meme batterie de tests extensifs? * Quand devrait-on referer le patient ... cours de l'evaluation initiale de la de'- mence. La Conference a de plus reconnu le ...
Dementia assessment
cases being due to depression and drugs. While this estimate is considerably smaller than earlier estimates, it still represents a significant increase given the consequences of missing a
reversible cause for dementia. The second contribution has been the recommendations on the assessment and diagnosis of dementia created by consensus conferences. Such recommendations have emerged from groups within both the United States4 and the United Kingdom.5 While these efforts have provided some initial benefit, they have created potential problems for the Canadian family physician. The guidelines from the two bodies provide conflicting recommendations, and one approach is
J.W FEIGHTNER, MD, CCFP Mj. BASS, MD, CCFP D.A. GASS, MD, CCFP
considerably more aggressive. Further, t is rare for the topic of dementia not to receive attention regularly in both the lay press and the med-
ical literature. This is hardly surprising; dementia is a significant health problem in today's society and one in which the family physician must play a key role. The burden of dementia is significant. It is estimated that 10% of Canadians older than 65 years suffer from dementia, with as many as 25 000 new cases occurring each year." 2 In those older than 85 years, as many as 40% might suffer from dementia.3 The implications for the individual sufferers and their families can be extraordinary. In addition, the burden on the formal health care system as a result of dementia is significant. Because of the large number of new patients and the limited number of appropriate specialists, much of the responsibility for treating dementia rests with family
physicians. Dr Feightner, a Fellow of the Colege, is J+ofessor of Fwri1y Medicine, McMaser Unuersqt, Hmilon, Ont. Dr Bass, a Felow of the CGoUlge, is Professor, Dpatent of Famil Medice, University of Western Ontaio, Lndn. Dr Gass, a Fellow of die Collge, is Pmfessor and Head of die D" ¢tof Fwnily Medicine, Dallouis-e Unwersiq, Halifax, NS. 1320 Canadian Family Physician VOL 38: June 1992
For the family physician the assessment of dementia can represent a significant challenge. While Alzheimer's disease is the most common cause of dementia, a small but significant percentage of causes can be reversed in whole or in part. Hence, there can be considerable pressure to identify reversible disorders. The list of potential investigations is extensive, and the cost can be great. Furthermore, while Alzheimer's is the most common cause, no single diagnostic test confirms this diagnosis. As a result, further demands are put on the diagnostic acumen and the decision making of the family physician. Two important contributions to the challenge of assessing dementia have been made in the last decade. The first is the recognition that the percentage of new cases of dementias, which are truly reversible, is much smaller than originally indicated. Earlier estimates of 40% were based on data from patient groups in which most did not live in the community and from patients whose dementia stemmed from causes that were only theoretically reversible. Data from community populations and a more careful analysis of which causes of dementia are truly reversible puts the figure for new dementia cases closer to 1 %, with half of these
the recommendations are from countries with health care systems different than Canada's, and none of the recommendations were specifically targeted for family physicians. In 1989 the Canadian Consensus Conference on the Assessment of Dementia was held in an attempt to address these problems. This conference was attended by 38 participants (34 from Canada and 4 from the United States) to address the evidence relating to the assessment of dementia, focusing particularly on the perspective ofthe family physician. These participants included physicians from a range of consulting specialties: family physicians, nurses, health economists, other methodologists, and representatives from the lay public. The conference considered the impact of existing evidence on six key issues. * How should the generalist physician approach the identification and assessment of patients with suspected cognitive impairment? * How should the diagnosis of dementia be confirmed clinically? * What should be the laboratory workup for reversible causes? * Should every patient with dementia receive the same extensive battery of tests? * When should the patient be re-
