Detection of cognitive impairment in the elderly by general practitioners in Brazil

Poster Presentations P1 suggests that decrease progranulin expression may play a pathogenetic role in late onset HpScl associated with FTLD-U in the elderly, and perhaps in cases of HpScl not associated with FTLD-U. The frequency of this process and it’s misdiagnosis as AD has important implications for treatment and case-control genetic studies. P1-060

SOCIAL IMPACT IN THE MEASUREMENT OF CLINICALLY MEANINGFUL CHANGE: FINDINGS FROM THE CROSS-SECTIONAL VALIDATION OF THE CLINICAL MEANINGFULNESS IN ALZHEIMER DISEASE TREATMENT (CLIMAT) SCALE

Claudia Jacova, Michael Schulzer, Jonathan Money, Sirad Deria, Anthony L. Kupferschmidt, B. Lynn Beattie, Howard H. Feldman, University of British Columbia, Vancouver, BC, Canada. Contact e-mail: [email protected] Background: There is a need for novel assessment methods in the determination of clinically meaningful change in Alzheimer Disease (AD). The Clinical Meaningfulness in Alzheimer Disease Treatment (CLIMAT) scale is a newly developed instrument that targets two constructs: severity, defined as the magnitude of AD symptoms, and social impact, defined as the importance patients and caregivers attribute to AD symptoms. If social impact can be established as a construct distinct from disease severity, it could aid in weighting treatment benefit in AD. This cross-sectional study investigated the relationship between CLIMAT severity and social impact ratings. Methods: The CLIMAT covers social, functional, cognitive and behavioral items in separate patient and informant interviews. In the patient interview, items were rated for severity and impact on self (I-Pat-self). In the informant interview items were rated for severity, impact on patient reported by informant (I-Inf-Pat) and impact on self reported by informant (IInf-self). Domain and total scores were computed for all ratings. Pearson correlation coefficients were used to assess the relation between severity and impact ratings. Collinearity was defined as r>.70. Results: Participants were n¼23 community-dwelling ‘probable’ AD subjects (MMSE M¼19.9, SD¼7.3, range 11-28), with spousal informants. For patient ratings, the correlation between total severity and total I-Pat-self ratings was r¼.54. Correlations between domain severity and domain I-Pat-self ratings were r<.50 for the social, functional and cognitive, r¼.74 for the behavioral domain. For informant ratings, the correlation between total severity and total I-Inf-Pat was r¼.50, and correlations between domain ratings r<.50 for social, functional and cognitive, r¼.72 for the behavioral domain. The correlation between total severity and I-Inf-self was r¼.78, with all correlations between domain ratings r>.70. Conclusions: Disease severity and social impact were hypothesized as two distinct constructs in AD symptom assessment. CLIMAT data largely support this hypothesis. The determination of the social impact on patients appears to add a valid dimension in the assessment of social, functional and cognitive symptoms, and in turn hold promise in the measurement of clinically meaningful response to treatment. The overlap between severity and social impact in the behavioral domain warrants further study. P1-061

THE CORRELATION OF DAILY LIVING ACTIVITIES AND COGNITION OF DEMENTIA SUBTYPES

clinical, laboratory and neuropsychological instruments. Neuropsychological tests included MMSE, Enstrumental daily living activity scale (EDLA), Blassed Dementia Scale, detailed standardized Attention, Construction, Verbal and Visio-Spatial Tests. Clock-Drawing Test (CDT), Yesevage Depression Scales, Neuropsychological Inventory (NPI), Clinical Dementia Rating Scale (CDR) and Global Deterioration Scales (GDS) have been performed also. Statistical analysis has been made using appropriate statistical methods. Results: The study groups has been composed as follows; 126 Alzheimer Disease (AD), 29 Vascular Dementia (VD), 60 Mild Cognitive Impairment (MCI) and 5 Fronto-temporal dementia (FTD) patients. There are no important age and education difference. The worst EDLA score was in FTD group and followed by AD group. MMSE (CC:0.78, p<0.001) and Blassed scores (0.62, p<0.05) were highly correlated with EDLA scores. Correlation and regression analysis showed that important effects of age, education, MMSE, NPI total scores and GDS on EDLA scores of all subjects. On the other hand GDS and Blassed scales have important effect on each subtype. Conclusions: It was concluded that functional and cognitive decline is parallel course in dementia subjects (included MCI) and GDS is a better prognostic device than CDR especially in older and lower educated persons. P1-062

