Primary and Secondary Care Consultations in Elderly

Original Research Article Dement Geriatr Cogn Disord 2008;26:407–415 DOI: 10.1159/000164692

Accepted: August 5, 2008 Published online: October 22, 2008

Primary and Secondary Care Consultations in Elderly Demented Individuals in France Results from the Three-City Study

Catherine Helmer a, b Karine Pérès a, b Antoine Pariente b, c, d Florence Pasquier e Sophie Auriacombe a, b, d Michel Poncet f Florence Portet g Olivier Rouaud i Karen Ritchie h Christophe Tzourio j, k Jean-François Dartigues a, b, d 3C study group a INSERM,

U897, b Université Victor-Segalen Bordeaux-2, c INSERM, U657, and d CHU de Bordeaux, Bordeaux, of Neurology, EA 2691, CHU de Lille, Lille, f CHU de Marseille, Marseille, g CHU de Montpellier and h INSERM, U888, Montpellier, i Department of Neurology, CMRR, CHU de Dijon, Dijon, and j INSERM, U708, and k Université Paris-6, Paris, France e Department

Abstract Background/Aims: Our purpose was to analyze consultations with primary- and secondary-care physicians by demented people and identify factors that hamper or facilitate consultation. Methods: In total, 498 demented subjects were evaluated within the Three-City Study, a populationbased cohort of individuals aged 665 years. Primary- and secondary-care consultations (consultation with a specialist and/or treatment with anti-dementia drugs) were assessed by a neurologist or geriatrician. Results: Thirty-five percent of the demented subjects did not seek advice for their cognitive problems and only 31% consulted a specialist. Consultation for primary care was principally dependent on the subjects’ own awareness of the cognitive disorder and on their

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age. Factors associated with consultation for secondary care were younger age, higher education level, higher instrumental activities of daily living disability and awareness of the cognitive disorder by the subject, all of which predicted more frequent consultation. The level of cognitive performance had only a slight influence on primary care and none on secondary care. Conclusion: The failure to see a physician due to dementia, especially secondary-care practitioners, is frequent in the community, particularly in the oldest subjects. Copyright © 2008 S. Karger AG, Basel

Introduction

Dementia is a common condition in elderly people (65 years of age or more) with an estimated prevalence of approximately 6–8% [1–4]. A recent consensus on the frequency of dementia has established that about 20 million Catherine Helmer INSERM, U897, Université Victor-Segalen Bordeaux-2, 146 rue Léo Saignat FR–33076 Bordeaux Cedex (France) Tel. +33 5 5757 1596, Fax +33 5 5757 1486 E-Mail Catherine.Helmer@isped.u-bordeaux2.fr

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Key Words Dementia, diagnosis ⴢ Recourse to consultation ⴢ Population-based study

Materials and Methods Study Population This study was part of the Three-City (3C) Study, a collaborative research program based on a longitudinal cohort of 9,294 subjects aged 665 years. Its main objective is to estimate the risk of dementia and cognitive impairment attributable to vascular factors and to define target groups for future preventive strategies [21]. The participants were recruited between March 1999 and March 2001 in 3 French cities: Bordeaux (2,104 participants), Dijon (4,931) and Montpellier (2,259). Details of the 3C Study have been reported elsewhere [21]. To be eligible, people had to: (1) be 665 years; (2) live in 1 of the 3 cities and be registered on the electoral rolls, and (3) not be institutionalized. The study protocol was

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Dement Geriatr Cogn Disord 2008;26:407–415

