Detection and Management of Cognitive Impairment in Primary Care: The Steel Valley Seniors Survey

Authors

  • Mary Ganguli MD, MPH,

    1. From the *Department of Psychiatry, Department of Medicine, and Department of Neurology, School of Medicine§Department of Epidemiology, Graduate School of Public HealthDepartment of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PennsylvaniaGeriatric Research, Education, and Clinical Center, Pittsburgh Veterans Administration Health System, Pittsburgh, Pennsylvania#Center for Neurosciences Research, Allegheny General Hospital, Pittsburgh, Pennsylvania**Family Medicine Associates, Ltd, McKeesport, Pennsylvania
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  • Eric Rodriguez MD,

    1. From the *Department of Psychiatry, Department of Medicine, and Department of Neurology, School of Medicine§Department of Epidemiology, Graduate School of Public HealthDepartment of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PennsylvaniaGeriatric Research, Education, and Clinical Center, Pittsburgh Veterans Administration Health System, Pittsburgh, Pennsylvania#Center for Neurosciences Research, Allegheny General Hospital, Pittsburgh, Pennsylvania**Family Medicine Associates, Ltd, McKeesport, Pennsylvania
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  • Benoit Mulsant MD,

    1. From the *Department of Psychiatry, Department of Medicine, and Department of Neurology, School of Medicine§Department of Epidemiology, Graduate School of Public HealthDepartment of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PennsylvaniaGeriatric Research, Education, and Clinical Center, Pittsburgh Veterans Administration Health System, Pittsburgh, Pennsylvania#Center for Neurosciences Research, Allegheny General Hospital, Pittsburgh, Pennsylvania**Family Medicine Associates, Ltd, McKeesport, Pennsylvania
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  • Stephanie Richards MD,

    1. From the *Department of Psychiatry, Department of Medicine, and Department of Neurology, School of Medicine§Department of Epidemiology, Graduate School of Public HealthDepartment of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PennsylvaniaGeriatric Research, Education, and Clinical Center, Pittsburgh Veterans Administration Health System, Pittsburgh, Pennsylvania#Center for Neurosciences Research, Allegheny General Hospital, Pittsburgh, Pennsylvania**Family Medicine Associates, Ltd, McKeesport, Pennsylvania
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  • Rajesh Pandav MBBS, MPH,

    1. From the *Department of Psychiatry, Department of Medicine, and Department of Neurology, School of Medicine§Department of Epidemiology, Graduate School of Public HealthDepartment of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PennsylvaniaGeriatric Research, Education, and Clinical Center, Pittsburgh Veterans Administration Health System, Pittsburgh, Pennsylvania#Center for Neurosciences Research, Allegheny General Hospital, Pittsburgh, Pennsylvania**Family Medicine Associates, Ltd, McKeesport, Pennsylvania
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  • Joni Vander Bilt MPH,

    1. From the *Department of Psychiatry, Department of Medicine, and Department of Neurology, School of Medicine§Department of Epidemiology, Graduate School of Public HealthDepartment of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PennsylvaniaGeriatric Research, Education, and Clinical Center, Pittsburgh Veterans Administration Health System, Pittsburgh, Pennsylvania#Center for Neurosciences Research, Allegheny General Hospital, Pittsburgh, Pennsylvania**Family Medicine Associates, Ltd, McKeesport, Pennsylvania
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  • Hiroko H. Dodge PhD,

    1. From the *Department of Psychiatry, Department of Medicine, and Department of Neurology, School of Medicine§Department of Epidemiology, Graduate School of Public HealthDepartment of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PennsylvaniaGeriatric Research, Education, and Clinical Center, Pittsburgh Veterans Administration Health System, Pittsburgh, Pennsylvania#Center for Neurosciences Research, Allegheny General Hospital, Pittsburgh, Pennsylvania**Family Medicine Associates, Ltd, McKeesport, Pennsylvania
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  • Gary P. Stoehr Pharm D,

    1. From the *Department of Psychiatry, Department of Medicine, and Department of Neurology, School of Medicine§Department of Epidemiology, Graduate School of Public HealthDepartment of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PennsylvaniaGeriatric Research, Education, and Clinical Center, Pittsburgh Veterans Administration Health System, Pittsburgh, Pennsylvania#Center for Neurosciences Research, Allegheny General Hospital, Pittsburgh, Pennsylvania**Family Medicine Associates, Ltd, McKeesport, Pennsylvania
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  • Judith Saxton PhD,