DETECTION OF COGNITIVE IMPAIRMENT IN THE ELDERLY BY GENERAL PRACTITIONERS IN BRAZIL

Alessandro F. Jacinto, Ricardo Nitrini, Sonia M. D. Brucki, Claudia S. Porto, University of Sa˜o Paulo, Sa˜o Paulo, Brazil. Contact e-mail: [email protected] Background: Elderly’s cognitive impairment (CI) is overlooked by the general practitioner (GP), according to medical literature. This study verified if elderly patients’ CI diagnosed by specialists had such impairment recognized by their GPs. It was verified if the instruments used in the diagnosing process of CI had good efficacy. Some of the instruments used in this diagnosing process were suggested to be used by GPs in their working sets. Methods: A list of elderly outpatients followed by GPS at Hospital das Clı´nicas (University of Sa˜o Paulo) was acquired randomly and they underwent cognitive evaluation by a geriatrician: anamnesis, MMSE, Short-IQCODE, Brief Cognitive Battery (BCB), Pfeffer-FAQ and GDS (15 items). MMSE and/or Short-IQCODE scores were chosen to classify these individuals into ‘‘suspects’’ or not. ‘‘Suspects’’ underwent blood analysis, brain CT scan and neuropsychological evaluation (Dementia Rating Scale). ‘‘Suspects’’ (N¼52) and a sample of ‘‘non-suspects’’ (N¼53) were given different diagnosis through consensus between the researcher and two neurologists. The GPs’ files of all the ‘‘suspects’’ and of a sample of ‘‘non-suspects’’ were checked. Sensitivity and specificity of the instruments were calculated. Results: 248 patients (median age of 70, median schooling of 4 years) were submitted to screening; 52 were classified as ‘‘suspects’’. Of them, 21 had dementia and 22, MCI (Table 1 and 2). In 7 (16.27%) of these patients’ records of the GPs there were notes on cognitive decline (Table 3,). Pfeffer-FAQ had the best sensitivity and specificity (84% and 94%). Pfeffer-FAQ combined

Table 1 Median, inter quartilic interval and comparisons considering age and schooling in the different groups Median (IQI)

Aynur Ozge1, Kahraman Kiral2, Selver Burcu Yuksekyalcin1, Osman Ozgur Yalin1, Seda Bayram1, Hakan Kaleagasi1, 1Mersin University School of Medicine, Mersin, Turkey; 2Mersin University School of Science and Letters, Mersin, Turkey. Contact e-mail: [email protected] Background: The association between cognitive and functional decline of the subjects with dementia subtypes is a controversial issue. On the other hand the approximation of functional decline of patients with dementia is highly important both of the medical and social care. This study aimed to investigate the association between cognitive and functional decline of the subjects with main dementia subtypes. Methods: The study included 220 patients with dementia with a female predominance (60.9%) as expected. They interviewed by the supervision of the same specialist using required

P189

CUI (N¼202)

MCI (N¼22)

Dementia (N¼21)

p*

Multiple comparisons**

Age

70 69.5 72 0.28 D¼MCI¼CUI (67-74) (67-73.3) (67-75.5) Schooling 4 (2-8) 4 (2-8.3) 2 (2-4) 0.02 D¼MCI MCI¼CUI D
Poster Presentations P1

P190

Table 2 Nosological diagnoses of individuals in the probable case (suspects) group and in the subsample from the probable non-case (non-suspects) group Diagnosis Probable Alzheimer’s Probable Alzheimer’s þ CVD Alzheimer’s þ CVD þ Depression VD Dementia due to intracranial mass lesions þ depression Dementia due to Parkinson’s disease Alcoholic dementia MCI OD M(-) MCI MD M(-) MCI M(þ) MCI MD M(þ) Depression SMC(þ) SMC(-) No diagnosis (insufficient data) Individuals with a diagnosis

Probable cases

SSNC (%)

12 (23.0) 3 (5.8) 1 (1.9) 2 (3.8) 1 (1.9)

0 0 0 0 0

1 (1.9) 1 (1.9) 2 (3.8) 8 (15.4) 4 (7.7) 8 (15.4) 0 2 (3.8) 4 (7.7) 3 (5.8) 52

0 0 0 0 0 0 7 (13.2) 17 (32.0) 29 (54.7) 0 53

AD, Alzheimer’s disease; CVD, cerebrovascular disease; VD, vascular dementia; MCI, mild cognitive impairment; MD, multiple domains; OD, one domain only; M (þ), amnesiac; M (-), non-amnesiac; SMC (þ), normal with subjective memory complaint; SMC(-), normal without subjective memory complaint; SSNC, subsample of probable non-cases.

with verbal fluency came out with a sensitivity of 88.4% and specificity of 93.5%; with clock drawing test, 93% and 92.5% and with delayed recall item of BCB, 86.4% and 89.6%.(Table 4). Conclusions: GPs’ CI detection rate was low. Some instruments used showed good efficacy. The tests with

