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Dementia Diagnostics in Primary Care: a Representative 8-Year Follow-Up Study in Lower Saxony, Germany

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Dementia Diagnostics in Primary Care: a Representative 8-Year Follow-Up Study in Lower Saxony, Germany View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by edoc Original Research Article Dement Geriatr Cogn Disord 2008;25:127–134 Accepted: November 2, 2007 DOI: 10.1159/000112514 Published online: December 17, 2007 Dementia Diagnostics in Primary Care: A Representative 8-Year Follow-Up Study in Lower Saxony, Germany a b c a Lienhard Maeck Sebastian Haak Anita Knoblauch Gabriela Stoppe a b University Psychiatric Hospitals, Basel , Switzerland; Klinikum Oldenburg, Oldenburg , and c Niedersächsisches Landeskrankenhaus, Wunstorf , Germany Key Words Introduction ؒ Primary care ؒ Dementia diagnostics ؒ Memory impairment Alzheimer’s disease ؒ Vascular dementia In the industrialized world and many developing countries, life expectancy is still increasing. As advanced age has to be regarded as the main risk factor for demen- Abstract tia, prevalence rates are supposed to double every 20 years Aim: To investigate whether primary-care physicians’ com- to 81.1 million by 2040 worldwide [1] . As for the situation petency regarding dementia diagnostics improved from in Germany, likewise, the number of about 1 million of 1993 to 2001. Methods: In a representative follow-up survey demented people today will double within the next 4 de- 122 out of 170 (71.8%) family physicians (FPs) were randomly cades [2] . The resulting economic burden on society is assigned to 2 written case samples presenting patients with immense, as at least for the largest subgroup of primary slight memory impairment (case 1a: female vs. case 1b: male) degenerative dementia of the Alzheimer type (DAT), and moderate dementia [vascular type (case 2a) vs. Alzhei- treatment options still remain limited. In general, de- mer’s disease (case 2b)]. Potential diagnostic workup was in- mentia should be diagnosed early, as potentially curable quired by a structured face-to-face interview. Results: ‘Basic’ causes of a dementia syndrome – like depression and diagnostics like history taking or laboratory investigations side-effects of polypharmacy – benefit from early treat- were considered in the first place. In case 1, neuropsycho- ment. Moreover, there is evidence that in case of primary logical screening was significantly more frequently consid- degenerative dementia, early treatment will result in ered at follow-up (19.3% in 1993 vs. 31.1% in 2001); it still slowing the course of disease and delay nursing home would have been applied rarely in case 2 (2a: 14.1 vs. 14.8%; placement significantly [3] . In Germany and other coun- 2b: 23.5 vs. 24.6%). Neuroimaging remained not to be con- tries, medical care for the elderly is particularly provided sidered as a standard procedure, and only a minority of FPs by family physicians (FPs) [4, 5] . Usually, the assumption would have performed a screening for depression (2001: 1a: of this task is in accordance with their professional self- 6.7%; 1b: 11.3%; 2a: 0.0%; 2b: 1.6%). Conclusions: With regard conception [6–8] . However, early diagnosis of dementia to dementia diagnostics in primary care, guideline adher- is a challenging subject, as the first symptoms are rather ence remained low at follow-up. Structured training efforts non-specific. Last but not least the physicians’ subjective aiming at FPs appear to be necessary. expectations towards the therapeutic impact of treatment Copyright © 2007 S. Karger AG, Basel options in dementia may also affect diagnostic consider- © 2007 S. Karger AG, Basel Prof. Dr. med. Gabriela Stoppe 1420–8008/08/0252–0127$24.50/0 University Psychiatric Hospitals Fax +41 61 306 12 34 Wilhelm Klein-Strasse 27 E-Mail [email protected] Accessible online at: CH–4025 Basel (Switzerland) www.karger.com www.karger.com/dem Tel. +41 61 325 5646, Fax +41 61 325 5582, E-Mail [email protected] Downloaded by: Universitätsbibliothek Medizin Basel 131.152.211.61 - 10/23/2017 5:00:14 PM ations. For example, earlier studies could demonstrate heim and their closer vicinity. To ensure satisfying collaboration, that both the rate of diagnosis and individual case man- the FPs were asked for a standardized face-to-face interview with respect to their diagnostic workup of cognitive decline in elderly agement depend on the doctors’ knowledge as well as on patients. By this mode of questioning, standardized open ques- his/her tenor with regard to dementia. Even more, they tions could be posed without disclosing any answer categories; also unravelled a high prevalence of nihilistic attitudes moreover, answers induced by the questionnaire could be avoid- [6–11] . It is therefore not amazing that during recent years ed. The term ‘dementia’ was not explicitly given to keep