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What could be behind your elderly patient’s subjective memory complaints?
Depression, anxiety, and dementia, as well as older age, female gender, lower education level, and decreased physical activity, have all been associated with memory loss reported by patients or family members (strength of recommendation [SOR]: B, cross-sectional studies). Memory complaints in patients with no cognitive impairment on short cognitive screening tests, such as the mini-mental status exam, may predict dementia (SOR: B, longitudinal studies). No consistent evidence supports pharmacologic treatment of reported memory loss that is not corroborated by objective findings (SOR: B, nonrandomized, poor-quality studies).
Is depression or polypharmacy at work?
Rajasree Nair, MD
Baylor College of Medicine, Houston, Tex
As the population ages, primary care physicians encounter a significant number of patients with memory loss and dementia. In clinical practice, patients with subjective memory complaints but normal cognitive testing present a diagnostic dilemma. Close attention to comorbid psychiatric conditions such as depression, anxiety, and substance use disorders, as well as polypharmacy, is essential.
While the US Preventive Services Task Force indicates that there is insufficient evidence to screen, it notes that recognizing cognitive impairment early not only facilitates diagnostic and treatment decisions, but also allows clinicians to anticipate problems the patient may have in understanding and adhering to recommended therapy. Even though evidence of early or minimal dementia may be difficult to detect, identifying it promptly enables physicians to counsel patients and caregivers on the course of disease progression, warning signs, medication adherence, finances, and safety.
Evidence Summary
Several cross-sectional studies indicate that patients with subjective memory loss are more likely to be older, female, less physically active, in poorer health, less educated, and more depressed or anxious than unaffected patients.1-4 These studies concentrate mostly on elderly people living in the community.
A study of 1883 patients with normal baseline short-cognitive test results found that those with subjective memory complaints had a higher incidence of dementia.5 At 5-year follow-up, 15% of patients with baseline subjective memory complaints had developed dementia compared to only 6% of those without such complaints (odds ratio=2.7; 95% confidence interval [CI], 1.45-4.98).
A prospective cohort study that followed 158 patients with no evidence of dementia showed a significant correlation between informant-reported memory problems and development of dementia at 5 years.6 Forty-five percent of patients with informant-reported memory problems developed dementia after 5 years compared with 25% of patients who had only self-reported memory problems (P =.02). This result suggests that subjective memory problems reported by observers (family or caregivers) may be more predictive of dementia than self-reported memory complaints.
Donepezil, ginkgo biloba may not help these patients
Most trials of interventions to preserve memory have not enrolled patients with subjective memory complaints. However, data from trials that enrolled either asymptomatic elderly patients or patients with mild cognitive impairment don’t support the use of donepezil, ginkgo biloba, NSAIDs, COX-2 inhibitors, vitamin E, vitamin B6, vitamin B12, statins, hormone replacement therapy, or omega-3 fatty acids to delay progression to dementia.7-16
Could mental exercise help?
One systematic review of 22 longitudinal cohort studies, which included more than 29,000 patients, evaluated complex patterns of mental activity in early, mid-, and late-life in relation to the incidence of dementia. Dementia was diagnosed at a significantly lower rate in patients with a higher level of cognitive exercise, such as memory-based leisure activities and social interactions, than those with less rigorous daily cognitive challenges (relative risk=0.54; 95% CI, 0.49-0.59).17
This raises the possibility that mental exercise has neuroprotective effects. No randomized trials exist to support this hypothesis, however.
Recommendations
There is no consensus regarding the nomenclature applied to reported memory loss and mild cognitive impairment. The Clinical Manual of Geriatric Psychiatry provides definitions that can be used in the clinical setting (TABLE).18
The US Preventive Services Task Force concludes that evidence is insufficient to recommend for or against routine screening for dementia in older adults (I recommendation).19 However, the Task Force notes that clinicians should assess cognitive function whenever they suspect impairment or deterioration based on direct observation, patient report, or concerns raised by family members, friends, or care-takers.
The American Geriatrics Society20 and American Academy of Neurology (AAN)21 acknowledge the subtle difference between age-associated memory impairment and mild cognitive impairment, and the difficulty of differentiating normal changes of aging from abnormal changes. The AAN’s guidelines for early detection of dementia emphasize the importance of diagnosing mild cognitive impairment or dementia early. However, the guidelines specifically exclude patients with subjective memory loss unaccompanied by objective cognitive deficits and offer no further discussion about these patients.
TABLE
Features of age-associated memory impairment vs mild cognitive impairment
| FEATURE | AGE-ASSOCIATED MEMORY IMPAIRMENT | MILD COGNITIVE IMPAIRMENT |
|---|---|---|
| Clinical presentation |
|
|
| Memory test results |
|
|
| Clinical course |
|
|
| ADLs, activities of daily living; IADLs, instrumental activities of daily living; SD, standard deviation. | ||
| Source: Spar JE, La Rue A. Clinical Manual of Geriatric Psychiatry.18 | ||
1. St John P, Montgomery P. Is subjective memory loss correlated with MMSE scores or dementia? J Geriatr Psychiatry Neurol. 2003;16:80-83.
2. Lautenschlager NT, Flicker L, Vasikaran S, et al. Subjective memory complaints with and without objective memory impairment: relationship with risk factors for dementia. Am J Geriatr Psychiatry. 2005;13:731-734.
3. Jonker C, Geerlings MI, Schmand B. Are memory complaints predictive for dementia? A review of clinical and population-based studies. Int J Geriatr Psychiatry. 2000;15:983-991.
4. Mol ME, van Boxtel MP, Willems D, et al. Do subjective memory complaints predict cognitive dysfunction over time? A six-year follow-up of the Maastricht aging study. Int J Geriatr Psychiatry. 2006;21:432-441.
5. Wang L, van Belle G, Crane PK, et al. Subjective memory deterioration and future dementia in people aged 65 and older. J Am Geriatr Soc. 2004;52:2045-2051.
