Screening for cognitive impairment

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1 . -A =S--l =FAI :Los : Clarissa Bush, PHD, CPSYCH Jean Kozak, PHD Tom Elmslie, MD, MSC, CCFP OBJECTIVE To evaluate the extent and type of screening for cognitive impairment primary care physicians use for their elderly patients, to identify perceived barriers to screening, and to explore whether physicians would be willing to use the clock drawing test as a cognitive screening tool. DESIGN Mailed questionnaire. SETTING Primary care practices in the Ottawa-Carleton region. PARTICIPANTS Family physicians and general practitioners culled from the Yellow Pages and Canadian Medical Directory; 368 of 568 questionnaires were returned for a response rate of 70%. Six respondents had fewer than 30 patients weekly and two responded too late to be included in the analysis; 360 cases were included in the analysis. MAIN OUTCOME MEASURES Responses to 10 questions on cognitive screening and five on demographics and the nature of respondents' practices. RESULTS About 80% of respondents reported doing at least one mental status examination during the past year. Only 24% routinely screened patients, although 82% believed screening was needed. Major barriers to cognitive screening were lack of time, risk of offending patients, and possible negative consequences of follow up. Clock drawing was perceived as an acceptable method of screening, if it were proven effective. CONCLUSIONS Most primary care physicians believe cognitive screening is needed, but few routinely screen their elderly patients. Lack of time is the most important perceived barrier to screening. Primary care physicians are receptive to using the clock drawing test, and, because it is not time-consuming, are less likely to consider lack of time a barrier to testing. The clock test might help bridge the gap between perceived need for screening and actual screening. OBJECTIF Evaluer l'etendue et le type de depistage des troubles cognitifs applique par les medecins de premiere ligne aupres de leurs patients ages, identifier les obstacles 'a ce depistage et explorer l'interet des medecins a utiliser le test de l'horloge comme outil de depistage des deficits cognitifs. CONCEPTION Questionnaire postal. CONTEXTE Pratiques de premiiere ligne de la region Ottawa-Carleton. PARTICIPANTS Medecins de famille et omnipraticiens selectionnes dans les pages jaunes et le Canadian Medical Directory; 368 des 568 questionnaires furent retournes pour un taux de reponses de 70 %. Six repondants voyaient moins de 30 patients par semaine et deux reponses sont arrivees trop tard pour l'analyse; celle-ci a donc ete faite 'a partir de 360 questionnaires retournes. PRINCIPALES MESURES DES RESULTATS Reponses 'a 10 questions sur le depistage des deficits cognitifs et 'a 5 questions touchant la demographie et la nature de la pratique des repondants. RESULTATS Environ 80 % des repondants ont rapporte avoir fait au moins un examen de l'etat mental au cours de la derniere annee. Seulement 24 % effectuaient couramment ce type de depistage; pourtant, 82 % etaient d'avis que ce depistage etait necessaire. Parmi les obstacles majeurs au depistage des troubles cognitifs, notons le manque de temps, le risque d'offenser les patients et la possibilite de consequences negatives lors du suivi. Le test de l'horloge fut percu comme une methode acceptable de depistage, 'a la condition de prouver son efficacite. CONCLUSIONS La plupart des medecins de premiere ligne croient en la necessite du depistage des troubles cognitifs mais peu l'appliquent de favon systematique. Le manque de temps en est le principal obstacle invoque. ils sont receptifs a l'utilisation du test de l'horloge; sa rapidite d'administration a plus de chances de faire tomber cet obstacle. Le test de l'horloge pourrait donc combler l'ecart entre le taux de perception du besoin de depistage et le taux d'application veritable. This article has been peer reviewed. Can Fam Physician 1997;43: *- FOR PRESCRIBING INFORMATION SEE PAGE 1850 VOL43: OCIOBER * OCIOBRE 1997* Canadian Family Physician Le Medecin defamille canadien 1763

