to reduce incorrect assessments.
“Our results highlighted the importance of obtaining informant-reported memory ratings of the patient from a spouse or close family member when possible, so this information can be taken into account when interpreting the brief test results.” – by Janel Miller
Disclosures: Ranson and colleagues report no relevant financial disclosures.