6. Carr DB, Gray S, Baty J, Morris JC. The value of informant versus individual’s complaints of memory impairment in early dementia. Neurology. 2000;55:1724-1726.
7. Birks J, Flicker L. Donepezil for mild cognitive impairment. Cochrane Database Syst Rev. 2006;(3):CD006104.-
8. Birks J, Grimley EV, Van Dongen M. Ginkgo biloba for cognitive impairment and demetia. Cochrane Database Syst Rev. 2007;(2):CD003120.-
9. Etminan M, Gill S, Samii A. Effect of nonsteroidal anti-inflammatory drugs on risk of Alzheimer’s disease: systematic review and meta-analysis of observational studies. Br Med J. 2003;327:128-131.
10. Aisen P, Schafer K, Grundman M. Effects of rofecoxib or naproxen vs placebo on Alzheimer disease progression: a randomized controlled trial. JAMA. 2003;289:2819-2826.
11. Isaac M, Quinn R, Tabet N. Vitamin E for Alzheimer’s disease and mild cognitive impairment. Cochrane Database Syst Rev. 2000;(4):CD002854.-
12. Malouf R, Grimley Evans J. Vitamin B6 for cognition. Cochrane Database Syst Rev. 2003;(4):CD004393.-
13. Malouf M, Grimley Evans J, Areosa SA. Folic acid with or without vitamin B12 for cognition and dementia. Cochrane Database Syst Rev. 2003;(4):004514.-
14. Scott HD, Laake K. Statins for the prevention of Alzheimer’s disease. Cochrane Database Syst Rev. 2001;(3):003160.-
15. US Preventive Services Task Force. Postmenopausal hormone replacement therapy for the primary prevention of chronic conditions: recommendations and rationale. Am Fam Physician. 2003;67:358-364.
16. Lim WS, Gammack JK, Van Niekerk JK, et al. Omega 3 fatty acid for the prevention of dementia. Cochrane Database Syst Rev. 2006;(1):CD005379.-
17. Valenzuela MJ, Sachdev P. Brain reserve and dementia: a systematic review. Psychol Med. 2006;36:441-454.
18. Spar JE, La Rue A. Clinical Manual of Geriatric Psychiatry. Illustrated ed. Arlington, Va: American Psychiatric Publishing, Inc; 2006.
19. US Preventive Services Task Force. Screening for dementia: recommendation and rationale summary for patients. Ann Intern Med. 2003;138:925-926.
20. Durso SC, Gwyther L, Roos B, et al. Clinical Practice Guidelines. Abstracted from the American Academy of Neurology’s dementia guidelines for early detection, diagnosis and management of dementia. New York: American Geriatrics Society; 2006. Available at: www.americangeriatrics.org/products/positionpapers/aan_dementia.shtml. Accessed April 9, 2007.
21. Petersen RC, Stevens JC, Ganguli M, et al. Practice parameter: early detection of dementia: mild cognitive impairment (an evidence-based review). Report of the quality standards subcommittee of the American Academy of Neurology. Neurology. 2001;56:1133-1142.
Depression, anxiety, and dementia, as well as older age, female gender, lower education level, and decreased physical activity, have all been associated with memory loss reported by patients or family members (strength of recommendation [SOR]: B, cross-sectional studies). Memory complaints in patients with no cognitive impairment on short cognitive screening tests, such as the mini-mental status exam, may predict dementia (SOR: B, longitudinal studies). No consistent evidence supports pharmacologic treatment of reported memory loss that is not corroborated by objective findings (SOR: B, nonrandomized, poor-quality studies).
Is depression or polypharmacy at work?
Rajasree Nair, MD
Baylor College of Medicine, Houston, Tex
As the population ages, primary care physicians encounter a significant number of patients with memory loss and dementia. In clinical practice, patients with subjective memory complaints but normal cognitive testing present a diagnostic dilemma. Close attention to comorbid psychiatric conditions such as depression, anxiety, and substance use disorders, as well as polypharmacy, is essential.
While the US Preventive Services Task Force indicates that there is insufficient evidence to screen, it notes that recognizing cognitive impairment early not only facilitates diagnostic and treatment decisions, but also allows clinicians to anticipate problems the patient may have in understanding and adhering to recommended therapy. Even though evidence of early or minimal dementia may be difficult to detect, identifying it promptly enables physicians to counsel patients and caregivers on the course of disease progression, warning signs, medication adherence, finances, and safety.
Evidence Summary
Several cross-sectional studies indicate that patients with subjective memory loss are more likely to be older, female, less physically active, in poorer health, less educated, and more depressed or anxious than unaffected patients.1-4 These studies concentrate mostly on elderly people living in the community.
A study of 1883 patients with normal baseline short-cognitive test results found that those with subjective memory complaints had a higher incidence of dementia.5 At 5-year follow-up, 15% of patients with baseline subjective memory complaints had developed dementia compared to only 6% of those without such complaints (odds ratio=2.7; 95% confidence interval [CI], 1.45-4.98).
A prospective cohort study that followed 158 patients with no evidence of dementia showed a significant correlation between informant-reported memory problems and development of dementia at 5 years.6 Forty-five percent of patients with informant-reported memory problems developed dementia after 5 years compared with 25% of patients who had only self-reported memory problems (P =.02). This result suggests that subjective memory problems reported by observers (family or caregivers) may be more predictive of dementia than self-reported memory complaints.
Donepezil, ginkgo biloba may not help these patients
Most trials of interventions to preserve memory have not enrolled patients with subjective memory complaints. However, data from trials that enrolled either asymptomatic elderly patients or patients with mild cognitive impairment don’t support the use of donepezil, ginkgo biloba, NSAIDs, COX-2 inhibitors, vitamin E, vitamin B6, vitamin B12, statins, hormone replacement therapy, or omega-3 fatty acids to delay progression to dementia.7-16
Could mental exercise help?
