Pam Harrison

October 11, 2016

WASHINGTON, DC — A resident-run initiative in a geriatric clinic clearly shows that when screening for cognitive impairment becomes a priority, to screen all patients opens the door toward timely intervention and optimized outcomes in this high-risk population.

"When we first started out on this project, we were all kind of sceptical," Youngchan Park, MD, resident, Medical College of Wisconsin, in Milwaukee, place told Medscape Medical News.

"But it's not rocket science. We came together to plan the project and decided this is what we wanted to do," he added.

"And it was fascinating to see that just the thought of knowing we were going to do this as a team helped, and we could also see that screening was making a difference to our patients as we went along."

The study was presented here at the Institute of Psychiatric Services (IPS): The Mental Health Services 2016 Conference.

Resident-Led Initiative

The quality improvement project was launched by residents who run the geropsychiatry clinic at the Milwaukee VA Medical Center in Wisconsin.

The goal of the project was to implement a standardized process that would increase the number of geriatric patients who underwent baseline cognitive screening.

"We proceeded through a cycle of the plan-do-study-act process to enhance the feasibility of this project, removing as many barriers as possible [to routine screening] in order to establish a sustainable process that would facilitate ongoing annual cognitive screening for these patients," the investigators note.

Obstacles that reduced the likelihood that patients would be assessed were first identified, and strategies were put into place to mitigate them, they added.

Screening was then performed by residents on all patients, and a sample of patient charts was reviewed at randomly selected times to determine whether patients had been subjected to any form of neuropsychological testing in the previous 12 months.

"Prior to any intervention, 34 out of 68 patients, or 50%, were found to have received cognitive screening in some form within the previous 12 months," Dr Park reported.

After each phase of the cycle, screening rates increased to 26 of 35 (74%) of the patients. At the end of the action plan, 50 of 60 (83%) of the cohort had been screened.

Put another way, the number of patients who did not undergo any baseline screening decreased from 28 of 68 (41%) of patients prior to initiating the project to only 10 of 60 patients (17%) overall once residents had completed the streamlined process.

"We were looking for ways to practice audit improvement in our work, because audit improvement saves money, leads to better quality of care, and is something that can be generalized to the public," Dr Park explained.

"And we showed that routine screening helped identify patients with mild cognitive impairment and other neurocognitive disorders [in a geropsychiatric clinic], and this allowed for better coordination of care," he said.

"So we think annual cognitive screening can be feasible by taking steps to streamline the process."

Underrecognized

Commenting on the findings for Medscape Medical News, Zaldy Tan, MD, MPH, medical director, Alzheimer's and Dementia Care Program, University of California, Los Angeles, noted that dementia, cognitive impairment, and especially Alzheimer's disease are underdiagnosed and underrecognized in the primary care setting in the United States.

Although the US Preventive Services Task Force does not recommend routine screening for dementia in primary care practice, it is appropriate to screen patients such as those screened in the current study, who were being treated in a geriatric clinic, Dr Tan added.

One the other hand, "there is a difference between screening and case identification," Dr Tan noted, "so it's a great idea for physicians to ask whether a patient is having any memory issues or cognitive issues and then be vigilant about any patient that may be having difficulties," he said.

Dr Tan also emphasized that physicians need to identify people with cognitive impairment because, although there is still no cure for dementia, "there are a lot of interventions that can impact patient's lives, starting off with FDA-approved medications for dementia, more caregiver education and support groups, and we can enroll patients into clinical trials if available as well," he said.

Physicians also need to identify patients with cognitive impairment in their practice because they are usually required to report patients with cognitive impairment so that authorities can take away those patients' driving privileges.

Dr Park and Dr Tan report no relevant financial relationships.

Institute of Psychiatric Services (IPS): The Mental Health Services 2016 Conference. Abstract 21. Presented October 6, 2016.

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