Brief Reports

Nursing Home Assessment of Cognitive Impairment: Development and Testing of a Brief Instrument of Mental Status

Joshua Chodosh, MD, MSHS, Maria Orlando Edelen, PhD, Joan L. Buchanan, PhD, Julia Ann Yosef, MS, Joseph G. Ouslander, MD, Dan R. Berlowitz, MD, MPH, Joel E. Streim, MD, and Debra Saliba, MD, MPH

OBJECTIVES: To test the accuracy of a brief cognitive assessment of nursing home (NH) residents and to determine whether facility nurses can reliably perform this assessment.

DESIGN: Cross-sectional, independent cognitive screening tests with NH residents.

SETTING: Six Department of Veteran Affairs nursing facilities.

PARTICIPANTS: Three hundred seventy-four residents from six regionally distributed Veteran Affairs NHs.

MEASUREMENTS: Three cognitive assessment instruments: the Brief Interview of Mental Status (BIMS), created for this study; the Minimum Data Set (MDS) 2.0 Cognitive Performance Scale (CPS), and the Modified Mini-Mental State Examination (3MS) as the criterion standard. The 15-point BIMS tests memory and orientation and includes free and cued recall items. Research assistants administered the 3MS and BIMS to all subjects. Facility nurses administered the same BIMS to a subsample.

RESULTS: Three hundred seventy-four of 417 (89.7%) residents approached completed the 3MS and research assistant–administered BIMS (BIMS-R); 212 residents also received a facility nurse–administered BIMS (BIMS-N). The BIMS-R was more highly correlated with the 3MS than was the CPS (Pearson correlation coefficient (r)=0.79 vs 0.62; P<.01 for difference). For the subset who received facility assessments, the BIMS-N was also more highly correlated with the 3MS (Pearson r=0.74 vs 0.65; P<.01 for difference). For any impairment (3MS<78), the area under the receiver operator characteristic curve (AUC) was 0.86 for the BIMS, versus 0.77 for the CPS. For severe impairment (3MS<48) the AUC was 0.94, versus 0.85 for the CPS.

CONCLUSION: In this population, a brief cognitive test is a more accurate approach to cognitive assessment than the current observational methods employed using the MDS 2.0. J Am Geriatr Soc 2008;56(11):2069-2075.

Physician Recommendations for Mammography in Women Aged 70 and Older

Julie M. Kapp, MPH, PhD, Joseph W. LeMaster, MD, MPH, Steven C. Zweig, MD, MSPH, and David R. Mehr, MD, MS

OBJECTIVES: To estimate the percentage of U.S. women aged 70 and older who reported a recent mammography recommendation and to identify whether factors suggesting limited life expectancy, such as comorbidities, are associated with a lower probability of a reported recommendation.

DESIGN: A national, population-based, cross-sectional survey.

SETTING: United States.

PARTICIPANTS: There were 1,782 screen-eligible women 70 and older who responded to the National Health Interview Survey in 2005 and met eligibility criteria, including reporting at least one doctor visit in the previous 12 months. Weighted, these women represented almost 9.3 million women nationally.

MEASUREMENTS: Multiple logistic regression was used to examine the relationship between demographic, comorbidity, and health services utilization variables on self-reported physician recommendation for a mammogram.

RESULTS: More than half (58.9%) of the sample reported a recent mammography recommendation (63.0% of those aged 70 to 79 and 51.5% of those aged 80 and older). The strongest multivariable association suggested that women who reported a recent clinical breast examination (CBE) had 5.9 times greater odds of reporting a mammography recommendation than women who reported never having a CBE.

CONCLUSION: This study failed to find negative associations between factors suggesting limited life expectancy and a recent mammography recommendation. Instead, findings revealed a strong positive association between a recent CBE and mammography recommendation. Findings may suggest that recent clinical interactions weigh more heavily on a decision to recommend mammography to older, screen-eligible women than considerations for the woman's overall long-term health or may reflect a greater perceived or actual recall of physician recommendations from women with a recent CBE. J Am Geriatr Soc 2008;56(11):2100-2106.

