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June 3, 2014 Issue

Clinical Practice Points

Medical Knowledge
Patient Care
High Value Care

Should Colorectal Cancer Screening Be Considered in Elderly Persons Without Previous Screening? A Cost-Effectiveness Analysis

Guidelines caution against routine screening for colorectal cancer in persons older than 75 years with an adequate screening history, but have not addressed screening in those without a screening history. This study estimates that screening elderly persons without previous screening has good value up to age 86 years for persons with no comorbid conditions, age 83 years for those with moderate comorbid conditions, and age 80 years for those with severe comorbid conditions.

Use this study to:

  • Review recent guideline recommendations for colorectal cancer screening in adults. Use a recent In The Clinic: Colorectal Cancer Screening to review key clinical questions regarding how to screen.
  • Ask what the requirements are for a screening test to be useful.
  • Ask your learners if they recommend screening to their elderly patients. At what age do they stop, and why?
  • Review the key findings of this study. Use the accompanying editorial to summarize and help interpret the key findings. Why does the presence of comorbidities and their severity matter?
  • Do your learners think they should start recommending screening to patients older than 75 who have not had prior screening?

Medical Knowledge
Interpersonal and Communication Skills
Patient Care

Screening for Cognitive Impairment in Older Adults: U.S. Preventive Services Task Force Recommendation Statement

The prevalence of dementia in the U.S. is 5% among persons aged 71 to 79 years and increases to 24% in those 80 to 89 years old. Approximately 40% to 50% of older adults report subjective memory symptoms. Yet, the U.S. Preventive Services Task Force found that evidence is insufficient to assess the balance of benefits and harms of screening for cognitive impairment in community-dwelling adults who are older than 65 years and have no signs or symptoms of cognitive impairment.

Use this guideline to:

  • Start a teaching session with some multiple-choice questions. We’ve provided two below.
  • Ask your learners to define mild cognitive impairment and dementia.
  • What might be the benefits of screening? What might be the harms?
  • Ask why the USPSTF felt there was insufficient evidence to recommend screening.
  • Ask your learners what evaluation is in order, and what therapies might be useful when a patient complains of memory loss.

Medical Knowledge
Patient Care

ITC logo Low Back Pain

Lower back pain has a lifetime prevalence of nearly 80%! This concise review covers key issues of this vexing issue, including what can be done to prevent it, which patients should or should not undergo imaging, and treatment.

Use this review to:

  • Answer the multiple-choice questions at the end. Intersperse them throughout your teaching session to introduce key teaching points. And, log on to enter your answer to claim CME credit for yourself.
  • Ask what warning signs indicate a possible systemic problem that requires evaluation.
  • Ask what factors are associated with low back pain or disability claims for low back pain. Ask your learners how they react when asked to complete disability claims.
  • Ask what psychosocial factors influence recovery.
  • Download the ready-to-use slides to help prepare a teaching session.

The Health Care System

Patient Care
Systems-based Practice
Interpersonal and Communication Skills

Premarket Approval Supplement Pathway: Do We Know What We Are Getting?

The U.S. Food and Drug Administration assesses the safety and effectiveness of new high-risk medical devices through a process known as “premarket approval” (PMA), whereas modifications of existing devices may be approved by a less rigorous procedure known as “PMA supplement.” This commentary discusses safety concerns for this alternate pathway and its implications for clinicians and policymakers.

Use this paper to:

  • Ask your learners what they know about how devices are evaluated and approved.
  • Invite an electrophysiologist to discuss the safety problems identified with certain defibrillator leads already implanted in many patients. How are they managing their patients who have received these devices?
  • Ask your learners what the effects might be on a patient who learns his or her device might fail. What might the effects be on the patient's emotional health? What does it say about the doctor who implanted the device? What is the responsibility of the doctor using a device to know about changes that might have occurred to it? On the basis of this paper, do you think a doctor can know enough? Should he or she tell a patient that when obtaining consent to implant a device?

Running an Internal Medicine Training Program

Training for the 21st Century?

This commentary raises concern that recently adopted requirements for continuous residency evaluations are untested and that the balance of milestones to be evaluated deemphasizes medical knowledge and diagnostic skills.

Use this paper to:

  • Ask your learners if they find the feedback they receive during training to be useful.
  • Do they think it is helping them to be better trained?
  • Do they think the process helps their attending physicians do a better job teaching?
  • How would they design a better system?
  • How do they provide feedback to the medical students with whom they work?

Humanism and Professionalism

Interpersonal and Communication Skills

On Being a Doctor: Of Leaves, Trees, Forests, and Primary Care

In this essay, Dr. Cifu considers how he sometimes sees only the leaves on his patients, and at others he is able to see whole trees and even the forest.

Use this essay to:

  • Play an audio recording of the essay, read by Michael LaCombe, MD.
  • Ask your learners what daily, personal and professional issues affect the care they provide their patients.
  • Do they think it is fair that such issues alter how they treat a patient? What can they do about it?
  • Ask your learners to try over the next week to ask their patients the questions Dr. Cifu recommends we ask them. Then, next week ask what the answers were. Did it make a difference to their patients? Did it make your learners feel differently as physicians?


