Psychiatric care of the older adult: an overview for primary care.

As the population ages, primary care providers will be frequently called on to manage psychiatric disorders suffered by their older patients. This overview of delirium, dementia, depression, and alcohol and substance misuse highlights the common presentations and suggests initial approaches to treatment. The challenges facing caregivers are also discussed.

Palliative care in advanced dementia.

Because neurodegenerative dementias are progressive and ultimately fatal, a palliative approach focusing on comfort, quality of life, and family support can have benefits for patients, families, and the health system. Elements of a palliative approach include discussion of prognosis and goals of care, completion of advance directives, and a thoughtful approach to common complications of advanced dementia. Physicians caring for patients with dementia should formulate a plan for end-of-life care in partnership with patients, families, and caregivers, and be prepared to manage common symptoms at the end of life in dementia, including pain and delirium.

The disappearing subject: exclusion of people with cognitive impairment and dementia from geriatrics research.

OBJECTIVES: To evaluate exclusion of persons with cognitive impairment from research in geriatrics by determining its frequency, method, and rationale and treatment in the resulting publications. DESIGN: All original research articles published in 2008 and 2009 in the Journal of the American Geriatrics Society (n = 434) were reviewed using a structured data collection tool. SETTING: The Journal of the American Geriatrics Society. PARTICIPANTS: There were no participants in this study. MEASUREMENTS: Data captured included recruitment method, explicit criterion for exclusion of persons with cognitive impairment, justification of exclusion criterion, reason given for exclusion, percentage of individuals excluded, and mention of exclusion as a possible limitation. RESULTS: Of 434 articles examined, 16% used recruitment methods likely to reduce participation by persons with cognitive impairment. At least 29% of studies (n = 127) employed explicit exclusion criteria. Half used the Folstein Mini-Mental State Examination (MMSE), with variable cut points (10, 12, 17, 18, 23, 26), and 19% excluded individuals for "having dementia" without specifying how this was determined. Few (6%) provided any justification for exclusion criteria used, only 43% gave any reason for exclusion, and only 14% discussed exclusion as a possible limitation. CONCLUSION: Persons with cognitive impairment are frequently excluded from research, often without rationale or mention of exclusion as a limitation or any discussion of its potential effect on the evidence base in geriatrics. When necessary, exclusion should be done thoughtfully and with awareness that this may reduce the clinical utility of study findings.

Comorbidity in aging and dementia: scales differ, and the difference matters.

BACKGROUND: Accurate assessment of the effect of dementia on healthcare utilization and costs requires separation of the effects of comorbid conditions, often poorly accounted for in existing claims-based studies. OBJECTIVE: To determine whether two different types of comorbidity and risk adjustment scales, the Chronic Disease Score (CDS) and the Cumulative Illness Rating Scale for Geriatrics (CIRS-G), perform similarly in older persons with and without dementia. METHODS: All subjects in the community-outreach diagnostic program of the University of Washington Alzheimer's Disease Research Center Satellite were included (N = 619). Subjects' mean age was 75 ± 9 years; 40% were cognitively normal, 17% were cognitively impaired but not demented, and 43% were demented. CDS and CIRS-G scores (neuropsychiatric disorders excluded to reduce colinearity with group) were examined across strata of age, education, and cognitive classification by using analysis of variance, analysis of covariance, and linear regression. RESULTS: CIRS-G scores were sensitive to factors known to be associated with chronic disease burden, including age (F = 21.3 [df = 2, 616], p <0.001), education (F = 6.6 [df = 3, 614], p <0.001), and cognitive status (F = 40.5 [df = 2, 616], p <0.001), whereas the CDS was not. In the subset of persons with CDS scores of 0 (40% of the total sample), CIRS-G scores ranged from very low to high burden of disease and remained significantly different across age, education, and cognitive status groups. In regression analyses predicting CIRS-G score, CDS score and cognitive status interacted (ß = -0.10, t = 1.9 [df = 1, 609], p = 0.06). After controlling for age, the amount of variance shared by the CIRS-G-13 and CDS differed by cognitive group (>32% for normal and mildly impaired groups combined, 17% for dementia). CONCLUSION: Different methods of measuring and adjusting for comorbidity are not equivalent, and dementia amplifies the discrepancies. The CDS, if used to control for comorbidity in comparative studies of healthcare utilization and costs for persons with and without dementia, will underestimate burden of comorbid disease and artificially inflate the costs attributed to dementia.

Neuroimaging in the clinical diagnosis of dementia: observations from a memory disorders clinic.

OBJECTIVES: To determine how often neuroimaging confirms, clarifies, or contradicts initial diagnoses of late-life cognitive disorders. DESIGN: Retrospective case review. SETTING: Outpatient clinic specializing in memory disorders. PARTICIPANTS: One hundred ninety-three consecutively referred cognitively impaired patients. MEASUREMENTS: Diagnoses using research criteria were developed for each patient at the first visit and ranged from cognitive impairment without dementia to dementias of single, complex, or indeterminate etiology. Structural (noncontrast magnetic resonance imaging) and perfusion (technetium-99m ethyl cysteine dimer single photon emission computed tomography) images were categorized together as normal, suggestive of specific diseases, or abnormal/not diagnostic. RESULTS: When a single neurodegenerative disease was suspected clinically (n=94), imaging confirmed the diagnosis in 50, contradicted the diagnosis in 32, and was abnormal/not diagnostic in 12. When more than one neurodegenerative etiology was clinically suspected (n=21), imaging assigned a single diagnosis in 13 and only cerebrovascular disease in one and was abnormal/not diagnostic in seven. In dementia not otherwise specified (NOS) (n=33), imaging suggested a specific etiology in 23 and was abnormal/not diagnostic in 10. Abnormal/not diagnostic images were more common in cognitive disorder NOS (n=25, 68%) than in other clinical groups (22%, chi-square=22.8 P<.001). Neuroimaging indicators of cerebrovascular disease were common (60% prevalence) but not predicted by the presence of vascular risk factors alone. CONCLUSION: Overall, neuroimaging confirmed, clarified, or contradicted the initial clinical diagnosis in more than 80% of patients, whereas fewer than 20% had abnormal/not diagnostic patterns. Imaging suggested a complex dementia etiology in 21% of cases clinically thought to be caused by a single process, whereas 46% of complex clinical differential diagnoses appeared to reflect a single causal pattern. Further work is needed to determine whether refinement of clinical diagnoses using specialized neuroimaging improves clinical decision-making and patient outcomes.