Dementia Services Mini-Screen: a simple method to identify patients and caregivers in need of enhanced dementia care services.

OBJECTIVE: Improving dementia care in health systems requires estimates of need in the population served. We explored whether dementia-specific service needs and gaps for patients and caregivers could be predicted by simple information readily captured in routine care settings. METHOD: Primary family caregivers (n = 215) rated their own current stress, challenging patient behaviors, and prior-year needs and gaps in 16 medical and psychosocial services. These were evaluated with other patient and caregiver characteristics in multivariate regressions to identify unique predictors of service needs and gaps. RESULTS: Caregiver stress and patient behavior problems together accounted for an average of 24% of the whole-sample variance in total needs and gaps. All other variables combined (comorbid chronic disease, dementia severity, age, caregiver relationship, and residence) accounted for a mean of 3%, with none yielding more than 4% in any equation. We combined stress and behavior problem indicators into a simple screen. In early/mild dementia dyads (n = 111) typical in primary care settings, the screen identified gaps in total (84%) and psychosocial (77%) care services for high stress/high behavior problem dyads vs. 25% and 23%, respectively, of low stress/low behavior problem dyads. Medical care gaps were dramatically higher in high stress/high behavior problem dyads (66%) than all others (12%). CONCLUSION: The Dementia Services Mini-Screen is a simple tool that could help clinicians and health systems rapidly identify dyads needing enhanced dementia care, track key patient and caregiver outcomes of interventions, and estimate population needs for new service development.

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.

Time that tells: critical clock-drawing errors for dementia screening.

BACKGROUND: Clock-drawing tests are popular components of dementia screens but no single scoring system has been universally accepted. We sought to identify an optimal subset of clock errors for dementia screening and compare them with three other systems representative of the existing wide variations in approach (Shulman, Mendez, Wolf-Klein), as well as with the CDT system used in the Mini-Cog, which combines clock drawing with delayed recall. METHODS: The clock drawings of an ethnolinguistically and educationally diverse sample (N = 536) were analyzed for the association of 24 different errors with the presence and severity of dementia defined by independent research criteria. The final sample included 364 subjects with > or = 5 years of education, as preliminary examination suggested different error patterns in subjects with 0-4 years of education and inadequate numbers of normal controls for reliable analysis. RESULTS: Eleven of 24 errors were significantly associated with dementia in subjects with > or = 5 years of education, and six were combined to identify dementia with 88% specificity and 71% sensitivity: inaccurate time setting, no hands, missing numbers, number substitutions or repetitions, or refusal to attempt clock drawing. Time setting was the most prevalent error at all dementia stages, refusal occurred only in moderate and severe dementia; and ethnicity and language of administration had no effect. All critical errors increased in frequency with dementia stage. This simplified scoring system had much better specificity than two other systems (88% vs 39% for Mendez's system - 63% for Shulman's) and much better sensitivity than Wolf-Klein's (71% vs 51%). Stepwise logistic regression found the simplified system to be more strongly predictive of dementia than the three other CDT systems of dementia. Substituting the new CDT algorithm for that used in the original CDT Mini-Cog improved the Mini-Cog's specificity from 89 to 93% with minimal change in sensitivity. CONCLUSIONS: Only six errors need be assessed to capture most of the power of clock drawing to discriminate between people with dementia and normal subjects, and improves specificity over older systems in subjects with > or = 5 years of education. These errors require minimal conceptual classification and are easily detected and scored by non-specialists.

Cognitive impairment, chronic disease burden, and functional disability: a population study of older Italians.

