Clinical judgement by primary care physicians for the diagnosis of all-cause dementia or cognitive impairment in symptomatic people

Diagnostic information in GP referral letters to a memory clinic: a retrospective cohort study

BACKGROUND

Dementia diagnostics can often be performed in primary care, yet older people with memory complaints are frequently referred to memory clinics (MCs).

AIM

To compare diagnostic information in GP referral letters of patients with and without an eventual dementia diagnosis.

DESIGN & SETTING

Retrospective cohort study in a Dutch academic MC.

METHOD

We collected electronic health record (EHR) data of consecutive patients aged ≥65 years referred by their GP between 2016 and 2020. EHR data included patient characteristics, diagnostic information in referral letters, ancillary investigations performed at the MC, and established diagnoses. We performed χ2 tests to compare groups.

RESULTS

Of 651 patients included, the average age was 78.0 years (standard deviation 6.8) and 348 (53.5%) were diagnosed with dementia. Most people with dementia were diagnosed without ancillary investigations (n = 235/348, 67.5%). In GP referral letters of people with dementia compared with people without dementia, a collateral history, any physical examination, a differential diagnosis including dementia, a Mini-Mental State Examination score, interference with daily functioning, and decline from previous levels of functioning were mentioned more often. Furthermore, the more diagnostic criteria mentioned in the referral letter, the more often dementia was diagnosed at the MC (no criteria: 35.4%; one criterion: 47.3%; two criteria: 53.4%; three criteria: 69.9%; and four or five criteria: 83.3%).

CONCLUSION

GPs often correctly mention diagnostic information and dementia criteria in referral letters of people with dementia, and they are often diagnosed without ancillary investigations. This suggests that referral is often unnecessary, and GPs can be empowered to diagnose dementia themselves.

Performance of an AI prediction tool for new-onset atrial fibrillation after coronary artery bypass grafting

Background

There is lack of tools to predict new-onset postoperative atrial fibrillation (NOAF) after coronary artery bypass grafting (CABG). We aimed to develop and validate a novel AI-based bedside tool that accurately predicts predict NOAF after CABG.

Methods

Data from 2994 patients who underwent CABG between March 2015 and July 2024 at two tertiary hospitals in China were retrospectively analyzed. 2486 patients from one hospital formed the derivation cohort, split 7:3 into training and test sets, while the 508 patients from a separate hospital formed the external validation cohort. A stacking model integrating 11 base learners was developed and evaluated using Accuracy, Precision, Recall, F1 score, and Area Under Curve (AUC). SHapley Additive exPlanations (SHAP) values were calculated and plotted to interpret the contributions of individual characteristics to the model's predictions.

Findings

Seventy-seven predictive characteristics were analyzed. The stacking model achieved superior performance with AUCs 0·931 and F1 scores 0·797 in the independent external validation, outperforming CHA2DS2-VASc, HATCH, and POAF scores (AUC 0·931 vs. 0·713, 0·708, and 0·667; p < 0·05). SHAP value indicate that the importance of predictive features for NOAF, in descending order, include: Brain natriuretic peptide, Left ventricular end-diastolic diameter, Ejection fraction, BMI, β-receptor blockers, Duration of surgery, Age, Neutrophil percentage-to-albumin ratio, Myocardial infarction, Left atrial diameter, Hypertension, and smoking status. Subsequently, we constructed an easy-to-use bedside clinical tool for NOAF risk assessment leveraging these characteristics.

Interpretation

The AI-based tool offers superior prediction of NOAF, outperforming three existing predictive tools. Future studies should further explore how various patient characteristics influence the timing of NOAF onset, whether early or late.

Funding

This work was funded by Lingnan Nightingale Nursing Research Institute of Guangdong Province, and Guangdong Nursing Society (GDHLYJYZ202401).

