Screening of cognitive impairment by general internists using two simple instruments

Jacinto, Alessandro Ferrari; Brucki, Sonia Maria Dozzi; Porto, Claudia Sellitto; Martins, Milton de Arruda; Nitrini, Ricardo

doi:10.1590/S1980-57642012DN06010007

ABSTRACT

General internists (GIs) tend to overlook cognitive impairment in the elderly. Lack of time to diagnose and/or poor knowledge on how to use screening instruments may be the reasons for this shortcoming.

Objectives:

To verify the efficacy of simple instruments in the screening of cognitive impairment in elders.

Methods:

In a previous study, 248 patients aged ≥65 that had been assisted by GIs within outpatient services of a public university hospital in São Paulo, Brazil, were evaluated. The Mini-Mental State Examination and/or the Informant Questionnaire on Cognitive Decline in the Elderly (short-IQCODE) were employed to classify patients into probable cognitively impaired cases or otherwise. Other tests and questionnaires were also applied, but were not used to perform this classification. After full assessment and consensus meetings, cases were classified into dementia, cognitively impaired not demented, and without cognitive impairment. In this study, the sensitivity and specificity of the combined use of the category fluency test (CFT) and the Functional Activities Questionnaire (FAQ) was evaluated as if used as screening instruments for the whole sample.

Results:

The combined use of the CFT and/or FAQ showed sensitivity of 88.3% and specificity of 76.5% in the screening of cognitive impairment for the whole sample.

Conclusions:

Two simple and easy-to-apply instruments showed high sensitivity and reasonable specificity, and are probably useful for the screening of cognitive impairment in the elderly in outpatient services.

Key words:
screening; dementia; cognitive impairment; questionnaire; functional activity; verbal fluency; general internists

RESUMO

Médicos generalistas (MGs) normalmente não detectam comprometimento cognitivo em idosos. Falta de tempo para realizar a triagem de comprometimento cognitivo e pouco conhecimento sobre a forma de realizá-la podem ser as razões desta falha.

Objetivos:

Verificar a eficácia de instrumentos simples no rastreio de comprometimento cognitivo em idosos.

Métodos:

Em um estudo prévio, 248 pacientes com idade ≥65, que tinham sido assistidos por MGs em serviços ambulatoriais de um hospital universitário público em São Paulo, Brasil, foram avaliados. O Mini-Exame do Estado Mental e/ou o Questionário com Informante sobre Declínio Cognitivo em Idosos (Short-IQCODE) foram utilizados para classificar os pacientes em casos prováveis de cognição prejudicada ou não. Outros testes e questionários também foram aplicados, mas não foram usados para esta classificação. Depois de avaliação completa e reuniões de consenso, os casos foram classificados como demência, cognição alterada não demência e sem comprometimento cognitivo. Neste estudo avaliamos a sensibilidade e a especificidade do uso de dois instrumentos, o teste de fluência verbal (TFV) e o Questionário de Atividades Funcionais (QAF), se eles tivessem sido empregados como instrumentos de rastreio para toda a amostra.

Resultados:

O uso combinado do TFV e/ou do QAF mostrou sensibilidade de 88,3% e especificidade de 76,5% no rastreio de comprometimento cognitivo em toda a amostra.

Conclusões:

Dois instrumentos simples e de fácil aplicação mostraram alta sensibilidade e razoável especificidade e são provavelmente úteis para o rastreio de comprometimento cognitivo de idosos em ambulatórios.