OBJECTIVE: To evaluate associations of cognitive impairment and disease burden with disability in an elderly population. METHODS: The Mini-Cog was used as a cognitive screen in a population-based survey of health and functional status of 2,192 randomly selected older adults (age 65+ years) in 11 regions of Italy. Associations of cognitive and disease measures with functional outcomes were calculated using hierarchical logistic regressions including age, Mini-Cog score, disease burden, age, education, and geographic region. Statistical significance was assigned at p <0.01. RESULTS: Mini-Cog scores were related to all functional indicators (activities of daily living [ADLs], social activities, exercise, telephone and face-to-face conversation, urinary control, and ability to read the newspaper) as well as stroke, falls, and dementia diagnoses. In univariate analyses, low education was associated with Mini-Cog scores, disease burden, and disability. However, in logistic regressions, Mini-Cog score and disease burden, but not education, remained significant predictors of all basic ADLs and most higher-order functions. Functional disability was best predicted by a Mini-Cog cutoff score of 1 out of 5. Overall, although both are significant, the impact of cognitive impairment on basic ADL impairment was over four times greater than that of disease burden (accounting for 14% versus 3% of variance). CONCLUSION: Cognitive impairment assessed by the Mini-Cog is a more powerful predictor of impaired ADLs than disease burden in older adults. The association of education with Mini-Cog score did not bias its ability to predict functional status. Results suggest that the Mini-Cog could be useful in assessing older population assistance needs.

Implementing routine cognitive screening of older adults in primary care: process and impact on physician behavior.

BACKGROUND: Early detection of cognitive impairment is a goal of high-quality geriatric medical care, but new approaches are needed to reduce rates of missed cases. OBJECTIVE: To evaluate whether adding routine cognitive screening to primary care visits for older adults increases rates of dementia diagnosis, specialist referral, or prescribing of antidementia medications. SETTING: Four primary care clinics in a university-affiliated primary care network. DESIGN: A quality improvement screening project and quasiexperimental comparison of 2 intervention clinics and 2 control clinics. The Mini-Cog was administered by medical assistants to intervention clinic patients aged 65+ years. Rates of dementia diagnoses, referrals, and medication prescribing were tracked over time using computerized administrative data. RESULTS: Twenty-six medical assistants successfully screened 70% (n = 524) of all eligible patients who made at least 1 clinic visit during the intervention period; 18% screened positive. There were no complaints about workflow interruption. Relative to baseline rates and control clinics, Mini-Cog screening was associated with increased dementia diagnoses, specialist referrals, and prescribing of cognitive enhancing medications. Patients without previous dementia indicators who had a positive Mini-Cog were more likely than all other patients to receive a new dementia diagnosis, specialty referral, or cognitive enhancing medication. However, relevant physician action occurred in only 17% of screen-positive patients. Responses were most related to the lowest Mini-Cog score level (0/5) and advanced age. CONCLUSION: Mini-Cog screening by office staff is feasible in primary care practice and has measurable effects on physician behavior. However, new physician action relevant to dementia was likely to occur only when impairment was severe, and additional efforts are needed to help primary care physicians follow up appropriately on information suggesting cognitive impairment in older patients.

Improving identification of cognitive impairment in primary care.

OBJECTIVES: To compare the relative level and predictors of accuracy of a brief cognitive screen, the Mini-Cog, with spontaneous detection of cognitive impairment by subjects' primary care physicians. PARTICIPANTS: A heterogeneous community sample (n=371) of predominantly ethnic minority elderly assessed by standardized research protocol, 231 of whom met criteria for dementia or mild cognitive impairment (MCI). RESULTS: The Mini-Cog detected cognitively impaired subjects much more effectively than did subject's own physicians (p<0.0001), correctly classifying 83% of the sample and 84% of cognitively impaired subjects. Physicians correctly classified 59% of all subjects but identified only 41% of cognitively impaired subjects. The Mini-Cog's advantage over physicians was greatest when impairment was mildest (screen vs physician recognition at CDR 0.5, 58% vs 6%; at CDR 1, 92% vs 41%). Additional subject variables associated with missed detection by physicians were non-Alzheimer type dementia and low education, low literacy, and non-English speaking, factors that had little or no effect on the performance of the Mini-Cog. Ethnic differences, also observed for physician recognition, were not significant in final regression equations. The number and recency of primary care visits, and duration of the primary care relationship, were not associated with physicians' recognition of cognitive impairment. CONCLUSION: This study demonstrates that recognition of cognitive impairment by primary care physicians is adversely influenced by important patient and disease characteristics. Results also show that use of the Mini-Cog would improve recognition of cognitive impairment in primary care, particularly in milder stages and in older adults subject to disparities in health care quality due to sociodemographic factors.

