Evaluation of suspected dementia: 2-visit approach is effective

Prevalence of dementia will increase as the U.S. and the world population ages. The text below is based on a recent review in the journal Am Fam Physician:

Risk factors for dementia include:

- age
- family history of dementia
- apolipoprotein E4 genotype
- cardiovascular comorbidities
- chronic anticholinergic use
- lower educational level

A two-visit approach is time-effective for primary care physicians.

During the first visit, the physician should administer a screening test such as:

- verbal fluency test
- Mini-Cognitive Assessment Instrument
- Sweet 16

The tests above have relatively high sensitivity and specificity for detecting dementia, and can be completed in as little as 60 seconds (Note by editor: this one-minute time estimate sounds too optimistic, it usually takes considerably longer).

If the screening test result is abnormal or another disease is suspected, laboratory and imaging tests should be ordered, and the patient should return for additional cognitive testing.

A second visit should include:

- Mini-Mental State Examination
- Geriatric Depression Scale
- verbal fluency
- clock drawing tests

For patients with dementia, the following characteristics are useful for identifying
patients at increased risk for unsafe driving:

- Clinical Dementia Rating scale (Level A)
- caregiver’s rating of a patient’s driving ability as marginal or unsafe (Level B)
- history of crashes or traffic citations (Level C)
- reduced driving mileage or self-reported situational avoidance (Level C)
- Mini-Mental State Examination scores of 24 or less (Level C)
- aggressive or impulsive personality characteristics (Level C)


Evaluation of driving risk in dementia (click to enlarge the image).

References:

Evaluation of suspected dementia. Simmons BB, Hartmann B, Dejoseph D. Am Fam Physician. 2011 Oct 15;84(8):895-902.

Chronic Diarrhea - Diagnostic Evaluation

Chronic diarrhea is defined as a decrease in stool consistency (loose BM) for more than 4 weeks (Am Fam Physician, 2011).

It can be divided into 3 categories:

- watery
- fatty (malabsorption)
- inflammatory

Watery diarrhea

Watery diarrhea may be subdivided into:

- osmotic
- secretory
- functional, e.g. IBS

Watery diarrhea includes irritable bowel syndrome (IBS), which is the most common cause of functional diarrhea. Another example of watery diarrhea is microscopic colitis, which is a secretory diarrhea affecting older persons.

Laxative-induced diarrhea is often osmotic.

Malabsorptive diarrhea

Malabsorptive diarrhea is characterized by excess gas, steatorrhea, or weight loss. Giardiasis is a classic infectious example of malabsorptive diarrhea.

Celiac disease (gluten-sensitive enteropathy) is also malabsorptive, and typically results in weight loss and iron deficiency anemia.

Inflammatory diarrhea

Inflammatory diarrhea, such as ulcerative colitis (UC) or Crohn disease, is characterized by blood and pus in the stool and an elevated fecal calprotectin level.

Invasive bacteria and parasites also produce inflammation. Infections caused by Clostridium difficile (C. diff.) subsequent to antibiotic use have become increasingly common and virulent.


Image source: Escherichia coli, Wikipedia, public domain.

Not all chronic diarrhea is strictly watery, malabsorptive, or inflammatory, because some categories overlap.

References:

Evaluation of Chronic Diarrhea. Juckett G, Trivedi R. Am Fam Physician. 2011 Nov 15;84(10):1119-1126.
Skin patch vaccine to prevent travelers' diarrhea
Image source: Colon (anatomy), Wikipedia, public domain.

Evaluation of Scrotal Masses - 2014 review from Am Fam Physician

Scrotal masses are caused by a variety of disorders, ranging from benign conditions to those requiring emergent surgical intervention. Painful scrotal masses require urgent evaluation.

Here are some causes of scrotal masses:

- Characteristics that suggest testicular torsion include rapid symptom onset, nausea and vomiting, high position of the testicle, and abnormal cremasteric reflex. Doppler ultrasonography or surgical exploration is required to confirm the diagnosis. Surgical repair must occur within 6 hours of symptom onset to reliably salvage the testicle.

- Epididymitis/orchitis have a slower onset and are associated with a C-reactive protein level greater than 24 mg per L (228.6 nmol per L) and increased blood flow on ultrasonography.

- Acute onset of pain with near normal physical examination and ultrasound findings is consistent with torsion of the testicular appendage.

- Testicular malignancies cause pain in 15% of cases. If ultrasonography shows an intratesticular mass, timely urology referral is indicated.

- Inguinal hernias are palpated separate to the testicle and can cause pain. Emergent surgery is indicated for a strangulated hernia.

- Hydrocele, varicocele, and scrotal skin lesions may be managed in nonurgent settings.

- A biopsy should be performed to rule out cancer in patients with scrotal skin lesions that are erosive, vascular, hyperkeratotic, or nonhealing, or that change color or have irregular borders.

References:

Evaluation of Scrotal Masses. Crawford P, Crop JA. Am Fam Physician. 2014 May 1;89(9):723-727.
http://www.ncbi.nlm.nih.gov/pubmed/24784335

Image source: The shield and spear of the Roman god Mars, which is also the alchemical symbol for iron, represents the male sex. Wikipedia, public domain.

Approach to evaluation and management of syncope in adults - BMJ Review

Syncope is common in all age groups, and it affects 40% of people during their lifetime, usually described as a "faint" or "blackout".

Neurally mediated syncope, which is benign, is the most common cause

Cardiac syncope as a result of arrhythmias or structural cardiopulmonary disease is more common with increasing age. Cardiac syncope is associated with increased mortality and must be excluded.

Brain imaging, carotid Doppler ultrasound, electroencephalography, and chest radiography are often not needed in patients with syncope.

References:

An approach to the evaluation and management of syncope in adults. BMJ 2010;340:c880.
http://www.bmj.com/cgi/content/short/340/feb19_1/c880

Image source: Illustration of the human brain and skull. Wikipedia, Patrick J. Lynch, medical illustrator, Creative Commons Attribution 2.5 License 2006.

Evaluation of driving risk in dementia - practice parameter update

For patients with dementia, the following characteristics are useful for identifying
patients at increased risk for unsafe driving:

- Clinical Dementia Rating scale (Level A)
- caregiver’s rating of a patient’s driving ability as marginal or unsafe (Level B)
- history of crashes or traffic citations (Level C)
- reduced driving mileage or self-reported situational avoidance (Level C)
- Mini-Mental State Examination scores of 24 or less (Level C)
- aggressive or impulsive personality characteristics (Level C)


Evaluation of driving risk in dementia (click to enlarge the image).

The following characteristics are not useful for identifying patients at increased risk for unsafe driving:

- patient’s self-rating of safe driving ability (Level A)
- lack of situational avoidance (Level C)

References:
Practice Parameter update: Evaluation and management of driving risk in dementia. Neurology 2010;74:1316–1324 (PDF)