The latest U.S. Preventive Services Task Force evidence report on screening for cognitive impairment in older adults raises many questions, but provides few answers for healthcare providers, patients, and families. The recommendation findings, published in JAMA, state that the tools to accurately identify cognitive impairment in older adults exist, but that there is insufficient evidence to assess the value of using them routinely in older people.
There is great benefit in providing quality care for people with cognitive impairment and dementia. A lot that needs to be done to care for these patients, and they and their loved ones benefit from and are grateful for early diagnosis, proper treatment, and education and counseling," said Howard Fillit, MD, Founding Executive Director and Chief Science Officer at the Alzheimer's Drug Discovery Foundation, a neuroscientist and geriatrician who has been caring for people with dementia for over 40 years.
The ADDF has invested more than $150 million to support research into finding effective treatments to prevent and treat Alzheimer's disease and related dementias. While we are making much progress, we do not yet have effective disease-modifying medications for Alzheimer's disease. Currently, we only have safe and modestly-effective medications to treat symptoms. But early detection and appropriate care and management care still provide tremendous value to physicians, patients, and their caregivers.
Even though the Task Force report does not imply people with memory or related cognitive problems should forego assessment, there is a risk that some will interpret the report's no evidence finding as negative evidence. In the accompanying editorials, Ronald Petersen, M.D., Ph.D. and Kristina Yaffe, Ph.D., warn "the absence of evidence for benefit may lead to inaction" and that it would be "a terrible mistake if clinicians did not consider the value of screening for cognitive impairment on a case-by-case basis."
"Physicians are trained to practice medicine in the care of each individual patient. If a patient has a memory complaint, or if a loved one or other related person reports a memory issue, or a change in personality, then a cognitive assessment should be done," said Dr. Fillit. "Cognitive assessments are valuable. For example, about 10% of people with cognitive impairment have a reversible cause; delayed diagnosis leads to poor medical and psychosocial outcomes, including major effects on caregivers."
Early diagnosis of dementia also has benefits. Currently, half of people with dementia in the U.S. (mostly related to Alzheimer's disease) are diagnosed two years after onset of symptoms and up to 50% are not diagnosed until the moderate stage of dementia. According to Dr. Fillit, this often leads to unnecessary hospitalizations from accidents/falls, poor medical management of common chronic diseases like diabetes, and many other avoidable medical outcomes.
"Evidence-based medicine is the holy grail and in the perfect world we could precisely quantify the benefits and risks (and costs) of each test, treatment, and non-pharmacologic intervention before we decide to use it, but sometimes that just isn't possible," explained Dr. Fillit. "In this case, we need to trust our medical experts. Individual patients with the warning signs of cognitive impairment and dementia should be properly assessed, diagnosed, treated, and managed just as they are for other chronic diseases of old age. Early diagnosis is critical to quality of care."