One systematic review of 22 longitudinal cohort studies, which included more than 29,000 patients, evaluated complex patterns of mental activity in early, mid-, and late-life in relation to the incidence of dementia. Dementia was diagnosed at a significantly lower rate in patients with a higher level of cognitive exercise, such as memory-based leisure activities and social interactions, than those with less rigorous daily cognitive challenges (relative risk=0.54; 95% CI, 0.49-0.59).17
This raises the possibility that mental exercise has neuroprotective effects. No randomized trials exist to support this hypothesis, however.
Recommendations
There is no consensus regarding the nomenclature applied to reported memory loss and mild cognitive impairment. The Clinical Manual of Geriatric Psychiatry provides definitions that can be used in the clinical setting (TABLE).18
The US Preventive Services Task Force concludes that evidence is insufficient to recommend for or against routine screening for dementia in older adults (I recommendation).19 However, the Task Force notes that clinicians should assess cognitive function whenever they suspect impairment or deterioration based on direct observation, patient report, or concerns raised by family members, friends, or care-takers.
The American Geriatrics Society20 and American Academy of Neurology (AAN)21 acknowledge the subtle difference between age-associated memory impairment and mild cognitive impairment, and the difficulty of differentiating normal changes of aging from abnormal changes. The AAN’s guidelines for early detection of dementia emphasize the importance of diagnosing mild cognitive impairment or dementia early. However, the guidelines specifically exclude patients with subjective memory loss unaccompanied by objective cognitive deficits and offer no further discussion about these patients.
TABLE
Features of age-associated memory impairment vs mild cognitive impairment
| FEATURE | AGE-ASSOCIATED MEMORY IMPAIRMENT | MILD COGNITIVE IMPAIRMENT |
|---|---|---|
| Clinical presentation |
|
|
| Memory test results |
|
|
| Clinical course |
|
|
| ADLs, activities of daily living; IADLs, instrumental activities of daily living; SD, standard deviation. | ||
| Source: Spar JE, La Rue A. Clinical Manual of Geriatric Psychiatry.18 | ||
Depression, anxiety, and dementia, as well as older age, female gender, lower education level, and decreased physical activity, have all been associated with memory loss reported by patients or family members (strength of recommendation [SOR]: B, cross-sectional studies). Memory complaints in patients with no cognitive impairment on short cognitive screening tests, such as the mini-mental status exam, may predict dementia (SOR: B, longitudinal studies). No consistent evidence supports pharmacologic treatment of reported memory loss that is not corroborated by objective findings (SOR: B, nonrandomized, poor-quality studies).
Is depression or polypharmacy at work?
Rajasree Nair, MD
Baylor College of Medicine, Houston, Tex
As the population ages, primary care physicians encounter a significant number of patients with memory loss and dementia. In clinical practice, patients with subjective memory complaints but normal cognitive testing present a diagnostic dilemma. Close attention to comorbid psychiatric conditions such as depression, anxiety, and substance use disorders, as well as polypharmacy, is essential.
While the US Preventive Services Task Force indicates that there is insufficient evidence to screen, it notes that recognizing cognitive impairment early not only facilitates diagnostic and treatment decisions, but also allows clinicians to anticipate problems the patient may have in understanding and adhering to recommended therapy. Even though evidence of early or minimal dementia may be difficult to detect, identifying it promptly enables physicians to counsel patients and caregivers on the course of disease progression, warning signs, medication adherence, finances, and safety.
Evidence Summary
Several cross-sectional studies indicate that patients with subjective memory loss are more likely to be older, female, less physically active, in poorer health, less educated, and more depressed or anxious than unaffected patients.1-4 These studies concentrate mostly on elderly people living in the community.
A study of 1883 patients with normal baseline short-cognitive test results found that those with subjective memory complaints had a higher incidence of dementia.5 At 5-year follow-up, 15% of patients with baseline subjective memory complaints had developed dementia compared to only 6% of those without such complaints (odds ratio=2.7; 95% confidence interval [CI], 1.45-4.98).
A prospective cohort study that followed 158 patients with no evidence of dementia showed a significant correlation between informant-reported memory problems and development of dementia at 5 years.6 Forty-five percent of patients with informant-reported memory problems developed dementia after 5 years compared with 25% of patients who had only self-reported memory problems (P =.02). This result suggests that subjective memory problems reported by observers (family or caregivers) may be more predictive of dementia than self-reported memory complaints.
Donepezil, ginkgo biloba may not help these patients
Most trials of interventions to preserve memory have not enrolled patients with subjective memory complaints. However, data from trials that enrolled either asymptomatic elderly patients or patients with mild cognitive impairment don’t support the use of donepezil, ginkgo biloba, NSAIDs, COX-2 inhibitors, vitamin E, vitamin B6, vitamin B12, statins, hormone replacement therapy, or omega-3 fatty acids to delay progression to dementia.7-16
Could mental exercise help?
One systematic review of 22 longitudinal cohort studies, which included more than 29,000 patients, evaluated complex patterns of mental activity in early, mid-, and late-life in relation to the incidence of dementia. Dementia was diagnosed at a significantly lower rate in patients with a higher level of cognitive exercise, such as memory-based leisure activities and social interactions, than those with less rigorous daily cognitive challenges (relative risk=0.54; 95% CI, 0.49-0.59).17
This raises the possibility that mental exercise has neuroprotective effects. No randomized trials exist to support this hypothesis, however.
Recommendations
There is no consensus regarding the nomenclature applied to reported memory loss and mild cognitive impairment. The Clinical Manual of Geriatric Psychiatry provides definitions that can be used in the clinical setting (TABLE).18
The US Preventive Services Task Force concludes that evidence is insufficient to recommend for or against routine screening for dementia in older adults (I recommendation).19 However, the Task Force notes that clinicians should assess cognitive function whenever they suspect impairment or deterioration based on direct observation, patient report, or concerns raised by family members, friends, or care-takers.
