Apart From Nihilism and Stigma: What Influences General Practitioners' Accuracy in Identifying Incident Dementia?

doi:10.1097/JGP.0b013e3181b2075e

The American Journal of Geriatric Psychiatry

Volume 17, Issue 11, November 2009, Pages 965-975

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https://doi.org/10.1097/JGP.0b013e3181b2075e Get rights and content

Objectives:

To assess the accuracy of the General Practitioner's (GP) judgment in the recognition of incident dementia cases and to explore factors associated with recognition.

Design:

Prospective observational cohort study, two follow-up assessments (FU 1 and FU 2) within 3 years after baseline.

Setting:

One hundred thirty-eight general practice surgeries in the six study centers of a prospective German study.

Participants:

Participants were between 75 and 89 years of age at baseline and were recruited from the GPs' patient lists. In FU 1, 2,402 patients and in FU 2, 2,177 patients were analyzed.

Measurements:

GPs' judgments on their patients' cognitive status as index test; at-home patient interviews and tests, consensus diagnosis as reference; validity of the GP judgment; associations between patient factors and GPs' dementia recognition.

Results:

One hundred eleven incident dementia cases with complete data were identified in FU 1 and FU 2. Overall sensitivity of the GP judgment was 51.4%, specificity 95.9%, positive predictive value 23.6%, and negative predictive value 98.8%. GPs missed dementia more frequently in patients living alone. GPs overrated the presence of dementia more frequently in patients with problems in mobility or hearing, in patients with memory complaints, and in patients with a GP-documented depression.

Conclusion:

GPs miss nearly half of incident dementia cases. They should be alert not to miss dementia in patients living alone. Without seeking additional information, a positive GP judgment seems not sufficient for case finding. GPs should be aware of their tendency to overestimate dementia in depressed and frail patients.

Section snippets

Study Design

The baseline cohort consists of 3,327 patients participating in a prospective study on early detection of mild cognitive impairment (MCI) and dementia within the framework of the German Study on Ageing, Cognition and Dementia in Primary Care Patients. The baseline recruitment is reported in detail elsewhere.¹⁹ In brief, patients were chosen at random from the files of 138 GP surgeries in six metropolitan study centers (Hamburg, Bonn, Germany, Düsseldorf, Leipzig, Mannheim, and Munich, Germany).

Sample

In baseline, 138 GPs (19–29 per center) recruited a total of 3,327 patients (mean 24.1 ± 11.73). 74.5% of the recruiting GPs were male, GPs' mean age was 50.9 ± 6.5 years, and mean years in practice was 14.9 ± 6.7. Assessments took place between January 2003 (start of baseline) and September 2007 (end of FU 2). Generally, Follow-up 1 was scheduled at 18 months and Follow-up 2 at 36 months after baseline-assessment. From the baseline sample, 2,402 patients were eligible for analysis in FU 1 and

DISCUSSION

GPs recognized approximately half of the incident dementia cases, which is between the estimates derived from cross-sectional studies on recognition of mild cases.30, 31 Consistent with cross-sectional findings, we found GPs' recognition to be associated with dementia severity (better in moderate and severe cases). Regarding the clinical application of diagnostic skills, the clinical utility of the GP judgment is “poor” regarding case finding but “excellent” for ruling out dementia. Hence, a

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The authors thank both all participating patients and their general practitioners for their good collaboration.

The German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe) is part of the German Competence Network Dementia (KND) and German Competence Network Degenerative Dementias (KNDD) and was funded by the German Federal Ministry of Education and Research (grants KND: 01GI0102, 01GI0420, 01GI0422, 01GI0423, 01GI0429, 01GI0431, 01GI0433, 01GI0434 and grants KNDD: 01GI0710, 01GI0711, 01GI0712, 01GI0713, 01GI0714, 01GI0715, 01GI0716).