Palavras-chave:
rastreio; demência; comprometimento cognitivo; questionário; atividade funcional; fluência verbal; médico generalista

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REFERENCES

Rodrigues MA, Facchini LA, Piccini RX, Tomasi E, Thumé E, Silveira DS, et al. Use of outpatient services by the elderly in the South and Northeast of Brazil. Cad Saude Publica 2008;24:2267-2278.
Takada LT, Caramelli P, Radanovic M, Anghinah R, Hartmann AP, Guariglia CC, et al. Prevalence of potentially reversible dementias in a dementia outpatient clinic of tertiary university-affiliated hospital in Brazil. Arq Neuropsiquiatr 2003;6:925-929.
Wimo A, Winblad B, Jönsson L. The worldwide societal costs of dementia: estimates for 2009. Alzheimers Dement 2010;6:98-103.
Boustani M, Peterson B, Hanson L, Harris R, Lohr KN. Screening for dementia in the primary care: a summary of the evidence for the US preventive services task force. Ann Intern Med 2003;138:927-937.
Valcour VG, Masaki H, Curb JD, Blanchette PL. The detection of dementia in the primary care setting. Arch Int Med 2000;160:2964-2968.
Barret JJ, Haley WE, Harrel LE, Powers RE. Knowledge about Alzheimer's disease among primary care physicians, psychologists, nurses and social workers. Alzheimer Dis Assoc Disord 1997;11:99-106.
Henriques SG, Fráguas R, Iosifescu DV, Menezes PR, Lucia MC, Gattaz WF, Martins MA. Recognition of depressive symptoms by physicians. Clinics 2009;64:629-635.
Renshaw J, Scurfield LC, Cloke L, Orrel M. General practitioner's views on the early diagnosis of dementia. Br J Gen Pract. 2001;51:37-38.
Cummings JL. The one-minute mental status examination. Neurology 2004;62:534-535.
Duff Canning SJ, Leach L, Stuss D, Ngo L, Black SE. Diagnostic utility of abbreviated fluency measures in Alzheimer disease and vascular dementia. Neurology 2004;62:556-562.
Brucki SMD, Malheiros SMF, Okamoto IH, Bertolucci PHF. Normative data on the verbal fluency test in the animal category in our milieu Arq Neuropsiquiatr 1997;55:56-61.
Brucki SMD, Rocha MSG. Category fluency test: effects of age, gender and education on total scores, clustering and switching in Brazilian Portuguese-speaking subjects. Brazilian Journal of Medical and Biological Research 2004;37:1771-1777.
Pfeffer RI, Kurosaki TT, Harrah Jr CH, Chance JM, Filos S. Measurement of functional activities in older adults in the community. J Gerontol 1982;37:323-329.
Jacinto AF, Brucki S, Porto CS, Martins MA, Nitrini R. Detection of cognitive impairment in the elderly by general internists in Brazil. Clinics 2011;66:1379-1384.
Folstein MF, Folstein SE, McHugh PR. "Mini-mental state": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-198.
Brucki SMD, Nitrini R, Caramelli P, Bertolucci PH, Okamoto IH. Suggestions for utilization of the mini-mental state examination in Brazil. Arq Neuropsiquiatr 2003;61:777-781.
Jorm AF. A short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): development and cross-validation. Psychol Med 1994;24:145-153.
Nitrini R, Caramelli P, Herrera Júnior E, Porto CS, Charchat-Fichman H, Carthery MT, et al. Performance of illiterate and literate nondemented elderly subjects in two tests of long-term memory. J Int Neuropsychol Soc 2004;10:634-638
Takada LT, Caramelli P, Fichman HC, Porto CS, Bahia VS, Anghinah R, et al. Comparison between two tests of delayed recall for the diagnosis of dementia. Arq Neuropsiquiatr 2006;64:35-40.
Sheikh JI, Yesavage JA. Geriatric depression scale (GDS): recent evidence and development of a shorter version. Clin Gerontol. 1986;5:165-173.
Bustamante SEZ, Bottino CMC, Lopes MA, et al. Combined instruments on the evaluation of dementia in the elderly: preliminary results. Arq Neuropsiquiatr 2003;61:601-606.
Mattis S. Dementia Rating Scale. Professional Manual. Florida: Psychological Assessment Resources, 1998.
Porto CS, Fichman HC, Caramelli P, Bahia VS, Nitrini R. Brazilian version of the Mattis dementia rating scale: diagnosis of mild dementia in Alzheimer's disease. Arq Neuropsiquiatr 2003;61:339-345.
Nitrini R, Caramelli P, Bottino CM, Damasceno BP, Brucki SM, Anghinah R. Diagnosis of Alzheimer's disease in Brazil: diagnostic criteria and auxiliary tests. Recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology. Arq Neuropsiquiatr 2005;63:713-919.
American Psychiatry Association. Diagnostic and Statistical Manual of Mental Disorders. 4 ed. Washington (DC): American Psychiatric Press; 1994.
Ebly EM, Hogan DB, Parhad IM. Cognitive impairment in the nondemented elderly: results from the Canadian Study of Health and Aging. Arch Neurol 1995;52:612-9.
Caramelli P, Carthery-Goulart MT, Porto CS, Charchat-Fichman H, Nitrini R. Category fluency as a screening test for Alzheimer disease in illiterate and literate patients. Alzheimer Dis Assoc Disord 2007;21:65-67.
Quiroga P, Albala C, Klaasen G. Validación de un test de tamizaje para el diagnóstico de demencia asociada a edad, en Chile. Rev Med Chile 2004;132:467-478.
Nitrini R. Editorial. Dement Neuropsychol 2007;3:225.
Bressan LA, Vale FAC, Speciali JG. The daily life of patients with dementia: a comparative study between the information provided by the caregiver and direct patient assessment. Dement Neuropsychol 2007; 1:288-295.
Lorentz WJ, Scanian JM, Borson S. Brief screening tests for dementia. Can J Psychiatry 2002;47:723-33.