ferred for consultation or special testing? * What are the priorities for future research in the diagnosis and assessment of dementia? In particular, the deliberations focused on office assessment, imaging investigations, and other laboratory investigations. Reports of these proceedings have been published re-
cently.6'7 Several key recommendations emerged from the conference and include the following. 1. Although the clinician should maintain a heightened awareness of the early presentation of dementia, routine case finding for asymptomatic patients is not recommended. 2. A careful history (incorporating data from a third party) and a physical examination should include attention to intellect, memory, affect, judgment, personality, orientation, and activities of daily living. 3. The Folstein mini-mental status examination is an excellent assessment aid. 4. Dementia must be differentiated from delirium. 5. The search for reversible causes or exacerbating factors should be focused on a limited list of likely contributors. This includes a selective use of laboratory investigations, unless specific findings from the patient's medical history and physical examination suggest otherwise. The minimum investigation includes only complete blood count, thyroid indices, electrolyte assessments, calcium tests, and glucose measurements. In addition, clinical guidelines were suggested for the selective use of computed tomographic scans, and several areas requiring research were identified. Recommended research includes assessing the benefit of early detection, evaluating the role of formal scales for depression and functional status in the office setting, and
assessing the value of home visits in the assessment of dementia. Where does this leave Canadian family physicians? The consensus conference confirmed the important role of the family physician in the assessment of dementia. The recommendations highlight the importance of assessment in the home and office and focus our efforts on a selective investigation strategy aimed at identifying reversible causes. The recommendations support an approach that limits the use of expensive investigative resources when they have not proved to be effective, particularly at the initial assessment for dementia. In addition, the conference acknowledged the need for consultations in specific cases. These deliberations reinforce the critical role of the family physician in the recognition and assessment of patients with dementia and in the management and support of patients and their families. Hence, the consensus conference has provided great assistance to family physicians. Many continuing challenges were also identified. These include the need for more effective and efficient assessment strategies within the office and the development of inexpensive, practical assessment instruments. Furthermore, while the Canadian Consensus Conference on the Assessment of Dementia focused on the diagnosis and assessment of new dementias, it recognized that this should not detract attention from the considerable challenge that still exists in caring for and supporting patients and families with established irreversible dementia. While the overall challenges continue, the recommendations from the consensus conference will provide valuable direction to family physicians in the assessment of patients U with dementia. Requests for reprints to: DrJ. K Feightner McMaster Universiy, Department of Famil Medicine, 1200 Main St 11 Hamilton, ONW L8JVSZ5
References 1. Robertson D, Rockwood K, Stoles P. l 'hc prevalence of cognitive impairmenit in a Canadiani population. tIcta Psychiatr Scand 1989;80:303-9. 2. Jorm Al, Korteni AL, Henderson AS. 'I'he prevalence of demenitia: a quantitative integration of the literature. Acta Psychiatr Scand 1987;76:465-79. 3. Evans DA, Funikenistein HH, Albert NIS, Scherr PA, Cook NR, Chown MJ, et a]. Prevalence of Alzheimer's disease in a community population of older persons. JAMA 1989;262:2551-6. 4. Conisensus Conference. Differential diagnosis of dementing discases. JAMA 1987;258:3411-6. 5. Royal College of Physicians, Committee on Geriatrics. Organic mental impairment in the elderly: implications for research, education and the provisioni of services. J R Coll Physicians Lond 1981; 15:141-67. 6. Organizing Committee, Canadian Consensus Conference on the Assessment of Dementia. Assessing dementia: the Canadian consensus. Organizing Committee, Canadian Consenisus Coniference on the Assessment of Dementia [editorial]. Can Med Assocj 1991;144:851-3. 7. Clarfield M. Caniadian Consensus Coniference on the Assessmenit of Demenitia. 5-6 October 1989. Can Med Assoc 3 1991; 144
(7 suppl).
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1Bvaluation .
