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February 5, 2013 Issue

Clinical Practice Points

Comparative Effectiveness of Alternative PSA-Based screening strategies

This modeling study found that using higher PSA thresholds for biopsy in older men and reducing the frequency of screening following an initially low PSA would reduce the harms of screening while preserving lives saved.

Use this study to:


Association Between Midlife Cardiorespiratory Fitness Levels and Later-Life Dementia

This cohort found that higher levels of physical fitness in middle age were associated with a lower hazard of dementia after age 65.

Use this study to:

  • Review the diagnostic approach to cognitive abnormalities, and the types of dementia (use In The Clinic: Dementia for a concise guide).
  • Discuss how physical fitness might decrease the risk for dementia and variables that might confound the relationship.
  • Ask what your residents tell their patients about exercise.
  • Start the teaching session with a MKSAP question about dementia. There's one below.

In the Clinic: Chlamydia and Gonorrhea

This concise and eminently practical review asks—and provides answers to—questions all residents need to know. It includes 5 MKSAP questions—structure an interactive teaching session around them.

Use this review to ask:

  • Who should be screened for chlamydia and gonorrhea, and how often?
  • What is the best method of diagnosis? Is a clinical diagnosis ever sufficient?
  • Has antibiotic resistance altered treatment recommendations, and what are they?

Recommended Adult Immunization Schedule: United States, 2013

The CDC’s Advisory Committee on Immunization Practices has updated its recommendations for adult immunizations.

Use this report to:

  • Review the new schedule for adult immunizations.
  • Pretend you're a patient who does not want a flu shot. Have your residents address your concerns.
  • Download the free ACP Immunization Advisor app at iTunes—residents can use it to help quickly check on ACIP recommendations and the vaccinations their patients need.

Quality Improvement

The Patient-Centered Medical Home

Do your residents know what a PCMH is? This systematic review found evidence that PCMH interventions have positive effects on preventive care services, as well as patient and staff experiences.

Use this study to:

  • Define a PCMH.
  • Discuss whether your resident practice is designed to provide patient-centered care.
  • Brainstorm ways to improve the performance of your practice. Review information about the Patient-Centered Medical Home from ACP.

Humanism and Professionalism

Nonadherent: A Four-Letter Word

Play an audio recording of this issue's On Being A Doctor. Ask your residents to reflect on patients who are "nonadherent" or "noncompliant." Does that label alter their attitude or approach to their patients' care? Are there limits to what a physician should "put up with?" Should they ever give up on a patient?


MKSAP Question

Begin a teaching session on Dementia with the following question from MKSAP 15:

An 81-year-old man is evaluated for the gradual onset and progression of memory loss over the past year. He says he has difficulty recalling the names of familiar people, has misplaced his wallet on numerous occasions, and is slower to find his car in large, crowded parking lots. He continues to manage his finances, travel with his wife, and perform the activities of daily living without difficulty. He has borderline hyperlipidemia that is managed by diet alone. A paternal uncle developed Alzheimer dementia at age 74 years. His only medications are aspirin and a daily multivitamin.

On physical examination, temperature is 36.7 °C (98.1 °F), blood pressure is 126/82 mm Hg, pulse rate is 68/min, respiration rate is 14/min, and BMI is 26. His level of alertness, speech, and gait are normal. He scores 26/30 on the Folstein Mini–Mental State Examination, losing all three points on the recall portion and one point on the orientation section for incorrectly stating today’s date.

Results of a complete blood count, serum vitamin B12 measurement, thyroid function tests, and a basic metabolic panel are normal.

An MRI of the brain without contrast shows no abnormalities.

Which of the following is the most likely diagnosis at this time?

A: Alzheimer dementia
B: Dementia with Lewy bodies
C: Frontotemporal dementia
D: Mild cognitive impairment
E: Vascular dementia

Answer: D: Mild cognitive impairment

Educational Objective: Diagnose mild cognitive impairment.

Key Point Mild cognitive impairment denotes abnormal cognitive decline that is not severe enough to produce disability.

Critique: This patient has mild cognitive impairment (MCI), which denotes abnormal cognitive decline that is not severe enough to produce disability. His self-reported memory loss, which is confirmed by his performance on the Folstein Mini–Mental State Examination, is his only symptom; there are no other signs of dementia. Memory loss is nonspecific and is part of many dementia syndromes. However, the lack of any functional impairment in this patient makes MCI the most likely diagnosis at this time. Although there are no universally accepted criteria for MCI, the disorder has been defined as a memory abnormality corroborated by objective memory impairment on standardized tests, without general cognitive impairment or an effect on functional independence. The rate of progression to dementia is approximately 10% to 15% per year.

Alzheimer dementia is the most common cause of MCI involving memory loss. Because this patient has no functional disabilities and thus does not meet the criteria for frank dementia, Alzheimer dementia is an incorrect diagnosis at this point. He may eventually develop the disease, given that the conversion rate of MCI to dementia is roughly 10% to 15% per year and that, at autopsy, approximately 80% of patients originally diagnosed with MCI have Alzheimer dementia.

Early-stage symptoms that are characteristic of frontotemporal dementia include changes in behavior and personality, such as increasing apathy, disinhibition, or perseverative (repetitive to an exceptional degree) fixations. This patient has exhibited no such changes. The onset of dementia with Lewy bodies could also be characterized by memory loss. Besides clearly not having dementia of any sort at this stage of his illness, this patient lacks any of the other symptoms of dementia with Lewy bodies, such as parkinsonism, visual hallucinations, psychomotor slowing, and dream enactment behavior.

Typical manifestations of vascular dementia include psychomotor slowing, a stepwise progression, and a history of stroke, none of which pertains to this patient.

Bibliography

Petersen RC, Stevens JC, Ganguli M, Tangalos EG, Cummings JL, DeKosky ST. Practice parameter: early detection of dementia: mild cognitive impairment (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001;56(9):1133-1142. [PMID: 11342677] - See PubMed

This question was derived from MKSAP® 15


From the Editors of Annals of Internal Medicine and Education Guest Editor, Erin Ney, MD, FACP Assistant Residency Program Director, Department of Internal Medicine, Thomas Jefferson University.

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