Publication Dates

Publication in this collection
Jan-Mar 2012

History

Received
15 Oct 2011
Accepted
20 Dec 2011

This is an open-access article distributed under the terms of the Creative Commons Attribution License

[1] Rodrigues MA, Facchini LA, Piccini RX, Tomasi E, Thumé E, Silveira DS, et al. Use of outpatient services by the elderly in the South and Northeast of Brazil. Cad Saude Publica 2008;24:2267-2278.

[2] Takada LT, Caramelli P, Radanovic M, Anghinah R, Hartmann AP, Guariglia CC, et al. Prevalence of potentially reversible dementias in a dementia outpatient clinic of tertiary university-affiliated hospital in Brazil. Arq Neuropsiquiatr 2003;6:925-929.

[3] Wimo A, Winblad B, Jönsson L. The worldwide societal costs of dementia: estimates for 2009. Alzheimers Dement 2010;6:98-103.

[4] Boustani M, Peterson B, Hanson L, Harris R, Lohr KN. Screening for dementia in the primary care: a summary of the evidence for the US preventive services task force. Ann Intern Med 2003;138:927-937.

[5] Valcour VG, Masaki H, Curb JD, Blanchette PL. The detection of dementia in the primary care setting. Arch Int Med 2000;160:2964-2968.

[6] Barret JJ, Haley WE, Harrel LE, Powers RE. Knowledge about Alzheimer's disease among primary care physicians, psychologists, nurses and social workers. Alzheimer Dis Assoc Disord 1997;11:99-106.

[7] Henriques SG, Fráguas R, Iosifescu DV, Menezes PR, Lucia MC, Gattaz WF, Martins MA. Recognition of depressive symptoms by physicians. Clinics 2009;64:629-635.

[8] Renshaw J, Scurfield LC, Cloke L, Orrel M. General practitioner's views on the early diagnosis of dementia. Br J Gen Pract. 2001;51:37-38.

[9] Cummings JL. The one-minute mental status examination. Neurology 2004;62:534-535.

[10] Duff Canning SJ, Leach L, Stuss D, Ngo L, Black SE. Diagnostic utility of abbreviated fluency measures in Alzheimer disease and vascular dementia. Neurology 2004;62:556-562.

[11] Brucki SMD, Malheiros SMF, Okamoto IH, Bertolucci PHF. Normative data on the verbal fluency test in the animal category in our milieu Arq Neuropsiquiatr 1997;55:56-61.