approved by the ethics committee of the Kremlin-Bicêtre University Hospital. The present paper included the 498 prevalent and incident demented cases diagnosed within the 3C Study. Data were collected at 3 time points using a standardized questionnaire administered by a psychologist during a face-to-face interview. The interviews were conducted at baseline, and 2 and 4 years later. General data included demographic characteristics, educational attainment, occupational history, daily life habits and functional evaluation. The medical history of vascular diseases and vascular risk factors was also assessed. The examination included an inventory of all drugs regularly used during the preceding month. Cognitive function assessment comprised a global mental status evaluation (Mini-Mental State Examination, MMSE) [22], the Benton test of visual memory [23] and the Isaacs test of verbal fluency [24]. Various other tests were also administered according to the site of the study. Cognitive complaints of the subjects were assessed during this interview and thereafter by the neurologist or geriatrician. Diagnosis of Dementia Dementia was diagnosed at baseline and at each follow-up visit. In the Dijon center, a 2-stage screening procedure was used because of a larger sample size. At the end of the interview with the psychologist, the participants were screened for possible dementia. The screening was based on the MMSE and Isaacs’ Set Test. Cutoffs according to education level were defined with reference to the results of a previous study in Bordeaux [25]. Those with suspected dementia were examined by a neurologist or geriatrician, in the presence of an informant for nearly half of the interviews (47%). In the Bordeaux and Montpellier centers, all participants were seen by a neurologist or geriatrician at baseline. At the 2- and 4-year follow-ups, a 2-stage screening procedure was also used in Bordeaux. The same clinical protocol was applied for dementia diagnosis and classification in each center. For each subject with suspected dementia, the neurologist or geriatrician who examined the participant documented the evolution and severity of the cognitive disorders and any consultation for care. After this examination, the final diagnosis of dementia was made by a panel of 5 highly qualified neurologists, independent of the 3C Study investigators, who reviewed all accessible information. Neuroimaging was not available for all the subjects, so the diagnosis was based on clinical evaluation. The diagnosis of dementia was established on the basis of DSM-IV criteria [26]. Alzheimer’s disease was diagnosed according to the NINCDS-ADRDA criteria [27]. Indicators of Consultation with Primary and Secondary Level of Care Recourse to care was assessed by both self-reported information given by the subject and/or the informant (most often the spouse) and by the inventory of all medications. The data were collected during a face-to-face interview conducted by the neurologist or geriatrician. The subjects were considered as having asked for primary care if they declared that they had consulted their family practitioner for their cognitive problems. They were regarded as having inquired about secondary care if they either declared consulting a specialist for their cognitive impairment or were treated with antidementia drugs. In France, the initial prescription of cholinesterase inhibitors (ChEIs) and memantine is restricted to specialists.

Helmer et al.


people suffer from it worldwide [5]. Although early identification of dementia can lead to the recognition of its treatable causes, maximizes the efficacy of drug treatment, leads to better management of comorbidities and also reduces some of the adverse consequences of the disease, such as accidents, dementia remains underdiagnosed in the population [6–18], in particular at the mild or moderate stage [16]. The reasons for poor case recognition rates include the fear that the diagnosis will engender negative consequences (social exclusion, abandonment by caregivers, depression) combined with limited proof of improvement of prognosis for patients systematically screened for dementia [19, 20]. As in many countries, 3 levels of care are available for the management of dementia in France. Primary care (general practice) constitutes the first step. Specialists (neurologists, psychiatrists or geriatricians) or the memory clinic comprise the second level. In France as in many other countries, secondary-level treatment is necessary for the prescription of anti-dementia medication. A supplementary level is access to specialist memory clinics (‘Centres Mémoire de Ressources et de Recherches’) located within university hospitals. This level is necessary for complex cases or when sophisticated neuroimaging procedures are required. Better understanding of the current functioning of these levels of care and their interaction would assist in the development of new strategies for optimizing care access and early diagnosis. This paper sought to analyze recourse to primary- and secondary-care physicians (including those located within university hospitals) by demented people and identify factors that hamper or facilitate consultation. Individuals with dementia were identified in a French populationbased cohort study of people 665 years of age who received systematic screening and diagnosis of all prevalent and incident cases, regardless of their previous diagnosis.

Results

come and way of life also differed between the prevalent and incident cases and the former tended to perceive their cognitive disorder more frequently. Recourse to Care Recourse to care was similar at the 3 visits. About one third of the demented subjects had not previously discussed their cognitive problems with their family practitioner (table 2). Among the two thirds who did, only half (a third of the demented subjects) had consulted a secondary-care physician (i.e. a specialist; fig. 1). Even among those seeing a specialist, only 50% were taking ChEI or memantine, leading to a 15.9% prevalence of treatment in this demented population. However, 65% of the subjects with Alzheimer’s disease who had consulted a specialist had received IChE or memantine. Whatever the level of care, no change in recourse to care was noted between baseline and the 4-year follow-up. Consultation with primary care did not vary by age (p = 0.19), whereas the number of subjects who had consulted a specialist declined with age (p ! 0.001; table 3). This proportion was about 46% between 65 and 74 years and fell to 20% after 85 years. The use of ChEI or memantine therapy also varied by age (p = 0.008). Before 80 years of age, about 20% of the subjects were treated with ChEI or memantine, whereas this proportion fell to 9% after 85 years of age (table 3). According to the severity of dementia evaluated by the MMSE score, recourse to care did not differ either for primary care (p = 0.28), secondary care (p = 0.86) or treatment (p = 0.76; table 3). For primary care, the mean MMSE score was 21.4 for nonconsulting subjects compared to 22.0 for consulting ones (p = 0.08). The mean MMSE scores for secondary care were 21.9 and 21.8, respectively (p = 0.83).