Cooperative dementia care clinics: A new model for managing cognitively impaired patients.

Cooperative health care clinics (CHCCs), or shared medical appointments, are a healthcare innovation that can improve access and expand physicians' capacity to manage common geriatric conditions. This report describes a pilot program and working model for extending CHCCs to patients with dementia. Three cooperative dementia care clinics (CDCCs) met monthly for up to 1 year, drawing participants from a dementia clinic roster of patients and caregivers who had required continued specialty care for at least 3 months. Twenty-six of 33 eligible patient-caregiver dyads expressed interest, and 21 enrolled; five whose clinical status changed during the year withdrew and were replaced with new members. Brief introductory socialization, individualized clinical management, and an educational focus selected from problems of patients and caregivers were common to all sessions. Most participants required several types of clinical intervention and educational support. One group ended after reaching a natural termination point, and two others are ongoing at the request of participants. CDCCs can be a viable approach to increasing dementia care capacity in health systems. Formal service intervention trials to evaluate the generalizability and comparative effectiveness and economic viability of this model versus usual care are an appropriate next step.

Simplifying detection of cognitive impairment: comparison of the Mini-Cog and Mini-Mental State Examination in a multiethnic sample.

OBJECTIVES: To compare detection of cognitive impairment using the Mini-Cog and Mini-Mental State Examination (MMSE) and to identify sociodemographic variables that influence detection in an ethnoculturally diverse sample. DESIGN: Cross-sectional. SETTING: A registry of the University of Washington Alzheimer's Disease Research Center Satellite. PARTICIPANTS: A heterogeneous community sample (n=371) of predominantly ethnic minority elderly assessed using a standardized research protocol, 231 of whom met criteria for dementia or mild cognitive impairment (MCI). MEASUREMENTS: Demographic data, a standardized research protocol for cognitive assessment and dementia diagnosis, MMSE, and Mini-Cog. RESULTS: Both screens effectively detected cognitive impairment, the Mini-Cog slightly better than the MMSE (P<.01). Overall accuracy of classification was 83% for the Mini-Cog and 81% for the MMSE. The Mini-Cog was superior in recognizing patients with Alzheimer-type dementias (P=.05). Low education negatively affected detection using the MMSE (P<.001), whereas education did not affect the Mini-Cog, and low literacy minimally affected it. CONCLUSION: The Mini-Cog detects clinically significant cognitive impairment as well as or better than the MMSE in multiethnic elderly individuals, is easier to administer to non-English speakers, and is less biased by low education and literacy.

Effects of topiramate in adults with Prader-Willi syndrome.

Prader-Willi syndrome is a multisystem neurogenetic obesity disorder with behavioral manifestations, including hyperphagia, compulsive behavior, self-injury, and mild to moderate mental retardation. In an 8-week open-label study, we evaluated adjunctive therapy with the anticonvulsant topiramate in 8 adults with Prader-Willi syndrome. Appetite was measured by a 1-hour access to food four times throughout the study and quantified with a visual analogue scale. Topiramate did not significantly change calories consumed, Body Mass Index, or increase self-reported appetite. In addition, there were no significant changes in compulsions. Surprisingly, topiramate treatment resulted in a clinically significant improvement in the self-injury (i.e., skin-picking) that is characteristic of this syndrome. Potential benefits of topiramate for self-injury should be evaluated further in controlled trials.

Brain activation by disgust-inducing pictures in obsessive-compulsive disorder.

