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Clues to Early Alzheimer Dementia in the Outpatient Setting
Cynthia Holzer, MD;
Gregg Warshaw, MD
Arch Fam Med. 2000;9:1066-1070.
ABSTRACT
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Background As the elderly population booms and the prevalence of dementia soars, it becomes imperative that primary care physicians recognize early dementia within their own practices. Early recognition and diagnosis of dementia will allow appropriate intervention and treatment to improve morbidity.
Objective To examine the most common symptoms associated with early Alzheimer disease (AD), as presented by patients and their families, and to compare these with the recommendations of the "7-Minute Screen" by Solomon et al for the identification of AD and the recommendations of the Agency for Health Care Policy and Research (AHCPR) for the early recognition of dementia.
Methods A retrospective medical record review was conducted in an outpatient referral population within 2 geriatric evaluation centers. Patient medical record selection was based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for AD, a Mini-Mental State Examination (MMSE) score of 23 or higher, a Geriatric Depression Scale score of less than 5, age above 60 years, and at least an eighth-grade level of education.
Results From 1025 medical records reviewed, 50 patients were chosen who fulfilled all inclusion criteria. Forty patients (80%) missed at least 2, if not all 3, recall items on the MMSE. Thirty patients (60%) had difficulty managing finances and/or balancing a checkbook; 16 (32%) frequently repeated stories and statements; 15 (30%) became lost while driving; 10 (20%) frequently forgot the names of relatives; and 10 (20%) had poor judgment. These results demonstrated a high correlation with recall as a diagnostic factor in diagnosing early AD as found in the 7-Minute Screen. Moreover, these "clues" correlated well with the AHCPR's symptoms that indicate dementia. The symptoms specifically overlapped in the areas of learning and retaining new information (repetition), handling complex tasks (calculation), reasoning ability (judgment), and spatial ability and orientation (driving).
Conclusions There may be a constellation of symptoms associated with early AD. This constellation includes missing recall items on the MMSE, difficulty in calculation, repetition, getting lost while driving, forgetting the names of relatives, and having poor judgment. Recall is the symptom most consistent with the findings of the 7-Minute Screen in diagnosing AD. However, repetition, calculation, judgment, and driving highly correlate with the AHCPR's dementia symptom checklist. Therefore, if primary care physicians keep this constellation of symptoms in mind while evaluating their geriatric population, they will have greater ability to suspect, diagnose, and treat AD at an early stage.
INTRODUCTION
AS THE ELDERLY population booms and medical economics forces more primary care physicians (PCPs) to treat their own patients with dementia, it becomes imperative that PCPs recognize early dementia within their own practice. Literature concerning this subject reveals that PCPs often do not recognize dementia, especially in its early stages, which results in late detection of the disease.1-2 The problem is further compounded by the fact that in the earlier stages of the illness patients can easily "hide" their symptoms from the PCP through confabulation.1 Moreover, although patients and families do report symptoms of decline, they may tend to underreport them.3-4 For example, a study done by McCormick et al3 found that the average duration of symptoms before diagnosis of Alzheimer disease (AD) was about 2 years. Another study by Roth5 suggests that there are up to 125 undiagnosed patients with AD in a typical primary care practice. Statistics such as these should provide incentives to educate PCPs about the diagnosis of AD at an early stage.
To improve recognition and diagnosis of dementia, PCPs must be made aware of its prevalence. In the United States, the most common cause of dementia is AD.4, 6 According to the Early Identification of Alzheimer's Disease and Related Dementias Panel, "An estimated 5 to 10 percent of the U.S. adult population 65 years of age and older is affected by a dementing disorder, and the incidence doubles every five years after the age 65."7(p1303) Overall, AD accounts for two thirds of all cases of dementia.5
The course of AD is an insidious, progressive deterioration of cognitive and functional impairment. This decline may directly affect patients by compromising their intellectual ability to care for themselves in both health and financial matters. Thus, AD in and of itself increases morbidity, which is why early detection is crucial.
