LETTER
Cognitive Impairment in Primary Care
David A. Nardone, MD
15 January 1996 | Volume 124 Issue 2 | Page 273
TO THE EDITOR:
I disagree with Callahan and colleagues [1] that their study was a systematic screening effort for cognitive abnormalities. This contradicts what the authors state as one of the limitations of their study. In an earlier communication [2], in response to an article by White and Davis [3], we noted differences in test characteristics between long (30-question) and short (10-question) mental status examinations. Longer mental status examinations have higher true-positive rates and lower likelihood-negative ratios; shorter mental status examinations have lower false-positive rates and higher likelihood-positive ratios. Consequently, the shorter versions are better for making a diagnosis of cognitive impairment, and the longer mental status examinations are better for ruling out such a diagnosis (screening). With the shorter mental status examination, a positive test result gives the physician more credibility when suggesting further evaluation for cognitive impairment. With the longer version, a negative test (normal) result is more likely to reassure patients, caretakers, and providers that cognitive impairment does not exist and to postpone further work-up.
In future studies, the authors might consider comparing the usefulness of 30-question and 10-question examinations, as did Foreman [4]. It would also be interesting if they could dispel the myth that performing the 30-question examination is more time consuming. I have used a 30-question mental status examination [5] in my practice for many years and have found it helpful. I believe that other primary care providers would be willing to invest the additional time to perform a longer version of the mental status examination if the yield (negative or positive) were higher. Such a practice might also save precious health care resources.
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Author and Article Information
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Veterans Health Administration Medical Center; Portland, OR 97207
1. Callahan CM, Hendrie HC, Tierney WT. Documentation and evaluation of cognitive impairment in elderly primary care patients. Ann Intern Med. 1995; 122:422-9.
2. Nardone DA, Gorman PN. Cognitive screening tests [Letter]. J Gen Intern Med. 1991; 6:267.
3. White H, Davis PB. Cognitive screening tests: an aid in the care of elderly outpatients. J Gen Intern Med. 1990; 5:438-45.
4. Foreman MD. Reliability and validity of mental status questionnaires in elderly hospitalized patients. Nurs Res. 1987; 36:216-20.
5. Jacobs JW, Bernhard MR, Delgado A, Strain JJ. Screening for organic mental syndromes in the medically ill. Ann Intern Med. 1977; 86:40-6.
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