BRIEF REPORTS

Perceptions of Physician Recommendations for Joint Replacement Surgery in Older Patients with Severe Hip or Knee Osteoarthritis

Mara A. Schonberg, MD, MPH, Edward R. Marcantonio, MD, SM, and Mary Beth Hamel, MD, MPH

OBJECTIVES: To examine patient perceptions of physician discussions and recommendations about total joint arthroplasty (TJA).

DESIGN: Prospective cohort study.

SETTING: One large academic medical center and four community affiliates in Boston.

PARTICIPANTS: One hundred seventy-four patients aged 65 and older with severe osteoarthritis of the hip or knee for at least 6 months not controlled with medications.

MEASUREMENTS: Patient perceptions of primary care physicians’ (PCPs) and orthopedists' communication about TJA were assessed at baseline for all patients and at 12 months for those who did not undergo surgery.

RESULTS: Of the 174 patients, 49 were aged 80 and older, 82% were non-Hispanic white, and 69% had knee osteoarthritis. Eighty-seven percent of individuals with baseline interviews and a PCP (142/163) reported that they had discussed their hip or knee arthritis with their PCP at baseline, and 26% (42/163) reported that their PCP discussed TJA as a treatment option. Of the 128 patients who saw an orthopedist, 65% reported that their orthopedist recommended TJA. Only 29% (51/174) of patients underwent TJA. Those who reported discussing TJA with their PCP at baseline were more likely to undergo TJA (P<.01). Thirty-six percent (44/123) of the patients who did not undergo TJA reported that their PCP discussed surgery as a treatment option at baseline or at 12-month follow-up.

CONCLUSION: Patients with severe osteoarthritis of their hip or knee who report discussing TJA as a treatment option with their PCP are more likely to undergo TJA within the next year, but few older adults report having these discussions. Improvement is needed in communication between PCPs and patients about TJA. J Am Geriatr Soc 2009;57(1):82-88.

Kidney Function and Cognitive Performance and Decline in Older Men

Yelena Slinin, MD, MS, Misti L. Paudel, MPH, Areef Ishani, MD, MS, Brent C. Taylor, PhD, MPH, Kristine Yaffe, MD, Anne M. Murray, MD, Howard A. Fink, MD, MPH, Eric S. Orwoll, MD, Steven R. Cummings, MD, Elizabeth Barrett-Connor, MD, Simerjot Jassal, MD, and Kristine E. Ensrud, MD, MPH for the Osteoporotic Fractures in Men Study Group

OBJECTIVES: To examine the association between kidney function and cognitive impairment and decline in elderly men.

DESIGN: Observational prospective cohort.

SETTING: Community based.

PARTICIPANTS: Five thousand five hundred twenty-nine community dwelling men aged 65 and older (mean age 73.6 ± 5.9).

MEASUREMENTS: Estimated glomerular filtration rate (eGFR) calculated using the standardized Modification of Diet in Renal Disease (MDRD) equation; cognitive function assessed using the Modified Mini-Mental State Examination (3MS) and Trail Making Test B (Trails B).

RESULTS: At baseline, 148 (2.7%) and 494 (9.1%) men were classified as cognitively impaired and, in the 5-year prospective analysis, 931 (23%) and 432 (11.6%) met the criteria for cognitive decline at follow-up defined according to 3MS and Trails B performance, respectively. In unadjusted analysis, the odds of prevalent cognitive impairment and risk of cognitive decline were significantly higher in men with an eGFR less than 45 and 45 to 59 mL/min per 1.73 m2 than in men with an eGFR 60 mL/min per 1.73 m2 or greater. Differences in age, race, and education between eGFR categories largely explained these associations, with the exception of the association between poorer renal function and higher odds of impairment based on Trails B test score, which persisted despite adjustment for multiple potential confounders.

CONCLUSION: This study found evidence of an independent association between mild to moderate reductions in kidney function and poor executive function at baseline but not with global cognitive impairment or risk of cognitive decline in older men. J Am Geriatr Soc 2008;56(11):2082-2088.