Once PCPs realize the importance of early detection of dementia, a method to facilitate the recognition of early dementia is necessary. This study looked at the most common symptoms associated with early AD, as presented by patients and their families, in an outpatient referral population and compared these with the recommendations of the "7-Minute Screen" by Solomon et al8-9 and those of the Agency for Health Care Policy and Research (AHCPR) for early recognition of dementia.10
MATERIALS AND METHODS
A medical record review was conducted within 2 geriatric evaluation centers of all new patient records from May 1994 to March 1998. We used a standardized form to record the information as listed in Table 1. All data were obtained from the patient's intake history and physical examination, as well as the complete geriatric assessment consult completed by the physicians at the respective evaluation centers. As the workup of each patient varied depending on the PCP, our resulting database included some data as provided by the referring physician's records, and it was combined with the very extensive evaluation data obtained at our geriatric evaluation center.
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Table 1. Data Collected From Each Patient's Medical Record*
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To be included in the study, the outpatient medical record was required to meet all of the following criteria: (1) Patients were required to meet diagnostic criteria for AD as set by Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition.11 (2) Patients were required to have scored 23 or higher on the Mini-Mental State Examination (MMSE) to achieve the MMSE's highest rate of sensitivity and specificity for early dementia.12 (3) Patients were required to have scored less than 5 on the Geriatric Depression Scale to exclude this comorbid Axis I possibility. (4) Patients were required to be 60 years or older to represent the age group most likely to be demented. (5) Education was required to be at least at the eighth-grade level, as results of the MMSE are compromised when used in patients with less than this level of education.13
The information for this study was corroborated with the histories given by the primary caregiver and family members. This was imperative, as patient interviews revealed that the subjects were either unaware of the severity of their symptoms or in denial concerning their mental state.
RESULTS
Out of 1025 medical records reviewed, only 50 met all of the inclusion criteria as listed above. The other 975 medical records were excluded, as these patients had histories of cerebrovascular disease or known causes of reversible dementia, scored less than 23 on the MMSE, or scored higher than 5 on the Geriatric Depression Scale. It is on the remaining 50 qualified medical records that the following results are based. The ages of the patients ranged from 61 to 89 years, with an average age of 78 years. Educational levels ranged from grade 8 through graduate school. Most patients fell under the category of having graduated from high school. Thirty-seven of the patients were women; 13 were men. Mini-Mental State Examination scores ranged from 28 to 23, with an average score of 25. The depression scale scores ranged from 0 to 5, with an average score of 2.
In 41 patients, families stated that the reason geriatric consultation was sought was for progressively worsening "memory loss," especially short-term memory. Seven patients were referred for "forgetfulness" and 2 were evaluated for "personality change." Thirty-two patients were referred to the geriatrician by their family members, while only 18 were directly referred by their PCP. There was no evidence from the medical records of these 18 patients that the PCP performed an MMSE or questioned the patient or caregiver specifically on the clues explored in this study. The average duration of symptoms, as recalled by family members, ranged from 6 months to 5 years.
The most significant and consistent clue to early AD involved the executive function of calculation. Thirty (60%) of the 50 patients admitted to difficulty in managing finances and/or balancing the checkbook. These results were verified by family members who already had taken over the financial responsibilities of the patients. Further evaluation of executive functions showed that poor judgment, specifically in the area of hygiene, was a concern to 10 (20%) of the 50 family members. They stated that the patients tended to bathe less frequently and were more inclined to wear soiled clothing. Another area of executive function of concern to 8 (16%) of 50 family members was that the patient could not complete a task without direction or cueing. This affected cooking, grocery shopping, and medication compliance.
A more detailed evaluation of specific memory loss complaints demonstrated that repetition was a common clue to advancing memory loss. Sixteen (32%) of 50 family members complained that the patients frequently repeated stories and statements. Another common clue in 15 (30%) of 50 patients was the patient getting lost while driving despite having directions or following a very familiar route. Another prevalent clue in 10 (20%) of 50 patients was the patient forgetting the names of relatives and neighbors. Other less common memory issues involved forgetting recent events, such as hospitalizations or familial deaths, overlooking appointments, and leaving the stove and burners ignited.