the study several investigators showed deficits in FPs’ skills with focus as blinded as possible. The interview was documented in written form, for the most part by ticking off prepared answer respect to the diagnosis and treatment of dementia [12– categories. In case the request was rejected, our investigators tried 15] . to get the statistical data of the physician and the practice by In a representative survey of FPs in Lower Saxony dat- phone, in order to evaluate any differences in the group of par- ing from 1993, our study group applied standardized ex- ticipants and non-participants [physicians’ age and gender, year emplary case vignettes in personal face-to-face inter- of licence to practise medicine, medical qualification, date of launching the medical practice, practice location, joint practice views in the physicians’ practices. Two written case sam- (yes/no), list size, special interest in geriatric psychiatry (yes/no), ples were presented to 145 general practitioners and typical clientele, estimated percentage of pensioners among clien- primary-care internists. One of them described a patient tele, estimated number of demented patients per year]. Physicians with slight memory complaints without any vascular risk consenting to an interview likewise answered the statistical ques- factors or somatic comorbidity, the other one a patient tionnaire as a first step. Then, to each participating doctor, 2 ran- domly assigned case vignettes were presented by the interviewers suffering from moderate dementia from either vascular (1a + 2a or 1a + 2b or 1b + 2a or 1b + 2b). To ensure comparability, or Alzheimer type, respectively, and common somatic the case vignettes were almost identical to those presented in our disorders of late life [16] . The physicians’ considerations preliminary survey dating from 1993 [16] . regarding their potential diagnostic management were Only differing in the patients’ gender, cases 1a and 1b de- recorded and statistically evaluated. Above all, ‘classical’ scribed a person with slight memory impairment of 6 months duration; according to ICD-10 criteria, a beginning dementia syn- diagnostic procedures were considered [detailed direct drome may be suggested [18] . In 1993, the patient was female and, anamnesis, physical examination, blood examination, in half of the cases, expressed the wish for a drug. Since no influ- blood pressure measurement, electrocardiogram (ECG)]. ence on the resulting prescription rate could be detected, the latter A minority of FPs decided on taking a thorough indirect topic was excluded in our survey from 2001 [19] . On the other anamnesis, neuropsychological testing, screening for de- hand, as another investigation on the primary-care management of depression unravelled gender differences with regard to the pression or neuroimaging. patients’ and physicians’ gender, we decided to allow for gender In the following years, the rollout of specifically acting differences in our follow-up [20] . cholinesterase inhibitors for the exclusive therapy of DAT Cases 2a and 2b both described a female patient suffering from attracted considerable public attention and was accom- moderate dementia and common disorders typical of old age, panied by substantial training efforts aiming at physi- such as adiposity, hypercholesterolaemia, type II diabetes, ar- throsis, myocardial insufficiency and arterial hypertension. Case cians involved in the diagnosis and treatment of demen- 2a pointed to a primarily vascular aetiology of the dementia syn- tia. Due to their relatively high price, cost-benefit ratio drome, whereas 2b described the characteristics of DAT. Com- has been a matter of controversial discussion from the pared to the situation in 1993, case 2 was modified with regard to very beginning. Nevertheless, as dementia increasingly drug therapy, as an ACE inhibitor replaced the treatment with got an issue at stake for physicians, geriatric contents be- digitalis and a diuretic. After studying the case presentations, the participating physi- came integrated into the education of future FPs. The cians were asked standardized questions regarding their potential present follow-up survey was conducted to verify the re- diagnostic management (average duration of interview: 15 min). sulting assumption that primary-care skills regarding The answers obtained were categorized to facilitate the interpre- the diagnostic management of cognitive decline in the tation of the data. In this paper, responses to the following ques- elderly might have improved since 1993. tions will be discussed: • What kind of diagnostics would you arrange for every patient (please also refer to ‘basic’ procedures)? • Would you refer the respective patient to a specialist (psychia- Materials and Methods trist or neurologist)? In 1993 we included a small number of neuropsychiatrists The detailed methods as well as
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