The American Geriatrics Society20 and American Academy of Neurology (AAN)21 acknowledge the subtle difference between age-associated memory impairment and mild cognitive impairment, and the difficulty of differentiating normal changes of aging from abnormal changes. The AAN’s guidelines for early detection of dementia emphasize the importance of diagnosing mild cognitive impairment or dementia early. However, the guidelines specifically exclude patients with subjective memory loss unaccompanied by objective cognitive deficits and offer no further discussion about these patients.
TABLE
Features of age-associated memory impairment vs mild cognitive impairment
| FEATURE | AGE-ASSOCIATED MEMORY IMPAIRMENT | MILD COGNITIVE IMPAIRMENT |
|---|---|---|
| Clinical presentation |
|
|
| Memory test results |
|
|
| Clinical course |
|
|
| ADLs, activities of daily living; IADLs, instrumental activities of daily living; SD, standard deviation. | ||
| Source: Spar JE, La Rue A. Clinical Manual of Geriatric Psychiatry.18 | ||
1. St John P, Montgomery P. Is subjective memory loss correlated with MMSE scores or dementia? J Geriatr Psychiatry Neurol. 2003;16:80-83.
2. Lautenschlager NT, Flicker L, Vasikaran S, et al. Subjective memory complaints with and without objective memory impairment: relationship with risk factors for dementia. Am J Geriatr Psychiatry. 2005;13:731-734.
3. Jonker C, Geerlings MI, Schmand B. Are memory complaints predictive for dementia? A review of clinical and population-based studies. Int J Geriatr Psychiatry. 2000;15:983-991.
4. Mol ME, van Boxtel MP, Willems D, et al. Do subjective memory complaints predict cognitive dysfunction over time? A six-year follow-up of the Maastricht aging study. Int J Geriatr Psychiatry. 2006;21:432-441.
5. Wang L, van Belle G, Crane PK, et al. Subjective memory deterioration and future dementia in people aged 65 and older. J Am Geriatr Soc. 2004;52:2045-2051.
6. Carr DB, Gray S, Baty J, Morris JC. The value of informant versus individual’s complaints of memory impairment in early dementia. Neurology. 2000;55:1724-1726.
7. Birks J, Flicker L. Donepezil for mild cognitive impairment. Cochrane Database Syst Rev. 2006;(3):CD006104.-
8. Birks J, Grimley EV, Van Dongen M. Ginkgo biloba for cognitive impairment and demetia. Cochrane Database Syst Rev. 2007;(2):CD003120.-
9. Etminan M, Gill S, Samii A. Effect of nonsteroidal anti-inflammatory drugs on risk of Alzheimer’s disease: systematic review and meta-analysis of observational studies. Br Med J. 2003;327:128-131.
10. Aisen P, Schafer K, Grundman M. Effects of rofecoxib or naproxen vs placebo on Alzheimer disease progression: a randomized controlled trial. JAMA. 2003;289:2819-2826.
11. Isaac M, Quinn R, Tabet N. Vitamin E for Alzheimer’s disease and mild cognitive impairment. Cochrane Database Syst Rev. 2000;(4):CD002854.-
12. Malouf R, Grimley Evans J. Vitamin B6 for cognition. Cochrane Database Syst Rev. 2003;(4):CD004393.-
13. Malouf M, Grimley Evans J, Areosa SA. Folic acid with or without vitamin B12 for cognition and dementia. Cochrane Database Syst Rev. 2003;(4):004514.-
14. Scott HD, Laake K. Statins for the prevention of Alzheimer’s disease. Cochrane Database Syst Rev. 2001;(3):003160.-
15. US Preventive Services Task Force. Postmenopausal hormone replacement therapy for the primary prevention of chronic conditions: recommendations and rationale. Am Fam Physician. 2003;67:358-364.
16. Lim WS, Gammack JK, Van Niekerk JK, et al. Omega 3 fatty acid for the prevention of dementia. Cochrane Database Syst Rev. 2006;(1):CD005379.-
17. Valenzuela MJ, Sachdev P. Brain reserve and dementia: a systematic review. Psychol Med. 2006;36:441-454.
18. Spar JE, La Rue A. Clinical Manual of Geriatric Psychiatry. Illustrated ed. Arlington, Va: American Psychiatric Publishing, Inc; 2006.
19. US Preventive Services Task Force. Screening for dementia: recommendation and rationale summary for patients. Ann Intern Med. 2003;138:925-926.
20. Durso SC, Gwyther L, Roos B, et al. Clinical Practice Guidelines. Abstracted from the American Academy of Neurology’s dementia guidelines for early detection, diagnosis and management of dementia. New York: American Geriatrics Society; 2006. Available at: www.americangeriatrics.org/products/positionpapers/aan_dementia.shtml. Accessed April 9, 2007.
21. Petersen RC, Stevens JC, Ganguli M, et al. Practice parameter: early detection of dementia: mild cognitive impairment (an evidence-based review). Report of the quality standards subcommittee of the American Academy of Neurology. Neurology. 2001;56:1133-1142.
1. St John P, Montgomery P. Is subjective memory loss correlated with MMSE scores or dementia? J Geriatr Psychiatry Neurol. 2003;16:80-83.
2. Lautenschlager NT, Flicker L, Vasikaran S, et al. Subjective memory complaints with and without objective memory impairment: relationship with risk factors for dementia. Am J Geriatr Psychiatry. 2005;13:731-734.
3. Jonker C, Geerlings MI, Schmand B. Are memory complaints predictive for dementia? A review of clinical and population-based studies. Int J Geriatr Psychiatry. 2000;15:983-991.