Funding had no influence on design, methods, subject recruitment, data collection, analysis, or preparation of the paper. Researchers were independent from the funding organization. All authors had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

The ethics committees of the participating centers approved the study. Written informed consent was obtained from all GPs and patients.

GPs who recruited patients into the study are listed as follows: Hamburg: Gundula Bormann, Winfried Bouché, Doris Fischer-Radizi, Michael Funke, Heike Gatermann, Wolfgang Herzog, Petra Hütter, Stefanie Kavka-Ziegenhagen, Günther Klötzl, Bernd-Uwe Krug, Dietrich Lau, Ursula Linn, Andrea Moritz, Karl-Christian Münter, Detlef Niemann, Klaus Richard-Klein, Walter Schreiber, Ursula Schröder-Höch, Gerhard Schulze, Klaus Stelter, Carl-Otto Stolzenbach, Ljudmila Titova, Klaus Weidner, Otto-Peter Witt, Eckehard Zeigert; Mannheim: Gerhard Arnold, Veit-Harold Bauer, Werner Besnier, Hanna Böttcher-Schmidt, Hartmut Grella, Gernot Kunzendorf, Ingrid Ludwig, Manfred Mayer, Hubert Mühlig, Arnt Müller, Adolf Noky, Helmut Perleberg, Carsten Rieder, Michael Rosen, Georg Scheer, Michael Schilp, Matthias Schneider, Jürgen Wachter, Brigitte Weingärtner, Hans-Georg Willhauck; Bonn, Germany: Jörg Eimers-Kleene, Klaus Fischer, Maria Goebel-Schlatholt, Peter Gülle, Wolf-Dietrich Honig, Hans Jürgen Kaschell, Hanna Liese, Manfred Marx, Eberhard Prechtel, Heinz-Peter Romberg, Heribert Schützendorf, Annemarie Straimer, Martin Tschoke, Karl-Michael Werner; Halstenbek: Herrmut Mayen; Königswinter: Theodor Alfen; Bad Honnef: Klaus Weckbecker; Niederkassel: Inge Bürfent; Alfter-Oedekoven: Johann von Aswege; Erfstadt-Liblar: Arndt Uhlenbrock; Windeck-Herchen: Wolf-Rüdiger Weisbach; Leipzig: Martina Amm, Heinz-Michael Assmann, Horst Bauer, Barbara Bräutigam, Jochen Ebert, Angelika Gabriel, Eva Hager, Gunter Kässner, Ina Lipp, Thomas Lipp, Ute Mühlmann, Gabi Müller, Thomas Paschke, Gabriele Rauchmaul, Ina Schmalbruch, Holger Schmidt, Hans-Christian Taut, Ute Voß, Bettina Winkler, Sabine Ziehbold; München, Germany: Eugen Allwein, Guntram Bloß, Peter Dick, Johann Eiber, Lutz-Ingo Fischer, Peter Friedrich, Helga Herbst, Andreas Hofmann, Günther Holthausen, Karl-Friedrich Holtz, Ulf Kahmann, Elke Kirchner, Hans Georg Kirchner, Luitpold Knauer, Andreas Koeppel, Heinz Koschine, Walter Krebs, Franz Kreuzer, Karl Ludwig Maier, Christoph Mohr, Elmar Schmid, Gabriel Schmidt, Johann Thaller; Haar: Richard Ellersdorfer, Michael Speth; Düsseldorf: Angela Ackermann, Pauline Berger, Florinela Cupsa, Barbara Damanakis, Klaus-Wolfgang Ebeling, Tim Oliver Flettner, Michael Frenkel, Friederike Ganßauge, Kurt Gillhausen, Hans-Christian Heede, Uwe Hellmessen, Benjamin Hodgson, Bernhard Hoff, Helga Hümmerich, Boguslaw-Marian Korman, Dieter Lüttringhaus, Dirk Matzies, Vladimir Miasnikov, Wolfgang Josef Peters, Birgitt Richter-Polynice, Gerhard Erich Richard Schiller, Ulrich Schott, Andre Schumacher, Harald Siegmund, Winfried Thraen, Roland Matthias Unkelbach, Clemens Wirtz.