Effectiveness and utilization of a cognitive screening program for primary geriatric care

BACKGROUND

Effective detection of cognitive impairment in the primary care setting is limited by lack of time and specialized expertise to conduct detailed objective cognitive testing and few well-validated cognitive screening instruments that can be administered and evaluated quickly without expert supervision. We therefore developed a model cognitive screening program to provide relatively brief, objective assessment of a geriatric patient's memory and other cognitive abilities in cases where the primary care physician suspects but is unsure of the presence of a deficit.

METHODS

Referred patients were tested during a 40-min session by a psychometrist or trained nurse in the clinic on a brief battery of neuropsychological tests that assessed multiple cognitive domains. Short questionnaires covering subjective cognitive complaints, symptoms of depression, and medical history were also administered. Results were conveyed to a dementia specialist who reviewed them and returned their judgement of the validity of the cognitive complaint to the primary care provider. Retrospective medical records review was carried out for a random (stratified) half of the sample to determine how screening results were utilized. Screening tests were repeated after two years in a subset of 69 patients.

RESULTS

The 638 patients screened (mean age = 75.9 years; mean education = 14.9 years; 58% women) were classified by screening as having normal cognition (n = 177), depression (with possible cognitive changes; n = 115), mild cognitive impairment (MCI; n = 107), or dementia (n = 239). Classification accuracy was shown by high agreement with the eventual clinical diagnosis in the medical record (69%; Cohen's Kappa = .38; p < .001; 77% if MCI and dementia were collapsed; Cohen's Kappa = .58; p < .001) and longitudinal decline in cognitive test scores only in those initially classified as having MCI or dementia. Medical records documented discussion of screening results with the patient in 69% of cases (80% if MCI or dementia was detected) and often referral to a specialist (62%), new brain imaging (54%), or change in medication (58%) when screening indicated potential cognitive impairment.

CONCLUSION

The cognitive screening program was well accepted by primary care providers as an efficient and effective way to evaluate concerns about cognitive decline in older adults.

Assessing and recovering Alzheimer's disease: a comparative analysis of standard neuropsychological approaches and virtual reality interventions with the use of digital storytelling

Background

Alzheimer's disease (AD), the most common form of dementia, is a progressive neurodegenerative disorder that predominantly affects the elderly population. Traditional assessment methods, including neuropsychological tests like the MMSE, have been the cornerstone of AD diagnosis for decades. These methods are grounded in a wealth of research and clinical experience, providing a robust framework for understanding the cognitive deficits of AD. The evolution of AD assessment and rehabilitation has recently been tackled with the introduction of Virtual Reality (VR) technologies.

Objectives

To evaluate the use of storytelling and reminiscence therapy in virtual reality programs as a complementary and enhancing modality alongside standard assessment and rehabilitation for Alzheimer's patients. To explore how regular interaction with VR narratives can slow cognitive decline or improve relevant features of cognitive functioning over the time. To propose a new assessment and rehabilitative tool based on the use of VR and digital storytelling.

Method

A comparative analysis of Standard Neuropsychological Approaches and Virtual Reality Interventions in patients with Alzheimer disorder was carried out. A literature overview on the empirical studies between 2019 and 2024 was conducted.

Results

We propose a new VR-based setup mediated by the use of storytelling for the assessment and recovery of AD.

Conclusion

The employment of storytelling within VR programs for the assessment and rehabilitation of Alzheimer's disease can positively impact both the cognitive and emotional realms of patients, with beneficial outcomes on caregivers' and families' burden. The successful implementation of this approach requires careful consideration of accessibility, data interpretation, and standard validation protocols.

Optimising Alzheimer's Disease Diagnosis and Treatment: Assessing Cost-Utility of Integrating Blood Biomarkers in Clinical Practice for Disease-Modifying Treatment

BACKGROUND

Recent developments in blood biomarkers (BBM) have shown promising results in diagnosing amyloid pathology in Alzheimer's Disease (AD). However, information on how these BBMs can best be used in clinical settings to optimise clinical decision-making and long-term health outcomes for individuals with AD is still lacking.

