Dementia is a syndrome of acquired persistent dysfunction in several domains of intellectual functioning, including memory, language, visuospatial ability, and cognition. Approximately 10% of adults above age 65 and 50% of adults above age 90 have dementia (1
). The annual health care–related costs and lost wages for US patients with dementia and their family caregivers is approximately $100 billion (2
). While the majority of dementing illnesses are progressive, 11% of patients with cognitive decline have reversible causes, and the course of the disease may be modified by early diagnosis and therapeutic interventions (1
). Given these factors as well as the social and psychosocial cost of dementing illnesses on patients and their families, early diagnosis and intervention are paramount.
The number of persons with dementia increases as the population ages. The number of persons aged 65 and older in 2030 is projected to be twice as large as in 2000, growing from 35 million to 72 million and representing nearly 20% of the total US population (6
). Given that the number of geriatricians is not increasing at a similar rate, family medicine and internal medicine physicians will be uniquely poised to be the first to identify cognitive changes indicative of dementia. Unfortunately, studies indicate that primary care physicians (PCPs) may not be identifying dementia in the majority of symptomatic patients. In 1995 Callahan et al found that PCPs recorded a diagnosis of dementia in only 23.5% of patients with demonstrated moderate to severe cognitive impairment (7
). Further, those PCPs who reported difficulty establishing a diagnosis of dementia had difficulty communicating the diagnosis to patients and family members (7
). These findings were echoed by Valcour et al, whose cross-sectional study of primary care (internal medicine) patients aged 65 and older found that 91% of cases of mild dementia were overlooked, and 65% of dementia cases were not documented in the outpatient medical record (9
Most likely, many factors—related to both the physician and the patient—contribute to the underdiagnosis of dementia. One possible factor is the lack of clear national guidelines for dementia screening. The 2003 US Preventive Services Task Force report does not recommend for or against routine screening for dementia in older adults (2
). The American Academy of Neurology and the Canadian Task Force of Preventive Healthcare concluded that there is insufficient evidence to recommend cognitive screening of asymptomatic individuals (10
). Despite the lack of evidence for routine screening, the US Preventive Services Task Force states that early recognition of cognitive impairment, in addition to helping make diagnostic and treatment decisions, allows clinicians to anticipate problems patients may have in understanding and adhering to recommended therapy.
Physicians' lack of comfort with dementia screening and diagnosis, due to inadequate training in the care of the elderly, plays a significant role in the delayed recognition of this disease. In a survey of 403 physicians in general practice, family medicine, and internal medicine, physicians scored 74%, or a “C,” on a test of knowledge about Alzheimer's disease (11
). Similarly, in a survey of PCPs, Cody and colleagues found that 54% had difficulty establishing a diagnosis of dementia, and 30% had difficulty communicating the dementia diagnosis to the patient and family (8
). The authors concluded that educational initiatives and behavioral changes targeting physicians and dementia assessment protocols would be beneficial for improving dementia care. In 2003, only 27 of the 91 Residency Review Committee–accredited specialties had specific geriatrics training. The average duration of training in geriatrics varied from 2 weeks to 6 weeks, with 62% of the programs having a structured 4-week geriatrics experience (12
Further, physicians' concerns about the futility of making a diagnosis of dementia due to a perceived lack of treatment options and the time required to effectively diagnose the disease and educate patients and their families play a significant role in underdiagnosis (10
Patient factors contributing to the underrecognition of dementia include the patient's and family members' lack of awareness of the disease process and cultural factors (16
). In many cultures, memory problems are assumed to be part of the aging process rather than a consequence of disease.
The purpose of this study was to survey PCPs in an effort to better understand the possible reasons for underdiagnosis of dementia. No studies to date have investigated the relationship between quantity of training in geriatrics and rates of screening and diagnosis among PCPs. Therefore, this study aimed to assess geriatric, family medicine, and internal medicine physicians' and residents' practice patterns in dementia evaluation and management in patients aged 65 and older to determine if such a relationship exists. A secondary purpose was to obtain physicians' opinions about establishing guidelines for dementia screening.