To what extent do geriatricians document the most bothersome symptoms of patients with advanced dementia?
OBJECTIVE
To assess whether geriatricians documented the bothersome symptoms of patients with advanced dementia, proxy reports of the most-bothersome symptoms affecting those patients (as elicited in research interviews) were compared with what geriatricians who had seen those patients in a proximate clinic visit documented in the medical record.


METHODS
Retrospective chart review.


METHODS
Outpatient geriatrics clinic at the University of Chicago.


METHODS
Fifty-seven pairs of patients with dementia (Functional Assessment Staging Tool stage 6 or 7) and their proxies.


METHODS
Clinic notes were reviewed for documentation of patients' bothersome symptoms that proxies reported during research interviews. Proxy reports had been recorded in the previously established Palliative Excellence in Alzheimer Care Efforts database.


RESULTS
The most-bothersome symptom was documented at least once in 84.2% (48/57) of clinic notes. The second-most-bothersome symptom was documented in 70.3% (26/37) of clinic notes. Most symptoms were documented in the Assessment and Plan section of the note.


CONCLUSIONS
Geriatricians identified and documented the vast majority of bothersome symptoms, as reported by proxies, of patients with moderate to severe dementia.
Garrett
Stephanie L
SL
Department of Family and Geriatric Medicine, University of Louisville, Louisville, Kentucky, USA.
Cox-Hayley
Déon
D
Hougham
Gavin W
GW
Sachs
Greg A
GA
D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care; D003704:Dementia / Q000150:complications* / Q000523:psychology*; D005260:Female; D005853:Geriatrics; D006801:Humans; D008297:Male; D008487:Medical History Taking; D008499:Medical Records; D019727:Proxy; D012189:Retrospective Studies; D012720:Severity of Illness Index