Date of Award


Document Type


Degree Name

Doctor of Philosophy (PhD)


Nursing Science

Research Advisor

Michael A. Carter, DNSc


Ronald L. Cowan, PhD Carolyn Graff, PhD Margaret Thorman Hartig, PhD Todd B. Monroe, PhD


Alzheimer's disease, Diagnosis, Pain, Primary Care


The burden of Alzheimer’s disease (AD) affects not just the individual but also families, providers, and society. Early recognition and diagnosis of AD may reduce cost by reducing interaction with the health care system, earlier initiation of treatment, and prolonging time to long- term care. Primary care providers, the first contact for diagnosis of patients with AD, are not fulfilling the potential of early diagnosis for a variety of reasons. Biomarkers of AD emerge on average 15 to 20 years before clinical diagnosis, yet currently established biomarkers are not easily available in the primary care setting. A growing body of literature is focused on identifying additional non-invasive early signs of AD. The aims of this program of research were to understand factors contributing to the AD diagnosis variability in primary care settings and methods to improve early diagnosis by primary care providers. Four studies were undertaken to achieve these aims. The first study reported the results of an integrated review estimating the prevalence of missed diagnosis in primary care when compared to trained raters’ diagnoses. The findings call to attention the difficulty primary care providers face to detect and diagnose AD at all levels of the healthcare system. This led to the second study. Chronic pain is a common comorbid ailment seen in those with AD and often is a driving factor of patients seeking medical care. In order to understand the pain experience in those with worsening cognition, the second study was a secondary analysis of a cross-sectional age- and sex-matched two group cohort study and found that the experience of pain differs between males and females as a measure of cognition worsened suggesting a possible role of pain as a tool to distinguish those at risk for AD. This finding led to the third study, which was a narrative review conducted to describe how alterations in senses have been associated with the diagnosis of AD. The results suggested differences in smell, taste, vision, hearing, and proprioception were associated with different levels of the AD continuum but points out an obvious gap in the literature concerning other senses. This led to the fourth study examining evidence that the ε4 allele of Apolipoprotein E modifies the experience of pain in those individuals carrying the allele such that greater temperatures are required to elicit pain and the experience of that pain is more unpleasant. Additional studies should expand on the results of this pilot study.

Declaration of Authorship

Declaration of Authorship is included in the supplemental files.




2020-036-Romano-DOA-oldV.pdf (153 kB)
Declaration of Authorship