Amy R. Ehrlich

Neuropsychological strategies for detecting early dementia

As new and more effective treatments for Alzheimers disease (AD) emerge, the development of efficient screening strategies in educationally and racially diverse primary care settings has increased in importance. A set of candidate screening tests and an independent diagnostic assessment were administered to a sample of 318 patients treated at a geriatric primary care center. Fifty-six subjects met criteria for dementia. Exploratory analysis led to the development of three two-stage screening strategies that differed in the composition of the first stage or Rapid Dementia Screen, which is applied to all patients over the age of 65. The second stage, applied to those patients who screen positively for dementia, is accomplished with the Free and Cued Selective Reminding Test to detect memory impairment. Using clinical diagnosis as a gold standard, the strategies had high sensitivity and specificity for identifying dementia and performed better for identifying AD than non-AD dementias. Sensitivity and specificity did not differ by race or education. The strategies provide an efficient approach to screening for early dementia.

Risk Factors for Fires and Burns in Homebound, Urban Elderly

This study examines the prevalence of risk factors for fires and burns in homebound urban elderly. A home safety assessment was performed on 83 patients enrolled in a physician home visiting program. Information was collected on the presence and functioning of smoke alarms, the presence of fire extinguishers and the maximum temperature of hot tap water. Functional smoke alarms were not present in 37% of households, 82% of households had no access to a fire extinguisher, 46% of households had hot tap water temperature greater than the recommended 120°F. Multiple risk factors for burns and fires exist in the homes of elderly homebound patients that are well known to the medical community. Further attention to burn and fire prevention should be incorporated into the medical and geriatrics curriculum.

Screening older Latinos for dementia in the primary care setting.

The purpose was to compare the Spanish language picture version of the Free and Cued Selective Reminding Test with Immediate Recall (pFCSRT+IR) and the Mini Mental State Exam (MMSE) in identifying very mild dementia among Spanish speaking Latino patients. The tests and an independent diagnostic assessment were administered to 112 Latino patients free of medically diagnosed dementia from an urban primary care clinic. Receiver operating characteristic (ROC) curves and the area under the curve (AUC) were used to examine differences in the operating characteristics of the pFCSRT+IR and the MMSE. Cut scores were manipulated to equate sensitivities (specificities) at clinically relevant values to compare differences in specificities (sensitivities) using the Pearson Chi Square test. Youdens index was used to select the optimal cut scores. Twenty-four of the 112 primary care patients (21%) received a research dementia diagnosis, indicating a substantial burden of unrecognized dementia. MMSE scores but not free recall scores were associated with years of education in patients free of dementia. AUC was significantly higher for free recall than for MMSE. Free recall performed significantly better than the MMSE in sensitivity and in specificity. Using optimal cut scores, patients with impaired free recall were 10 times more likely to have dementia than patients with intact recall, and patients with impaired MMSE scores were 4.5 times more likely to have dementia than patients with intact scores. These results suggest that the Spanish language pFCSRT+IR may be an effective tool for dementia screening in educationally diverse Latino primary care populations.

Very Mild Dementia and Medical Comorbidity Independently Predict Health Care Use in the Elderly

Objective: To determine whether dementia status and medical burden were independent predictors of emergency department (ED) visits and hospitalizations in older patients from an urban geriatric practice participating in a primary care based cognitive screening program. Participants and Methods: A comprehensive chart review was conducted for 300 African American and Caucasian patients, including 46 with prevalent dementia and 28 with incident dementia using the Cumulative Illness Burden Scale. Hospital-based claims data was used to retrieve ED visits and hospital admissions for 5 years following baseline assessment. Results: Patients with dementia had a 49% higher rate of ED visits (IRR = 1.49; 95% CI = 1.06, 2.09) and an 83% higher risk of death than patients without dementia (HR = 1.83; 95% CI = 3.07, 0.03). Dementia status predicted hospital admissions after adjustment for medical burden (IRR = 1.37; 95% CI = 0.99, 1.89). For each one point increase in medical burden, there was an 11% increase in ED visits (IRR = 1.11; 95% CI = 1.06, 1.16), a 13% increase in hospital admissions (IRR = 1.13; 95% CI = 1.09, 1.17), and an 11% higher risk of death (HR = 1.11; 95% CI = 1.04, 1.17). Age did not predict utilization. Conclusion: Dementia status and medical burden were independent predictors of ED visits and death in patients with clinically diagnosed dementia followed from the early stage of disease.

Two-stage screening for early dementia in primary care

ABSTRACT Objective: The objective was to compare two screening strategies for dementia in an urban primary care clinic, serving a low-education, minority community composed largely of Latino and African American patients. Method: Two hundred and fifty-seven patients underwent two-stage patient-based screening (PBS) and informant-based screening (IBS) followed by a diagnostic evaluation. In the first stage, PBS included brief tests of episodic memory (Memory Impairment Screen), semantic memory (Animal Fluency), and executive function (Reciting Months Backwards). For IBS, the first stage consisted of the short Informant Questionnaire on Cognitive Decline in the Elderly, administered to a family member or friend. Patients who screened positive in the first stage of either strategy underwent testing with the picture version of the Free and Cued Selective Reminding Test with Immediate Recall to identify memory impairment. Sensitivity, specificity, and positive and negative predictive values were computed for various cutoffs of each test and combination of tests. Dementia was diagnosed using Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition (DSM–IV) criteria without access to the screening test results. Results: We identified 66 patients (25.7%) with previously undiagnosed dementia. Sensitivity was the same (77%) for both strategies but specificity was higher for IBS than for PBS (92% versus 83%). IBS’s higher specificity makes it the preferred strategy if a knowledgeable informant is available. Conclusion: Unrecognized dementia is common in primary care. Case-finding can be improved using either PBS or IBS two-stage screening strategies.

Identifying memory impairment and early dementia in primary care

This study examined the operating characteristics of two‐stage case finding to identify memory impairment and very mild dementia.