"Who came with you?" A diagnostic observation in patients with memory problems?
http://www.100md.com
《神经病学神经外科学杂志》
Cognitive Function Clinic, Walton Centre for Neurology and Neurosurgery, Liverpool, UK
Correspondence to:
Dr A J Larner
Cognitive Function Clinic, Walton Centre for Neurology and Neurosurgery, Lower Lane, Fazakerley, Liverpool, L9 7LJ, UK; a.larner@thewaltoncentre.nhs.uk
Keywords: Dementia; diagnosis
The importance of obtaining collateral history when assessing patients attending the neurology clinic complaining of memory difficulties is well known.1,2 Patients developing amnesia in the context of Alzheimer’s disease may underplay their difficulties because of cognitive anosognosia, whereas those with purely subjective memory complaints (the "worried well") may overemphasise difficulties. Memory complaint, preferably corroborated by an informant, is one of the suggested diagnostic criteria of mild cognitive impairment (MCI).3 Misdiagnosis of memory complaints may occur when no collateral history is available.4
For these reasons, all patients referred to my cognitive function clinic are sent, as part of their clinic appointment letter, a request asking them to bring a relative, friend, or carer from whom additional clinical information may be obtained; this is printed in bold type and in a separate paragraph. Despite this, some patients attend the clinic alone. A study was undertaken to measure the diagnostic value of this observation.
As part of an audit of referrals over a 2 year period (September 2002 to August 2004 inclusive), attendance or non-attendance of a relative or friend at each consultation was noted. Diagnosis of dementia was based on DSM-IV criteria, established by clinical interview, neuropsychological assessment and structural neuroimaging. Diagnosis of dementia subtype (Alzheimer’s disease, vascular dementia, dementia with Lewy bodies, frontotemporal dementia) and of MCI followed widely
Of 183 new referrals seen, 150 (82%; 95% confidence interval (CI) 76 to 88%) followed the written instruction in the clinic appointment letter and attended with a relative, friend or carer; the remaining 33 (18%; 95% CI 4 to 31%) attended alone. In this cohort, 90 patients were diagnosed with dementia and 93 were not demented; three had MCI. Of the 150 patients accompanied to the clinic, 90 (60%; 95% CI 52 to 68%) had dementia; of the 60 not demented, one had MCI. None of the 33 patients attending alone had dementia, although two had MCI.
Hence, if attending the clinic with a relative, friend, or carer (that is, following the instructions given in the appointment letter) were considered a diagnostic test for dementia, it would have a sensitivity of 100% (95% CI 96 to 100%, Wilson method), specificity of 35% (95% CI 26 to 46%), and positive and negative predictive values of 60% (95% CI 52 to 67%) and 100% (95% CI 90 to 100%) respectively. Positive likelihood ratio was 1.55 (95% CI 1.33 to 1.80, log method), judged unimportant, but negative likelihood ratio (0) was large.
Although not absolute, as those unaccompanied patients with MCI might yet evolve to dementia, the period of follow up for some patients is brief, and clinically established diagnoses may require revision (for example, when neuropathological data become available), these findings nevertheless support the belief that attending the neurology clinic alone despite written instructions to the contrary is a robust sign of the absence of dementia.5
References
Tierney MC, Szalai JP, Snow WG, et al. The prediction of Alzheimer disease: the role of patient and informant perceptions of cognitive deficits. Arch Neurol 1996;53:423–7.
Carr DB, Gray S, Baty J, et al. The value of informant versus individual’s complaints of memory impairment in early dementia. Neurology 2000;55:1724–6.
Petersen RC. Mild cognitive impairment as a diagnostic entity. J Intern Med 2004;256:183–94.
Larner AJ. Getting it wrong: the clinical misdiagnosis of Alzheimer’s disease. Int J Clin Pract 2004;58:1092–4.
Matthews WB. Practical neurology. 3rd ed. Oxford: Blackwell Science, 1975:111.(A J Larner)
Correspondence to:
Dr A J Larner
Cognitive Function Clinic, Walton Centre for Neurology and Neurosurgery, Lower Lane, Fazakerley, Liverpool, L9 7LJ, UK; a.larner@thewaltoncentre.nhs.uk
Keywords: Dementia; diagnosis
The importance of obtaining collateral history when assessing patients attending the neurology clinic complaining of memory difficulties is well known.1,2 Patients developing amnesia in the context of Alzheimer’s disease may underplay their difficulties because of cognitive anosognosia, whereas those with purely subjective memory complaints (the "worried well") may overemphasise difficulties. Memory complaint, preferably corroborated by an informant, is one of the suggested diagnostic criteria of mild cognitive impairment (MCI).3 Misdiagnosis of memory complaints may occur when no collateral history is available.4
For these reasons, all patients referred to my cognitive function clinic are sent, as part of their clinic appointment letter, a request asking them to bring a relative, friend, or carer from whom additional clinical information may be obtained; this is printed in bold type and in a separate paragraph. Despite this, some patients attend the clinic alone. A study was undertaken to measure the diagnostic value of this observation.
As part of an audit of referrals over a 2 year period (September 2002 to August 2004 inclusive), attendance or non-attendance of a relative or friend at each consultation was noted. Diagnosis of dementia was based on DSM-IV criteria, established by clinical interview, neuropsychological assessment and structural neuroimaging. Diagnosis of dementia subtype (Alzheimer’s disease, vascular dementia, dementia with Lewy bodies, frontotemporal dementia) and of MCI followed widely
Of 183 new referrals seen, 150 (82%; 95% confidence interval (CI) 76 to 88%) followed the written instruction in the clinic appointment letter and attended with a relative, friend or carer; the remaining 33 (18%; 95% CI 4 to 31%) attended alone. In this cohort, 90 patients were diagnosed with dementia and 93 were not demented; three had MCI. Of the 150 patients accompanied to the clinic, 90 (60%; 95% CI 52 to 68%) had dementia; of the 60 not demented, one had MCI. None of the 33 patients attending alone had dementia, although two had MCI.
Hence, if attending the clinic with a relative, friend, or carer (that is, following the instructions given in the appointment letter) were considered a diagnostic test for dementia, it would have a sensitivity of 100% (95% CI 96 to 100%, Wilson method), specificity of 35% (95% CI 26 to 46%), and positive and negative predictive values of 60% (95% CI 52 to 67%) and 100% (95% CI 90 to 100%) respectively. Positive likelihood ratio was 1.55 (95% CI 1.33 to 1.80, log method), judged unimportant, but negative likelihood ratio (0) was large.
Although not absolute, as those unaccompanied patients with MCI might yet evolve to dementia, the period of follow up for some patients is brief, and clinically established diagnoses may require revision (for example, when neuropathological data become available), these findings nevertheless support the belief that attending the neurology clinic alone despite written instructions to the contrary is a robust sign of the absence of dementia.5
References
Tierney MC, Szalai JP, Snow WG, et al. The prediction of Alzheimer disease: the role of patient and informant perceptions of cognitive deficits. Arch Neurol 1996;53:423–7.
Carr DB, Gray S, Baty J, et al. The value of informant versus individual’s complaints of memory impairment in early dementia. Neurology 2000;55:1724–6.
Petersen RC. Mild cognitive impairment as a diagnostic entity. J Intern Med 2004;256:183–94.
Larner AJ. Getting it wrong: the clinical misdiagnosis of Alzheimer’s disease. Int J Clin Pract 2004;58:1092–4.
Matthews WB. Practical neurology. 3rd ed. Oxford: Blackwell Science, 1975:111.(A J Larner)