An integrated, collaborative healthcare model for the early diagnosis and management of dementia: Preliminary audit results from the first transdisciplinary service integrating family medicine and geriatric psychiatry services to the heart of patients' homes.

BACKGROUND: The number of dementia cases is expected to rise exponentially over the years in many parts of the world. Collaborative healthcare partnerships are envisaged as a solution to this problem. Primary care physicians form the vanguard of early detection of dementia and influence clinical care that these patients receive. However, evidence suggests that they will benefit from closer support from specialist services in dementia care. An interdisciplinary, collaborative memory clinic was established in 2012 as a collaborative effort between a large family medicine based service and a specialist geriatric psychiatry service in Singapore. It is the first service in the world that integrates a family medicine based service with geriatric psychiatry expertise in conjunction with community-based partnerships in an effort to provide holistic, integrated care right into the heart of patients' homes as well as training in dementia care for family medicine physicians. We describe our model of care and the preliminary findings of our audit on the results of this new model of care. METHODS: This was a retrospective audit done on the electronic medical records of all patients seen at the Memory Clinic in Choa Chu Kang Polyclinic from August 2013 to March 2016. The information collected included gender, referral source, patient trajectories, presence of behavioural and psychological symptoms of dementia and percentage of caregivers found to be in need of support. A detailed outline of the service workflow and processes were described. RESULTS: A majority (93.5%) of the patients had their memory problems managed at the memory clinic without escalation to other specialist services. 22.7% of patients presented with behavioural and psychological symptoms of dementia. When initially assessed, a majority (82.2%) of patients' caregivers were found to be in need of support with 99.5% of such caregivers' needs addressed with memory clinic services. CONCLUSION: Our model of care has the potential to shape future dementia care in Singapore and other countries with a similar healthcare setting. Redesigning and evolving healthcare services to promote close collaboration between primary care practitioners and specialist services for dementia care can facilitate seamless delivery of care for the benefit of patients.

Montreal Cognitive Assessment for screening mild cognitive impairment: variations in test performance and scores by education in Singapore.

BACKGROUND: The Montreal Cognitive Assessment (MoCA) was developed as a screening instrument for mild cognitive impairment (MCI). We evaluated the MoCA's test performance by educational groups among older Singaporean Chinese adults. METHOD: The MoCA and Mini-Mental State Examination (MMSE) were evaluated in two independent studies (clinic-based sample and community-based sample) of MCI and normal cognition (NC) controls, using receiver operating characteristic curve analyses: area under the curve (AUC), sensitivity (Sn), and specificity (Sp). RESULTS: The MoCA modestly discriminated MCI from NC in both study samples (AUC = 0.63 and 0.65): Sn = 0.64 and Sp = 0.36 at a cut-off of 28/29 in the clinic-based sample, and Sn = 0.65 and Sp = 0.55 at a cut-off of 22/23 in the community-based sample. The MoCA's test performance was least satisfactory in the highest (>6 years) education group: AUC = 0.50 (p = 0.98), Sn = 0.54, and Sp = 0.51 at a cut-off of 27/28. Overall, the MoCA's test performance was not better than that of the MMSE. In multivariate analyses controlling for age and gender, MCI diagnosis was associated with a <1-point decrement in MoCA score (η(2) = 0.010), but lower (1-6 years) and no education was associated with a 3- to 5-point decrement (η(2) = 0.115 and η(2) = 0.162, respectively). CONCLUSION: The MoCA's ability to discriminate MCI from NC was modest in this Chinese population, because it was far more sensitive to the effect of education than MCI diagnosis.

Metabolic active peritoneal sites affect tumor debulking in ovarian and peritoneal cancers.

