Page S, Hope K, Bee P, Burns A
Manchester Mental Health and Social Care Trust, Wythenshawe Hospital, Manchester, UK.
Int J Geriatr Psychiatry. 2008 Jan;23(1):27-33. doi: 10.1002/gps.1831.
To compare nurse initial diagnoses following domiciliary visits with subsequent formal multidisciplinary formulation based upon the full possession of investigations, neuropsychological tests and brain imaging.
Retrospective case note study.
Home-based nurse assessments, secondary care based multidisciplinary memory clinic.
Four hundred and four consecutive referrals over an 18-month period.
One hundred and seventy-five patients (43.3%) were diagnosed by the multi-disciplinary team as having a dementia. Seventy-three (41.5%) were classified as Alzheimer's disease, 81 (46%) of mixed sub-type and 20 (11.4%) of vascular origin. Overall nurse-MDT diagnosis agreement was 0.88 (Kappa = 0.82). Together, two nurses were able to detect dementia with 94% accuracy (Kappa = 0.88) Sensitivity was 92% and specificity 96%. The positive and negative predictive values of their judgements were 94% and 98% respectively. Nurses were able to sub-diagnose dementia with 86% (kappa = 0.76) accuracy. Multivariate logistic regression modelling showed a MDT dementia diagnosis to be independently and significantly associated with lower scores on the KOLT and total MMSE, and with the absence of biological markers of depression. Nurse dementia diagnoses were associated with lower KOLT scores and the absence of biological depression markers, high past alcohol consumption or a history of hypercholesteraemia.
In this study, structured initial assessment by a specialist nurse was shown to be an accurate method of determining a diagnosis of cognitive impairment, when compared with formal MDT judgement. The principal benefit of this approach was that signposting to subsequent care pathways was expedited. Arguably, such distributed responsibility affords a viable option for the future detection of early dementia.
比较家访后护士的初步诊断与随后基于全面检查、神经心理测试和脑成像得出的正式多学科诊断结果。
回顾性病例记录研究。
居家护士评估、二级护理多学科记忆门诊。
18个月内连续转诊的404例患者。
多学科团队诊断出175例患者（43.3%）患有痴呆症。其中73例（41.5%）被归类为阿尔茨海默病，81例（46%）为混合型，20例（11.4%）为血管性痴呆。护士与多学科团队的总体诊断一致性为0.88（Kappa值 = 0.82）。两名护士共同诊断痴呆症的准确率为94%（Kappa值 = 0.88），敏感性为92%，特异性为96%。他们判断的阳性预测值和阴性预测值分别为94%和98%。护士对痴呆症进行亚诊断的准确率为86%（kappa值 = 0.76）。多变量逻辑回归模型显示，多学科团队对痴呆症的诊断与KOLT得分较低、MMSE总分较低以及不存在抑郁症生物学标志物独立且显著相关。护士对痴呆症的诊断与KOLT得分较低、不存在生物学抑郁症标志物、过去饮酒量高或有高胆固醇血症病史相关。
在本研究中，与正式的多学科团队判断相比，专科护士进行的结构化初步评估被证明是确定认知障碍诊断的准确方法。这种方法的主要好处是加快了后续护理路径的指引。可以说，这种责任分担为未来早期痴呆症的检测提供了一个可行的选择。
