Editor—We have a critical comment on the North of England dementia guideline’s emphasis on the use of cognitive screening tests such as the mini-mental state examination by general practitioners.1 We do not oppose the use of screening tests but emphasise that in a primary care setting general practitioners have different and equally effective means of diagnosing dementia. To illustrate this we report on an evaluation study of the diagnostic accuracy of general practitioners who applied the Dutch national dementia guideline for general practitioners.2
In this study a cross sectional comparison was conducted between the diagnoses of a sample of 64 general practitioners and an outpatient memory clinic in the district of Nijmegen in the Netherlands. The general practitioners were recruited by mailing and were representative of the Dutch population of general practitioners regarding age, sex, and practice size.3 A case finding approach was used, with elderly patients suspected of having dementia being diagnosed according to the national guideline and subsequently referred to the memory clinic. The dementia guideline held diagnostic criteria of the Diagnostic Statistical Manual of Mental Disorders4 and comprised 29 diagnostic key recommendations for a cognitive, physical, and behavioural examination. A cognitive screening test such as the mini-mental state examination was optional. The memory clinic’s diagnosis acted as a gold standard. We related the general practitioners’ diagnostic accuracy to whether or not they used the mini-mental state examination.
For the analysis of accuracy, data on 93 patients were available. In 18 cases the mini-mental state examination was applied. The average rate of application of the recommendations was 86% (SD 8.6%) and did not differ between general practitioners who used the mini-mental state examination and those who did not (Mann-Whitney U=683, P=0.3). The overall accuracy as expressed by Cohen’s κ was 0.5, which is moderate. Use of the mini-mental state examination was not associated with better diagnostic accuracy (Pearson r=0.04, P=0.4).
Thus use of the mini-mental state examination may be unnecessary to diagnose dementia in general practice when diagnostic recommendations are applied.
References
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