To screen, or not to screen (for dementia), that is still the question

by

A lead­ing group of med­ical experts on Tues­day declined to endorse cog­ni­tive screen­ing for old­er adults, fuel­ing a debate that has sim­mered for years.

The U.S. Pre­ven­tive Ser­vices Task Force said it could nei­ther rec­om­mend nor oppose cog­ni­tive screen­ing, cit­ing insuf­fi­cient sci­en­tif­ic evi­dence of the practice’s ben­e­fits and harms and call­ing for fur­ther studies.

The task force’s work informs poli­cies set by Medicare and pri­vate insur­ers. Its rec­om­men­da­tions, an accom­pa­ny­ing sci­en­tif­ic state­ment and two edi­to­ri­als were pub­lished Tues­day in the Jour­nal of the Amer­i­can Med­ical Association.

The task force’s new posi­tion comes as con­cern mounts over a ris­ing tide of old­er adults with Alzheimer’s dis­ease and oth­er demen­tias and treat­ments remain elu­sive. Near­ly 6 mil­lion Amer­i­cans have Alzheimer’s dis­ease; that pop­u­la­tion is expect­ed to swell to near­ly 14 mil­lion by 2050.

Because seniors are at high­er risk of cog­ni­tive impair­ment, pro­po­nents say screen­ing ? test­ing peo­ple with­out any symp­toms — is an impor­tant strat­e­gy to iden­ti­fy peo­ple with unrec­og­nized dif­fi­cul­ties and poten­tial­ly lead to bet­ter care.

“This can start a dis­cus­sion with your doc­tor: ‘You know, you’re hav­ing prob­lems with your cog­ni­tion, let’s fol­low this up,’” said Stephen Rao of Cleve­land Clinic’s Lou Ruvo Cen­ter for Brain Health.

Oppo­nents say the ben­e­fits of screen­ing are unproven and the poten­tial for harm is wor­ri­some. “Get­ting a pos­i­tive result can make some­one wary about their cog­ni­tion and mem­o­ry for the rest of their life,” said Ben­jamin Ben­sadon, an asso­ciate pro­fes­sor of geri­atric med­i­cine at the Uni­ver­si­ty of Flori­da Col­lege of Medicine.

The task force’s stance is con­tro­ver­sial, giv­en how poor­ly the health care sys­tem serves seniors with mem­o­ry and think­ing prob­lems. Physi­cians rou­tine­ly over­look cog­ni­tive impair­ment and demen­tia in old­er patients, fail­ing to rec­og­nize these con­di­tions at least 50% of the time, accord­ing to sev­er­al studies.

When the Alzheimer’s Asso­ci­a­tion sur­veyed 1,954 seniors in Decem­ber 2018, 82% said they thought it was impor­tant to have their think­ing or mem­o­ry checked. But only 16% said physi­cians reg­u­lar­ly checked their cognition.

What’s more, Medicare poli­cies appear to affirm the val­ue of screen­ing. Since 2011, Medicare has required that physi­cians assess a patient’s cog­ni­tion dur­ing an annu­al well­ness vis­it. But only 19% of seniors took advan­tage of this vol­un­tary ben­e­fit in 2016, the most recent year for which data is available.

Dr. Ronald Petersen, co-author of an edi­to­r­i­al accom­pa­ny­ing the rec­om­men­da­tions, cau­tioned that they shouldn’t dis­cour­age physi­cians from eval­u­at­ing old­er patients’ mem­o­ry and thinking.

“There is increased aware­ness, both on the part of patients and physi­cians, of the impor­tance of cog­ni­tive impair­ment,” said Petersen, direc­tor of the Mayo Clinic’s Alzheimer’s Dis­ease Research Cen­ter. “It would be a mis­take if physi­cians didn’t pay more atten­tion to cog­ni­tion and con­sid­er screen­ing on a case-by-case basis.”

Sim­i­lar­ly, seniors shouldn’t avoid address­ing wor­ri­some symptoms.

“If some­one has con­cerns or a fam­i­ly mem­ber has con­cerns about their mem­o­ry or cog­ni­tive abil­i­ties, they should cer­tain­ly dis­cuss that with their clin­i­cian,” said Dr. Dou­glas Owens, chair of the task force and a pro­fes­sor at Stan­ford Uni­ver­si­ty School of Medicine.

