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Should primary care involve dementia screening for older adults?

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The July 2013 edition of The Journal of American Geriatrics Society has an interesting debate.   The article takes a pro and con stance to the idea of screening for cognitive impairment in older adults. 

Unfortunately I cannot find a link to the full article from the doctor who took the opposing stance and neither the article nor the abstract is available online.  But Dr. Boustani who took the opposing stance has done so for years so if you want to read for yourself some of his arguments you can find them here and here.  I’ll attempt to summarize their points in this column.

Dr. McCarten is a neurologist specializing in Alzheimer’s disease at Memory Clinic in Minneapolis.  Dr. Boustani is the Chief Research Officer of the Indianapolis Discovery Network for Dementia and the Research Director of the Healthy Aging Brain Center in Indiana.

McCarten argues that currently primary care physicians consider a patient to be in a default position of alert and oriented to person, place and time.  Based on those assessments of a patient as “normal” an unsuspecting physician may trust the history given him or her by the patient as accurate.  The patient may also fail to adhere to medication requirements or fail to notify the physician when a care need has been resolved.  As a result, the physician diagnoses health issues with the faulty information provided by the individual.  If instead the physician was aware of cognitive issues, that knowledge could influence and improve the care the patient would receive.  McCarten said in his argument that “Recognizing and diagnosing cognitive disorders, particularly early in the course of terminal dementia empowers individuals and families to address predictable needs and potentially live their lives differently, should they so choose.  Failure to recognize and diagnose not only robs them of this opportunity, by may also tie them to a more-limited, unhappy existence.”

Boustani argues that one of the arguments for or against screening of any disease is knowing whether or not that screening will lead to negative unintended consequences for the patient.  We’ve talked about those consequences before on this website because the moment a test is reported positive for many diseases it becomes harder for individuals to purchase long term care insurance or health insurance.  Nevertheless, the medical community does screen for a variety of health issues in the normal course of delivering health care such as screenings for prostate cancer.  Because so little is known about dementia, he argues there is a very real concern involving the loss of independence including losing a drivers license, being forced to move into an institutional setting, losing a job and losing options for long term care insurance.  He also argues that screening would be expensive if it was applied across the board to every individual within a certain population and may not be cost effective.

Both doctors agree that dementia is such a scary diagnosis that individuals, their families and society in general fear the results of a screening regardless of the outcome.  The result is that patients and families often don’t want any screening done.  The top three barriers to screening regardless of whether the individual being surveyed is the patient or the caregiver are the emotional suffering of the family, loss of driving privileges and becoming depressed.   In addition, primary care doctors are already so overwhelmed with work that a screening for dementia would add a further burden to their workload and might as a result have unintended consequences for the patient such as high use of psychotropic medications and longer hospital stays.

So why, I suppose you are wondering, am I bothering with a somewhat detailed explanation of two stances in primary care medicine that when it comes down to it appear to agree that while it may or may not be a bad idea to screen, society as a whole probably can’t afford it financially or psychologically?  Because there are doctors who are not still hung up on the issues these primary care doctors are arguing about.  Geriatric care physicians are already aware of the types of impairment that appear in elderly people such as mobility issues, fall concerns, incontinence and of course cognitive failure.  They are aware of the fact that one individual may exhibit many of these issues due to their age, multiple chronic conditions or polypharmacy.  But more importantly they are aware of and prepared to partner with other professionals to engage in processes that allow older individuals to continue to live life independently as long as possible and can provide referrals to help make that possible.  Because if the thing that is keeping you from knowing your health situation is something that can be addressed, doesn’t it make sense to address the possible consequence as part of a pro-active solution to your health needs rather than a reactive one?

Additional articles on Health Care Screenings:

Alzheimer’s diagnosis outstrips our ability to do anything about it

Alzheimer’s Genes – Do You Want To Know?

Additional articles on Geriatric Physicians:

Why bother hiring a geriatric physician?

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