Re: Would doctors routinely asking older patients about their memory improve dementia outcomes? Yes
There has been much debate about the risks and benefits of screening for dementia in older patients (Rasmussen and McCartney, 2013) and the outcomes of the Alzheimer’s Society evidence reviews are keenly awaited. Although the first of the WHO criteria for effective screening programmes (Wilson and Junger, 1968) - that the condition should be an important health problem - is clearly applicable, it remains far from clear that dementia screening could meet the other nine criteria. However, the Department of Health (DH)’s nationwide ‘Find Assess Investigate Refer (FAIR)’ CQUIN (Commissioning for Quality and Innovation) has prompted hospitals across the country to devise systems to fulfil this financially incentivised requirement for dementia case-finding. In our large teaching hospital, care has been taken in developing a process that combines the DH ‘screening’ question – “Has this person been more forgetful over the past year such that it significantly interferes with daily life?” - with previously validated tools selected to maximise completion rates in a busy clinical setting. This ‘stepped’ process also included prompts to consider further investigations according to the hospitals guidelines on the care of patients with dementia and/or delirium, and the discharge summary letter informs the GP of the process outcome. The pathway may include referral to the older people’s liaison psychiatry service but, without such fuller assessment, the case-finding tool can only alert GPs if there is a concern about cognition, advising post-discharge re-assessment and possible specialist referral if appropriate.
As part of a broader evaluation of the usefulness of this dementia case-finding tool currently used in our hospital, we surveyed clinical staff potentially involved in using the tool. Overall, 29 clinicians participated in the survey: 25 doctors and 4 nurses. All 29 had heard of the tool and all but two had used the form at least once (20 filled in the form at least once a week and 7 less than once a week).
We asked respondents to rate the usefulness of the case-finding tool from a scale of not very useful to very useful on a 1-5 scale. Excluding the nurses surveyed because of their roles specifically involving these assessments, only 1/5 of the 25 doctors found it ‘quite useful’, and just under half ‘moderately useful’, although nine of them were interviewed in the emergency department where usually they only completed the form’s initial brief assessment and the DH ‘screening question’. It tended to be the more junior doctors who added positive comments such as “a useful reminder to screen for dementia and to order routine screening tests of CT head, TSH, B12 and folate,” “a good template or structure for a non-biased assessment” and “it identifies new cognitive issues.” Negative comments tended to come from more experienced medics who had concerns about the choice of cognitive assessment, the additional paperwork that added nothing to what they felt would have been done anyway, the difficulty in differentiating between dementia and delirium, and consequent reservations about whether this was an appropriate timing or setting. Although the tool in use is not intended for diagnosis, the specialist nurses also raised the issue of possible misdiagnosis.
Further evaluation of the screening tool in is progress aiming to determine its clinical validity. Meantime, our survey suggests that efforts to fulfil the ‘FAIR’ CQUIN’s requirements are at least raising awareness of dementia case-finding and serving to prompt less experienced doctors to follow good practice guidelines on the management of delirium and dementia.
References
Rasmussen J. Would doctors routinely asking older patients about their memory improve dementia outcomes? Yes. BMJ. 2013 Mar 26;346:f1780. doi: 10.1136/bmj.f1780.
McCartney M. Would doctors routinely asking older patients about their memory improve dementia outcomes? No. 2013 Mar 26;346:f1745. doi: 10.1136/bmj.f1745.
Wilson JMG, Jungner G. Principles and practice of screening for disease. Geneva, Switzerland: World Health Organization; 1968. 22(11):473. Public Health Papers, #34.
Competing interests:
No competing interests
10 June 2013
Samuel HR Kim
5th Year Medical Student
Dr Chiara Lombardo, Research Associate, University of Cambridge, Dr Jane Fleming, Senior Research Associate, University of Cambridge, Dr Claire Nicholl, Consultant Physician, CUHFT, Dr Fiona Thompson, Consultant Psychiatrist, CPFT
Rapid Response:
Re: Would doctors routinely asking older patients about their memory improve dementia outcomes? Yes
There has been much debate about the risks and benefits of screening for dementia in older patients (Rasmussen and McCartney, 2013) and the outcomes of the Alzheimer’s Society evidence reviews are keenly awaited. Although the first of the WHO criteria for effective screening programmes (Wilson and Junger, 1968) - that the condition should be an important health problem - is clearly applicable, it remains far from clear that dementia screening could meet the other nine criteria. However, the Department of Health (DH)’s nationwide ‘Find Assess Investigate Refer (FAIR)’ CQUIN (Commissioning for Quality and Innovation) has prompted hospitals across the country to devise systems to fulfil this financially incentivised requirement for dementia case-finding. In our large teaching hospital, care has been taken in developing a process that combines the DH ‘screening’ question – “Has this person been more forgetful over the past year such that it significantly interferes with daily life?” - with previously validated tools selected to maximise completion rates in a busy clinical setting. This ‘stepped’ process also included prompts to consider further investigations according to the hospitals guidelines on the care of patients with dementia and/or delirium, and the discharge summary letter informs the GP of the process outcome. The pathway may include referral to the older people’s liaison psychiatry service but, without such fuller assessment, the case-finding tool can only alert GPs if there is a concern about cognition, advising post-discharge re-assessment and possible specialist referral if appropriate.
As part of a broader evaluation of the usefulness of this dementia case-finding tool currently used in our hospital, we surveyed clinical staff potentially involved in using the tool. Overall, 29 clinicians participated in the survey: 25 doctors and 4 nurses. All 29 had heard of the tool and all but two had used the form at least once (20 filled in the form at least once a week and 7 less than once a week).
We asked respondents to rate the usefulness of the case-finding tool from a scale of not very useful to very useful on a 1-5 scale. Excluding the nurses surveyed because of their roles specifically involving these assessments, only 1/5 of the 25 doctors found it ‘quite useful’, and just under half ‘moderately useful’, although nine of them were interviewed in the emergency department where usually they only completed the form’s initial brief assessment and the DH ‘screening question’. It tended to be the more junior doctors who added positive comments such as “a useful reminder to screen for dementia and to order routine screening tests of CT head, TSH, B12 and folate,” “a good template or structure for a non-biased assessment” and “it identifies new cognitive issues.” Negative comments tended to come from more experienced medics who had concerns about the choice of cognitive assessment, the additional paperwork that added nothing to what they felt would have been done anyway, the difficulty in differentiating between dementia and delirium, and consequent reservations about whether this was an appropriate timing or setting. Although the tool in use is not intended for diagnosis, the specialist nurses also raised the issue of possible misdiagnosis.
Further evaluation of the screening tool in is progress aiming to determine its clinical validity. Meantime, our survey suggests that efforts to fulfil the ‘FAIR’ CQUIN’s requirements are at least raising awareness of dementia case-finding and serving to prompt less experienced doctors to follow good practice guidelines on the management of delirium and dementia.
References
Rasmussen J. Would doctors routinely asking older patients about their memory improve dementia outcomes? Yes. BMJ. 2013 Mar 26;346:f1780. doi: 10.1136/bmj.f1780.
McCartney M. Would doctors routinely asking older patients about their memory improve dementia outcomes? No. 2013 Mar 26;346:f1745. doi: 10.1136/bmj.f1745.
Wilson JMG, Jungner G. Principles and practice of screening for disease. Geneva, Switzerland: World Health Organization; 1968. 22(11):473. Public Health Papers, #34.
Competing interests: No competing interests