Research Lacking on Screening for Cognitive Impairment

September 23, 2019 04:19 pm Chris Crawford – On Sept. 10, the U.S. Preventive Services Task Force posted a draft recommendation statement and draft evidence review on screening for cognitive impairment in older adults. Notably, this impairment can range from mild cognitive impairment to severe dementia, such as Alzheimer's disease.

Update of 2014 Final Recommendation

This draft recommendation statement is consistent with the task force's 2014 final recommendation on the topic, which the AAFP supported at the time.

To update its previous recommendation, the USPSTF commissioned a systematic review of research on the benefits and harms of screening for all levels of cognitive impairment in community-dwelling adults, including those 65 and older who reside in independent living facilities.

Among other factors, the review assessed the accuracy of screening tests to detect cognitive impairment and the benefits and harms of treatments and interventions for older adults with cognitive impairment and their caregivers. Because older adults with MCI or mild to moderate dementia are the patients most likely to be identified by screening, the review focused on these groups.

Still, the evidence just isn't there, USPSTF members found. "More research is needed to address this important and challenging issue," said task force member Chyke Doubeni, M.D., M.P.H., in the release. "We need more research on whether screening and early detection improve health care decision-making and planning for patients, their families and their clinicians."

Family Physician's Perspective

Between 29% and 76% of patients with dementia are missed in the primary care setting, said Sarah Coles, M.D., of Phoenix, a member of the Academy's Commission on Health of the Public and Science and chair of the AAFP panel currently charged with developing a dementia guideline.

"This highlights how important it is for physicians to not only be on the lookout for symptoms of cognitive impairment and have an assessment strategy for when they present, but also to create a safe space for patients and families to share concerns," Coles told AAFP News. "Cognitive impairment and dementia are highly distressing and vulnerable conditions for patients, and some may be reluctant to bring it up."

Coles emphasized that caregivers must be part of the equation when working with patients who have cognitive impairment.

"Caregiver burden is high, and these individuals are at risk for physical and mental health disorders," she said. "Family physicians are well positioned to diagnose and treat dementia, as well as help patients and caregivers connect with needed resources, implement strategies to improve quality of life and function, and engage in end-of-life planning to ensure that the patient's values and goals are met."

The USPSTF's draft recommendation did not identify any trials that evaluated the direct effect of screening on patient or caregiver outcomes.

"Screening places the patient and caregivers at risk for harms without clear benefits," Coles said.

Unfortunately, she added, treatments for dementia also have limited effectiveness.

"Medications for dementia, such as acetylcholinesterase inhibitors, have significant side effects such as behavioral disturbance, insomnia, falls, incontinence and cardiac dysrhythmias," Coles explained. "Diagnosis can lead to anxiety and depression, worsen stress and lower quality of life."

Dementia is a common condition and affects as many as 5.5 million people in the United States, Coles noted, and "as the population ages, we expect to see more and more in our practices."

Given those circumstances, family physicians should be looking for signs and symptoms of cognitive impairment or dementia in older adults, she said, including memory loss, decreased organizational ability, tendency to become lost or confused, difficulty completing daily activities, withdrawal from friends and family, and changes in activity or engagement.

"Clues may be subtle, such as patients forgetting medications or appointments, new sleep problems, worsening of chronic conditions, or depressed or apathetic mood," Coles said.

Many patients lack insight into their deficits and may underestimate their symptoms or offer explanations to explain away problems they are facing, she added.

"Discussing concerns with someone who has known the patient well over a long period of time, like family or friends, can be incredibly valuable to assess if there have been cognitive changes," said Coles.

Physicians must first take a careful history to identify any cognitive or behavioral changes and to see if any known or reversible causes can be found. A careful review of medications is key, because many medications can cause cognitive changes in older adults, she noted.

Additionally, family physicians can review activities of daily living and instrumental activities of daily living to assess for any changes from the patient's previous baseline, said Coles. A careful social history, including education and work history, as well as information about support networks, hobbies and goals, can help shape future discussions should dementia be diagnosed.

Finally, Coles said physicians should remember to evaluate for depression, because symptoms of depression in older adults can mimic dementia.

Physicians can perform cognitive testing using a brief, validated, standardized instrument, such as the Mini-Mental State Exam or the Montreal Cognitive Assessment, she said.

"Brief cognitive tests have high sensitivity and specificity for distinguishing clinical Alzheimer-type dementia from normal cognition," Coles said. "If abnormal, these tests can help physicians decide who needs more comprehensive evaluation.

"Depending on history and physical exam findings, laboratory testing with B12 levels, complete blood count and thyroid-stimulating hormone measurement, and neuroimaging with CT or MRI may be indicated."

AAFP Dementia Guideline

As for the AAFP's upcoming dementia guideline, Coles said the Agency for Healthcare Research and Quality is assisting the AAFP's efforts by conducting a systematic review on the diagnosis and treatment of clinical Alzheimer-type dementia.

Key questions covered in this review have focused on the accuracy and harms of brief cognitive tests, imaging and labs for the diagnosis of clinical Alzheimer-type dementia, along with the efficacy and harms of pharmacologic management, Coles said.

"We are looking at how treatment impacts cognitive, behavioral and psychological symptoms of dementia as well as quality of life, function and caregiver outcomes," she said.

The guideline panel is currently being convened and soon will begin the rigorous process of reviewing the data, developing recommendations and drafting the manuscript, Coles added.

Up Next

The USPSTF is accepting comments on the draft recommendation statement and draft evidence review on screening older adults for cognitive impairment until 8 p.m. EDT on Oct. 7. All comments received will be considered as the task force prepares its final recommendation.

The AAFP will review the USPSTF's draft recommendation statement and supporting evidence and will provide comments to the task force. The Academy will release its own recommendation on the topic after the task force finalizes its guidance.