2 he prevalence of dementia has been described as a "rising tide" in western countries.' A recent review of 47 studies suggested an overall prevalence of moderate and severe dementia of 7.8% among those older than 60.2 Other elderly people suffer cognitive impairment not severe enough to be classified as dementia, but possibly serious enough to affect daily function and medical care. These people might make up as much as 17% of general practice patients older than 65 years&7 and are expected to become more numerous.8'9 Several studies have suggested that elderly people's mild cognitive deficits are not always detected by primary care physicians.5,'0' A Canadian survey of community-dwelling, elderly, primary care patients found detection rates of 100% for "severe cognitive impairment," but none of the charts of 15 patients rated moderately impaired on mental status testing carried any mention of cognitive changes.'2 Two recent surveys suggest that this low detection rate is due to the infrequency with which physicians formally assess the mental status of their elderly patients.'3"14 A survey of physicians (41% general practitioners, the remainder primarily internists) in the Johns Hopkins Hospital catchment area found that 42% did not do any formal mental status testing in the diagnosis of dementia.3 A survey of family physicians in Alberta'4 found that 33% reported they routinely screened for cognitive impairment in elderly patients and half used a formal test (usually the Mini-Mental State Examination [MMSE]15) to do so. Only 48% of all respondents reported using a formal instrument to assess cognitive functioning in the diagnosis of dementia. To date, the Alberta study is the only one examining the mental status assessment practices of Canadian physicians, and the results are difficult to interpret due to a low response rate (15%).'4 Several reasons could explain why mental status is not assessed more often, including the extent to which physicians and their staff perceive it to interfere with office routine, time constraints,'6 patients' failure to express concern about cognitive function or actively covering up,'7"18 lack of overt presenting features to trigger assessment,'6 lack of effective treatnent for demen- Dr Bush is a psychologist at the Sisters ofcharity of Ottawa Hospital. Dr Kozak is Director ofresearch at the Sisters of Charity ofottawa Health Service. Dr Elmslie is Director ofthe Clinical Epidemiology Unit at the Sisters ofcharity ofottawa Hospital and is an Associate Professor in the Department offamily Medicine at the University of Ottawa. tia, fear of provoking patient hostility,'6 and lack of physician training in cognitive function and assessment. Awareness of the recommendations of the Canadian Consensus Conference on the Assessment of Dementia"9 and the 1991 Task Force on the Periodic Health Examination,20 which found insufficient evidence to include or exclude routine cognitive screening of the elderly (grade C recommendation), might also be a factor in the decision. The Task Force's recommendation, however, was based in part on lack of effective treatment. As this situation changes and as the importance of communication and management tailored to patients with dementia becomes recognized, a missed diagnosis becomes important and the mechanics, cost, and effect of a screening program need to be explored. Recently, interest in clock drawing as a rapid cognitive screening measure for use in both community and inpatient settings has increased (see sidebar).2126 Clock drawing has been demonstrated to have good sensitivity and specificity,27'28 to correlate well with the MMSE and other tests,'5'25'27 and to be free from cultural bias.27 It is also faster to administer than the MMSE.29 We wanted to know whether physicians would use this type of test in their practices. A survey questionnaire was mailed out to determine general and family practitioners' attitudes and current practices regarding screening for cognitive impairment in their elderly patients and their opinions as to whether the clock drawing test is a suitable screening tool. METHODS The 10-item questionnaire was designed to identify physicians' methods of assessing mental status in elderly patients, their perception of the need for cognitive screening, the perceived obstacles to screening, their perception of how cognitive impairment affects management of the elderly, and their opinions as to the utility of clock drawing as a screening tool. Five additional questions asked about demographics and the nature of the practice. The questionnaire was pilot tested on a convenience sample of faculty and residents in family medicine at the University of Ottawa and, based on their responses, was revised to the format described above. Using the 1994 Ottawa-Hull Yellow Pages (Tele- Direct), the 1994 Southam Canadian Medical Directory, and telephone calls to clarify unclear listings, we identified 568 family physicians and general practitioners in the Ottawa-Carleton region whose primary occupation was patient care. A previous study has shown this to be a valid method of 1764 Canadian Family Physician. Le Medecin defamille canadien * VOL 43: OCIOBER * OC'OBRE 1997