dle
a
d%emence
J.W FEIGHTNER, MD, CCFP Mj. BASS, MD, CCFP D.A GASS, MD, CCFP
a litterature medicale et la presse populaire publient regulierement des articles sur le theme de la demence. I1 ne faut pas s'en surprendre; la demence est devenue un probleme significatif de sante dans notre societe actuelle et l'un des troubles ofu le medecin de famille doit s'impliquer comme chef de file. La demence impose une charge sociale de plus en plus lourde. On estime que plus de 10% des Canadiens de plus de 65 ans sont atteints de demence et, chaque annee, on en identifie tout pres de 25 000 nouveaux cas."2 On estime a presque 40% le nombre des patients de plus de 85 ans souffrant de demence.3 I1 en resulte des implications et des consequences individuelles et familiales enormes. On realise egalement que la demence impose une charge significative au systeme de sante. Etant donne la quantite importante de nouveaux Dr Feightner, felbw du Coll*, est pmfesseur titdaie de mnefanilae a l'Uniersitv McMaster, Hilton, Ont. Dr Bass, fellow du CoUge, est professeur Wulae, Deli)rnent de mr wfwniikl4, Unirsitl de Westen OPntO, London. Dr Gass, fellow du Coleg, est professeur titlai et dimctsur du Dpanemn de ml cinefamiiale, Uniersiti
Dalousi, HalWax, NS. 1322 Le Medecin defamille canadien VOL 38: juin 1992
patients et le nombre limite de specialistes appropries, une bonne part du traitement de la demence incombe aux medecins de famille. Par consequent, l'evaluation de la demence devient un defi significatif pour le medecin de famille. Bien que la maladie d'Alzheimer soit la cause la plus frequente de demence, il existe un pourcentage non negligeable de causes totalement ou partiellement reversibles. On voit donc la pression considerable qui peut s'exercer pour tenter d'identifier les causes reversibles. La liste des investigations possibles est extensive et peut impliquer un cou-t considerable. Bien que la maladie d'Alzheimer en soit l'etiologie la plus frequente, il n'existe aucun test capable a lui seul de confirmer ce diagnostic, ce qui met encore plus a l'preuve l'acuite diagnostique et la capacite decisionnelle du medecin de famille. La derniere decennie nous aura apporte deux importantes contributions pour attenuer le defi que comporte l'valuation de la demence. La premiere est la constatation que le pourcentage des nouveaux cas de demence reellement reversibles est beaucoup plus faible que celui propose anterieurement. On avait alors estime a 40% le pourcentage de cas reversibles mais ces chiffres s'inspiraient de donnees cumu-
lees a partir de groupes de patients ne vivant pas dans la communaute et de patients dont la demence avait ete attribuee a des causes dont la reversibilite n'etait que theorique. Les donn(ees provenant de populations reellement communautaires et I'analyse plus poussee des causes veritablement reversibles ramenent le chiffre des nouveaux cas de demence aux environs de 11%, dont la moitie sont attribuables a la depression et aux medicaments. Bien que cet estime soit considerablement plus faible que les precedents, il represente neanmoins une augmentation significative si l'on prend en consideration les consequences d'avoir manque une cause reversible de demence. La deuxieme contribution des conferences de consensus fut de proposer des recommandations touchant l'evaluation et le diagnostic de la demence. Ces recommandations proviennent de groupes des Etats-Unis4 et du Royaume-Uni.5 Ces efforts ont permis de faire progresser le dossier mais, en meme temps, ils ont cree des problemes chez le medecin de famille canadien. La ligne de conduite proposee par ces deux organismes suggere des recommandations conffictuelles, et l'une des approches est reellement plus agressive. II faut noter egalement que les recommandations proviennent de pays dont les systemes de sante sont differents de celui en vigueur au Canada, et aucune des recommandations proposees ne visait specifiquement les medecins de famille. En 1989, se tenait la Conference canadienne de consensus sur l'evaluation de la deence ayant pour but de clarifier ces problemes. Trente-huit participants (34 Canadiens et 4 Americains) ont tente d'analyser les donnees touchant l'evaluation de la demence en insistant particulierement sur la perspective du medecin de famille. De ce nombre, on comptait des professionnels de diverses specialites: medecins de famille, infirmieres, economistes de la sante, methodologistes et des representants de la population. Cette Conference a analyse l'impact des donnees
