Objectives To determine whether brief cognitive screening tests perform as well as a longer screening test in diagnosis of cognitive impairment, no dementia ( CIND ) or dementia. Design A cross‐sectional comparison of cognitive screening tests to an independent criterion standard evaluation using D iagnostic and S tatistical M anual of M ental D isorders, F ourth E dition ( DSM ‐ IV ) criteria. Performance of the cognitive screening tests for identifying dementia, and separately for identifying dementia or CIND , was characterized using sensitivity, specificity, likelihood ratios, and diagnostic odds ratios. Setting Three D epartment of V eterans A ffairs primary care clinics. Participants Of 826 independently living veterans aged 65 and older without a prior diagnosis of dementia, 639 participated and 630 were assigned a research diagnosis. Measurements Screening tests included the modified M ini‐ M ental S tate E xamination (3 MS ; average time to administer, 17 minutes) and three brief instruments: the M emory I mpairment S creen ( MIS ; 4 minutes), the M ini‐ C og (3 minutes), and a novel two‐item functional memory screen ( MF ‐2; 1.5 minutes). Results Participants were aged 74.8 on average and were mostly white or black. They were mostly male (92.9%) and had been prescribed a mean of 7.7 medications for chronic conditions. The prevalence of dementia and CIND was 3.3% and 39.2%, respectively. Sensitivity and specificity for dementia were 86% and 79% for the 3 MS , 76% and 73% for the M ini‐ C og, 43% and 93% for the MIS , and 38% and 87% for the MF ‐2, respectively. Conclusion In individuals without a prior diagnosis of cognitive impairment, the prevalence of dementia was low, but the prevalence of CIND was high. The 3 MS and M ini‐ C og had reasonable performance characteristics for detecting dementia, but a definitive diagnosis requires additional evaluation.
Background: Changes in federal health policy are providing more access to medical care for persons with chronic disease. Providing quality care may require a team approach, which the American College of Physicians calls the "medical home." One new model may involve nurse-managed protocols. Purpose: To determine whether nurse-managed protocols are effective for outpatient management of adults with diabetes, hypertension, and hyperlipidemia. Data Sources: MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, and CINAHL from January 1980 through January 2014. Study Selection: Two reviewers used eligibility criteria to assess all titles, abstracts, and full texts and resolved disagreements by discussion or by consulting a third reviewer. Data Extraction: One reviewer did data abstractions and quality assessments, which were confirmed by a second reviewer. Data Synthesis: From 2954 studies, 18 were included. All studies used a registered nurse or equivalent who titrated medications by following a protocol. In a meta-analysis, hemoglobin A1c level decreased by 0.4% (95% CI, 0.1% to 0.7%) (n = 8); systolic and diastolic blood pressure decreased by 3.68 mm Hg (CI, 1.05 to 6.31 mm Hg) and 1.56 mm Hg (CI, 0.36 to 2.76 mm Hg), respectively (n = 12); total cholesterol level decreased by 0.24 mmol/L (9.37 mg/dL) (CI, 0.54-mmol/L decrease to 0.05-mmol/L increase [20.77-mg/dL decrease to 2.02-mg/dL increase]) (n = 9); and low-density-lipoprotein cholesterol level decreased by 0.31 mmol/L (12.07 mg/dL) (CI, 0.73-mmol/L decrease to 0.11-mmol/L increase [28.27-mg/dL decrease to 4.13-mg/dL increase]) (n = 6). Limitation: Studies had limited descriptions of the interventions and protocols used. Conclusion: A team approach that uses nurse-managed protocols may have positive effects on the outpatient management of adults with chronic conditions, such as diabetes, hypertension, and hyperlipidemia. Primary Funding Source: U.S. Department of Veterans Affairs.
study protocolThe methods section in a protocol should provide a description of the intervention(s) (whether active, usual practice, or placebo) that is sufficiently detailed to enable people with appropriate expertise to reproduce them.This should include:• What were the "contents," including all constituent components, materials, and resources and their quality • Who delivered the intervention, including their expertise, additional training, and support • Where the intervention was delivered (the setting) • How and when the intervention was delivered: the dose, the schedule (intensity, frequency, duration), and interaction • The degree of flexibility permissible, including options and decision points. 3 This list is readily adaptable for interventions beyond clinical treatments and encounters-for example, to health systems and other complex interventions.Attention should be paid to the different meanings that terms such as counselling or physical therapy may have in different settings.Space constraints in trial registration databases and
OBJECTIVE: To compare case‐finding tools for depression in the nursing home setting and to evaluate effects of subject function, cognition, and disease number on test performance. DESIGN : Cross‐sectional survey. SETTING : One academic and four community homes. SUBJECTS : One hundred thirty‐four randomly selected, mildly cognitively impaired, functionally dependent residents. METHODS AND MEASURES : The Geriatric Depression Scale (GDS), Short Geriatric Depression Scale (SGDS), Center for Epidemiologic Studies Depression Scale (CES‐D), and Brief Carrol Depression Rating Scale (BCDRS) were administered. The Structured Clinical Interview for DSM‐III‐R diagnoses was administered independently. Operating characteristics and the effects of subject characteristics on test performance were evaluated using McNemar's test and logistic regression. Selection of “optimal” threshold scores was guided by Kraemer's quality indices and clinical judgment. RESULTS : Thirty‐five subjects (26%) had major depression. No differences were found among the instruments in sensitivity (range 0.74–0.89), specificity (range 0.62–0.77), or area under the receiver operating curve (ROC) (range 0.85–0.91). Resident characteristics did not affect test performance. Quality indices showed the GDS and BCDRS met criteria for moderate to substantial agreement with the criterion standard, whereas the SGDS and the CES‐D achieved only fair agreement. No change in threshold scores was warranted. CONCLUSIONS : The GDS and BCDRS performed well in the nursing home. As the GDS can serve as a both a case‐finding and severity instrument, it is preferred. Use of brief, interviewer‐administered tools may improve detection of depression in the nursing home.
