The Case for Dementia Screening in At-Risk Populations
By Dr. Howard Fillit
Years ago, I consulted on a managed care case that encapsulated the value of screening for dementia in at-risk populations. A Texas nurse described an 80-year-old patient with a number of comorbidities—heart disease, diabetes and obesity—who was readmitted to her hospital on a near-monthly basis. The patient would pay the hospital a visit, get a tune up and leave in stable shape with prescriptions and detailed care instructions in tow. But without fail, he’d be back in the hospital a month later with the same complaints. I asked the nurse about his cognitive status and she told me, “I have no idea.”
I suggested a home visit to better ascertain his mental state, and a member of her team traveled 50-plus miles to the man’s sprawling, remote ranch house. The man lived alone, his house was a mess, and it was clear that—like more than 50 percent of the people with Alzheimer’s and other forms of dementia—he was undiagnosed. The reason for his return visits was clear. By the time he’d exited the hospital and settled into a taxi for the long ride home, he’d forgotten everything he’d been instructed to do.
Just imagine how that man would have fared if he had been screened for dementia when he hit 75—an age at which up to 25 percent of all individuals have dementia. His care team would have had the information they needed to ensure that his medical issues were adequately treated in a manner that accounted for his compromised cognitive state. His health would have improved, and the cumulative cost and frequency of his hospital visits would have plummeted.
By continuing to waffle on a recommendation regarding screening for cognitive impairment, the U.S. Preventive Services Task Force (USPSTF) is failing to recognize how valuable early diagnosis can be for patients and caregivers. When people are diagnosed early, they can prepare for the long and difficult road ahead, and they can better understand their challenges and their loved ones’ challenges. Moreover, the physicians and nurses who treat these patients can benefit from vital knowledge that will inform their care recommendations and their understanding of patients’ unique struggles.
In its formal recommendation, the USPSTF says there is insufficient evidence to recommend for or against dementia screening, adding: “There is fair to good evidence that several drug therapies have a beneficial effect on cognitive function (equivalent to delaying the natural progression of Alzheimer's disease from 2 to 7 months), but the evidence of their beneficial effects on instrumental activities of daily living is mixed, with the benefit being small, at best.”
By focusing on the therapeutic benefits of screening—and evaluating but dismissing evidence demonstrating how screening benefits care planning—the USPSTF misses the mark. We all agree that current medications are not highly effective, which is why the Alzheimer’s Drug Discovery Foundation has provided more than $65 million to support research into more effective therapeutics to prevent, treat or slow the progression of Alzheimer’s disease and related dementias. But that doesn’t mean that early detection can’t provide tremendous value to caregivers, physicians and patients.
The focus on drug efficacy over care planning is not the only flaw in the USPSTF’s recommendation. The task force looked at screening benefits in patients 65 and up—a threshold at which the number of patients with dementia is relatively low and the benefits of screening are not always apparent. Had they evaluated the benefits of screening in patients 75 and up, the yield versus the cost of screening would have been much higher and the task force may have found conclusive evidence in favor of routine screening.
Alzheimer’s and other dementias place tremendous pressure on patients, families, providers and the economy. We must do everything in our power to mitigate these challenges—and that means supporting dementia screening that promotes early detection and aids care planning, as well as funding novel drug discovery research and development.