Further members of the AgeCoDe study group (German Study on Ageing, Cognition and Dementia in Primary Care Patients): Wolfgang Blank, Michaela Buchwald, Mirjam Colditz, Moritz Daerr, Sandra Eiffländer-Gorfer, Marion Eisele, Sven Heinrich, Hanna Kaduszkiewicz, Teresa Kaufeler, Hans-Helmut König, Tobias Luck, Melanie Luppa, Manfred Mayer, Julia Olbrich, Heinz-Peter Romberg, Anja Rudolph, Melanie Sauder, Britta Schuermann, and Michael Wagner.

Contributors: MP, HHA, HvdB, and WM contributed to study conception and design; all authors contributed to recruitment of GPs and patients, data acquisition, analysis, and interpretation; BW organized data management and assured data quality; BW and MP performed the statistical analyses based on the discussions of all authors; MP and AF drafted the article; HHA, AW, and HvdB critically discussed all versions of the manuscript; all authors revised and finally approved the version to be published. MP is guarantor.

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Regular Research ArticlesApart From Nihilism and Stigma: What Influences General Practitioners' Accuracy in Identifying Incident Dementia?

Objectives:

Design:

Setting:

Participants:

Measurements:

Results:

Conclusion:

Section snippets

Study Design

Sample

DISCUSSION

Lancet

Z Evid Fortbild Qual Gesundh wesen

J Psychiatr Res

Am J Geriatr Psychiatry

Am J Geriatr Psychiatry

Am J Geriatr Psychiatry

The 2006 Revision [Database Online]. New York (NY), United Nations, Department of Economic and Social Affairs, Population Division, 2006 [cited October 1, 2008]

Predicting health care utilization in the very old: the role of physical health, mental health, attitudinal and social factors

J Aging Health

Familiarity with a GP and patients' evaluations of care. A cross-sectional study

Fam Pract

The role of general practice and the primary care team in dementia diagnosis and management

Int J Geriatr Psychiatry

Professional competence, attitude and approach of physicians to patients with dementia in ambulatory care—differences between general practitioners and specialists in Germany

BMC Health Services Res

Beliefs about memory problems and help seeking in elderly persons

Clin Gerontol

Knowledge about symptoms of Alzheimer's disease: correlates and relationship to help-seeking behaviour

Int J Geriatr Psychiatry

Diagnosis-seeking at subspecialty memory clinics: trigger events

Int J Geriatr Psychiatry

A memory clinic for the early diagnosis of dementia

Int J Geriatr Psychiatry

General practitioners' knowledge of their patients' socioeconomic data and their ability to identify vulnerable groups

Scand J Prim Health Care

Are general practitioners able to accurately diagnose dementia and identify Alzheimer's disease? A comparison with an outpatient memory clinic

Br J Gen Pract

Recognition of dementia in general practice: comparison of general practitioners' opinions with assessments using the Mini Mental State Examination and the Blessed Dementia Rating Scale

Fam Pract

Differences in prevalence of dementia based on community survey and general practitioner recognition

Psychol Med

The detection of dementia in the primary care setting

Arch Intern Med

Physician recognition of cognitive impairment: evaluating the need for improvement

J Am Geriatr Soc

Evaluating dementia screening tests: methodologic standards to rate their performance

Neurology

Mild cognitive impairment in general practice: age-specific prevalence and correlate results from the german study on ageing, cognition and dementia in primary care patients (AgeCoDe)

Dement Geriatr Cogn Disord

The Global Deterioration Scale for assessment of primary degenerative dementia

Am J Psychiatry

Regular Research Articles
Apart From Nihilism and Stigma: What Influences General Practitioners' Accuracy in Identifying Incident Dementia?