The Rural Older Adult Memory (ROAM) Study: A Practice-based Intervention to Improve Dementia Screening and Diagnosis

The Journal of the American Board of Family Medicine

Linda Boise³  Monica Goubaud¹  David I. Buckley¹  Elizabeth Eckstrom²  Lyle Fagnan¹  Anne King¹  Cynthia Morris¹ 

[1] Oregon Rural Practice-based Research Network (LF, AK, MG, DIB, CM), Oregon Health and Science University, Portland;Department of Internal Medicine (EE), Oregon Health and Science University, Portland;Layton Aging and Alzheimer`s Disease Center (LB), Oregon Health and Science University, Portland

关键词: Practice-based Research;    PBRN;    Dementia;    Rural Health;    Primary Health Care;   

DOI  :  10.3122/jabfm.2010.04.090225

学科分类：过敏症与临床免疫学

来源: The American Board of Family Medicine

【 摘 要 】

Introduction: The aim of the Rural Older Adult Memory (ROAM) pilot study was to evaluate the feasibility of screening and diagnosing dementia in patients aged 75 years or older in 6 rural primary care practices in a practice-based research network.

Methods: Clinicians and medical assistants were trained in dementia screening using the ROAM protocol via distance learning methods. Medical assistants screened patients aged 75 years of age and older. For patients who screened positive, the clinician was alerted to the need for a dementia work-up. Outcomes included change in the proportion of patients who were screened and diagnosed with dementia or mild cognitive impairment, clinician confidence in diagnosing and managing dementia, and response to the intervention.

Results: Results included a substantial increase in screening for dementia, a modest increase in the proportion of patients who were diagnosed with dementia or mild cognitive impairment, and improved clinician confidence in diagnosing dementia. Although clinicians and medical assistants found the ROAM protocol easy to implement, there was substantial variability in adherence to the protocol among the 6 practices.

Conclusion: This study demonstrated the complex issues that must be addressed in implementing a dementia screening process in rural primary care. Further study is needed to develop effective strategies for overcoming the factors that impeded the full uptake of the protocol, including the logistic challenges in implementing practice change and clinicians’ attitudes toward dementia screening and diagnosis.

• Practice-based Research
• PBRN
• Dementia
• Rural Health
• Primary Health Care

Dementia is common among older adults, with an estimated prevalence of 11% to 16% among people older than 70.¹ Often, a primary care clinician (PCP) is the only clinician available to older patients with memory complaints, but numerous studies have found that as many as 50% of patients with dementia do not have a diagnosis of dementia documented in their medical chart.^2–5 The subtlety of symptoms and time constraints in primary care practice make it challenging for PCPs to recognize and diagnose dementia.^6,7

Although the US Preventive Services Task Force has not recommended screening for dementia,⁸ Alzheimer disease experts have identified a number of reasons why diagnosis is important, including ruling out treatable conditions that can cause cognitive impairment (eg, medication effects, cardiovascular conditions, or depression)⁹; offering treatments for cognitive and behavioral symptoms of dementia¹⁰; maintaining patients’ safety¹¹; and support for the family.¹² Given clinicians’ reliance on patients’ memories for symptom reporting and adherence to treatment recommendations, the identification of cognitive impairment in patients is essential.^13–15

Several studies to improve the diagnosis of dementia conducted in academic and/or urban settings have had varying degrees of success.^3,16,17 This is the first known study to test a dementia screen and diagnosis intervention in rural primary care. Improving dementia care is particularly challenging in rural areas where access to community resources, including medical specialists, are limited and primary care workloads are greater than in urban areas.^18,19

Practice-based research networks offer a promising approach to improving primary care because clinicians and their staff are directly engaged in testing practice changes.^20,21 Among other resources, practice-based research networks can provide direct assistance to practices engaged in the quality improvement studies through a “change facilitator.”²²

The Rural Older Adult Memory (ROAM) study was conducted in the Oregon Rural Practice-based Research Network (ORPRN), a statewide network of 46 primary care practices in 35 communities that serve approximately 223,000 patients. Our aim was to evaluate the feasibility of the ROAM study for dementia screening and diagnosis in 6 rural practices that were members of ORPRN. We adapted the materials and procedures for the dementia-specific component of the Assessing Care of the Vulnerable Elders (ACOVE) model developed by geriatric experts at the University of California—Los Angeles and Rand Corp.¹⁷ ACOVE uses 5 clinic-based methods to improve practice: (1) efficient collection of condition-specific clinical data, (2) medical record prompts to encourage performance of essential care processes, (3) patient education materials and activation of the patient's role in follow-up, (4) physician decision support, and (5) physician education. Preliminary tests of this model found it to be feasible in urban and suburban practices but, to our knowledge, it has not been tested in rural practices. Furthermore, the ACOVE model has had limited testing of its dementia component as a single-condition intervention.

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