Screening for dementia red flags in primary care: Is it time?

Nov 27 2007

Primary care physicians should focus on "dementia red flags" rather than routinely screen individuals with no dementia symptoms just because they've reached a certain age, according to Malaz Boustani, M.D., MPH, of the Indiana University School of Medicine and the Regenstrief Institute, Inc. and colleagues from the University of Kent and the University of Cambridge in the United Kingdom in a commentary published in the Nov. 28 issue of the Journal of the American Medical Association.

“To screen without symptoms, unless there is a suspicion of a problem, either by the individual, caregivers, or a physician, may led to negative consequences for the person and for society” says Dr. Boustani, who is a geriatrician.

“There currently is no accurate screening test and we would be faced with an unacceptable number of false positives and false negatives. If we focus on dementia red flags we will be identifying individuals who will have a very high probability of having dementia and be able to focus our resources, including diagnostic testing, on these people,” Dr. Boustani says.

Dementia red flags include medication adherence problems, more than 7 prescribed medications, agitation, multiple falls, and more than 2 hospitalizations or emergency department visits in the past year. Dr. Boustani, who says the healthcare system in the United States misses between 60% and 80% of individuals with dementia, is currently testing ways to help physicians identify dementia red flags in their patients so these missed individuals can be helped.

Someone in the United States develops Alzheimer disease every 72 seconds, according to the Alzheimer's Association. The average primary care physician sees 2,000 patients per year of whom 300 are aged 65 or older. Of these 24 will develop dementia.

Despite this burden of disease, the benefit-harm ratio of conducting general population-based screening has not yet reached the point where the benefit outweighs the harm, the commentary maintains. Harms include possible stigma, loss of long term care insurance, emotional dislocation for both the individual and family, and resources' shifting from other health problems.

Dr. Boustani is the author of a 2003 report evaluating the wisdom of routine screening for dementia in primary care settings prepared for the U.S Preventative Services Task Force. The report found that while two-thirds of dementia cases are undetected by the patient's primary care physician, insufficient data exists to indicate whether or not it is a good idea to administer dementia screening tests to patients who do not have symptoms of memory loss or confusion.

“Pressures to institute screening of unproven benefit could divert much needed resources from the health and social care systems and have an overall negative impact on care for patients with dementia and other illnesses, ultimately delaying the point when dementia screening becomes indicated. The goal should continue to be the best possible care for the most patients, which currently does not include screening for dementia,” the commentary concludes.