BACKGROUND: There is growing interest in the role of disgust in the pathogenesis of obsessive-compulsive disorder (OCD). METHODS: Eight OCD subjects with contamination preoccupations and eight gender- and age-matched healthy volunteers viewed pictures from the International Affective Picture System during functional magnetic resonance imaging scans. RESULTS: A different distribution of brain activations was found during disgust-inducing visual stimulation in several areas, most notably the insula, compared with neutral stimulation in both OCD subjects and healthy volunteers. Furthermore, whereas activation during the threat-inducing task in OCD subjects showed a pattern similar to that in healthy volunteers, the pattern of activation during the disgust-inducing task was significantly different, including greater increases in the right insula, parahippocampal region, and inferior frontal sites. CONCLUSIONS: This pilot study supports the relevance of disgust in the neurocircuitry of OCD with contamination-preoccupation symptoms; future studies looking at non-OCD individuals with high disgust ratings, non-contamination-preoccupied OCD individuals, and individuals with other anxiety disorders are needed.

Problematic internet use: proposed classification and diagnostic criteria.

Since the mid-1990s, there have been frequent reports of individuals whose use of the computer and internet is problematic. Given the recent expansion and the expected increase in internet availability and usage in the coming years, it is important that healthcare professionals be informed about this behavior and its associated problems. Recently, psychological and psychiatric literature has described individuals that exhibit problematic internet use who often suffer from other psychiatric disorders. In the face of this comorbidity, it is essential to evaluate whether these individuals represent a distinct class of disorder, or a manifestation/coping mechanism related to other underlying diagnosis. In either event, problematic internet use negatively impacts social and emotional functioning. Based on the current limited empirical evidence, problematic internet use may best be classified as an impulse control disorder. It is therefore imperative that problematic internet use be appropriately identified among symptomatic individuals. For these reasons, we propose specific diagnostic criteria that will allow for consistent identification and assist in further study of this behavior.

Evaluation of open-label topiramate for scar therapy.

A 3-month open-label pilot study was carried out to assess the safety, tolerability, and effect of the antiepilectic topiramate on the cosmetic appearance of scars. Ten adult subjects with discolored or raised scars at least 2 years old were given an oral dosage of 15 mg per day of topiramate for 1 month. The dosage was then increased to 30 mg per day if there was minimal or no improvement. The safety of topiramate was assessed in this study by reviewing adverse events and vital signs. Efficacy outcomes included a Clinician Global Impression Scale (CGI) to document changes such as thickness and color. Digital photos were taken with consistent variables. In addition, two independent medical reviewers blindly reviewed the photos. The Rosenberg Self-Esteem Scale was done at each visit to measure patients' levels of self-esteem. Side effects were generally mild with the most common being language problems (n = 3) and sleep disturbances (n = 3). All subjects completed the study and experienced at least minimal thinning and decreased coloration (usually redness) of their scars. Based on CGI-assessment data at 3 months, two subjects were very much improved, four were much improved, and four had minimal improvement. One independent medical reviewer arranged before and after treatment picture sets for ten out of ten subjects. The other independent medical reviewer arranged before and after treatment pictures sets for nine out of ten subjects (both p-values less than 0.025). The data indicate that topiramate may be a safe and effective treatment for scar therapy.

Topiramate attenuates self-injurious behaviour in Prader-Willi Syndrome.

Self-injurious behaviour (SIB), most notably skin picking, has been described by various terms in the literature ranging from neurotic/psychogenic excoriations to compulsive/pathological skin picking. Prader-Willi Syndrome (PWS) is a neurogenetic multisystem disorder characterized by infantile hypotonia, mental retardation, short stature, hypogonadism, dysmorphic features, and hyperphagia with a high risk of obesity. Psychiatric manifestations include SIBs in the form of skin picking, nail biting and rectal gouging. Topiramate is a novel anti-epileptic medication without significant liability of weight gain. There are no published reports of topiramate being utilized in PWS or SIB. We report attenuation of SIB with resultant lesion healing in three PWS adults treated with topiramate in an 8-wk open-label trial. Although our findings should be treated with caution, they suggest that double-blind or cross-over studies with topiramate are warranted to establish the possible role of topiramate in attenuating SIB in PWS and other disorders that involve SIB.