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Published on: September 11, 2013
by Nancy Walsh for MedPage Today:
The current quest to diagnose dementia and cognitive impairment early with screening is ill-advised, is fueled by profit motives, and ignores the potentially devastating harms associated with the diagnosis, according to an opinion paper by dementia and geriatric medicine specialists.
Many countries have begun encouraging screening for cognitive changes in older individuals. For example, in the U.S., the Affordable Care Act will provide Medicare coverage for annual “wellness” visits that include cognitive testing. In England, general practitioners will be recompensed for screening all individuals over 75, according to David G. Le Couteur, MD, of the University of Sydney, and colleagues.
Yet screening is not recommended in the U.S., the U.K., or Australia, as there is no way currently of either preventing or treating the condition, Le Couteur and colleagues explained online in BMJ.
“The desire of politicians, dementia organizations, and academics and clinicians in the field to raise the profile of dementia is understandable, but we risk being conscripted into an unwanted ‘war against dementia’,” they warned.
An underlying assumption for this push for screening is that individuals with mild cognitive impairment will proceed in a predictable fashion to dementia — yet an estimated 40% to 70% of people with mild symptoms don’t progress over time.
This shift in attitude is reflected by changes in the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which spells out the criteria for “minor neurocognitive disorder” as being a “modest decline” more than one standard deviation below normal in any aspect of cognition as observed by patient, caregiver, or physician.
The result of this, according to Le Couteur and colleagues, is likely to be about 16% of the population being given the diagnosis.
The implications can be inferred from a meta-analysis of the accuracy of diagnostic testing that suggested if 100 patients were screened, and dementia prevalence was 6%, four of six patients would be correctly identified, but 23 others would be wrongly diagnosed.
A further concern is that screening doesn’t come cheap. A single diagnostic evaluation can be $5,000, and many patients undergo multiple assessments, including neuroimaging and cerebrospinal fluid tests for biomarkers.
Furthermore, “the diagnostic processes can be distressing, alarming, and stigmatizing as well as costly,” the authors stated.
“The diagnosis of dementia-related illness affects identify, leading to feelings of loss, anger, uncertainty, and frustration. It also affects roles and relationships within the family and in wider social networks. The distress of getting a diagnosis may also result in suicide or euthanasia,” they observed.
The greatest beneficiaries of more widespread screening are companies that develop and market diagnostic tests, and others that sell drugs or supplements alleged to help maintain mental function among the elderly, Le Couteur and colleagues argued.
Until there is more evidence to support screening, the elderly population might benefit more from greater efforts to prevent obesity and to encourage smoking cessation, factors that have been associated with dementia, and preserve “resources that are badly needed for the care of people with advanced dementia,” they concluded.
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