Most Dementia Patients Never Screened

Pauline Anderson

November 28, 2014

Only a small minority of community-dwelling older patients receives a clinical cognitive evaluation (CCE) for thinking and memory concerns, a new study reports.

The researchers found that about 5% of those 70 years or older with cognitive impairment not dementia (CIND), and less than half of those with frank dementia, received a CCE.

Identifying and evaluating affected patients may allow them and their families to receive earlier attention, which could improve quality of care, said lead author Vikas Kotagal, MD, assistant professor of neurology, University of Michigan, Ann Arbor.

"This study is a first step towards trying to answer the question of how often these evaluations are being done; the next question is how often should they be happening."

The study was published online November 26 in Neurology.

Unique Element

A US Preventive Services Task Force concluded in 2013 that there's insufficient evidence to recommend routine screening for dementia. However, Dr Kotagal believes that patients should be evaluated if experts suspect they have cognitive impairment resulting in a decline in their quality of life.

Such evaluations, he said, can identify reversible factors such as sleep conditions and some medications that contribute to the decline. He used the example of cardiovascular factors that, if identified as contributing to cognitive impairment, might merit a more aggressive medical management strategy that can alter the rate of disease progression.

The Aging, Demographics and Memory Study (ADAMS) included patients aged 70 years and older from the larger Health and Retirement Study (HRS), a nationally representative community-based cohort study of individuals aged 51 and older that began in 1992.

"The unique element of our study was the dataset we used, which was this nationally representative sample of elderly individuals who live in various parts around the country," said Dr Kotagal.

Of the 1770 patients identified as qualifying for ADAMS, 856 consented (56% of eligible living participants) and were assessed within 2 years with detailed neuropsychological testing, clinical examination, and informant interviews.

The sample was categorized to identify strata that were likely to include individuals with normal cognition, CIND, and dementia.

After applying sample weights to the ADAMS cohort, CCEs were reported in 1.2% of individuals with normal cognition, 5.3% of individuals with CIND, and 44.8% of individuals with confirmed dementia.

In total, 8.1% of patients in the weighted-adjusted cohort reported a CCE. This translates into 55.2% of Americans over age 70 years with dementia, or 1.8 million people, would not report having a CCE.

The most common community-physician diagnoses were dementia (31.6%) and Alzheimer's disease (28.8%), followed by strokes or TIAs (17.3%).

More severe dementia, as indicated on the Clinical Dementia Rating, Dementia Severity Rating Scale, and Mini-Mental State Examination, was associated with an increased likelihood of receiving a CCE.

Among patients with dementia, being married (P = .031) was the only demographic factor associated with an increased likelihood of receiving a CCE.

Older people living alone "probably feel their autonomy is on the cusp of being compromised," so they may not want to bring up issues of cognitive decline to their physician "even if it is playing a role in their quality of life," said Dr Kotagal.

Interestingly, although this didn't hold up in the multivariate analysis, a univariate analysis (comparing those who did and did not have cognitive evaluations) showed that not having children living within 10 miles increased the likelihood of receiving a CCE.

"One thought is that those who have children living close by have a safety net, and even if they have cognitive impairment, they can get help from nearby family members," commented Dr Kotagal.

No one party is responsible for the relatively small number of elderly being evaluated. "I don't think it's an issue of neurologists or primary care providers or patients; I think all parties are contributing to this trend to some degree," said Dr Kotagal.

"If anything is at fault, it's a shared fault, and the shared reason is that there's a medical, patient, and societal-wide feeling that these evaluations have limited impact or limited value to patients."

Physicians find the evaluations time-consuming and they have a degree of "therapeutic pessimism" about the efficacy of disease-modifying treatments if it's discovered the patient has Alzheimer's disease, said Dr Kotagal.

The authors note that in 2011, Medicare coverage was expanded to include an annual wellness visit that requires screening to assess cognition.

The Alzheimer's Association has published guidelines for these annual wellness visits and a list of suggested cognitive screening tools.

Heroic Attempt

Asked to comment, Steven DeKosky, MD, visiting professor, neurology and radiology, University of Pittsburgh, Pennsylvania, said the study was an "almost heroic attempt" to determine patterns extrapolated from a database that "certainly wasn't meant to be used in this form."

However, the study confirms other data in the literature, as well as physician and family surveys, he said.

A number of factors "conspire" to result in physicians not carrying out cognitive evaluations, said Dr DeKosky. Physicians don't feel comfortable doing behavioral neurologic or psychiatric evaluations, and they don't feel there’s a lot they can do should a serious cognitive problem be identified, he said.

There's also no one clear tool to use. Experts disagree on the best test, although generally the longer and more detailed, the more reliable it is, he said.

"So if you spend a little more time, you get a little more accuracy, but spending a little more time doing something that doctors don't generally do is a hard sell to really busy physicians."

Technology may help cut down on this time. A number of computerized tablet-based cognitive assessments are emerging that can be completed at the office while patients wait to see their doctor.

Dr DeKosky noted that patients themselves are often reluctant to report cognitive problems because they don't have the insight to realize they have dementia, they're in denial, or think their problems are a part of normal aging.

Dr Kotagal reports research funding from the American Academy of Neurology Clinical Research Training Fellowship and Blue Cross Blue Shield of Michigan Foundation. Dr DeKosky has reported no relevant financial relationships.

Neurology. Published online November 26, 2014. Abstract

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