Question 1

A 78-year-old man is evaluated for a 1-year history of forgetfulness and not being able to remember names. He is a retired attorney. He reports no problems with performing activities of daily living, planning his day, or managing his finances. He is frustrated but not depressed and is still able to enjoy life. He has hypertension and hyperlipidemia, controlled with hydrochlorothiazide and simvastatin.

On physical examination, he is afebrile, blood pressure is 140/82 mm Hg, and pulse rate is 78/min. Mini-Mental State Examination score is 25. The lungs are clear. The heart is without murmur. Neurologic, motor, and sensory examinations are normal.

Which of the following is the most likely diagnosis?
A. Alzheimer disease
B. Mild cognitive impairment
C. Pseudodementia
D. Vascular dementia

Correct Answer
B. Mild cognitive impairment

Key Point
Patients with mild cognitive impairment have a single or few areas of cognitive impairment, and the Mini-Mental State Examination score is typically 24 or 25.

Educational Objective
Diagnose mild cognitive impairment.

This patient most likely has mild cognitive impairment (MCI). Memory is the only cognitive domain that is impaired. Impairment of other domains that might suggest dementia would include impairment of language, apraxia (for example, problems with dressing not related to motor dysfunction), and impaired executive functioning, none of which are abnormal in this patient. Patients with MCI have a single or few areas of cognitive impairment, and this patient's deficit is limited to forgetfulness and recalling names. His age is typical for MCI and about one-fifth of patients older than age 70 years have this condition. His Mini-Mental State Examination (MMSE) score is within the expected range of 24-25 for MCI and may even be falsely elevated because of his high intellectual level.

Alzheimer disease is less likely in this patient because there are no impairments in other domains, such as activities of daily living and instrumental activities of daily living; other language difficulties; or personality changes. MMSE scores of 19 to 24 suggest mild dementia, and scores of 10 to 19 suggest moderate dementia. His MMSE score of 25 suggests MCI rather than dementia.

Pseudodementia is a condition in which the cognitive impairment is secondary to depression. Treatment of the depression leads to improvement in cognition. Whereas this patient is frustrated with his condition, he is not depressed.

Although he has risk factors for cerebrovascular disease, vascular dementia would be less likely with his MMSE score of 25 and normal neurologic examination. In addition, vascular dementia would not affect memory in isolation and would likely affect additional cognitive domains and neurologic functioning.

Plassman BL, Langa KM, Fisher GG, et al. Prevalence of cognitive impairment without dementia in the United States. Ann Intern Med. 2008;148(6):427-434. PMID: 18347351

Question 2

A 68-year-old man is evaluated for memory loss. He still teaches history at the local university, supervises graduate students, and writes chapters of textbooks. He reports having difficulty remembering the names of his students and colleagues, forgetting telephone numbers, and often misplacing his glasses. The patient has not experienced confusion and has no history of depression, hallucinations, or head trauma. He drives, manages his own financial affairs, and is fully independent.

Physical examination shows an anxious-appearing man. Vital signs are normal, as are other findings from the general physical examination. He scores 29/30 on the Mini-Mental State Examination.

Which of the following is the most appropriate next step in management?
A. Brain MRI
B. Determination of apolipoprotein E4 status
C. Formal neuropsychological testing
D. Trial of donepezil
E. Reassurance

Correct Answer
E. Reassurance

Key Point
Memory loss that does not interfere significantly with a patient's social or occupational function does not indicate dementia and requires no evaluation or treatment.

Educational Objective
Manage age-related memory loss.

This patient should be reassured that his degree of memory loss is a normal part of aging. His symptoms of memory impairment are primarily related to short-term memory (recall of names, numbers, faces, and the location of placed objects). In other cognitive domains, he continues to function at a high level, with no evidence of deterioration from his previous performance and no impairment in social or occupational function. Nothing suggests that his perceived memory loss is progressive. His score on the Mini-Mental State Examination does not meet clinical criteria for dementia. Memory loss that does not interfere significantly with a patient's social or occupational function does not indicate dementia and requires no evaluation or treatment.

Mild cognitive impairment (MCI) describes a loss of cognitive ability that exceeds the expected age-related memory loss but does not interfere significantly with daily activities. The boundary between MCI and dementia is unclear, although 10% to 15% of patients with MCI will meet the criteria for dementia within 1 year. Currently, no method exists by which to identify persons with predementia MCI, and no neuroprotective agent has been shown to prevent this progression.

If this patient had evidence of dementia or a history of head trauma, MRI of the brain (or CT of the head) would be appropriate. However, it serves no purpose in age-related memory loss or MCI.

Determination of this patient's apolipoprotein E4 status could help define his risk of developing Alzheimer disease but would not indicate if he had the disorder; his symptoms do not support that diagnosis.

Although formal neuropsychological testing can more fully reveal a patient's cognitive deficits and abilities, this intervention is unnecessary in this patient who is functioning normally.

Donepezil is a cholinesterase inhibitor shown to improve the cognitive function of persons with mild, moderate, and even severe dementia due to Alzheimer disease. The drug has no role in preventing or treating age-related memory loss or in preventing the progression from MCI to dementia.

Petersen RC. Clinical practice. Mild cognitive impairment. N Engl J Med. 2011;364(23):2227-2234. PMID: 21651394

These questions are derived from MKSAP® 16, the Medical Knowledge Self-Assessment Program.

From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Program Director in Internal Medicine, Thomas Jefferson University.


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