Underrecognition of cognitive impairment in assisted living facilities.

OBJECTIVES: To determine the prevalence of cognitive impairment (CI), dementia diagnosis and treatment, assistance with medications, and surrogate decision-makers for residents of assisted living facilities (ALFs). DESIGN: Cross-sectional study. SETTING: Seven ALFs in Omaha, Nebraska, and the surrounding area. None of the ALFs in this study were designated "Alzheimer's" or "dementia" facilities. PARTICIPANTS: Four hundred seven of 455 ALF residents were solicited, and 230 consented. The average age +/- standard deviation of participants was 83.3+/-8.3. MEASUREMENTS: ALF residents were examined using the Mini-Mental State Examination (MMSE), and their medical charts were reviewed. RESULTS: Fifty-eight percent of ALF residents had CI according to the MMSE. Of those with CI, 63% had no diagnosis of dementia, 75% were not treated for dementia, 41% with a documented diagnosis of dementia were not treated for dementia, 22% self-administered an average of 5.4+/-3.4 medications daily, and 11% had surrogate decision makers. CONCLUSION: More than half of ALF residents in this study had CI and a significant percentage was undiagnosed. Even when diagnosed as dementia, CI is significantly undertreated in this setting. These deficits must be addressed to promote quality of care and the need for specialized attention.

Primary care for elderly people: why do doctors find it so hard?

PURPOSE: Many primary care physicians find caring for elderly patients difficult. The goal of this study was to develop a detailed understanding of why physicians find primary care with elderly patients difficult. DESIGN AND METHODS: We conducted in-depth interviews with 20 primary care physicians. Using an iterative approach based on grounded theory techniques, a multidisciplinary team analyzed the content of the interviews and developed a conceptual model of the difficulty. RESULTS: Three major domains of difficulty emerged: (i) medical complexity and chronicity, (ii) personal and interpersonal challenges, and (iii) administrative burden. The greatest challenge occurred when difficulty in more than one area was present. Contextual conditions, such as the practice environment and the physician's training and personal values, shaped the experience of providing care and how difficult it seemed. IMPLICATIONS: Much of the difficulty participants experienced could be facilitated by changes in the health care delivery system and in medical education. The voices of these physicians and the model resulting from our analysis can inform such change.