Dementia Screening: Saying No to the USPSTF and Yes to Brief Cognitive Evaluation

Abstract

Recently, the U.S. Preventive Services Task Force [1] released a widely-publicized review advocating against screening for dementia in older adults. After their review of the literature, they concluded that dementia screening did no harm, but likely did little good. Their position was not based on evidence demonstrating negative outcomes for screening, as they were unable to find any particularly relevant studies that addressed the outcomes question directly. Nor was it based on significant medical risks arising from dementia treatments. They cited the common side effects of cholinesterase inhibitors and memantine, which have been known for decades and are surprisingly minimal for an old and often infirm patient population. Instead, they argued that presently available dementia treatments were not very effective. In other words, if we do not yet have good treatments, why identify the disease state?In our opinion, the USPSTF's reasoning is flawed and their conclusion is potentially harmful to patients suffering from or developing dementia. We believe that the USPSTF position leaves the public and many physicians confused about what to do and the patients with cognitive loss disenfranchised. We Concur, and Here is WhyFirst, and in rebuttal to the USPSTF assertion, the treatment picture for dementia is not as dismal as their position suggests. A contemporaneous review of the same literature [7] makes a convincing case that cholinesterase inhibitors and memantine slow cognitive and functional decline and delay nursing home placement. It also finds that combined treatment is superior to monotherapy. A previous large scale investigation [8] found that patients on continuous anti-dementia treatment lived three years longer, on average, than those who had no treatment or interrupted medication. Add to this a finding from residential care settings [9] documenting better function in patients taking anti-dementia medication, including a reduced need for antipsychotic medications that carry an FDA "black-box" warning. There are a number of single studies with similar findings which became the basis for FDA approval of dementia drugs. We can add to the clinical findings the economic benefit that treatment of dementia with donepezil reduces costs of other medical services [10].But, as noted before, treatment outcome should not be the primary or the governing reason for screening of cognition. In fact, we will argue that screening should be reframed or re-conceptualized in broader terms. We propose to replace the limited concept of screening with a more robust and useful concept called "Brief Cognitive Evaluation" or BCE. Brief Cognitive EvaluationBrief Cognitive Evaluation would employ an economical, easily administered, validated, performance-based tool to produce a metric that is reliable, sensitive to change over time, and useful in broader contexts. In our view, BCE would occur during primary care visits for older patients to measure each patient's global cognitive level as it exists today, just as we measure other impor...

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