Population At baseline, the 3C cohort included 9,294 participants; 5,644 were women (60.7%). The mean age was 74.3 years (SD = 5.6). A total of 215 subjects were classified as demented at baseline (2.3%). Over the follow-up, 146 incident cases of dementia were detected at the 2-year followup and 137 at the 4-year follow-up; thus the incidence of dementia was 1.02 for 100 person-years. The principal characteristics of the 498 demented subjects are described in table 1. Their mean age was 80.4 years at the diagnostic visit and 57.6% were women. The mean MMSE score at the diagnostic visit was 21.8. Two thirds of the dementia cases were classified as possible or probable Alzheimer’s disease. Compared to the prevalent cases, the incident ones were older and had a higher MMSE score. The in-

Factors Associated with Recourse to Care Regarding primary care, only awareness cognitive disorder and MMSE were significantly associated with consultation in univariate analysis at a 0.05 level. Additionally, 3 other variables were introduced into the multivariate analysis: age, educational level and IADL disability. After adjustment, awareness of cognitive disorder still significantly increased recourse to primary care, with an odds ratio (OR) of 4 (table 4). Age became significantly associated with recourse, with a decreased frequency of consultation in older subjects. In addition, a higher educational level and having at least 3 IADL disabilities tended to be related to greater recourse to primary care. On the contrary, a lower MMSE score tended to be associated with a decreased frequency of consultation. However, for

Recourse to Care in Elderly Demented


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Statistical Analyses Student’s t test (for quantitative variables) and the ␹2 test (for qualitative analysis) were used to compare sociodemographic characteristics between prevalent and incident demented subjects. The proportions of demented participants with primaryand secondary-care consultations were evaluated by age category and disease severity using the Cochran-Armitage trend test. Factors associated with consultation for primary and secondary care were analyzed applying logistic regression models. The following factors were examined: age at diagnosis, sex, education at 5 levels (from no education up to university level), level of income in 5 stages and living conditions (living alone, with the spouse or with other people). Depressive symptomatology was measured using the Center for Epidemiological Study Depression Scale. As previously validated, the subjects scoring 116 for men and 122 for women were considered to have significant levels of depressive symptomatology [28]. Those reporting cognitive complaints during the interview with the neurologist or geriatrician were defined as being aware of their cognitive disorder. Disability for 5 instrumental activities of daily living (IADL) common to both sexes was assessed: telephone use, shopping, use of transportation, responsibility for medication intake and budget management. The number of activities for which a subject needed help was also taken into account [29]. Cognitive performances for the MMSE, in which the scores range from 0 to 30 with higher scores indicating better cognitive functioning, were also considered. The scores were split into tertiles: ^20, 21–23 and 624. In addition, because missing data for psychometric tests are often associated with poorer cognitive performances, a dummy variable for missing data was added. Finally, the etiology of dementia (Alzheimer possible or probable versus other etiologies) was considered. In the first step, logistic regression models adjusted for age were performed separately for each factor. In the second step, in addition to age, all significant variables at a 0.20 level were added to the model. To take into account differences related to area, the models were controlled for the 3 centers of the study.

Consultation with secondary care (with treatment) Consultation with secondary care (without treatment) Consultation with primary care only

No consultation with care

Fig. 1. Proportion of demented subjects

0

5

10

15

20

25

30

35

40

Patients (%)

consulting primary- and secondary-care physicians.

Table 1. Principal characteristics of prevalent and incident demented subjects

410


Incident (n = 283)

Total (n = 498)

p value

79.686.1 55.4

81.085.8 59.4

80.486.0 57.6

0.008 0.369 0.077

25.2 26.7 22.4 11.4 14.3

17.4 22.7 24.5 17.0 18.4

20.7 24.4 23.6 14.6 16.7

16.7 24.2 21.4 16.3 21.4

11.0 34.3 21.9 23.3 9.5

13.5 29.9 21.7 20.3 14.7

34.0 58.1 7.9 19.9 74.8

39.6 47.0 13.4 25.7 82.1

37.2 51.8 11.0 23.2 78.9

38.4 18.5 16.1 27.0 21.084.0

44.2 19.0 13.9 23.0 22.483.2

41.7 18.8 14.8 24.7 21.883.6

27.9 27.4 39.1 5.6 64.7

36.0 36.4 24.7 2.8 65.0

32.5 32.5 30.9 4.0 64.9