3 Screening for cognitive impairnent establishing a sampling frame of family and general physicians.30 Family physicians at University of Ottawa clinics were excluded because they had participated in validation of the questionnaire. Dillman's total design method3' was used for the mail survey. Nonresponders were contacted by telephone to confirm that they were currently in family or general practice. Forty-two questionnaires were returned as undeliverable or because the physician was not in practice, resulting in a final sample size of 526. X2 analysis was performed where appropriate and 95% confidence intervals (CI) were calculated for key items. Table 1. Reasons for not screening elderly patients for cognitive impairment: 62 physicians responded. NO. OF RESPONDENTS CONFIDENCE REASON (%)* INTERVALS (95%) Should assess cognition 32 (51) only if suspicions aroused by other evidence No proven benefit 12 (19) 0-41 Usually obvious 8 (13) 0-36 without screening Inefficient or not 6 (9) 0-32 cost-effective Other reasons 18 (29) 8-50 Reason unclear 10 (16) 0-39 *Figures are rounded to whole numbers; some respondents gave more than one reason. RESULTS Three hundred sixty-eight questionnaires were returned, giving an excellent response rate of 70%. Six respondents were excluded because they had less than 30 patient visits per week (and therefore did not meet our criteria of primary occupation being patient care), and two responses arrived too late to be included in the analysis. Three hundred sixty questionnaires were included in the analysis; not all respondents answered all questions. Responses to open-ended and partially open-ended questions were classified into similar conceptual categories. Percentages based on frequency of mention were computed for these categories, the sum of which often exceeded 100% because respondents checked more than one answer. Demographic information Two hundred three (57.2%) respondents were men (because not all respondents answered all questions, percentages are based on the number of respondents to particular questions). Mean age was 42.5 years (range 26 to 76 years), and mean year of graduation was 1978 (range 1948 to 1994). One third reported an evenly age-mixed patient distribution in their practices; only 38 (10.7%) focused specifically on elderly patients. Mean number of patient visits weekly was (range 30 to 250). Attitudes and practices with respect to cognitive assessment Mental status testing. Of the 349 respondents who answered this question, 302 (86.5%) reported that they had performed a mental status examination of one or more of their elderly patients in the past year; 220 (72.8%) had assessed mental status primarily by using clinical judgment, through an interview, or by asking specific questions, and 82 (27.2%) had used a formal mental status test. Almost all who did formal testing used the MMSE."5 Physicians who perceived a need to screen for cognitive impairment were no more likely than those who did not to have carried out mental status examination in the past year; there was no relationship between age, sex, or characteristics of the practice and reported testing practices. However, 264 (82.5%) of those who believed cognitive impairment affects medical management had done mental status examinations in the past year, compared with only 10 (58.8%) of those who did not (%2 = 5.96, df= 1, P< 0.01). Routine screening. Of the 350 respondents to this question, 260 (74.3%) reported no routine cognitive screening of their elderly patients (95% CI, 69.7% to 78.9%); their reasons are given in Table 1. Despite this, 287 (82.2%) believed in a need to screen (95% CI, 78.2% to 86.2%). Physicians who believed that cognitive impairment affects management of their patients (270 of 321 respondents) wern significantly more likely to believe in a need to screen than those who did not endorse the belief (10 of 18 respondents: X' = 9.67, df= 1, P < 0.002) (this statistic should be interpreted cautiously due to small cell size). While there was no relationship between age or characteristics of respondents' practices and perceived need to screen, women were somewhat more likely than men to endorse cognitive screening (' = 4.49, df= 1, P < 0.03). Table 2 lists perceived barriers to screening Canadian Family Physician. Le Medecin defamille canadien * VOL 43: OCIOBER * OCIOBRE 1997