RATIONALE AND OBJECTIVES: To evaluate the impact of metabolic parameters in the peritoneal cavity on the likelihood of achieving complete tumor debulking in patients with ovarian and peritoneal cancers. MATERIALS AND METHODS: Forty-nine patients with ovarian and peritoneal cancers were included, who underwent pre-operative 18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (18F-FDG PET/CT). The immediate surgical outcome was dichotomized into complete and incomplete tumor debulking. 18F-FDG PET/CT was qualitatively and quantitatively assessed by scrutinizing 15 anatomical sites for the presence of peritoneal carcinomatosis (PC). Patient-based and site-based diagnostic characteristics were described. Metabolic parameters (SUVmax, metabolic tumor volume and total lesion glycolysis) and the number of 18F-FDG avid peritoneal sites were evaluated between the two groups. Receiver operating curve (ROC) analysis was performed to determine the optimal cut-off value in predicting incomplete tumor debulking. RESULTS: Twenty-seven out of the 49 patients had PC and 11 had incomplete debulking. Patient-based and site-based accuracies for detection of PC were 87.8 and 97.6%, respectively. The number of 18F-FDG avid peritoneal sites was significantly different between complete and incomplete debulking groups (0.6 ± 0.8 versus 2.3 ± 1.7 sites respectively, p = 0.001), and the only independent significant risk factor among other metabolic parameters tested (odd ratio = 2.983, 95% CI 1.104-8.062) for incomplete tumor debulking with an optimal cut-off value of ≥4 (AUC = 0.816). CONCLUSION: The number of 18F-FDG avid peritoneal sites increased the risk of incomplete tumor debulking after surgery and potentially useful in assisting treatment stratification in patients with ovarian and peritoneal cancers.

Physical Frailty, Cognitive Impairment, and the Risk of Neurocognitive Disorder in the Singapore Longitudinal Ageing Studies.

Background: The independent and combined effects of physical and cognitive domains of frailty in predicting the development of mild cognitive impairment (MCI) or dementia are not firmly established. Methods: This study included cross-sectional and longitudinal analyses of physical frailty (Cardiovascular Health Study criteria), cognitive impairment (Mini-Mental State Examination [MMSE]), and neurocognitive disorder (DSM-5 criteria) among 1,575 community-living Chinese older adults from the Singapore Longitudinal Ageing Studies. Results: At baseline, 2% were frail, 32% were prefrail, and 9% had cognitive impairment (MMSE score < 23). Frailty at baseline was significantly associated with prevalent cognitive impairment. Physical frailty categories were not significantly associated with incident NCD, but continuous physical frailty score and MMSE score showed significant individual and joint associations with incident mild NCD and dementia. Compared with those who were robust and cognitively normal, prefrail or frail old adults without cognitive impairment had no increased risk of incident NCD, but elevated odds of association with incident NCD were observed for robust with cognitive impairment (odds ratio [OR] = 4.04, p < .001), prefrail with cognitive impairment (OR = 2.22, p = .044), and especially for frail with cognitive impairment (OR = 6.37, p = .005). The prevalence of co-existing frailty and cognitive impairment (cognitive frailty) was 1% (95% confidence interval [CI]: 0.5-1.4), but was higher among participants aged 75 and older at 5.0% (95% CI: 1.8-8.1). Conclusions: Physical frailty is associated with increased prevalence and incidence of cognitive impairment, and co-existing physical frailty and cognitive impairment confers additionally greater risk of incident NCD.

Early frontal executive impairment as a predictor of subsequent behavior disturbance in dementia.

OBJECTIVE: To determine the extent to which frontal executive impairment early in the course of dementia is predictive of subsequent disturbed behavior. METHODS: This was a prospective follow-up study set in the Memory Clinic, Leicester, United Kingdom. A patient cohort (N = 42) diagnosed with mild to moderate dementia was followed up between three and six years after initial assessment. Executive function at baseline was assessed using the The Cambridge Examination for Mental Disorders of the Elderly-Revised (CAMCOG-R) Executive Function score. Disturbed behavior and caregiver distress at follow-up were assessed on the Neuropsychiatric Inventory (NPI), Cohen-Mansfield Agitation Inventory (CMAI), and Dementia Apathy Interview and Rating (DAIR). RESULTS: After adjustment, the Executive Function score at baseline was predictive of disturbed behavior and caregiver distress (NPI, CMAI, DAIR) at follow up, with higher levels of executive impairment associated with higher levels of disturbance/distress. Baseline measures of global cognitive impairment (Mini-Mental State Exam, CAMCOG) were not predictive of subsequent disturbed behavior or caregiver distress. CONCLUSION: Executive impairments identifiable relatively early in the clinical course of dementia are predictive of disturbed behavior and associated caregiver distress at long-term follow-up, which supports the view that executive dysfunction is important in the etiology of these problems.