Evaluation of the MMSE established that recall was by far the most problematic area of testing. Forty (80%) of 50 patients missed at least 2, if not all 3, recall items. The next most common areas of error were stating the day and the date incorrectly, as proven by 20 (40%) and 18 (36%) of the 50 patients, respectively.
Overall, 6 (12%) presented with 1 clue; 18 (36%) with 2 clues; 15 (30%) with 3 clues; 8 (16%) with 4 clues; and 3 (6%) with 5 clues. Not one patient in this study presented with all 6 clues. Table 2 presents a synopsis of the most common clues to early AD, as found in this study.
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Table 2. Clues to Diagnosing Early Alzheimer Disease
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According to the 7-Minute Screen by Solomon et al, their combination of 4 neurocognitive tests was able to diagnose 92% of patients with AD and 96% of normal subjects.8-9 Their battery of tests also performed well when only patients with mild and very mild AD were included. The first of their 4 tests includes the evaluation of orientation via the Benton Temporal Orientation Test, which assesses a patient's ability to identify the month, date, year, day of the week, and time of day. With the exception of the time of day, all of these factors were tested in our study via the MMSE. However, our results suggest that orientation was not a consistent factor for the early diagnosis of AD.
The second portion of the 7-Minute Screen focuses on memory by using an abbreviated version of the Enhanced Cued Recall Test to better distinguish between AD and the memory deficits associated with the normal aging process. In our study, memory testing was based on the recall of 3 items during the MMSE. However, only the noncued recall of 3 items was measured. Our study established that recall was by far the most problematic area of testing. Thus, recall should be viewed as one of the greatest clues to the early diagnosis of AD.
The third testing area of Solomon et al is visuospatial ability, based on the clock-drawing test. Although clock drawing was accounted for as part of the geriatric assessment, clock drawing and its separate attributes were not featured specifically in our study.
The final portion of the 7-Minute Screen tests expressive language based on verbal fluency. Our study did not evaluate verbal fluency.
The AHCPR panel created a clinical guide focusing on triggers for the recognition of possible dementia. It was developed by the panel from clinical experience and the dementia literature. The AHCPR triggers are listed in Table 3.
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Table 3. Agency for Health Care Policy and Research (AHCPR) Triggers
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The clues as found in our study (Table 2) compared well with the AHCPR's symptoms that indicate dementia. The symptoms specifically overlapped in the areas of learning and retaining new information (repetition), handling complex tasks (calculation), reasoning ability (judgment), and spatial ability and orientation (driving).
COMMENT
A significant limitation of this study is that we identified our patients from a referred population. Eighteen of the 50 patients had been referred by their PCP for evaluation of memory loss. Thus, the study included patients whose dementia may have already been recognized by the PCP. However, if the PCPs did recognize the dementia, there was no evidence from the medical records of these 18 patients that the PCP performed an MMSE or questioned the patient or caregiver specifically on the clues explored in this study. Despite the recognition of memory loss, the PCPs did not properly evaluate these patients for early AD, nor were they able to accurately diagnose the memory loss as early AD.
Another limitation of this study is the sample size. Strict inclusion criteria made the selection of 50 patients arduous. For example, it was very difficult to find patients who did not have a comorbid illness, such as cerebrovascular disease or a documented reversible cause of dementia. Numerous patients scored higher than 5 on the Geriatric Depression Scale and thus could not be included in the study. Also, it was difficult to find patients older than 60 years who scored 23 or higher on the MMSE. It is important to note that since the patients were selected from 2 different geriatric evaluation centers, there may have been minor variations in the evaluators' determination of correct responses on the MMSE and Geriatric Depression Scale.
Lastly, this study is limited by not being able to report sensitivity and specificity of the clues, as there is no comparison group of persons who are diagnosed as not having AD. We did not attempt to identify potential control groups with, for example, pure vascular dementia or pure depression. However, we believe our criteria to be valid clues for AD because of the agreement between our clues and other recognized tools to identify AD, such as the 7-Minute Screen and AHCPR recommendations. In future research, it will be important to apply these criteria to patients with pure diagnoses in the differential diagnoses of AD.
