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.

KEYWORDS:

• Early dementia
• Primary care
• Memory
• Free and Cued Selective Reminding Test
• Diagnostic screener

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the National Institutes of Health (NIH) [grant number R21 AG036935] to Ellen Grober. Richard B. Lipton receives research support from the NIH: [grant number PO1 AG003949] (Program Director), [grant number RO1 AG038651-01A1] (PI, Einstein), [grant number U10 NS077308-01] (PI), [grant number RO1 NS07792503] (Investigator), [grant number RO1 AG042595-01A1] (Investigator), [grant number RO1 NS08243203] (Investigator), [grant number K23 NS096107-01] (Mentor), the National Headache Foundation and Boston Scientific. The Free and Cued Selective Reminding Test with Immediate Recall (FCSRT+IR) is copyrighted by the Albert Einstein College of Medicine and is made freely available for noncommercial purposes. Ellen Grober receives a small percentage of any royalties on the FCSRT+IR when it is used for commercial purposes. Richard B. Lipton serves on the editorial boards of Neurology and as senior advisor to Headache. He has reviewed for the National Institute on Aging (NIA) and National Institute of Neurological Disorders and Stroke (NINDS), holds stock options in eNeura Therapeutics and serves as consultant, advisory board member, or has received honoraria from: Alder, Allergan, American Headache Society, Amgen, Autonomic Technologies, Avanir, Boehringer-Ingelheim, Boston Scientific, Bristol-Myers Squibb, Colucid, Dr. Reddy's, Electrocore, Eli Lilly, eNeura Therapeutics, Merck, Novartis, Pfizer, Teva, Vedanta. He receives royalties from Wolff's Headache, 8th Edition, Oxford Press University, 2009 and Informa.