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

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.