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CME

Dementia Evaluation

General Information

Description

  • Dementia, or major neurocognitive disorder, is a progressive disorder with cognitive decline from a prior level of functioning in one or more cognitive domains which interferes with independence in everyday activities including occupational, domestic, or social functioning. 1,2

Also called

Definitions

  • neurocognitive disorder - decline from a previously attained level of cognitive functioning
    • major neurocognitive disorder
      • significant cognitive decline from a previous level of performance in ≥ 1 cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) that interferes with independence in everyday activities
      • includes dementia (see Diagnosis for precise diagnostic criteria)
    • mild neurocognitive disorder
      • modest cognitive decline from a previous level of performance in ≥ 1 cognitive domains that does not interfere with independence in everyday activities
      • includes mild cognitive impairment (see Mild Cognitive Impairment (MCI) for details)
    • delirium - disturbance in attention and awareness that develops within hours-to-days and is accompanied by an additional disturbance in cognition (see Delirium in Hospitalized Patients for details)
    • Reference - Nat Rev Neurol 2014 Nov;10(11):634
  • rapidly progressive dementia - dementia where the time from first symptoms to dementia is less than two years (see Rapidly Progressive Dementia - Approach to the Patient for additional information)
  • early-onset dementia - dementia in patient < 65 years old (Can J Neurol Sci 2012 Nov;39(6 Suppl 5):S1)

Considerations for discussing dementia diagnosis

  • consider using a professional care manager to ensure that plans are appropriate, coordinated, and relayed to a patient's caregivers1
  • provide patient and/or caregivers with oral and written information describing1,4
    • characteristics of dementia type and expected changes as disease progresses; this may help
      • identify potentially dangerous situations and safety risks
      • help prepare everyone for increased supervision
    • healthcare and social care teams involved in management and how to contact them
    • how dementia affects driving and what they need to tell insurance and governmental agencies
    • their legal rights and responsibilities, including any reasonable work-related adjustments
    • whom to contact in order to get more information
    • potential research studies they can participate in
  • encourage patient to communicate their own views and opinions regarding their care4
  • consider using a structured tool to assess patient's likes, dislikes, routines, and personal history4
  • ensure patient and family/carers have access to memory service or similar multidisciplinary dementia service4
  • ask patient (and document discussion) about healthcare services sharing information including4
    • consent for healthcare services to share information
    • whom the services can share information with (such as family members or carers)
    • what information can be shared
  • at follow-up visits, continually assess for emerging dementia-related needs and ask about need for additional support4
  • if patient declines follow-up visits, ask if they would like to be contacted at a specific future date4
  • discuss advanced care planning including4
    • benefits of planning ahead
    • lasting power of attorney (for health and welfare decisions and property and financial affairs decisions)
    • an advance statement about their wishes, preferences, beliefs, and values regarding their future care
    • advance decisions to refuse treatment
    • their preferences for place of care and place of death
    • explaining that decisions can be changed later
    • see Advance Care Planning and Directives for additional information

References

General references used

  1. Moga DC, Roberts M, Jicha G. Dementia for the Primary Care Provider. Prim Care. 2017 Sep;44(3):439-456
  2. Gale SA, Acar D, Daffner KR. Dementia. Am J Med. 2018 Oct;131(10):1161-1169
  3. Sorbi S, Hort J, Erkinjuntti T, et al; EFNS Scientist Panel on Dementia and Cognitive Neurology. EFNS-ENS Guidelines on the diagnosis and management of disorders associated with dementia. Eur J Neurol. 2012 Sep;19(9):1159-79
  4. National Institute for Health and Clinical Excellence (NICE). Dementia: assessment, management and support for people living with dementia and their carers. NICE 2018 Jun: NG97

Recommendation grading systems used

  • European Federation of Neurological Science (EFNS) evidence classification scheme for diagnostic measure
    • rating of recommendations
      • Level A - useful/predictive or not useful/predictive, based on ≥ 1 convincing class I study or ≥ 2 consistent, convincing class II studies
      • Level B - probably useful/predictive or not useful/predictive, based on ≥ 1 convincing class II study or overwhelming class III evidence
      • Level C - possibly useful/predictive or not useful/predictive, based on ≥ 2 convincing class III studies
    • classification of evidence
      • Class I - prospective study in broad spectrum of persons with suspected condition, using "gold standard" for case definition, test applied in blinded evaluation, and enabling assessment of appropriate tests of diagnostic accuracy
      • Class II - prospective study in narrow spectrum of persons with suspected condition, or well-designed retrospective study in broad spectrum of persons with established diagnosis compared to broad spectrum of controls, with test applied in blinded evaluation, and enabling assessment of appropriate tests of diagnostic accuracy
      • Class III - retrospective study with persons with established condition or controls of narrow spectrum, and test applied in blinded evaluation
      • Class IV - any nonblinded study design, expert opinion, or case series without controls
  • American Academy of Neurology (AAN) levels of diagnostic recommendations
    • levels of recommendations
      • Level A - established as effective, ineffective, or harmful (or established as useful/predictive or not useful/predictive) for given condition in specified population (requires at least two consistent Class I studies)
      • Level B - probably effective, ineffective, or harmful (or probably useful/predictive or not useful/predictive) for given condition in specified population (requires at least one Class I study or two consistent Class II studies)
      • Level C - possibly effective, ineffective, or harmful (or possibly useful/predictive or not useful/predictive) for given condition in specified population (requires at least one Class II study or two consistent Class III studies)
      • Level U - data inadequate or conflicting; given current knowledge, treatment (test, predictor) is unproven
    • classification of evidence for studies of diagnostic accuracy
      • Class I study
        • cohort study with prospective data collection of a broad spectrum of persons with suspected condition, using acceptable reference standard for case definition
        • diagnostic test is objective or performed and interpreted without knowledge of patient’s clinical status
        • study results allow calculation of measures of diagnostic accuracy
      • Class II study
        • case-control study of broad spectrum of persons with condition established by acceptable reference standard compared to broad spectrum of controls or cohort study where broad spectrum of persons with suspected condition where data was collected retrospectively
        • diagnostic test is objective or performed and interpreted without knowledge of disease status
        • study results allow calculation of measures of diagnostic accuracy
      • Class III study
        • case-control study or cohort study where either persons with condition or controls are of narrow spectrum
        • condition is established by acceptable reference standard
        • reference standard and diagnostic test are objective or performed and interpreted by different observers
        • study results allow calculation of measures of diagnostic accuracy
      • Class IV study - studies not meeting Class I, II, or III criteria including consensus, expert opinion, or a case report

Synthesized Recommendation Grading System for DynaMed Content

  • The DynaMed Team systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based Methodology).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed content, we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed Team-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

  • DynaMed topics are created and maintained by the DynaMed Editorial Team and Process.
  • All editorial team members and reviewers have declared that they have no financial or other competing interests related to this topic, unless otherwise indicated.
  • DynaMed content includes Practice-Changing Updates, with support from our partners, McMaster University and F1000.

Special acknowledgements

On behalf of the American College of Physicians
  • Barbara Turner, MD, MSEd, MACP, ACP Deputy Editor, Clinical Decision Resource, as part of the ACP-EBSCO Health collaboration, managed the ACP peer review of the Overview and Recommendations section and related clinical content in this topic.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T115618, Dementia Evaluation; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T115618. Registration and login required.

Published by EBSCO Information Services. Copyright © 2020, EBSCO Information Services. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission.

EBSCO Information Services accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional.

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