4 Effect of cognitive impairment on health management. Three hundred forty-seven (94.8%) respondents believed that cognitive impairment affects medical management (95% CI, 92.7% to 97.3%). Thus, although most physicians did not report screening their elderly patients for cognitive impairment, they nonetheless thought it was an important factor in determining successful management of health problems. Clock drawing If it were proven effective, 328 (92.7%) respondents would be likely to use clock drawing as a screening test Most (268; 94%) believed a physician could administer the test, and 124 (37.2%o) thought a practice nurse could do so also. Perceived barriers to using clock drawing were similar to barriers to cognitive screening in general; however, lack of time was listed by only 59 respondents (22.9Yo), as opposed to 288 (85.4%) for barriers to screening in general. Also, characteristics of patients (eg, illiteracy, culture) were seen as barriers to clock drawing but not to screening in general. DISCUSSION While most physicians reported assessing cognitive status in at least one of their elderly patients in the past year, only 25% used formal mental status testing. Two previous surveys"3" 4 had shown a higher rate of formal mental status testing for diagnosing dementia (58% and 51.7%, respectively); however, the first study included only 41% general practitioners and the response rate to the second was low (15%o). Our results suggest that many primary care physicians believe they can identify cognitive problems without formal testing. Given evidence that as many as half of the cases of dementia go undetected in primary care,'5,102 some practitioners might be overestimating their ability to detect cognitive change. Although most believe screening is needed, holding this belief is unrelated to the likelihood of performing mental status examination. Those physicians who believed that cognitive impairment affects the management of health problems did report a higher rate of formal mental status examination. Barriers The main reported barrier to using formal mental status testing was lack of time. This appears to be less of a problem for clock drawing, which might be perceived as an intermediate step between clinical judgment and more lengthy mental status tests. Almost all respondents would be willing to use the clock test in their practices. Many are concerned about offending their patients by introducing either traditional mental status testing or clock drawing, a factor that needs to be addressed through education before any trial of screening is implemented. Table 2. Perceived barriers to screening for cognitive impairment: 337physicians responded. NO. OF RESPONDENTS CONFIDENCE BARRIER (%)* INTERVALS (95%) Lack of time 288 (85) Patients offended or resistant 197 (58) Negative consequences 82 (24) of follow up Lack of proven benefit 76 (22) Available tests inadequate 74 (22) I... Other 31(9) 0-19 *Figures are rounded to whole numbers; all respondents listed more than one barrier. limitations Several limitations to this study might have led to overestimation of the frequency of formal mental status testing. One is use of reported rather than actual practice, with social desirability bias possibly causing physicians to report using formal tests more often than they actually do. Similarly, nonrespondents might be less likely to assess mental status than respondents. These factors, however, tend to strengthen our finding of gaps in the current practice of assessing cognitive function in elderly patients. Family physicians seem to recognize the need to evaluate cognition, but relatively few do it formally. There is clearly a need for a simple, quick screening test that is acceptable to both physicians and patients. Clock drawing has potential because it is quick, is uncomplicated to administer, and appears to be acceptable, at least in theory, to most primary care physicians. Its effectiveness and accuracy in this setting require further study. Acknowledgment We thank danielle dagenais for her expert help in the preparation of this manuscript. This research was funded by the National Health Research and Development Program, Project No Correspondence to: Dr C. Bush, Department offamily Medicine, University ofottawa, Elisabeth Bruyere Pavilion, SCO Hospital, 43 Bruyere St, Ottawa ON KlN 5C8 VOL43: OCIOBER * OCIOBRE Canadian Family Physician. Le Medecin defamille canadien 1767

