Should we screen everyone for dementia?

medical decisionMore than 5 million adults in the U.S. suffer from Alzheimer’s disease, and even more suffer from other dementias that result in memory loss and speech difficulties, and interfere with thinking and plans skills.

Most of the time, dementia is diagnosed when a caregiver such as a doctor notices symptoms in a patient, or when a caregiver suspects something is wrong. Experts believe that leaves a vast majority of dementia cases in the primary setting undiagnosed.

In 2011, Medicare – the federal health insurance for the elderly – began covering cognitive screening as part of every senior citizen’s an annual check-up. But does the evidence say this change will help?

The U.S. Preventative Services Task Force recently reviewed all of the evidence available to determine whether this type of screening is beneficial. The task force makes recommendations about the effectiveness of preventative care treatments for patients without any signs or symptoms.

In this case, the Task Force did not find enough evidence to support screenings for dementia if a patient has no evidence of cognitive impairment.  After screening dozens of studies, the experts found no evidence for concrete benefits to the screenings. While there are some screening tools that seem to work, treatment of mild to moderate dementia results in very small improvements in cognitive function. And there is no evidence the screening helps with decision-making or planning for future care.

“As in so many clinical matters, the decision to screen for cognitive impairment is a judgment call,” explained Dr. Robert Abrams, Professor of Clinical Psychiatry at Weill Cornell Medical College.

Patients who are interested in participating in research are obvious candidates for screening, he said. Screening is also appropriate for patients who understand the limitations of medication for cognitive decline and still wish to try them.

“It should be understood, however, that simple screening is not without a potential for collateral damage,” he said. “Some individuals experience painful shame and embarrassment when they find themselves unable to give correct responses to what they realize are basic items.  Also, the tests themselves are not reliable for all individuals.  They are  subject to ‘state effects,’  whereby acute anxiety or depression can adversely affect performance.  There are also patients who test more poorly than they function, and others who function more poorly than they test.”

The task force did find that early detection and diagnosis of dementia by recognizing the signs and symptoms of the disease are helpful. They also called for more research in large-scale dementia screenings. The bottom line in this case is that there is so much that we don’t know.

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