In more than a dozen inter­views, experts teased out com­plex­i­ties sur­round­ing this top­ic. Here’s what they told me:

Screen­ing basics. Cog­ni­tive screen­ing involves admin­is­ter­ing short tests (usu­al­ly five min­utes or less) to peo­ple with­out any symp­toms of cog­ni­tive decline. It’s an effort to bring to light prob­lems with think­ing and mem­o­ry that oth­er­wise might escape attention.

Depend­ing on the test, peo­ple may be asked to recall words, draw a clock face, name the date, spell a word back­ward, relate a recent news event or sort items into dif­fer­ent cat­e­gories, among oth­er tasks. Com­mon tests include the Mini-Cog, the Mem­o­ry Impair­ment Screen, the Gen­er­al Prac­ti­tion­er Assess­ment of Cog­ni­tion and the Mini-Men­tal Sta­tus Exam­i­na­tion.

The task force’s eval­u­a­tion focus­es on “uni­ver­sal screen­ing”: whether all adults age 65 and old­er with­out symp­toms should be giv­en tests to assess their cog­ni­tion. It found a lack of high-qual­i­ty sci­en­tif­ic evi­dence that this prac­tice would improve old­er adults’ qual­i­ty of life, ensure that they get bet­ter care or pos­i­tive­ly affect oth­er out­comes such as care­givers’ effi­ca­cy and well-being.

A dis­ap­point­ing study. High hopes had rest­ed on a study by researchers at Indi­ana Uni­ver­si­ty, pub­lished in Decem­ber. In that tri­al, 1,723 old­er adults were screened for cog­ni­tive impair­ment, while 1,693 were not.

A year lat­er, seniors in the screen­ing group were not more depressed or anx­ious — impor­tant evi­dence of the lack of harm from the assess­ment. But the study failed to find evi­dence that peo­ple screened had a bet­ter health-relat­ed qual­i­ty of life or low­er rates of hos­pi­tal­iza­tions or emer­gency depart­ment visits.

Two-thirds of seniors who test­ed pos­i­tive for cog­ni­tive impair­ment in her study declined to under­go fur­ther eval­u­a­tion. That’s con­sis­tent with find­ings from oth­er stud­ies, and it tes­ti­fies to “how many peo­ple are ter­ri­fied of demen­tia,” said Dr. Tim­o­thy Hold­en, an assis­tant pro­fes­sor at Wash­ing­ton Uni­ver­si­ty School of Med­i­cine in St. Louis.

“What seems clear is that screen­ing in and of itself doesn’t yield ben­e­fits unless it’s accom­pa­nied by appro­pri­ate diag­nos­tic fol­low-up and care,” said Nicole Fowler, asso­ciate direc­tor of the Cen­ter for Aging Research at Indi­ana University’s Regen­strief Institute.

Selec­tive screen­ing. “Selec­tive screen­ing” for cog­ni­tive impair­ment is an alter­na­tive to uni­ver­sal screen­ing and has gained support.

In a state­ment pub­lished last fall, the Amer­i­can Acad­e­my of Neu­rol­o­gy rec­om­mend­ed that all patients 65 and old­er seen by neu­rol­o­gists get year­ly cog­ni­tive health assess­ments. Also, the Amer­i­can Dia­betes Asso­ci­a­tion  rec­om­mends that all adults with dia­betes age 65 and old­er be screened for cog­ni­tive impair­ment at an ini­tial vis­it and annu­al­ly there­after “as appro­pri­ate.” And the Amer­i­can Col­lege of Sur­geons now rec­om­mends screen­ing old­er adults for cog­ni­tive impair­ment before surgery.

Why test select groups? Many patients with dia­betes or neu­ro­log­i­cal con­di­tions have over­lap­ping cog­ni­tive symp­toms and “it’s impor­tant to know if a patient is hav­ing trou­ble remem­ber­ing what the doc­tor said,” said Dr. Nor­man Fos­ter, chair of the work­group that devel­oped the neu­rol­o­gy state­ment and a pro­fes­sor of neu­rol­o­gy at the Uni­ver­si­ty of Utah.

Physi­cians may need to alter treat­ment reg­i­mens for old­er adults with cog­ni­tive impair­ment or work more close­ly with fam­i­ly mem­bers. “If some­one needs to man­age their own care, it’s impor­tant to know if they can do that reli­ably,” Fos­ter said.

With surgery, old­er patients who have pre­ex­ist­ing cog­ni­tive impair­ments are at high­er risk of devel­op­ing delir­i­um, an acute, sud­den-onset brain dis­or­der. Iden­ti­fy­ing these patients can alert med­ical staff to this risk, which can be pre­vent­ed or mit­i­gat­ed with appro­pri­ate med­ical attention.

