Cognitive impairment in older adults often unrecognized in the primary care setting

A new study published in the Journal of the American Geriatrics Society reveals that brief cognitive screenings combined with offering further evaluation increased new diagnoses of cognitive impairment in older veterans two to three fold.

15 feb 2012--Led by J. Riley McCarten, MD, of the Minneapolis VA Health Care System and the University of Minnesota, researchers assessed the effect of screening on diagnosing cognitive impairment in patients who were seen in VA primary care clinics and had no indiction of memory loss. Veterans aged 70 and older who failed the brief cognitive screen at a routine primary care visit were offered a further, comprehensive evaluation.

Of the 8,342 Veterans offered screening, 8,063 (97%) accepted, 2,081 (26%) failed the screen, and 580 (28%) agreed to further evaluation.

Among those accepting further evaluation, 93% were documented to have cognitive impairment, including 75% with dementia.

Additionally, 118 patients who passed the initial screen still requested further evaluation, and 87% were found to have cognitive impairment, including 70% with dementia.

"Our study demonstrates that proactive strategies such as routine screening are well-accepted and effective in diagnosing cognitive impairment, and that primary care providers value the diagnostic and management services involved," McCarten notes. "This project has implications for strategies that seek to improve care and contain costs in dementia."

The findings of this study run counter to the current standard recommendations by the American College of Physicians, U.S. Preventive Health Task Force, and Alzheimer's Association, which discourage routine cognitive impairment/dementia screening on all older patients at a certain age. Screening is only recommended if a person comes to a provider with some type of complaint that could be due to dementia.

Provided by Wiley

Promote the Generalists

Isn’t it ironic that just as America is waking
up to the importance of primary care
medicine, our own representative organizations
are selling us down the river?
The training of primary care physicians
has for decades allowed us to
branch out and follow our patients in
multiple sites of care. We are the masters
of managing care across this continuum.
Government and big business are
finally recognizing that they need to bolster
primary care to manage patients in
the new chronic care medical home
models. They are finally recognizing the
need to better supply, equip, and finance
primary care physicians.
The American College of
Physicians (ACP), the American
Academy of Family Practice (AAFP), and
the American Medical Association all
appear to support this concept. So where
is the irony?
The American Board of Internal
Medicine (ABIM), along with the aforementioned
groups and others, continues
to carve medicine into ever increasing
sub areas, based on sites of care and interests.
Hospitalists (who already have three
branches—general hospitalists, proceduralists,
and nocturnists) are seeking special
certification recognition through
ABIM. Palliative care is a new certification.
These branches of medicine deserve
recognition, but do we need all these
fractured certifications?
Soon, no primary care physicians
will be certified as capable of practicing
in multiple sites of care without multiple
certifications for each separate site and
individual function. Soon there will be
no "general" primary care physicians.
Can hospitalists equally manage the
whole continuum of care, or will they
need to become generalists again to do
the job?
Medicine teaches us to care for the
whole person—body, mind, and spirit—
not just individual parts. I urge the
ABIM, the ACP, the AAFP, the AMA,
SHM, and others to stop this fracturing
of primary care. Now is the time to promote
the generalists. Now is the time to
lift all primary care-related areas of medicine
together, leaving no one behind.
John M. Colombo, MD
HAN/Colombo