4. Mol ME, van Boxtel MP, Willems D, et al. Do subjective memory complaints predict cognitive dysfunction over time? A six-year follow-up of the Maastricht aging study. Int J Geriatr Psychiatry. 2006;21:432-441.
5. Wang L, van Belle G, Crane PK, et al. Subjective memory deterioration and future dementia in people aged 65 and older. J Am Geriatr Soc. 2004;52:2045-2051.
6. Carr DB, Gray S, Baty J, Morris JC. The value of informant versus individual’s complaints of memory impairment in early dementia. Neurology. 2000;55:1724-1726.
7. Birks J, Flicker L. Donepezil for mild cognitive impairment. Cochrane Database Syst Rev. 2006;(3):CD006104.-
8. Birks J, Grimley EV, Van Dongen M. Ginkgo biloba for cognitive impairment and demetia. Cochrane Database Syst Rev. 2007;(2):CD003120.-
9. Etminan M, Gill S, Samii A. Effect of nonsteroidal anti-inflammatory drugs on risk of Alzheimer’s disease: systematic review and meta-analysis of observational studies. Br Med J. 2003;327:128-131.
10. Aisen P, Schafer K, Grundman M. Effects of rofecoxib or naproxen vs placebo on Alzheimer disease progression: a randomized controlled trial. JAMA. 2003;289:2819-2826.
11. Isaac M, Quinn R, Tabet N. Vitamin E for Alzheimer’s disease and mild cognitive impairment. Cochrane Database Syst Rev. 2000;(4):CD002854.-
12. Malouf R, Grimley Evans J. Vitamin B6 for cognition. Cochrane Database Syst Rev. 2003;(4):CD004393.-
13. Malouf M, Grimley Evans J, Areosa SA. Folic acid with or without vitamin B12 for cognition and dementia. Cochrane Database Syst Rev. 2003;(4):004514.-
14. Scott HD, Laake K. Statins for the prevention of Alzheimer’s disease. Cochrane Database Syst Rev. 2001;(3):003160.-
15. US Preventive Services Task Force. Postmenopausal hormone replacement therapy for the primary prevention of chronic conditions: recommendations and rationale. Am Fam Physician. 2003;67:358-364.
16. Lim WS, Gammack JK, Van Niekerk JK, et al. Omega 3 fatty acid for the prevention of dementia. Cochrane Database Syst Rev. 2006;(1):CD005379.-
17. Valenzuela MJ, Sachdev P. Brain reserve and dementia: a systematic review. Psychol Med. 2006;36:441-454.
18. Spar JE, La Rue A. Clinical Manual of Geriatric Psychiatry. Illustrated ed. Arlington, Va: American Psychiatric Publishing, Inc; 2006.
19. US Preventive Services Task Force. Screening for dementia: recommendation and rationale summary for patients. Ann Intern Med. 2003;138:925-926.
20. Durso SC, Gwyther L, Roos B, et al. Clinical Practice Guidelines. Abstracted from the American Academy of Neurology’s dementia guidelines for early detection, diagnosis and management of dementia. New York: American Geriatrics Society; 2006. Available at: www.americangeriatrics.org/products/positionpapers/aan_dementia.shtml. Accessed April 9, 2007.
21. Petersen RC, Stevens JC, Ganguli M, et al. Practice parameter: early detection of dementia: mild cognitive impairment (an evidence-based review). Report of the quality standards subcommittee of the American Academy of Neurology. Neurology. 2001;56:1133-1142.
Evidence-based answers from the Family Physicians Inquiries Network
When should you admit a patient with suspected CAP?
When the patient has 2 or more of the following CURB-65 criteria: respiratory rate ≥30, acute confusion, low blood pressure (systolic blood pressure <90 or diastolic BP ≤60 mm Hg), blood urea nitrogen [BUN] >19.6 mg/dL, and age ≥65 years (strength of recommendation [SOR]: B, based on 3 prospective cohort studies). Alternatively, consider hospitalization for patients presenting with a Pneumonia Severity Index (PSI) class of 4 or 5 (SOR: B; 1 prospective cohort study). There are no studies that test whether using these rules improve outcomes over standard care.
What about the homeless man, or the debilitated woman?
Timothy E. Huber, MD
Oroville, Calif
I occasionally work in my community hospital’s emergency room. Clinical decision rules are often very helpful, but they are limited when dealing with special populations, such as patients who are immunosuppressed or pregnant, or those with underlying cardiac or lung disease.
In addition, there are often social factors that must be taken into account when considering admitting a patient. For instance, a homeless man may not be able to purchase his medications; a debilitated woman living alone may not be able to adequately care for herself, despite a low CURB-65 score. Clinical decision rules provide a useful starting point, but they are meant to supplement, not replace, clinical decision-making.
Evidence summary
The CURB-65 criteria: Having ≥2 factors increases mortality
In a split-sample (derivation and validation) analysis1 of 3 prospective studies involving 1068 patients presenting to the hospital with the diagnosis of pneumonia, various clinical features were analyzed for their association with 30-day mortality. The 5 parameters that were most strongly associated with mortality were:
- acute confusion (odds ratio [OR]=8.1; 95% confidence interval [CI], 4.8–13.7)
- BUN >19.6 mg/dL (OR= 5.6; 95% CI, 3.1–10)
- respiratory rate ≥30 (OR=1.7; 95% CI, 1.07–2.8)
- low blood pressure (SBP <90 or DBP ≤60) (OR=2.4; 95% CI, 1.4–3.8)
- age ≥65 years (OR=5.5; 95% CI, 2.8–10.9).
The 30-day mortality estimation using these 5 criteria is called CURB-65 (Confusion, Urea, Respiratory rate, low Blood pressure, and age ≥65).
In patients with 2 or more of these factors, the associated rate of mortality increased significantly compared with patients who had none or only 1 of the factors (TABLE 1). Although albumin <3.0 g/dL was also significantly associated with an increased mortality rate (OR=4.7; 95% CI, 2.5–8.7), it was not included in CURB-65 because it is not a routine lab ordered for patients with pneumonia.
