Dr Tracey McDonald AM PhD FACN, Professor of Ageing, 2012
Many of you have tolerated me lamenting the struggle associated with getting an accurate medical diagnosis for people who are mentally confused. The poor assessment and diagnostic skills of many medical practitioners in hospitals in relation to mental confusion means delays in being able to treat conditions that are reversible and to moderate those that might be confounded by other temporary issues such as urinary tract infection. A meta-analysis has just been released that confirms what I have been talking about and provides detail of poor medical diagnosis of older people with dementia (Mitchell et al 2011). The consequences of this skill deficit are that almost one in four people admitted to dementia units may be there because of medical diagnostic errors rather than their need for specific dementia care, protection and treatment.
The implications for nurses are that we are the last line of advocacy for people admitted to dementia units. Our assessment skills and professional integrity as clinicians demand that we ensure we are satisfied that those who should be receiving a different type of care have access to it - and if not, to do something about the situation for the person’s sake.
The 2011 meta-analysis looked at the ability of general practitioners (GPs) to recognize a spectrum of cognitive impairment from mild cognitive impairment to severe dementia in routine practice using their own clinical judgment. The authors found 15 studies reporting on dementia, seven studies that examined recognition of broadly defined cognitive impairment, and eight regarding mild cognitive impairment.
Using clinical judgment, medical practitioners were able to identify 73.4% of people with dementia and 75.5% of those without dementia, but they only made correct annotations in medical records in 37.9% of cases (and 90.5% of non-cases). For cognitive impairment, detection sensitivity was 62.8% using their own clinician judgment but 33.1% according to medical records that they had written. Using their clinical judgement, specificity was 92.6% for patients without cognitive impairment.
GPs recognised only 44.7% of people with mild cognitive impairment. This diagnosis was recorded in medical notes only 10.9% of the time. Their ability to identify healthy individuals without mild cognitive impairment was between 87.3% and 95.5% (detection specificity).
The authors concluded that GPs have considerable difficulty identifying those with mild cognitive impairment and those with mild dementia and are generally poor at recording such diagnoses in medical records. This may be why so many rely on the narrative of families rather than seeking scientific evidence of impairment.
The implications for nurses working in dementia units is that it is possible that some of the people in your care may have reversible mental confusion, for example because of reactions to medication, urinary tract infection, dehydration, depression, and many others. It is up to us advocate for patients if we believe they are not getting the care and attention they need, and to make sure that the situation does not continue unchecked.
Mitchell AJ, Meader N, Pentzek M. Clinical recognition of dementia and cognitive impairment in primary care: a meta-analysis of physician accuracy. Acta Psychiatr Scand. 2011 Jun 11. doi: 10.1111/j.1600-0447.2011.01730.x. [Epub ahead of print]