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Research ArticleResearch

Diagnosis and management of dementia in primary care

Exploratory study

Jasneet Parmar, Bonnie Dobbs, Rhianne McKay, Catherine Kirwan, Tim Cooper, Alexandra Marin and Nancy Gupta
Canadian Family Physician May 2014; 60 (5) 457-465;
Jasneet Parmar
Associate Professor, in the Division of Care of the Elderly at the University of Alberta in Edmonton.
MB BS CoE
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  • For correspondence: jasneet.parmar@albertahealthservices.ca
Bonnie Dobbs
Professor and Director of Research, in the Division of Care of the Elderly at the University of Alberta in Edmonton.
PhD
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Rhianne McKay
Research Coordinator, in the Division of Care of the Elderly at the University of Alberta in Edmonton.
MA
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Catherine Kirwan
Student at the University of Alberta.
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Tim Cooper
Resident at the University of Alberta.
MD
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Alexandra Marin
Assistant Clinical Professor in the Division of Care of the Elderly at the University of Alberta.
MD CCFP Dip CoE
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Nancy Gupta
International medical graduate and a volunteer in the Division of Care of the Elderly at the University of Alberta.
MB BS
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  • Figure 1.
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    Figure 1.

    Study sample selection

    CC—community care, GAT—geriatric assessment team, PCN—primary care network.

    *Meeting inclusion criteria of having a diagnosis of dementia or mild cognitive impairment (made by the GAT physician).

    †Randomly selected from the 267 charts.

    ‡All CC patients had corresponding PCN charts.

  • Figure 2.
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    Figure 2.

    Reasons for referral to the GAT: Referrals total more than 100% because there could be multiple reasons for referral.

    GAT—geriatric assessment team.

Tables

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  • The following are considered indicative of high-quality dementia care:
    • Documented diagnosis of dementia and its severity

    • Cognitive testing (Mini-Mental State Examination,26 clock-drawing test, the Montreal Cognitive Assessment,27 or other)

    • Inquiry into basic activities of daily living28 and instrumental activities of daily living29

    • Laboratory testing (including complete blood count and measurement of electrolyte, thyroid-stimulating hormone, blood glucose, and calcium levels)

    • Identification of behavioural and psychological issues of dementia

    • Identification of caregiver burden

    • Identification of safety issues (eg, wandering and driving status)

    • Identification of medicolegal issues (eg, personal directives, enduring power of attorney, capacity assessment)

    • Interventions (eg, referral to community care)

    • Data from the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia.30

    • View popup
    Table 1.

    Demographic characteristics of sample

    VARIABLEGAT (N = 100)PCN (N = 81)CC (N = 73)
    Age, y
      • Mean (SD)80.9 (7.43)81.2 (7.35)82.2 (6.55)
      • Range56–9656–9665–96
    Sex, %
      • Female555762
    Marital status, %
      • Married, common-law525143
      • Widowed404151
      • Separated, divorced, never married897
    Living arrangements, %
      • With spouse or family member575749
      • Alone394245
      • Other436
    Residence, %
      • House or apartment727262
      • Assisted living272737
      • Long-term care111
    Family physician, %
      • Yes100100100
    Home care involvement, %
      • Yes6765NA
    • CC—community care, GAT—geriatric assessment team, NA—not applicable, PCN—primary care network.

    • View popup
    Table 2.

    Comparison of family physician and GAT data on selected indices of dementia assessment and care