A variation of the CURB-65 score, CRB-65, uses only the clinical parameters without laboratory data (confusion, respiratory rate, blood pressure, and age). Patients with a score of 0 had a 0.9% 30-day mortality rate. However, the rate increased to 8.15% when patients had 1 or 2 of the 4 clinical criteria.
TABLE 1
CURB-65 criteria
Give 1 point for each:
|
| |
| SCORE | 30-DAY MORTALITY | POSSIBLE TREATMENT OPTIONS |
| 0 or 1 | Low (1.5%) | Consider outpatient treatment |
| 2 | Intermediate (9.2%) | Short-stay hospitalization or closely monitored outpatient therapy |
| 3 or more | High (22%) | Hospitalize and consider ICU |
| Source: Lim et al 2003.1 | ||
Pneumonia Severity Index has similar sensitivity to CURB-65
A more detailed assessment using 20 parameters called the Pneumonia Severity Index (PSI) was derived and validated in separate cohorts (TABLE 2).2 When compared with CURB-65 and CRB-65, the PSI has similar sensitivity and specificity in predicting 30-day mortality.3 All 3 predictive rules had high negative predictive values for mortality but a low positive predictive value at all cutoff points.
Larger proportions of patients were identified as low-risk by PSI (47.2%) and CURB-65 (43.3%) than by CRB-65 (12.6%). Therefore PSI and CURB-65 are much more helpful in identifying patients who could be treated in the outpatient setting.
TABLE 2
Pneumonia Severity Index
| CHARACTERISTIC | POINTS ASSIGNED | |
| Demographic factors | ||
| Age, men | Age in years | |
| Age, women | Age in years –10 | |
| Nursing home resident | +10 | |
| Coexisting illnesses | ||
| Neoplastic disease | +30 | |
| Liver disease | +20 | |
| Congestive heart failure | +10 | |
| Cerebrovascular disease | +10 | |
| Renal disease | +10 | |
| Physical examination findings | ||
| Altered mental status | +20 | |
| Respiratory rate ≥30/min | +20 | |
| Systolic blood pressure <90 mm Hg | +20 | |
| Temperature <35°C (95°F) or ≥40°C (104°F) | +15 | |
| Pulse ≥125 beats/min | +10 | |
| Laboratory and radiographic findings | ||
| Arterial blood pH <7.35 | +30 | |
| Blood urea nitrogen level ≥30 mg/dL | +20 | |
| Sodium level <130 mmol/L | +20 | |
| Glucose level ≥250 mg/dL | +10 | |
| Hematocrit <30% | +10 | |
| Partial pressure of arterial O2 <60 mm Hg or O2 saturation <90% on pulse oximetry | +10 | |
| Pleural effusion | +10 | |
| RISK CLASS | POINTS | 30-DAY MORTALITY |
| I | 0–50 | 0.1%–0.4% |
| II | 51–70 | 0.6%–0.7% |
| III | 71–90 | 0.9%–2.8% |
| IV | 91–130 | 8.3%–9.3% |
| V | >130 | 27.0%–31.1% |
| Patients in classes I, II, and III can be managed on an outpatient basis; patients in classes IV and V should be hospitalized. | ||
| Source: Fine et al 1997.2 | ||
Recommendations from others
The 2007 Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS), in their Consensus Guidelines on the Management of Community-Acquired Pneumonia,4 concluded that severity-of-illness scores, such as the CURB-65 or PSI, can be used to identify patients with CAP who may be candidates for outpatient treatment (evidence level I by IDSA/ATS rating).
The guidelines recommend that objective criteria or scores always be supplemented with physician determination of subjective factors, including the ability to safely and reliably take oral medication and the availability of outpatient support resources. Also, CURB-65 is more suitable than PSI for use in the emergency department because of its simplicity of application and ability to identify low-risk patients (evidence level II).4
1. Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003;58:377-382.
2. Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997;336:243-250.
3. Yan Man S, Lee N, Ip M, et al. Prospective comparison of three predictive rules for assessing severity of community-acquired pneumonia in Hong Kong. Thorax 2007;62:348-353.
4. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44(Suppl 2):S27-S72.
When the patient has 2 or more of the following CURB-65 criteria: respiratory rate ≥30, acute confusion, low blood pressure (systolic blood pressure <90 or diastolic BP ≤60 mm Hg), blood urea nitrogen [BUN] >19.6 mg/dL, and age ≥65 years (strength of recommendation [SOR]: B, based on 3 prospective cohort studies). Alternatively, consider hospitalization for patients presenting with a Pneumonia Severity Index (PSI) class of 4 or 5 (SOR: B; 1 prospective cohort study). There are no studies that test whether using these rules improve outcomes over standard care.
What about the homeless man, or the debilitated woman?
Timothy E. Huber, MD
Oroville, Calif
I occasionally work in my community hospital’s emergency room. Clinical decision rules are often very helpful, but they are limited when dealing with special populations, such as patients who are immunosuppressed or pregnant, or those with underlying cardiac or lung disease.
In addition, there are often social factors that must be taken into account when considering admitting a patient. For instance, a homeless man may not be able to purchase his medications; a debilitated woman living alone may not be able to adequately care for herself, despite a low CURB-65 score. Clinical decision rules provide a useful starting point, but they are meant to supplement, not replace, clinical decision-making.
Evidence summary
The CURB-65 criteria: Having ≥2 factors increases mortality
In a split-sample (derivation and validation) analysis1 of 3 prospective studies involving 1068 patients presenting to the hospital with the diagnosis of pneumonia, various clinical features were analyzed for their association with 30-day mortality. The 5 parameters that were most strongly associated with mortality were:
- acute confusion (odds ratio [OR]=8.1; 95% confidence interval [CI], 4.8–13.7)
- BUN >19.6 mg/dL (OR= 5.6; 95% CI, 3.1–10)
- respiratory rate ≥30 (OR=1.7; 95% CI, 1.07–2.8)
- low blood pressure (SBP <90 or DBP ≤60) (OR=2.4; 95% CI, 1.4–3.8)
- age ≥65 years (OR=5.5; 95% CI, 2.8–10.9).