Table 3 Demographic data, MMSE and Short-IQCODE scores and notes of the general practitioners’ files GPs’ files notes C A G S Diagnosis MMSE Short- ACMG IQCODE

AGD

1 82 F 0 Probable 18 AD

3.83

Subjective memory complaint

2 88 F 5 Probable 11 AD 3 73 F 0 Probable 13 AD 4 79 F 4 Probable 17 AD

4.84

AD diagnosis

4.37

AD diagnosis

3.9

Subjective memory complaint and impairment in daily life activities

5 70 F 1 Probable 0 AD 6 85 F 4 ADþCVD 18

5.0

AD diagnosis

3.96

Impairment in daily life activities

C: Case; A: age; G: gender; S: schooling; ACMG: internal medicine outpatients’s clinic 1; AGD: internal medicine outpatients’ clinic 2; AD: Alzheimer’s Disease; CVD: Cerebrovascular Disease; F: female; Short-IQCODE: ‘‘Short Informant Questionnaire on Cognitive Decline in the Elderly’’; MMSE: Mini Mental State Exam.

Table 4 Areas under ROC curve, sensibilities and specificities of the instruments used considering ‘‘dementia’’ and ‘‘MCI’’ groups in relation to ‘‘cognitively unimpaired individuals’’ CI (area: 95%)

Area p Pfeffer-FAQ Digit span (forwards) Digit span (backwards) Visual perception and naming of 10 simple figures Incidental memory Immediate memory Learning Verbal fluency Clock drawing test Delayed recall of simple figures Recognition of simple figures Geriatric Depression Scale Pfeffer-FAQ þClock drawing Pfeffer-FAQ þ Delayed recall Pfeffer-FAQ þ Verbal fluency

Cutoff Sensibility Specificity score (%) (%)

0.945 <0.001 0.902-0.988 3 0.691 <0.001 0.600-0.783 4

84.0 70.8

94.0 58.1

0.720 <0.001 0.634-0.805 1

77.2

48.8

0.610

95.5

25.6

5 6 7 10 6 6

68.3 81.7 70.3 71.3 79.2 77.2

67.4 51.2 81.4 69.8 67.4 69.8

0.804 <0.001 0.721-0.886 9

75.7

76.7

0.629

71.0

45.0

0.965 <0.001 0.941-0.989 -

93.0

92.5

0.944 <0.001 0.930-0.983 -

86.4

89.6

0.957 <0.001 0.905-0.983 -

88.4

93.5

0.730 0.759 0.826 0.777 0.821 0.799

0.024 0.507-0.713 9

<0.001 <0.001 <0.001 <0.001 <0.001 <0.001

0.644-0.815 0.681-0.836 0.754-0.898 0.701-0.853 0.754-0.888 0.726-0.872

0.009 0.536-0.721 3

MCI, mild cognitive impairment; QAF, functional activities questionnaire. better performance are easy, fast and easy to be interpreted, which make them good tools in GPs’ sets (high demand of patients and little time). Verbal fluency seems to be the most interesting tool since patients do not even need a pencil to get it done nor appliers need a great amount to check results.

P1-063

DEMENTIA IN GENERAL PRACTICE

Constance D. Pond, Jessica Swain, Karen Mate, Ageing in General Practice team, University of Newcastle, CALLAGHAN, Australia. Contact e-mail: [email protected] Background: Increasingly dementia is being recognised as a major concern, with dementia prevalence rates rising dramatically as the population ages. General Practitioners (GPs/Family physicians) are often at the forefront of dementia detection and management. In Australia more than 80% of elderly people attend their GP regularly. Evidence suggests a need for improvement in GPs’ ability to diagnose and manage dementia, as studies show that GPs fail to identify over 50% of dementia cases. Benefits of early diagnosis include allowing patients time to plan for the future and mobilisation of appropriate support services for patients and carers. The overall study aims to determine whether GP education in dementia detection and management guidelines - as well as use of a brief screening instrument, the GPCOG - can improve diagnostic rates, management as well as patient and carer outcomes. This paper will report on baseline data collection. Methods: GPs and w2,000 of their 75þ patients are being recruited across five Australian cities. GPs audit their patients for possible, probable or definite dementia. Intervention GPs receive training on dementia guidelines. Control GPs undertake usual care of their patients. All participants complete a battery of assessments, including the CAMCOG as a gold standard and the GPCOG, with a research nurse. Following training, intervention GPs administer the GPCOG to their patients. At 12 months GPs will re-audit their patients. Baseline measures will be repeated at 12 and 24 months. Results: Baseline recruitment for the trial will be completed by February 2009. Baseline data including the relationship between