[12] Brucki SMD, Rocha MSG. Category fluency test: effects of age, gender and education on total scores, clustering and switching in Brazilian Portuguese-speaking subjects. Brazilian Journal of Medical and Biological Research 2004;37:1771-1777.

[13] Pfeffer RI, Kurosaki TT, Harrah Jr CH, Chance JM, Filos S. Measurement of functional activities in older adults in the community. J Gerontol 1982;37:323-329.

[14] Jacinto AF, Brucki S, Porto CS, Martins MA, Nitrini R. Detection of cognitive impairment in the elderly by general internists in Brazil. Clinics 2011;66:1379-1384.

[15] Folstein MF, Folstein SE, McHugh PR. "Mini-mental state": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-198.

[16] Brucki SMD, Nitrini R, Caramelli P, Bertolucci PH, Okamoto IH. Suggestions for utilization of the mini-mental state examination in Brazil. Arq Neuropsiquiatr 2003;61:777-781.

[17] Jorm AF. A short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): development and cross-validation. Psychol Med 1994;24:145-153.

[18] Nitrini R, Caramelli P, Herrera Júnior E, Porto CS, Charchat-Fichman H, Carthery MT, et al. Performance of illiterate and literate nondemented elderly subjects in two tests of long-term memory. J Int Neuropsychol Soc 2004;10:634-638

[19] Takada LT, Caramelli P, Fichman HC, Porto CS, Bahia VS, Anghinah R, et al. Comparison between two tests of delayed recall for the diagnosis of dementia. Arq Neuropsiquiatr 2006;64:35-40.

[20] Sheikh JI, Yesavage JA. Geriatric depression scale (GDS): recent evidence and development of a shorter version. Clin Gerontol. 1986;5:165-173.

[21] Bustamante SEZ, Bottino CMC, Lopes MA, et al. Combined instruments on the evaluation of dementia in the elderly: preliminary results. Arq Neuropsiquiatr 2003;61:601-606.

[22] Mattis S. Dementia Rating Scale. Professional Manual. Florida: Psychological Assessment Resources, 1998.

[23] Porto CS, Fichman HC, Caramelli P, Bahia VS, Nitrini R. Brazilian version of the Mattis dementia rating scale: diagnosis of mild dementia in Alzheimer's disease. Arq Neuropsiquiatr 2003;61:339-345.

[24] Nitrini R, Caramelli P, Bottino CM, Damasceno BP, Brucki SM, Anghinah R. Diagnosis of Alzheimer's disease in Brazil: diagnostic criteria and auxiliary tests. Recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology. Arq Neuropsiquiatr 2005;63:713-919.

[25] American Psychiatry Association. Diagnostic and Statistical Manual of Mental Disorders. 4 ed. Washington (DC): American Psychiatric Press; 1994.

[26] Ebly EM, Hogan DB, Parhad IM. Cognitive impairment in the nondemented elderly: results from the Canadian Study of Health and Aging. Arch Neurol 1995;52:612-9.

[27] Caramelli P, Carthery-Goulart MT, Porto CS, Charchat-Fichman H, Nitrini R. Category fluency as a screening test for Alzheimer disease in illiterate and literate patients. Alzheimer Dis Assoc Disord 2007;21:65-67.

[28] Quiroga P, Albala C, Klaasen G. Validación de un test de tamizaje para el diagnóstico de demencia asociada a edad, en Chile. Rev Med Chile 2004;132:467-478.

[29] Nitrini R. Editorial. Dement Neuropsychol 2007;3:225.

[30] Bressan LA, Vale FAC, Speciali JG. The daily life of patients with dementia: a comparative study between the information provided by the caregiver and direct patient assessment. Dement Neuropsychol 2007; 1:288-295.

[31] Lorentz WJ, Scanian JM, Borson S. Brief screening tests for dementia. Can J Psychiatry 2002;47:723-33.

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