The 30-day mortality estimation using these 5 criteria is called CURB-65 (Confusion, Urea, Respiratory rate, low Blood pressure, and age ≥65).
In patients with 2 or more of these factors, the associated rate of mortality increased significantly compared with patients who had none or only 1 of the factors (TABLE 1). Although albumin <3.0 g/dL was also significantly associated with an increased mortality rate (OR=4.7; 95% CI, 2.5–8.7), it was not included in CURB-65 because it is not a routine lab ordered for patients with pneumonia.
A variation of the CURB-65 score, CRB-65, uses only the clinical parameters without laboratory data (confusion, respiratory rate, blood pressure, and age). Patients with a score of 0 had a 0.9% 30-day mortality rate. However, the rate increased to 8.15% when patients had 1 or 2 of the 4 clinical criteria.
TABLE 1
CURB-65 criteria
Give 1 point for each:
|
| |
| SCORE | 30-DAY MORTALITY | POSSIBLE TREATMENT OPTIONS |
| 0 or 1 | Low (1.5%) | Consider outpatient treatment |
| 2 | Intermediate (9.2%) | Short-stay hospitalization or closely monitored outpatient therapy |
| 3 or more | High (22%) | Hospitalize and consider ICU |
| Source: Lim et al 2003.1 | ||
Pneumonia Severity Index has similar sensitivity to CURB-65
A more detailed assessment using 20 parameters called the Pneumonia Severity Index (PSI) was derived and validated in separate cohorts (TABLE 2).2 When compared with CURB-65 and CRB-65, the PSI has similar sensitivity and specificity in predicting 30-day mortality.3 All 3 predictive rules had high negative predictive values for mortality but a low positive predictive value at all cutoff points.
Larger proportions of patients were identified as low-risk by PSI (47.2%) and CURB-65 (43.3%) than by CRB-65 (12.6%). Therefore PSI and CURB-65 are much more helpful in identifying patients who could be treated in the outpatient setting.
TABLE 2
Pneumonia Severity Index
| CHARACTERISTIC | POINTS ASSIGNED | |
| Demographic factors | ||
| Age, men | Age in years | |
| Age, women | Age in years –10 | |
| Nursing home resident | +10 | |
| Coexisting illnesses | ||
| Neoplastic disease | +30 | |
| Liver disease | +20 | |
| Congestive heart failure | +10 | |
| Cerebrovascular disease | +10 | |
| Renal disease | +10 | |
| Physical examination findings | ||
| Altered mental status | +20 | |
| Respiratory rate ≥30/min | +20 | |
| Systolic blood pressure <90 mm Hg | +20 | |
| Temperature <35°C (95°F) or ≥40°C (104°F) | +15 | |
| Pulse ≥125 beats/min | +10 | |
| Laboratory and radiographic findings | ||
| Arterial blood pH <7.35 | +30 | |
| Blood urea nitrogen level ≥30 mg/dL | +20 | |
| Sodium level <130 mmol/L | +20 | |
| Glucose level ≥250 mg/dL | +10 | |
| Hematocrit <30% | +10 | |
| Partial pressure of arterial O2 <60 mm Hg or O2 saturation <90% on pulse oximetry | +10 | |
| Pleural effusion | +10 | |
| RISK CLASS | POINTS | 30-DAY MORTALITY |
| I | 0–50 | 0.1%–0.4% |
| II | 51–70 | 0.6%–0.7% |
| III | 71–90 | 0.9%–2.8% |
| IV | 91–130 | 8.3%–9.3% |
| V | >130 | 27.0%–31.1% |
| Patients in classes I, II, and III can be managed on an outpatient basis; patients in classes IV and V should be hospitalized. | ||
| Source: Fine et al 1997.2 | ||
Recommendations from others
The 2007 Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS), in their Consensus Guidelines on the Management of Community-Acquired Pneumonia,4 concluded that severity-of-illness scores, such as the CURB-65 or PSI, can be used to identify patients with CAP who may be candidates for outpatient treatment (evidence level I by IDSA/ATS rating).
The guidelines recommend that objective criteria or scores always be supplemented with physician determination of subjective factors, including the ability to safely and reliably take oral medication and the availability of outpatient support resources. Also, CURB-65 is more suitable than PSI for use in the emergency department because of its simplicity of application and ability to identify low-risk patients (evidence level II).4
When the patient has 2 or more of the following CURB-65 criteria: respiratory rate ≥30, acute confusion, low blood pressure (systolic blood pressure <90 or diastolic BP ≤60 mm Hg), blood urea nitrogen [BUN] >19.6 mg/dL, and age ≥65 years (strength of recommendation [SOR]: B, based on 3 prospective cohort studies). Alternatively, consider hospitalization for patients presenting with a Pneumonia Severity Index (PSI) class of 4 or 5 (SOR: B; 1 prospective cohort study). There are no studies that test whether using these rules improve outcomes over standard care.
What about the homeless man, or the debilitated woman?
Timothy E. Huber, MD
Oroville, Calif
I occasionally work in my community hospital’s emergency room. Clinical decision rules are often very helpful, but they are limited when dealing with special populations, such as patients who are immunosuppressed or pregnant, or those with underlying cardiac or lung disease.
In addition, there are often social factors that must be taken into account when considering admitting a patient. For instance, a homeless man may not be able to purchase his medications; a debilitated woman living alone may not be able to adequately care for herself, despite a low CURB-65 score. Clinical decision rules provide a useful starting point, but they are meant to supplement, not replace, clinical decision-making.
