Dementia Screening at Stonehaven Medical Group Dr. Claire Johnston, Stonehaven Medical Group 2014

Part 1 - Audit IntroductionThe author recognised that dementia prevalence was lower than expected at Stonehaven Medical Group (SMG). It was therefore decided to analyse dementia screening within the practice. An audit was undertaken to determine if screening was being undertaken by GPs in “high risk” patients.

MethodA search was made on vision for patients aged 75 and over with a new diagnosis of depression made within the last 5 years. These patients would be considered “high risk” for having / developing dementia and should ideally have a formal cognitive assessment.  The total number of patients identified was 56. Five patients were excluded as they already had a dementia diagnosis. A further 4 patients were excluded who were under old age psychiatry. Therefore 47 sets of medical records were identified and examined by the author. Results and Discussion83% (n= 39) of patients who were diagnosed with depression had no formal cognitive assessment at diagnosis. The majority of these patients were diagnosed with depression for the first time or a recurrence of depression with a long period since last illness. 17% (n=8) of patients who were diagnosed with depression did have screening. Of the 83% of patients that did NOT have any screening, 9% (n=4) were given a diagnosis of dementia some time after they were diagnosed with depression, one case was only 6 months later, one a year later, one 2 years later and one 3 years later.

Of the 8 patients who were formally assessed for cognition, 50% (4 patients) were diagnosed with dementia around the same time, one patient with Lewy Body Dementia. The other 4 patients had no cognitive impairment identified. The screening tests used were MoCA, MMSE and AMT. Five of these patients were seen by old age psychiatry who screened them for dementia. Only 3 patients had dementia screening performed by the GP.

Of the patients that did not have any cognitive assessment at depression diagnosis and who had not been subsequently diagnosed with dementia (ie n=35), 74% (n=26) were identified by the author as “high risk” for dementia due to multiple risk factors including new diagnosis of depression, vascular co-morbidities, reduced drug compliance etc. These patients had a flag put on their notes requesting GPs consider dementia screening at a future appointment.

Part 2 – GP Questionnaire

A questionnaire was prepared by the author to explore opinions of GPs working within SMG on screening for dementia and their preferred screening tools. 12 GPs were surveyed and responses were obtained from all GPs which included 8 partners, 2 long term locums, 1 salaried GP, and 1 GP retainer. The survey questions were: 1. How often would you consider screening elderly (age >75 years) patients for dementia with known risk factors for the disease (eg depression, cardiovascular co-morbidities, FHx etc)?2. Do you feel comfortable assessing patients for possible dementia?3. If you are assessing for dementia which of the following would you most commonly use; history, history plus informant history, screening tool, history plus screening tool, history plus informant history plus screening tool?4. Which screening tool would you use; AMT, MMSE, GPCOG, MoCA, 6CIT, Other?5. Which of the following would you be happy to adopt as "routine

practice"; MMSE, GPCOG, 6CIT?

Survey responses:

DiscussionInterestingly, although GPs stated they would consider screening

high risk patients, the reality is that very few patients with obvious risk factors are being screened. In addition, the perceived tool of choice is the MMSE, however, it was observed that this tool was seldom used. A copy of alternative screening tools was provided in the questionnaire and opinions sought. The tool of choice, however was still MMSE, although GPs were, in the main, willing to consider other tools.

Conclusions It was observed during the project on Dementia Screening that

some “high risk” patients were not being considered for formal cognitive testing. This may be due to lack of awareness, limited skills and confidence of GPs and pressures of time in the GP consultation. It is hoped that after some education sessions and dissemination of knowledge gained by the author that GPs will have an increased awareness of the benefits of dementia screening and of early diagnosis, and feel more confident in undertaking cognitive assessment. The questionnaire identified that the MMSE was the tool of choice for the majority of GPs, however, most GPs were willing to consider an alternative tool. It is proposed by the author that the 6CIT screening tool be adopted by SMG to increase the likelihood of GPs screening for dementia within a routine consultation. It is also hoped that the 26 patients identified in the above project will be screened for dementia in the near future due to flags on their medical records.