Neuropsychological testing in skilled nursing facilities: The failure to confirm diagnoses of dementia

Objective: To investigate to what degree dementia diagnoses of record in skilled nursing facilities (SNFs) are supported by objective neuropsychological testing data. Design: Retrospective analysis of ongoing neuropsychological testing data Setting: Nursing facilities in New York state (n = 11) Participants: Nursing home residents (n = 73) Intervention: Neuropsychological testing Measurements: Standardized neuropsychological testing instruments that included the Cognistat neurobehavioral status examination, the Dementia Rating Scale-2 (DRS-2), the Wechsler Abbreviated Scale of Intelligence (WASI), and the battery of the Consortium to Establish a Registry for Alzheimer's Disease (CERAD battery). Results: A total of 41 males and 32 females were examined. Of those tested, 10 residents were not suspected of having dementia, but required testing to ascertain the nature of certain cognitive complaints presented. Of the remaining residents, 44 had an established diagnosis of dementia in their medical records, and 19 were referred because of a suspicion of dementia, but with no established diagnosis in the record. Based on data from the testing studies, of those with established diagnoses, only 17 (38.6%) met criteria for dementia, while with those with "suspected" dementia, only 3 of the 19 referred (15.7%) met criteria. Of those that did not meet criteria but had an established dementia diagnosis in the record, about half met criteria for "Mild Cognitive Impairment" (MCI), a possible "predementia" condition that involves memory disturbance, but no other cognitive disability. The remaining half met criteria for an Axis I diagnosis, which, in this sample, included mostly depressive disorder, but also cases of anxiety and noncompliance. For those with "suspected" dementia, the overwhelming majority (84.2%) did not meet criteria for a dementia diagnosis, with 75% of those residents meeting criteria for an Axis I diagnosis and 25% meeting criteria for MCI. Only 3 of the 19 "suspected" cases (15.7%) actually met criteria for dementia, according to DSM-IV criteria. Conclusion: Dementia diagnoses may be inaccurate for many nursing home residents. Using objective measurement of cognitive functioning provided by neuropsychological testing could result in greater diagnostic accuracy and help provide for more accurate and appropriate treatment planning.