Also, peo­ple who learn they have ear­ly-stage cog­ni­tive impair­ment can be con­nect­ed with com­mu­ni­ty resources and take steps to plan for their future, med­ical­ly and finan­cial­ly. The hope is that, one day, med­ical treat­ments will be able to halt or slow the pro­gres­sion of demen­tia. But treat­ments cur­rent­ly avail­able don’t ful­fill that promise.

Steps after screen­ing. Screen­ing shouldn’t be con­fused with diag­no­sis: All these short tests can do is sig­nal poten­tial problems.

If results indi­cate rea­son for con­cern, a physi­cian should ask knowl­edge­able fam­i­ly mem­bers or friends what’s going on with an old­er patient. “Are they depressed? Hav­ing prob­lems tak­ing care of them­selves? Ask­ing the same ques­tion repeat­ed­ly?” said Dr. David Reuben, chief of geri­atrics at UCLA’s David Gef­fen School of Med­i­cine and direc­tor of UCLA’s Alzheimer’s and Demen­tia Care program.

A com­pre­hen­sive his­to­ry and phys­i­cal exam­i­na­tion should then be under­tak­en to rule out poten­tial reversible caus­es of cog­ni­tive dif­fi­cul­ties, impli­cat­ed in about 10% of cas­es. These include sleep apnea, depres­sion, hear­ing or vision loss, vit­a­min B12 or folic acid defi­cien­cies, alco­hol abuse and side effects from anti­cholin­er­gic drugs or oth­er med­ica­tions, among oth­er conditions.

Once oth­er caus­es are ruled out, neu­ropsy­cho­log­i­cal tests can help estab­lish a diagnosis.

“If I detect mild cog­ni­tive impair­ment, the first thing I’ll do is tell a patient I don’t have any drugs for that but I can help you com­pen­sate for deficits,” Reuben said. The good news, he said: A sub­stan­tial num­ber of patients with MCI ? about 50% — don’t devel­op demen­tia with­in five years of being diagnosed.

The bot­tom line. “If you’re con­cerned about your mem­o­ry or think­ing, ask your physi­cian for an assess­ment,” said Dr. David Knop­man, a neu­rol­o­gist at the Mayo Clin­ic. If that test indi­cates rea­son for con­cern, make sure you get appro­pri­ate follow-up.

That’s eas­i­er said than done if you want to see a demen­tia spe­cial­ist, not­ed Dr. Soo Bor­son, a pro­fes­sor emeri­ta of psy­chi­a­try at the Uni­ver­si­ty of Wash­ing­ton. “Every­one I know who’s doing clin­i­cal demen­tia care says they have wait lists of four to six months,” she said.

With short­ages of geri­atric psy­chi­a­trists, geri­a­tri­cians, neu­ropsy­chol­o­gists and neu­rol­o­gists, there aren’t enough spe­cial­ists to han­dle demands that would arise if uni­ver­sal screen­ing for cog­ni­tive impair­ment were imple­ment­ed, Bor­son warned.

If you’re a fam­i­ly mem­ber of an old­er adult who’s resist­ing get­ting test­ed, “reach out pri­vate­ly to your pri­ma­ry care physi­cian and express your con­cerns,” said Hold­en of Wash­ing­ton Uni­ver­si­ty. “And let your doc­tor know if the per­son isn’t see­ing these changes or is resis­tant to talk about it.”

This hap­pens fre­quent­ly because peo­ple with cog­ni­tive impair­ments are often unaware of their prob­lems. “But there are ways that we, as physi­cians, can work around that,” Hold­en said. “If a physi­cian han­dles the sit­u­a­tion with sen­si­tiv­i­ty and takes things one step at a time, you can build trust and that can make things much easier.”

Kaiser Health News (KHN) is a nation­al health pol­i­cy news ser­vice. It is an edi­to­ri­al­ly inde­pen­dent pro­gram of the Hen­ry J. Kaiser Fam­i­ly Foun­da­tion, which is not affil­i­at­ed with Kaiser Permanente.

In the col­umn “Nav­i­gat­ing Aging,” KHN con­tribut­ing colum­nist Judith Gra­ham focus­es on med­ical issues and advice asso­ci­at­ed with aging and end-of-life care, help­ing America’s 45 mil­lion seniors and their fam­i­lies nav­i­gate the health care system.

News in Context: