Tangalos, Eric G.

Abstract Background Cognitive impairment often goes undetected by clinicians due to time constraints, limited expertise, and lack of standardized tools. Structured cognitive assessments improve detection accuracy compared to unstructured clinical judgment. In 2013, the Alzheimer’s Association published recommendations to help primary care clinicians incorporate cognitive assessments into the Medicare Annual Wellness Visit. Since then, advances in cognitive assessment tools, availability of disease‐modifying therapies, and shifting expectations around early diagnosis have highlighted the need for updated guidance. In response, the Alzheimer’s Association is developing an evidence‐based clinical practice guideline for cognitive testing in primary care, using the GRADE approach, informed by a systematic review of the best available evidence. Method A multidisciplinary panel formulated a clinical question to inform the development of this guideline. A systematic review was conducted (search range: 1999‐2024) to evaluate the diagnostic accuracy of ten cognitive tests (5‐Cog, AD8, GPCOG, IQCODE, Mini‐Cog, MIS, MoCA, QDRS, RUDAS, and SLUMS) for the early detection of cognitive impairment (including MCI and dementia), in adults aged 55+ in ambulatory settings. The panel also narratively summarized data on emerging digital tools. Result Forty‐one studies meeting eligibility criteria were included in the systematic review. Results were analyzed separately by test (including short‐IQCODE and short‐MoCA) and for primary care and for ambulatory clinic settings (e.g., neurology, memory disorder clinics), as well as for English and Spanish language, resulting in 21 separate analyses. Only three analyses, all related to MoCA, allowed for meta‐analysis. The panel will use the evidence to inform conditional recommendations for or against each specific test. Conclusion By evaluating the diagnostic performance of selected tests, this guideline aims to support healthcare professionals in primary care settings in effective triaging of individuals who may benefit from further cognitive evaluation. To enhance real‐world applicability, considerations such as administration time, ease of scoring, and diagnostic accuracy ‐ along with appropriate cut‐offs by race/ethnicity, education, and language ‐ should be prioritized. This guideline will be regularly updated over time to reflect emerging evidence and the needs of diverse populations.

A woman in her 60s with a history of hypertension and stasis dermatitis presented to a primary care clinic with a bilateral, erythematous rash on the legs, stomach, and chest. Photosensitive rash and dermatitis may be caused by many conditions. Hydrochlorothiazide-induced dermatitis is a rare side effect of thiazide diuretics. Early identification of sulfa-sensitivity and photoallergic or phototoxic reaction is essential to accurate diagnosis and treatment of photosensitive dermatitis. Soliciting a targeted history is essential to delineating drug-induced dermatitis from stasis dermatitis. A thorough skin examination can elucidate the focal or extensive nature of the rash and is essential to making an accurate diagnosis. Immediate cessation of hydrochlorothiazide and switching drugs classes for hypertension management typically leads to resolution of symptoms.

Microdeletions involving chromosome 2p15-16.1 are a rare genetic abnormality and have been reported in 18 separate patients, mainly children, since 2007. This microdeletion syndrome is characterised by a heterogeneous expression of intellectual impairment, dysmorphic facies, musculoskeletal abnormalities and potential neurodevelopmental anomalies. We report the first case of natural progression in an adult patient who died at a young age of metastatic esophageal adenocarcinoma. Important learning points include the variable phenotypic expression of this microdeletion syndrome and the fact that clinicians must be thorough in investigating objective discrepancies in patients who cannot endorse classical symptoms.

Objectives To determine the proportion of nursing home ( NH ) residents ( NHR ) with overactive bladder ( OAB ) or urinary incontinence ( UI ) with potential pharmacodynamic contraindications to antimuscarinic treatment because of concomitant anticholinergic medications or acetylcholinesterase inhibitors ( AC h EI s) and nonpharmacological limitations to antimuscarinic treatment. Design Cross‐sectional retrospective analysis. Setting U.S. skilled nursing facilities. Participants Nursing home residents with a diagnosis of OAB or UI . Measurements Linked and deidentified pharmacy claims and Minimum Data Set ( MDS ) 3.0 records (October 1, 2010 to September 30, 2012). Results Of NHR s, 71.3% received at least one anticholinergic medication. Medications that can cause or worsen UI were used commonly. AC h EI s and antimuscarinic treatment were prescribed concurrently in 24% of NHR s with OAB or UI . NHR s with OAB or UI were more likely to have concurrent moderate to severe cognitive impairment ( MSCI ) (70.1%) than those without (29.9%) ( P < .001). NHR s with or without OAB or UI and with MSCI were more likely to be treated with an anticholinergic medication than those without MSCI ( P = .001). When NHR s with MSCI , severe mobility impairment ( SMI ), and anticholinergic medication and AC h EI use were excluded, only a small proportion of NHR s were potential candidates for antimuscarinic treatment (6.6% with OAB or UI , 6.2% with UI ). Conclusions This study advances understanding of the challenges in prescribing antimuscarinic treatment safely and appropriately in elderly NHR s with a high prevalence of drug interactions, underlying MSCI , and SMI .

Principles and Practice of Nursing Home Care . Edited by Paul R. Katz, MD and Evan Calkins, MD. New York, Springer Publishing Company, Inc., 1989. 443 pages. $43.95.