investigations de laboratoire a actuelles autour de six questions primoins de trouvailles specifiques mordiales: dans les antecedents medicaux et * Comment l'omnipraticien devrait-il 1'examen physique du patient. L'indefinir son approche a l'identificavestigation minimale doit se limiter tion et 'a l'evaluation des patients a la formule sanguine complete, les chez qui on soupconne des troubles tests de fonction thyroidienne, les cognitifs? electrolytes, la calcemie et la * Comment devrait-on confirmer glycemie. cliniquement le diagnostic de demence? De plus, la Conference a suggere un * Comment devrait-on evaluer par guide clinique permettant l'utilisation des tests de laboratoire les causes judicieuse de la tomodensitometrie et reversibles? a identifie plusieurs domaines necessi* Tous les patients atteints de demen- tant des recherches. Parmi les sujets ce devraient-ils faire l'objet de la de recherche recommandes, notons meme batterie de tests extensifs? I'evaluation du role des differentes * Quand devrait-on referer le patient echelles pour mesurer la depression et en consultation ou pour des tests l'etat fonctionnel dans un contexte de speciaux? et l'evaluation de la valeur bureau, * Quelles sont les priorites a etablir des visites 'a domicile pour apprecier pour la recherche future concerla demence. nant le diagnostic et l'evaluation de Ou le medecin de famille canadien la demence? Ces deliberations ont particuliere- se retrouve-t-il dans tout cela? Cette ment insiste sur l'evaluation au bu- Conference de consensus a confirme reau, l'investigation utilisant l'ima- l'importance du role du medecin de gerie et les autres tests de laboratoire. famille dans l'evaluation de la demenOn a recemment publie les rapports ce. Les recommandations mettent l'emphase sur l'importance de l'evade ces deliberations.6,7 Cette conference a permis de de- luation a domicile et au bureau et gager plusieurs recommandations im- orientent les efforts vers une strategie portantes dont voici les principales. impliquant une investigation selective 1. Malgre la necessite de demeurer visant 'a identifier les causes reversifortement sensibilise aux signes et bles. Ces recommandations supporsympt6mes precoces de la de- tent une approche qui limite l'utilisamence, il n'est pas recormmande au tion des ressources d'investigation clinicien de proceder a un depistage trop cofiteuses dont l'efficacite n'a pas systematique des cas chez les pa- ete demontree, particulierement au tients asymptomatiques. cours de l' evaluation initiale de la de'2. L'histoire detailke (induant les ren- mence. La Conference a de plus seignements provenant d'une tierce reconnu le besoin de recourir a des partie) et l'examen physique de- consultations dans certains cas specivraient apporter une attention fiques. speciale aux facultes intellectuelles, a Ces deliberations viennent renforla memoire, a l'affect, au jugement, cer le role majeur du medecin de faa la personnalite, a l'orientation et mille dans l'identification et l'evaluaaux activites de la vie quotidienne. tion de patients atteints de demence, 3. Le "mini-examen de l'etat mental ainsi dans le que et le management de Folstein" constitue un excellent soutien des patients et de familleurs outil de travail. 4. Il faut distinguer la demence du les. La Conference de consensus a donc mis les medecins de famille sur delire. la sellette. Elle a egalement permis 5. La recherche des causes reversibles d'identifier de nombreux defis qui ou des facteurs d'exacerbation doit continuent de barrer la route. Parmi se concentrer sur une liste limitee ceux-ci, notons le besoin de strategies de facteurs contributoires. Parmi au bureau qui soient ceux-ci, notons un choix selectif des d'evaluation
plus efficaces et plus efficientes et le developpement d'instruments d'evaluation peu couiteux et pratiques. La Conference canadienne de consensus sur l'evaluation de la demence a aussi insistie sur le diagnostic et l'evaluation des nouvelles formes de demence, mais elle a egalement reconnu qu'on ne devrait pas se laisser distraire du defi majeur qui persiste dans le domaine de la prise en charge et du soutien des families et des patients atteints de demence irrieversible. Malgre l'absence de solutions definitives a ces problemes, les recommandations de la Conference de consensus indiquent aux medecins de famille la direction a suivre dans l'evaluation des patients atteints de U demence. Les demandes de tire-A-part peuvent etre adressees au: Dr J. W Feightner, Unwerstie McMaster, Departement de mrdecinefamiliale, 1200 Main St W, Hamilton, On L8N 3Z5
References 1. Robertson D, Rockwood K, Stoles P. The prevalence of cognitive impairment in a Canadian population. Acta Psychiatr Scand 1989;80:303-9. 2. Jorm AF, Korten AE, Henderson AS. The prevalence of dementia: a quantitative integration of the literature. Acta Psychiatr Scand 1987;76:465-79. 3. Evans DA, Funkenstein HH, Albert MS, Scherr PA, Cook NR, Chown MJ, et al. Prevalence of Alzheimer's disease in a community population of older persons.
JAMA 1989;262:2551-6. 4. Consensus Conference. Differential diagnosis of dementing diseases. JAMA 1987;
258:2411-6. 5. College royal des medecins, Comite de geriatrie. Organic mental impairment in the elderly: implications for research, education and the provision of services. J R Coll Physicians Lond 198 1; 1 5:141-67. 6. Comite organisateur, Conference canadienne de consensus sur l'evaluation de la demence. Evaluation de la demence: le consensus canadien. Comite organisateur, Conference canadienne de consensus sur l'evaluation de la demence (editorial). JAssoc Mid Can 199 1; 144:851-3. 7. Clarfield M. Conference canadienne de consensus sur l'evaluation de la demence. 5-6 octobre 1989. J Assoc Med Can 1991; 144(suppl 7).
Le M&decin defamille canadien VOL 38: juin 1992 1323
