Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
Int J Geriatr Psychiatry. 2019 Nov;34(11):1605-1612. doi: 10.1002/gps.5172. Epub 2019 Jul 28.
Cognitive impairment is underdiagnosed in primary care. Understanding factors that precipitate memory-related discussion could inform strategies to improve diagnosis and counseling. We assessed whether: 1) having a cognitive impairment or dementia diagnosis, 2) ratings of cognition by clinicians, or 3) ratings of cognition by family companions were associated with memory-related discussion during primary care visits.
We examined audio-recorded primary care visits of cognitively impaired patients aged 65 years and older, family companions (n = 93 dyads), and clinicians (n = 14). Cognitive impairment and dementia diagnoses were extracted from the electronic health record. Clinicians and family rated patient cognition on a 10-point scale in postvisit surveys. We measured memory-related discussion using a ratio of memory-related discussion episodes to total visit statements.
We observed more memory-related discussion during primary care visits of patients with a diagnosis of mild cognitive impairment (+7.8% episodes; P < .001) or dementia (+26.3% episodes; P < .001) than no diagnosis. Clinician and family ratings of cognition varied by diagnosis: among patients with no diagnosis, family rated worse impairment than clinicians (average: 2.4 versus 1.3; P = .004) while for patients with a dementia diagnosis, clinicians rated worse impairment than family (average: 7.1 versus 5.5; P = .006). Each unit increase in clinician-rated severity of cognitive impairment was associated with more memory-related discussion (+2.6% episodes; P < .001); this association was attenuated for family (+0.7% episodes; P = .095).
Discussion of cognitive impairment appears largely driven by clinician ratings of cognition and presence of an established diagnosis. Findings suggest potential benefit of engaging family to improve cognitive impairment detection in primary care.
认知障碍在初级保健中被漏诊。了解引发与记忆相关讨论的因素可以为改善诊断和咨询策略提供信息。我们评估了以下因素是否与初级保健就诊期间的与记忆相关的讨论相关：1）是否存在认知障碍或痴呆症诊断，2）临床医生对认知的评估，或 3）家庭成员对认知的评估。
我们检查了年龄在 65 岁及以上的认知障碍患者、家庭成员（n = 93 对）和临床医生（n = 14）的录音初级保健就诊记录。从电子健康记录中提取认知障碍和痴呆症的诊断。临床医生和家庭成员在就诊后调查中对患者认知能力进行了 10 分制评估。我们使用记忆相关讨论事件与总就诊陈述的比例来衡量与记忆相关的讨论。
与无诊断相比，轻度认知障碍（+7.8%的事件；P <.001）或痴呆症（+26.3%的事件；P <.001）患者的初级保健就诊期间观察到更多与记忆相关的讨论。认知的临床医生和家庭成员的评估因诊断而异：在无诊断的患者中，家庭成员的评估比临床医生更差（平均：2.4 与 1.3；P =.004），而对于痴呆症患者，临床医生的评估比家庭成员更差（平均：7.1 与 5.5；P =.006）。临床医生评估的认知障碍严重程度每增加一个单位，与更多的与记忆相关的讨论相关（+2.6%的事件；P <.001）；这种关联对于家庭成员而言减弱（+0.7%的事件；P =.095）。
与认知障碍相关的讨论似乎主要由临床医生对认知的评估和既定诊断驱动。研究结果表明，在初级保健中，让家庭成员参与可以提高认知障碍的检测，这可能会带来好处。