Evidence summary
The CURB-65 criteria: Having ≥2 factors increases mortality
In a split-sample (derivation and validation) analysis1 of 3 prospective studies involving 1068 patients presenting to the hospital with the diagnosis of pneumonia, various clinical features were analyzed for their association with 30-day mortality. The 5 parameters that were most strongly associated with mortality were:
- acute confusion (odds ratio [OR]=8.1; 95% confidence interval [CI], 4.8–13.7)
- BUN >19.6 mg/dL (OR= 5.6; 95% CI, 3.1–10)
- respiratory rate ≥30 (OR=1.7; 95% CI, 1.07–2.8)
- low blood pressure (SBP <90 or DBP ≤60) (OR=2.4; 95% CI, 1.4–3.8)
- age ≥65 years (OR=5.5; 95% CI, 2.8–10.9).
The 30-day mortality estimation using these 5 criteria is called CURB-65 (Confusion, Urea, Respiratory rate, low Blood pressure, and age ≥65).
In patients with 2 or more of these factors, the associated rate of mortality increased significantly compared with patients who had none or only 1 of the factors (TABLE 1). Although albumin <3.0 g/dL was also significantly associated with an increased mortality rate (OR=4.7; 95% CI, 2.5–8.7), it was not included in CURB-65 because it is not a routine lab ordered for patients with pneumonia.
A variation of the CURB-65 score, CRB-65, uses only the clinical parameters without laboratory data (confusion, respiratory rate, blood pressure, and age). Patients with a score of 0 had a 0.9% 30-day mortality rate. However, the rate increased to 8.15% when patients had 1 or 2 of the 4 clinical criteria.
TABLE 1
CURB-65 criteria
Give 1 point for each:
|
| |
| SCORE | 30-DAY MORTALITY | POSSIBLE TREATMENT OPTIONS |
| 0 or 1 | Low (1.5%) | Consider outpatient treatment |
| 2 | Intermediate (9.2%) | Short-stay hospitalization or closely monitored outpatient therapy |
| 3 or more | High (22%) | Hospitalize and consider ICU |
| Source: Lim et al 2003.1 | ||
Pneumonia Severity Index has similar sensitivity to CURB-65
A more detailed assessment using 20 parameters called the Pneumonia Severity Index (PSI) was derived and validated in separate cohorts (TABLE 2).2 When compared with CURB-65 and CRB-65, the PSI has similar sensitivity and specificity in predicting 30-day mortality.3 All 3 predictive rules had high negative predictive values for mortality but a low positive predictive value at all cutoff points.
Larger proportions of patients were identified as low-risk by PSI (47.2%) and CURB-65 (43.3%) than by CRB-65 (12.6%). Therefore PSI and CURB-65 are much more helpful in identifying patients who could be treated in the outpatient setting.
TABLE 2
Pneumonia Severity Index
| CHARACTERISTIC | POINTS ASSIGNED | |
| Demographic factors | ||
| Age, men | Age in years | |
| Age, women | Age in years –10 | |
| Nursing home resident | +10 | |
| Coexisting illnesses | ||
| Neoplastic disease | +30 | |
| Liver disease | +20 | |
| Congestive heart failure | +10 | |
| Cerebrovascular disease | +10 | |
| Renal disease | +10 | |
| Physical examination findings | ||
| Altered mental status | +20 | |
| Respiratory rate ≥30/min | +20 | |
| Systolic blood pressure <90 mm Hg | +20 | |
| Temperature <35°C (95°F) or ≥40°C (104°F) | +15 | |
| Pulse ≥125 beats/min | +10 | |
| Laboratory and radiographic findings | ||
| Arterial blood pH <7.35 | +30 | |
| Blood urea nitrogen level ≥30 mg/dL | +20 | |
| Sodium level <130 mmol/L | +20 | |
| Glucose level ≥250 mg/dL | +10 | |
| Hematocrit <30% | +10 | |
| Partial pressure of arterial O2 <60 mm Hg or O2 saturation <90% on pulse oximetry | +10 | |
| Pleural effusion | +10 | |
| RISK CLASS | POINTS | 30-DAY MORTALITY |
| I | 0–50 | 0.1%–0.4% |
| II | 51–70 | 0.6%–0.7% |
| III | 71–90 | 0.9%–2.8% |
| IV | 91–130 | 8.3%–9.3% |
| V | >130 | 27.0%–31.1% |
| Patients in classes I, II, and III can be managed on an outpatient basis; patients in classes IV and V should be hospitalized. | ||
| Source: Fine et al 1997.2 | ||
Recommendations from others
The 2007 Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS), in their Consensus Guidelines on the Management of Community-Acquired Pneumonia,4 concluded that severity-of-illness scores, such as the CURB-65 or PSI, can be used to identify patients with CAP who may be candidates for outpatient treatment (evidence level I by IDSA/ATS rating).
The guidelines recommend that objective criteria or scores always be supplemented with physician determination of subjective factors, including the ability to safely and reliably take oral medication and the availability of outpatient support resources. Also, CURB-65 is more suitable than PSI for use in the emergency department because of its simplicity of application and ability to identify low-risk patients (evidence level II).4
1. Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003;58:377-382.
2. Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997;336:243-250.
3. Yan Man S, Lee N, Ip M, et al. Prospective comparison of three predictive rules for assessing severity of community-acquired pneumonia in Hong Kong. Thorax 2007;62:348-353.
4. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44(Suppl 2):S27-S72.
1. Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003;58:377-382.
2. Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997;336:243-250.
3. Yan Man S, Lee N, Ip M, et al. Prospective comparison of three predictive rules for assessing severity of community-acquired pneumonia in Hong Kong. Thorax 2007;62:348-353.
4. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44(Suppl 2):S27-S72.
Evidence-based answers from the Family Physicians Inquiries Network