A Systematic Evidence Review of the Signs and Symptoms of Dementia and Brief Cognitive Tests Available in VA (Paperback)

The Veterans Health Administration (VHA) Office of Geriatrics and Extended Care (OGEC) in Patient Care Services has primary responsibility for coordination and direction of VHA dementia initiatives. OGEC convened an interdisciplinary Dementia Steering Committee (DSC) in December 2006, with the goal of making recommendations on comprehensive, coordinated care for Veterans with dementia. In 2004, the Office of the Assistant Deputy Under Secretary for Health for Policy and Planning estimated that the total number of Veterans with dementia would be as high as 563,758 in FY 2010. A cost analysis of data from the VA determined that the average annual cost of care for a patient with dementia was $19,522 in FY 1999.Broad-based dementia screening programs have not been widely advocated given lack of evidence that earlier detection will improve health outcomes. When implemented, screening programs have been associated with high false positive rates, patient hesitation to undergo diagnostic confirmation, and high cost per case identified. Furthermore, several studies have suggested the public is concerned about the implications of dementia screening. The alternative to systematic screening is a case-finding approach in which clinicians initiate diagnostic assessment of dementia when patients and/or their caregivers describe symptoms or present with signs suggestive of dementia. However, with current case-finding approaches, the diagnosis of dementia is often missed in primary care practice. Improving the accuracy of case-finding techniques depends both on an understanding of signs and symptoms that help distinguish patients with dementia from those without, and the reliability of brief assessment tests that can be incorporated into primary care practice when appropriate. Currently, several organizations have issued statements including signs and symptoms that should prompt a diagnostic evaluation for dementia. However, these recommendations are based largely on expert opinion. One objective of this review, then, is to determine which signs and symptoms help distinguish demented patients from those without dementia. The second objective of this review is to compare the relative accuracy and usability of 6 brief dementia assessment methods available for use in VA. The DSC requested VA HSR&D's Evidence-based Synthesis Program (ESP) to review evidence on selected topics to assist with DSC planning efforts. Broad-based dementia screening programs have not been widely advocated given lack of evidence that earlier detection will improve health outcomes. Improving the accuracy of case-finding techniques depends both on an understanding of signs and symptoms that help distinguish patients with dementia from those without, and the reliability of brief assessment tests that can be incorporated into primary care practice when appropriate. The purpose of this report is to systematically review the evidence on identifying the signs and symptoms of dementia in undiagnosed patients, and evaluating several brief mental status measures currently being used in VHA. The key questions and scope of this review are the following: Key Question #1. What signs and symptoms should prompt VA providers to assess cognitive function as part of an initial diagnostic workup for dementia? Key Question #2. Which measures of cognitive function provide the optimal sensitivity, specificity, and time to completion among the measures available to VA providers? Key Question #3. What are adverse consequences of using these measures?