5 Screening for cognitive impainnent References 1. Ineichen B. Measuring the rising tide: how many dementia cases will there be by 2001? BrJ Psychiatry 1987;150: Jorn AF, Korten AE, Henderson AS. The prevalence of dementia: a quantitative review of the literature. Acta Psychiatr Scand 1987;76: Katzman R Early detection of senile dementia. Hosp Pract 1981;16(6): Robertson D, Rockwood K, Stolee P. The prevalence of cognitive impairment in an elderly Canadian population. Acta Psychiatr Scand 1989;80: Iliffe S, Booroff A, Galivan S, Goldenberg E, Morgan P, HainesA using the mini-mental state examination. Bri Gen Pract 1990; 40: Worrall G. Assessment of cognitive impairment [letter]. BrJ Gen Pract 1991;41: Cooper B, Bickel H, Schaufele M. Demenzerkrankungen und leichtere kognitive Beeintrachtigungen bei alteren Patienten in der arztlichen Allgemeinpraxis. Nervenarzt 1992;63: Hofman A, Rocca WA. The prevalence of dementia in Europe: a collaborative study of findings. IntJEpidemiol 1991;20: Jorm AF, Kortan PA, Jacomb NA Projected increases in the number of dementia cases for 29 developed countries: application of a new method for making projections. Acta Psychiatr Scand 1988;78: O'Connor DW, Pollitt PA, Hyde JB, Brook CPB, Reiss BB, Roth M. Do general practitioners miss dementia in elderly patients? BMJ 1988;297: Bowers J, Jorm AF, Henderson S, Harris P. General practitioners' detection of depression and dementia in elderly patients. MedJAust 1990;153: Worrall G, Moulton N. Cognitive function: survey of elderly persons living at home in rural Newfoundland. Can Fam Physician 1993;39: Somerfield MR, Weisman CS, Ury W, Chase GA, Folstein MF. Physician practices in the diagnosis of dementing disorders.jam Geriatr Soc 1991;39: Parboosingh EJ. Screening and diagnosis ofdementia in family practice including the role ofthe geriatrician. Poster presented at the Annual Meeting of the Royal College of Physicians and Surgeons of Canada; 1992 Sept 11-14; Ottawa. 15. Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: a practical guide for grading the cognitive state of patients for the clinician.jpsychiatrres 1975;12: Goldberg RJ, Faust D, Novack D. Integrating the cognitive mental status examination into the medical interview. South MedJ 1992;85: O'Connor DW, Fertig A, Grande MJ, Hyde JB, Perry JR, Roland MO, et al. Dementia in general practice: the practical consequences of a more positive approach to diagnosis. BrJ Gen Pract 1993;43: Zec RF. Neuropsychological functioning in Alzheimer's disease. In: Parks RW, Zec RF, Wilson RS, editors. Neuropsychology ofalzheimer's disease and other dementias. New York: Oxford University Press; p Canadian Consensus Conference on the Assessment of Dementia. Assessing dementia: the Canadian consensus. Can Med Assoc J 1991;144: Canadian Task Force on the Periodic Health Examination. Periodic health examination, 1991 update. 1. Screening for cognitive impairment. Can Med Assoc J 1991; 144: Bourke J, Castleden CM, Stephen R, Dennis M. A comparison of clock and pentagon drawings in Alzheimer's disease. IntJ Geriatr Psychiatry 1995;10: Monaghan JC. Procedures for your practice: a how-to update and clinical review of procedures commonly performed in the primary care setting. Patient Care 1993; 27(11): Garcia CE, Loyola JC, Armstrong T, Von Muhlenbrock F, Blake E. Prueba del reloj: un metodo simple para evaluar demencia. Rev Med Chile 1993;121: Manos PJ, Wu R. The ten point clock test: a quick screen and grading method for cognitive impairment in medical and surgical patients. Intj Psychiatry Med 1994;24: Death J, Douglas A, Kenny RA. Comparison of clock drawing with Mini Mental State Examination as a screening test in elderly acute hospital admissions. Postgrad MedJ 1993; 69: Watson YI, Arfken CA, Birge SJ. Clock completion: an objective screening test for dementia.jam Geriatr Soc 1993; 41: Shulman KI, Shedletsky R, Silver IL The challenge of time: clock-drawing and cognitive function. IntJ Geriatr Psychiatry 1986;1: Tuokko H, Hadjistavropoulos T, Miller JA, Beattie BL. The clock test: a sensitive measure to differentiate normal elderly from those with Alzheimer disease.jam Geriatr Soc 1992;40: Huntzinger JA, Rosse RB, Schwartz BL, Ross LA, Deutsch SI. Clock drawing in the screening assessment of cognitive impairment in an ambulatory care setting: a preliminary report. Gen Hosp Psychiatry 1992;14: Elmslie TJ, Wells G, Hollingsworth G, McDowell I. Study of sexual behaviour associated with transmission ofhiv infection among women in the primary care setting. Final report. Ottawa: National Health Research Development Program, Health and Welfare Canada; Dillman DA. Mail and telephone surveys: the total design method. New York: Academic Press; * * a 1768 Canadian Family Physician Le Medecin defamille canadien * VOLL43:OCT1OBER * OCTOBMEP1997 FOR PRESCRIBING INFORMATION SEE PAGE 1863 *

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