    1. From the *Department of Psychiatry, Department of Medicine, and Department of Neurology, School of Medicine§Department of Epidemiology, Graduate School of Public HealthDepartment of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PennsylvaniaGeriatric Research, Education, and Clinical Center, Pittsburgh Veterans Administration Health System, Pittsburgh, Pennsylvania#Center for Neurosciences Research, Allegheny General Hospital, Pittsburgh, Pennsylvania**Family Medicine Associates, Ltd, McKeesport, Pennsylvania
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  • Richard K. Morycz PhD,

    1. From the *Department of Psychiatry, Department of Medicine, and Department of Neurology, School of Medicine§Department of Epidemiology, Graduate School of Public HealthDepartment of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PennsylvaniaGeriatric Research, Education, and Clinical Center, Pittsburgh Veterans Administration Health System, Pittsburgh, Pennsylvania#Center for Neurosciences Research, Allegheny General Hospital, Pittsburgh, Pennsylvania**Family Medicine Associates, Ltd, McKeesport, Pennsylvania
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  • Robert T. Rubin MD, PhD,

    1. From the *Department of Psychiatry, Department of Medicine, and Department of Neurology, School of Medicine§Department of Epidemiology, Graduate School of Public HealthDepartment of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PennsylvaniaGeriatric Research, Education, and Clinical Center, Pittsburgh Veterans Administration Health System, Pittsburgh, Pennsylvania#Center for Neurosciences Research, Allegheny General Hospital, Pittsburgh, Pennsylvania**Family Medicine Associates, Ltd, McKeesport, Pennsylvania
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  • Barry Farkas MD, MPH,

    1. From the *Department of Psychiatry, Department of Medicine, and Department of Neurology, School of Medicine§Department of Epidemiology, Graduate School of Public HealthDepartment of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PennsylvaniaGeriatric Research, Education, and Clinical Center, Pittsburgh Veterans Administration Health System, Pittsburgh, Pennsylvania#Center for Neurosciences Research, Allegheny General Hospital, Pittsburgh, Pennsylvania**Family Medicine Associates, Ltd, McKeesport, Pennsylvania
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  • Steven T. DeKosky MD

    1. From the *Department of Psychiatry, Department of Medicine, and Department of Neurology, School of Medicine§Department of Epidemiology, Graduate School of Public HealthDepartment of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PennsylvaniaGeriatric Research, Education, and Clinical Center, Pittsburgh Veterans Administration Health System, Pittsburgh, Pennsylvania#Center for Neurosciences Research, Allegheny General Hospital, Pittsburgh, Pennsylvania**Family Medicine Associates, Ltd, McKeesport, Pennsylvania
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  • Supported in part by Grant AG16705 from the National Institute on Aging, National Institutes of Health, U.S. Department of Health and Human Services.

Address correspondence to Dr. M. Ganguli, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, 3811 O'Hara Street, Pittsburgh, PA 15213. E-mail: gangulim@upmc.edu

Abstract

Objectives: To identify characteristics of older primary care patients who were cognitively impaired and who underwent mental status testing by their physicians.

Design: Cross-sectional and retrospective analysis.

Setting: Seven small-town primary care practices.

Participants: A total of 1,107 patients with a mean±standard deviation age of 76.3±6.6, screened using the Mini-Mental State Examination (MMSE); medical records reviewed.

Measurements: Demographics, MMSE, medical record information. Odds ratios (OR) with 95% confidence intervals (CI), adjusted for age, sex, and education.

Results: Thirty-one percent of the sample had MMSE scores of less than 25. Among these patients, physicians documented memory loss in only 23% which was significantly more often than in the higher scoring group (OR=1.9, 95% CI=1.3–2.8), basic activity of daily living (ADL) impairment in 7.9% (OR=2.4, 95% CI=1.3–4.4), instrumental ADL (IADL) impairment in 6.7% (OR=2.2, 95% CI=1.1=4.2), dementia in 12.2% (OR=3.7, 95% CI=2.0–6.8), and prescription of cholinesterase inhibitors in 7.6% (OR=4.4, 95% CI=1.9–10.2). Physicians recorded mental status testing largely in patients with research MMSE scores of 24 to 28, significantly more often when they also documented memory loss (OR=3.8, 95% CI=2.5–5.6) or impaired IADLs (OR=2.7, 95% CI=1.4–5.2), diagnosed dementia (OR=4.9, 95% CI=2.8–8.6), referred to specialists (OR=6.3, 95% CI=2.5–16.2) or social services (OR=3.6, 95% CI=1.8–7.3), or prescribed cholinesterase inhibitors (OR=8.5, 95% CI=4.2–17.5).

Conclusion: Physicians noted impairment in a minority of impaired patients. They tested mental status in those with documented cognitive and functional difficulties, in very mildly impaired patients, and in those for whom they intervened.

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