Virginia A. Moyer, MD, MPH; on behalf of the U.S. Preventive Services Task Force (*)
Disclaimer: Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Financial Support: The USPSTF is an independent, voluntary body. The U.S. Congress mandates that the Agency for Healthcare Research and Quality support the operations of the USPSTF.
Disclosures: Authors followed the policy regarding conflicts of interest described at www.uspreventiveservicestaskforce.org/methods.htm. Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOf InterestForms.do?msNum=M14-0496.
Requests for Single Reprints: Reprints are available from the USPSTF Web site (www.uspreventiveservicestaskforce.org).
Moyer VA, on behalf of the U.S. Preventive Services Task Force. Screening for Cognitive Impairment in Older Adults: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2014;160:791-797. doi: 10.7326/M14-0496
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Published: Ann Intern Med. 2014;160(11):791-797.
Update of the 2003 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for dementia.
The USPSTF reviewed the evidence on the benefits, harms, and sensitivity and specificity of screening instruments for cognitive impairment in older adults and the benefits and harms of commonly used treatment and management options for older adults with mild cognitive impairment or early dementia and their caregivers.
This recommendation applies to universal screening with formal screening instruments in community-dwelling adults in the general primary care population who are older than 65 years and have no signs or symptoms of cognitive impairment.
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for cognitive impairment. (I statement)
Screening for cognitive impairment in older adults: clinical summary of U.S. Preventive Services Task Force recommendation.
Appendix Table 1. What the USPSTF Grades Mean and Suggestions for Practice
Appendix Table 2. USPSTF Levels of Certainty Regarding Net Benefit
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Kathryn Agarwal, MD, Angela Catic, MD, Aanand Naik, MD
Agarwal, & Naik - Baylor College of Medicine, Houston, TX; Catic - Beth Israel Deaconess Medical Center, Boston, MA
June 4, 2014
Cognitively Adjusted Care
It was with great interest that we read the opinion of the USPSTF to not recommend screening for cognitive impairment in individuals over age 65 years.1 We understand the lack of enthusiasm for screening is driven by the modest effectiveness of the available drugs one might use to intervene in patients with unrecognized dementia or mild cognitive impairment. Unfortunately, this is a myopic view that ignores the fact that most patients with cognitive impairment also have other chronic medical conditions. For patients with comorbid cognitive impairment, standard approaches to treatment for many common conditions will need modification. We have found that these individuals often suffer from unrecognized executive cognitive dysfunction which is severe enough to interfere with self-management of conditions including diabetes and congestive heart failure. In the outpatient setting, unrecognized cognitive dysfunction has been linked to poor diabetic control.2 Failure to adjust the complexity of a patient’s diabetic regimen to account for their cognitive abilities can lead to significant adverse events including misuse of medication resulting in hypoglycemic episodes. Alternatively, involvement of family members or caregivers to assist in medication management may be warranted. Similar issues exist in the management of congestive heart failure among patients with cognitive impairment in both inpatient and outpatient settings. Evidence from multiple studies suggests that heart failure is independently associated with cognitive impairment.3 Most recently, Gorodeski presented convincing evidence at the 2014 American College of Cardiology conference that CHF patients with abnormal Mini-Cog results had substantially higher 30-day readmission rates than patients who performed normally on the cognitive screen.4 In these individuals, cognitive dysfunction is frequently missed by treating physicians and nurses when preparing discharge plans or outpatient regimens. There is limited recognition by practitioners of the differences between repeating back catch phrases (“teach back”) and integrating complex treatment plans into action. In both the care of diabetes and heart failure, diagnosis of cognitive impairment would allow clinicians to “cognitively adjust” medication regimens in much in same the way medications are “renally adjusted” for renal impairment. In addition, contingencies such as involvement of a family member or reliance on technology could be put into place to improve care of the chronic illnesses. While we understand the lack of efficacy of the treatments for dementia is driving the USPSTF decision, our experience suggests that this may reflect a lack of experience addressing the multiple co-morbid diseases and social complexities facing today’s older patient. 1. Moyer VA. Screening for Cognitive Impairment in Older Adults: U.S. Preventive Services Task Force Recommendation Statement. . 2014 Mar 25. doi: 10.7326/M14-0496. [Epub ahead of print] PMID: 246638152. Munshi M, Grande L, Hayes M, Ayres D, Suhl E, Capelson R, et al. Cognitive dysfunction is associated with poor diabetes control in older adults. Diabetes Care. 2006;29:1794-1799. PMID: 168737823. Vogels RL, Scheltens P, Schroeder-Tanka JM, Weinstein HC. Cognitive impairment in heart failure: a systematic review of the literature. Eur J Heart Fail. 2007;9:440-449. PMID: 17174152.4. Patel A, Parikh R, Howell E, Hsich E, Gorodeski E. J Am Coll Cardiol. 2014;63(12_S):. doi:10.1016/S0735-1097(14)60755-5 J Am Coll Cardiol. 2014;63(12_S):. doi:10.1016/S0735-1097(14)60755-5.
Thomas E. Finucane, MD
Johns Hopkins Bayview Medical Center
Screening for Dementia
To the Editor:The USPSTF “concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for cognitive impairment”. A notable event highlights one severe risk of diagnosing cognitive impairment. The first person Jack Kevorkian assisted in committing suicide was a 54 year-old woman who came to him in 1990 because she had been told she had Alzheimer Disease. If I am to develop Alzheimer Disease I hope never to be told. I would prefer to notice that my children were becoming a bit more solicitous and my wife was, for the first time ever, becoming a little bossy.
Dementia, Geriatric Medicine, Guidelines, Neurology, Prevention/Screening.
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