Cognitive Assessment of Elderly Primary Care Patients

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DESCRIPTION (provided by applicant): Significant numbers of older individuals experience cognitive decline with aging. The causes of cognitive dysfunction range from the devastating effects of Alzheimer's disease (AD) to normal mild forgetfulness described by most older individuals. However, the vast majority of cognitive dysfunction in older persons is related to potentially treatable disorders e.g. thyroid disease, renal disease or depression. Most older Americans receive their health care solely within the general practice setting and even mild cognitive dysfunction can impact adherence with medical interventions and impair decision-making. However, most primary care physicians (PCP) do not screen for cognitive difficulties and most older patients do not report cognitive problems. Identification of cognitive impairment at an office visit would permit earlier referral for diagnostic work-up and earlier and more appropriate treatment. To date, no studies have examined the effectiveness of providing cognitive screening in the primary care setting. We propose to screen 1000 patients age 65+ within four participating community practices for the presence of cognitive dysfunction using standardized neuropsychological tools. The four physician practices will be randomly assigned to either a "treatment as usual" (TAU) or "Cognitive Report" (CR) group. For the patients in the CR group the cognitive results will be provided to their PCP together with supporting educational activities. We will follow both groups over two years to assess outcomes of interest (e.g. change in cognition, service utilization, medications and medication adherence, PCP office and ER visits, hospitalizations, specialist referrals, mortality etc). We hypothesize that if the PCP is aware of cognitive difficulties he/she will modify patient interactions and treatment plans to accommodate the patient's level of functioning resulting in improved clinical practice and clinical outcomes. Finally, we plan to investigate a brief computerized test of cognition. Such a test could be routinely administered in PCP offices, making cognitive data readily available in the primary care setting. The results of this study will have both immediate and long-term practical and public health significance. First, this study will immediately provide PCP's with the knowledge and ability to identify, and therefore treat, patients with (1) early AD, slowing the progression of cognitive decline from the earliest point; (2) potentially reversible causes of cognitive decline thus reducing the added burden of cognitive deficits; and (3) mild cognitive dysfunction which may affect ability to follow medication regimens or treatment plans. Second, this study will help prepare PCP's to identify and manage older patients with cognitive decline as improved treatments for AD and other cognitive disorders become available over the next three-five years.