The population included in this study is a stringently selected one, and not large enough to make conclusive recommendations about the clues to early diagnosis of AD in the outpatient setting. Nevertheless, some interesting points have emerged.
Because PCPs see their elderly patients on a regular basis, this continuity places them in an excellent position to note deterioration of their patients' mental status.14 However, physicians and/or their office staff need to take the initiative to routinely involve the caregivers and family members in elderly outpatient evaluation. "Informant reports can supplement information from patients who have experienced memory loss and who may lack insight into the severity of their decline."7(p1306) As most patient information was gathered from caregiver history, this study suggests that the information provided by caregivers is an important component of a complete evaluation as patients with AD are often unaware of their own deficits.
The data collected in this study indicate that there may be a constellation of symptoms associated with early AD. This constellation specifically includes difficulty in calculation, repetition, getting lost while driving, and missing the recall items on the MMSE. However, these clues may be difficult to extract unless the PCP actively searches for them. This study suggests that a PCP's ability to detect early AD may improve by including the following steps into a routine elderly patient visit: question primary caregivers about changes in patient memory or mood, specifically asking about calculation and financial capabilities, repetition, driving ability, and hygiene. Also, administer the MMSE, paying close attention to the areas of recall, day, and date, to allow an objective screening baseline of cognitive function. If time permits, conduct a geriatric depression test to exclude the confounding factor of depression would be valuable. If history and objective questioning warrants, further workup is essential. As required by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria, imaging and blood work to exclude central nervous system conditions and reversible causes of dementia should be completed before the diagnosis of AD.11 Interestingly, in review of the medical records from this study population, 31 patients had a partial to complete workup for reversible causes of dementia completed by the PCP before geriatric consultation. The workup for reversible causes typically included a complete blood cell count; the Venereal Disease Research Laboratory test for syphilis; testing levels of calcium, phosphorus, alkaline phosphatase, thyroid-stimulating hormone, cyanocobalamin, folic acid, electrolytes, and glucose; renal and liver function tests; and computed tomographic scans of the head. However, despite extensive testing, no definitive diagnosis of dementia or AD was made by the referring physicians after the workup had been completed. Even though the PCPs may have alluded to dementia by virtue of their test selection and referral, they certainly did not have the confidence to diagnose AD.
In comparison with the 7-Minute Screen by Solomon et al, our study also suggested that recall was a significant area of impairment required to diagnose early AD. However, what becomes difficult in using the 7-Minute Screen is that one must be familiar with using and interpreting its neuropsychiatric tests. This would mean training PCPs to use these tests specifically, which would defeat the purpose of using a quick and easily available screen.
Moreover, our study was more consistent with the symptoms of possible dementia as recommended by the AHCPR. Thus, the constellation of symptoms associated with early AD as presented in our study should have a high clinical correlation with early AD.
Therefore, if the clues found in our study are consistently sought during evaluation of those patients older than 60 years, early diagnosis of AD can be heightened with appropriate intervention, such as advanced planning and treatment to improve the symptoms of the disease. Early recognition of dementia can allow the patient and family to plan for the future and consider participating in trials of promising new therapies as they are developed.7 This ability to suspect, diagnose, and treat AD at an early stage will improve the morbidity and mortality of our aging population, ameliorate caregiver stress, and strengthen the physician-patient relationship.15
AUTHOR INFORMATION
Accepted for publication August 31, 2000.
We thank Sally Brooks, MD, for her original critical review.
Corresponding author: Cynthia Holzer, MD, University of Cincinnati Medical Center, Office of Geriatric Medicine, PO Box 670504, Cincinnati, OH 45267-0504 (e-mail: clholzer{at}pol.net).
From the Departments of Geriatric Medicine (Dr Holzer) and Family Medicine (Dr Warshaw), University of Cincinnati, Cincinnati, Ohio.
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