May 29, 2014

Should You Be Screened for Cognitive Impairment?

While the new health law requires Medicare to pay for seniors’ cognitive impairment screenings during annual wellness visits, the U.S. Preventive Services Task Force (USPST) -- an independent panel of medical experts -- isn’t sure it’s a good idea for asymptomatic seniors.

As reported in a recent issue of Kaiser Health News, those USPST experts evaluated evidence of the benefit, harm, and clinical utility of several screening tools for cognitive impairment, and determined that the evidence was not sufficient to recommend the tests for seniors without symptoms.

Why not?

Asymptomatic seniors might perform poorly on these cognitive tests for other reasons, like sleep apnea or depression – which can also affect memory and function. Dean Hartley, director of science initiatives at the Alzheimer’s Association, recommends that people take cognitive tests only in a medical setting with a trained profession who can draw reliable conclusions based on the full medical history from patients and their families.

The Risk of Fear
Experts concur that isolated screenings at health fairs and shopping malls – tests that do not take into account patients’ broader medical history – are a bad idea. They can cause unnecessary fear and raise more questions than they answer.

Nonetheless, the Alzheimer’s Association endorses the tests when they’re properly performed, because they establish a baseline for comparison against future results. In addition, large-scale testing might give individuals and their families an early warning, important because drugs – like Aricept – are most effective during the early stages of dementia.

Ariel Green, a geriatrician at Johns Hopkins Bayview Medical Center, said there are no studies that show screening programs actually improve the care of people with dementia.

Family History Matters
However, if a patient has memory lapses, and especially if there’s some family history of dementia, a cognitive screening completed in the context of the patient’s full medical history can be useful.

Green added, “It’s helpful for people to hear a diagnosis of dementia, if it’s an accurate diagnosis, because it can help people anticipate their future needs and plan for that.”

The screenings typically involve a questionnaire that evaluates functions like memory, attention and language and visuospatial skills. A common screening -- the "mini mental state examination” -- takes about ten minutes. It asks 30 questions, like “What month is this?” and “What country are we in?”

Alzheimer’s disease accounts for about 80 percent of all dementia cases. There are other varieties, too, including vascular dementia, and cognitive impairment that can accompany Parkinson’s and Huntington disease.

What’s in a Name?
How do experts define “mild cognitive impairment”? While many descriptions exist, the term typically refers to an impairment that does not hamper people’s ability to manage their daily lives. Estimates suggest that up to 42 percent of people over 65 have cognitive impairment. While it may be a warning sign, it does not always lead to Alzheimer’s.

In the meantime, the debate continues. No experts dispute, though, that these cognitive screenings are best conducted by professionals in the context of the patient’s broader medical and family history.

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