Alzheimer's and Dementia Screening

Summary:  As part of the new health care reform law in the U.S., Medicare will begin covering dementia screening next year.  Researchers who developed a new screening questionnaire called AD8 at Washington University in St. Louis believe it is the right tool for screening.  No matter which tool is best, screening all older adults for dementia may not be practical or useful. 

Along with more than 100 other participants, I listened to Tuesday’s Alzheimer Research Forum webinar about a new paper and pencil test to screen for dementia.  The new screening tool, called AD8, was developed by researchers at Washington University in St. Louis.  It consists of eight questions about changes in behavior that could be caused by problems with memory and thinking, and is meant to be answered by a family member or close relative or friend.  It can also be filled out by the person being screened.

A good portion of the webinar was a presentation by one of the tool’s developers, Dr. James Galvin (now at New York University).  He presented research showing AD8 is better at detecting early dementia than some other tools.  But the panel discussion and questions towards the end of the hour got at the more fundamental question:  is screening all older adults for dementia a good idea?

Whether or not it’s a good idea, dementia screening may soon become part of routine care for Americans over 65 (the age of eligibility for Medicare).  As part of this year’s health care reform legislation in the U.S., Medicare will cover “detection of cognitive impairment” and development of a personalized plan for future screenings starting in 2011. [AARP has published a good explanation of the new coverage for preventive services.] 

It appears most older adults wouldn’t mind being screened.   During the webinar, Dr. Tracey Holsinger, of Duke University and the Durham (N.C.) Veterans Affairs Medical Center, presented her research showing the majority of primary care patients would accept this type of screening.

Even though screening for memory problems will be covered by Medicare, the U.S. Preventive Services Task Force (convened by the Agency for Healthcare Research and Quality, or AHRQ) does not recommend screening all older adults for dementia.  In a rationale developed in 2003, the Task Force said there was not enough evidence that current treatments help people with dementia carry out everyday activities, and not enough evidence that any benefits shown in clinical trials would apply to primary care patients in general. 

The Task Force recommendation against screening also cites doubts about the feasibility of screening and treatment in routine doctor visits.  These doubts were echoed by webinar presenters.  While administering AD8 may not require too much effort from health care professionals, it works best when filled out by a family member or other “informant.”   However, most older adults still go to doctor visits alone, said Dr. Eric Tangalos, a primary care physician and co-director for education at the Alzheimer's Disease Research Center at Mayo Clinic.  Dr. Tangalos and Dr. Holsinger both said that even when patients do screen positive for dementia, busy primary care doctors might not be able to coordinate the more complicated care needed.

in view of the new diagnostic tools and imaging techniques in development, as well as new research on screening tools like AD8, Dr. Galvin thinks it’s time to reconvene the Task Force and ask them to revisit their dementia screening recommendations.   He and other webinar panelists agreed that screening all older adults may not be practical or useful, and would like the Task Force to issue evidence-based guidelines on when patients should be screened.

I can see some benefits to screening for dementia, especially when a patient complains about memory.  I’m sure a screening tool like AD8 would have confirmed my father’s fears about dementia during the years his primary care physician brushed aside his concerns.   Screening resulting in earlier diagnosis gives patients and families more time to plan care, of course.  Screening all older adults would also give us data about how prevalent problems with memory and thinking might be in the older population, and could help recruit appropriate participants for clinical trials. 

But are there enough overall benefits to recommend general screening?  Will it improve our nation’s cognitive health, or ensure better care?  Even if my father had been referred to a memory disorder clinic early on, I doubt it would have made his diagnosis any easier, his care any better, or his treatments more effective.   New imaging techniques may eventually make diagnosis more accurate, new treatments will eventually be developed, and research may improve the standard of care.   None of these advances will come quickly, though.  Until available treatment and care improves, I’m not sure about the value of screening.

Comments

[Richard Taylor]

Hello, several years ago I was a proponent of screening, then the more I learned about how little anyone really knows about dementia and it's many forms, and when I experienced first hand the trama of the diagnosis I changed my mind.

We have the dementia cart, full of instruments, imaging machines, gene counters, and wisful thinkers way ahead of the horse of science, the team of horse that comprise a consesus as to exactly what it is that is being measured.

It's reckless to throw around terms that are know to product major emotional and life changing responses without out first knowing lots more than we now know about dementia, alzheimer's disease, and how the brain works on a good day.

All this testing talk takes away from dealing with the everyday problems of living that are common to many folks with many forms of disability. We spend too much time measuring and try to measure something we can't all agree on exactly what it is we are measuring.

Useing words, especially the words, thoughts and feelings of somone other than the individual primarily impacted by the symptoms is worrysome at best and just wrong at worst.

And we still don't have a consesus as to staging the forms of dementia, the progression of each of the forms, the role each of our unique brains plays in repressing the observable symptoms, etc. etc.

Dare I say physicians are looking for something quick, easy, and inespensive that produces a number that they can then compare to chart to determine what box we are to stand in for the rest of our lives.

Let's stop this rush to judgement of all folks using the same chart, the same questions, and relying on the consistency of observational abilities across spouses.

Let's just stop all this, and start talking with and about the everyday problems of living with the symptoms of dementia, and the role the medical community should play in providing leadership to families that are faced with these symptoms.

Richard

[Despr8caregiver]

My experience with chronic illness and dementia is that without an accurate diagnosis, there is not going to be a helpful or efficient treatment. My father was the victim of a false Dx of Alzheimer's disease and therefore was given unneeded medication that contributed to his frailty and an earlier death. He did have dementia, however, and a true diagnosis of the type of dementia he was suffering from might have helped him. Wrong diagnosis or no diagnosis--no possibility of help or hope.

We write about this problem and others we have faced as caregivers at
http://www.desperatecaregivers.com/trying-to-take-care-of-the-elderly-without-really-knowing-how