OBJECTIVES

We aim to assess the potential value of BBM in AD diagnosis within the context of disease-modifying treatment (DMT).

DESIGN

We developed a decision analytic model to evaluate the long-term health outcomes using BBM in AD diagnosis. We compared standard of care (SOC) diagnosis workflow to the integration of BBM as a (1) referral decision tool in primary health center (PHC) and (2) triaging tool for invasive CSF examination in specialist memory clinic (MC). We combined a decision tree and a Markov model to simulate the patient's diagnostic journey, treatment decisions following diagnosis and long-term health outcomes. Input parameters for the model were identified from published literature and registry data analysis. We conducted a cost-utility analysis from the societal perspective using a one-year cycle length and a 30-year (lifetime) horizon.

MEASUREMENTS

We reported the simulated outcomes in the percentage of correct diagnosis, costs (in 2022 Euros), quality-adjusted life year (QALY), and incremental cost-effectiveness ratios (ICER) associated with each diagnosis strategy.

RESULTS

Compared to SOC, integrating BBM in PHC increased patient referrals by 8% and true positive AD diagnoses by 10.4%. The lifetime costs for individuals diagnosed with AD were € 249,685 and €250,287, and QALYs were 9.5 and 9.52 in SOC and PHC pathways, respectively. The cost increments were €603, and QALYs gained were 0.01, resulting in an ICER of €48,296. Using BBM in MC reduced the exposure to invasive CSF procedures and costs but also reduced true positive AD diagnoses and QALYs.

CONCLUSIONS

Using BBM at PHC to make referral decisions might increase initial diagnostic costs but can prevent high costs associated with disease progression, providing a cost-effective DMT is available, whereas using BBM in MC could reduce the initial evaluation cost but incur high costs associated with disease progression.

The potential clinical value of plasma biomarkers in Alzheimer's disease

INTRODUCTION

Many people with cognitive complaints or impairment never receive an accurate diagnosis of the underlying condition, potentially impacting their access to appropriate treatment. To address this unmet need, plasma biomarker tests are being developed for use in Alzheimer's disease (AD). Plasma biomarker tests span various stages of development, including in vitro diagnostic devices (or tests) (IVDs), laboratory-developed tests (LDTs) and research use only devices (or tests) (RUOs). Understanding the differences between each test type is important for appropriate implementation into the AD diagnostic pathway and care continuum.

METHODS

Authors reviewed scientific literature (PubMed, meeting abstracts and presentations, company press releases and websites) on AD plasma biomarkers.

RESULTS

This article defines IVDs, LDTs, and RUOs, discusses potential clinical applications and highlights the steps necessary for their clinical implementation.

DISCUSSION

Plasma biomarkers could revolutionize many areas of the AD diagnostic pathway and care continuum, but further research is needed.

HIGHLIGHTS

There is a need for a minimally invasive Alzheimer's disease (AD) diagnostic tool. AD plasma biomarker tests exist at various stages of commercial development. Understanding the development stage of a test is important for its appropriate use. Plasma biomarker tests could function as a triage tool to streamline AD diagnosis. Further steps remain before AD plasma biomarkers can be used routinely.

A Perspective: Challenges in Dementia Research

Although dementia is a common and devastating disease that has been studied intensely for more than 100 years, no effective disease modifying treatment has been found. At this impasse, new approaches are important. The purpose of this paper is to provide, in the context of current research, one clinician's perspective regarding important challenges in the field in the form of specific challenges. These challenges not only illustrate the scope of the problems inherent in finding treatments for dementia, but can also be specific targets to foster discussion, criticism and new research. One common theme is the need to transform research activities from small projects in individual laboratories/clinics to larger multinational projects, in which each clinician and researcher works as an integral part. This transformation will require collaboration between researchers, large corporations, regulatory/governmental authorities and the general population, as well as significant financial investments. However, the costs of transforming the approach are small in comparison with the cost of dementia.