    VARIABLEPCN, % (N = 81)GAT, % (N = 81)P VALUE
    Diagnosis of dementia documented
      • On referral to GAT5237.02
    Cognitive testing
      • Any cognitive testing performed44100< .001
    Cognitive tests used*
      • MMSE44100< .001
      • MoCA732< .001
      • CDT1288< .001
      • Other315.01
    ADLs
      • Assessment of BADLs2817100< .001
      • Assessment of IADLs2917100< .001
    Safety
      • Driving status explored3099< .001
      • Wandering explored1788< .001
    Medicolegal
      • Personal directive explored699< .001
      • EPOA explored1099< .001
      • DMC assessment explored539< .001
      • DMC assessment provided436< .001
      • Elder abuse explored126< .001
    BPSD
      • Identification of BPSD46100< .001
    Caregiver stress
      • Caregiver coping or stress explored2053< .001
    CC services
      • Referral to CC services1657< .001
    • ADLs—activities of daily living, BADLs—basic activities of daily living, BPSD—behavioural and psychological symptoms of dementia, CC—community care, CDT—clock-drawing test, DMC—decision-making capacity, EPOA—enduring power of attorney, GAT—geriatric assessment team, IADLs—instrumental activities of daily living, MMSE—Mini-Mental State Examination, MoCA—Montreal Cognitive Assessment, PCN—primary care network.

    • ↵* Out of those for whom cognitive testing was performed.

    • View popup
    Table 3.

    Comparison of CC and GAT data on selected indices of dementia assessment and care

    VARIABLECC, % (N = 73)GAT, % (N = 73)P VALUE
    Diagnosis of dementia documented
      • On referral to GAT4544> .999
    Cognitive testing
      • Any cognitive testing performed79100< .001
    Cognitive tests used*
      • MMSE77100< .001
      • MoCA632< .001
      • CDT4788< .001
      • Other715.39
    Number of cognitive tests used*
      • 1389
      • 25554
      • 33431
      • 426
    ADLs
      • Assessment of BADLs2893100.06
      • Assessment of IADLs2989100.01
    Safety
      • Driving status explored7099<.001
      • Wandering explored7388.04
    Medicolegal
      • Personal directive explored7399<.001
      • EPOA explored6499<.001
      • DMC assessment exploredNA†36NA
      • DMC assessment providedNA†33NA
      • Elder abuse explored1430.03
    BPSD
      • Identification of BPSD88100.004
    Caregiver stress
      • Caregiver coping or stress explored55520.832
    CC services
      • Referral to CC servicesNA‡59NA
    • ADLs—activities of daily living, BADLs—basic activities of daily living, BPSD—behavioural and psychological symptoms of dementia, CC—community care, CDT—clock-drawing test, DMC—decision-making capacity, EPOA—enduring power of attorney, GAT—geriatric assessment team, IADLs—instrumental activities of daily living, MMSE—Mini-Mental State Examination, MoCA—Montreal Cognitive Assessment, NA—not applicable.

    • ↵* Out of those for whom cognitive testing was performed.

    • ↵† CC does not conduct capacity assessments.

    • ↵‡ CC cannot refer to itself.

    • View popup
    Table 4.

    Contingency table of dementia diagnosis: Sensitivity = 0.59; specificity = 0.92; PPV = 0.98; NPV = 0.28.

    GAT (CRITERION STANDARD)
    YESNOTOTALS
    PCNYES41142
    NO281139
    TOTALS691281
    • GAT—geriatric assessment team, NPV—negative predictive value, PCN—primary care network, PPV—positive predictive value.

    • View popup
    Table 5.

    Contingency table of MCi diagnosis: Sensitivity = 0; specificity = 0.99; PPV = 0; NPV = 0.85.

    GAT (CRITERION STANDARD)
    YESNOTOTALS
    PCNYES011
    NO126880
    TOTALS126981
    • GAT—geriatric assessment team, MCI—mild cognitive impairment, NPV—negative predictive value, PCN—primary care network, PPV—positive predictive value.

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Canadian Family Physician: 60 (5)
Canadian Family Physician
Vol. 60, Issue 5
1 May 2014
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Diagnosis and management of dementia in primary care
Jasneet Parmar, Bonnie Dobbs, Rhianne McKay, Catherine Kirwan, Tim Cooper, Alexandra Marin, Nancy Gupta
Canadian Family Physician May 2014, 60 (5) 457-465;

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Diagnosis and management of dementia in primary care
Jasneet Parmar, Bonnie Dobbs, Rhianne McKay, Catherine Kirwan, Tim Cooper, Alexandra Marin, Nancy Gupta
Canadian Family Physician May 2014, 60 (5) 457-465;
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