Who refuses the diagnostic assessment for dementia in primary care?

Department of Psychiatry, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana, United States
International Journal of Geriatric Psychiatry (Impact Factor: 2.87). 06/2006; 21(6):556-63. DOI: 10.1002/gps.1524
Source: PubMed


Early screening and detection of dementia in primary care remains controversial. At least half of the patients identified as cognitively impaired by screening instruments do not meet criteria for dementia and some patients refuse further evaluation following a positive screen. The aim of this study was to identify the characteristics of patients who refuse a clinical diagnostic assessment for dementia after screening.
Cross sectional study.
Seven primary care practice centers in Indianapolis.
Four hundred and thirty-four individuals aged 65 and older who screened positive for dementia with a mean age of 74.6, 67% women, and 68% African-American.
Patients' acceptance of undergoing a dementia diagnostic assessment that included neuropsychological testing, caregiver interview, and medical chart review.
Among patients with positive screening results for dementia, approximately half (47.7%) refused further assessment to confirm their screening results. In a bivariate analysis, possible factors associated with a higher probability of refusing dementia assessment were older age and better screening score. In a multiple logistic regression model, performing well on the temporal orientation of the screening instrument was associated with a higher probability of refusing diagnostic assessment for dementia (OR = 1.37; p = 0.001). Also, African-American patients aged 80 and older were more likely to refuse the diagnostic assessment than African-Americans less than 80 years of age (OR = 3.1, p < 0.001), while there was no significant age association for white patients (OR = 0.9, p = 0.728).
Older primary care patients who perceived themselves as having no cognitive symptoms refused dementia diagnostic assessment despite their positive screening results. We must improve our understanding of the decision-making process driving patients' beliefs and behaviors about the benefits and risks of dementia screening and diagnosis before implementing any broad-based screening initiatives for dementia.

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Available from: Malaz Boustani, Apr 17, 2014
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    • "Obtaining an early diagnosis can help patients begin treatment as soon as possible to help slow cognitive and functional decline with pharmacological treatment.6 However, a dementia-screening and -diagnosis program in the US showed that patients had high refusal rates for a dementia diagnostic workup following a positive screening.7 Therefore, it is important that screening tools be valid and easy to complete and have a low psychological burden. "
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    ABSTRACT: Introduction Screening tools for dementia should be valid and easy to complete and have a low psychological burden. Consistent with these principles, the Yamaguchi fox/pigeon-imitation test (YFPIT) has been developed. However, there is little information on the utility of the YFPIT for preclinical populations, although the detection of proven prodromal and preclinical states is important. Materials and methods We recruited 392 volunteers who were at least 60 years old (139 men and 253 women) and had participated in the Iwaki Health Promotion Project. The YFPIT was administered to all participants. Results Most subjects succeeded in imitating the fox gesture regardless of their cognitive function impairment, while the success rates for the pigeon gesture were 75.3% in the normal group and 56.3% in the cognitive impairment group. The sensitivity, specificity, positive predictive value (PV+), and negative predictive value (PV−) were 43.8%, 75.3%, 7.0%, and 97.0%, respectively. The greatest significant difference between the imitation of the pigeon gesture and cognitive impairment was found in females with subjective memory impairments (P=0.001). In that group, the sensitivity, specificity, PV+, and PV− were 100%, 81.9%, 18.8%, and 100%, respectively. Conclusion This study suggests that the utility of the YFPIT is limited in the general population, but that it is a useful tool in females with subjective memory impairments in a community-dwelling population.
    Full-text · Article · Sep 2014 · Neuropsychiatric Disease and Treatment
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    • "This required sensitivity and high-level skills to engage in discussions about assessment, information giving and possibly referral for diagnosis of dementia, particularly if pre-diagnostic screening for dementia was carried out. Pre-diagnosis screening would require a professional to work at a high level of complexity and to be sensitive to the emotional responses to both a possible diagnosis and a confirmed diagnosis of dementia (Boustani et al., 2006; 2008). "
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    ABSTRACT: Objectives: The need to improve the response of primary care in terms of identification of people with undiagnosed dementia has long been recognised. The role of Primary Care Liaison was identified as a possible solution. An in-depth consultation was undertaken to identify professional competencies required in executing such a role. Methods: Comprehensive literature and policy reviews were conducted to establish draft competencies or different options/combinations of competencies and competency levels. Consultations with a wide range of professional stakeholders (n = 23) and over 70 users and carers were conducted through focus groups, electronic document circulation and telephone interviews. An Equality Impact Assessment was conducted concurrent to the consultation. Results: The literature demonstrated a clear need both to improve the rate of diagnosis for people with dementia and to improve the way in which the diagnosis is made. The stakeholder consultation repeatedly affirmed that without a diagnosis the person with dementia and their caregivers did not get access to the appropriate services, and validated the need for a role that would be able to improve a system that would deliver an early and 'timely' diagnosis. Competencies, based on the literature and policy documents, were developed and debated through the consultation processes. Conclusions: Three main areas of competency were identified: counselling; screening; and health education and promotion. The competencies identified require a skilled experienced professional approach. A useful team model would be that the role is placed within a 'GP cluster' as accessibility to GP records and collaborative working with GPs is essential within the role. Personal continuing professional development has a high profile in maintaining these competencies.
    Full-text · Article · Nov 2012 · Primary Health Care Research & Development
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    • "In one sample, almost 50% of older adults in a retirement community said they did not want screening for dementia (Boustani et al., 2003b). In another sample, only 52% of patients referred for evaluation of a positive screen agreed to an assessment (Boustani et al., 2006). However, these studies were conducted in selected samples with either relatively high socioeconomic status (Boustani et al., 2003b) or at higher risk for dementia (Boustani et al., 2008). "
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    ABSTRACT: To determine the acceptability of dementia screening in two populations of older adults in different primary care settings. Cross-sectional study of consecutive patients presenting for primary care appointments in the Duke University Health System (n = 152) or Durham VA Medical Center (n = 193) were evaluated face to face using the Dementia Screening and Perceived Harms (SAPH) questionnaire. Overall, 81% of primary care patients indicated that they would want to be screened to determine if they are developing dementia. After exposure to possible risks and benefits of screening, 86% of patients indicated they would like to be screened. The SAPH was easy to use and contained five relevant and cohesive domains. The items most associated with a desire for dementia screening were male gender, acceptance of other types of screening, and a belief that a treatment for dementia exists. Primary care patients in two different health care systems indicated they would like to be screened for dementia. The SAPH was easy to use and contains cohesive domains.
    Full-text · Article · Apr 2011 · International Journal of Geriatric Psychiatry
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