Conflicting directives from the federal government and the USPSTF might make clinicians cringe when faced with the cognitive-screening mandate, Dr. Galvin said. “There is just no clear plan about how best to screen and what instrument to use. … Dementia screening simply has not been a routine part of primary care practice,” and certainly not for a nontargeted population that begins at a relatively low-risk age for age-related dementias. “Targeted screening makes a lot more sense, and it's my belief that large population screening will yield very few cases.” However, he said, this is the hand that politicians have dealt primary care, “unless the Task Force can be persuaded to review its recommendations and make new ones based on the current data.”
Even if physicians quail at the thought of having one more box to tick off in an annual exam, patients will probably like the security an annual cognitive screen can provide, Dr. Holsinger said. She and her colleagues recently conducted a survey of 345 primary care patients at the Durham VA Medical Center. After discussing the risks and benefits of a cognitive screen that could identify early dementia, the subjects were asked whether they would want to know of their probable diagnosis. “Eighty-one percent said they would want to know,” she said.
Factors associated with the desire for screening were acceptance of other screening tests (depression, breast, and prostate cancer; odds ratio 3.7), male gender (OR 3.2), and the belief that effective treatment for dementia exists (OR 2) (Int. J. Geriatr. Psych. 2010 [doi:10.1002/gps.2536]).
The AD8 sounds good on the surface, but how it will fit into a busy primary care day is still unclear, said Dr. Eric Tangalos, an internist at the Mayo Clinic, Rochester, Minn. Having an informant fill out the paper might throw some bias into the pot at the very beginning of the process, he said during the webinar. “In my practice, if a 65-year-old shows up for an annual wellness exam with a spouse, that sends my red flags flying. We need to be very cautious about applying an instrument [that was tested in dementia clinics] to a broad population that is not at a high-risk age.”
Primary care physicians already are ultracautious about entering the dementia arena, he said. “We already know primary care docs do not want to open Pandora's box, even when the disease is confronting them. We're saying 'Run toward that diagnosis, rather than run away from it.'”
Dr. Galvin agreed, but reminded the panel that the die has been cast. “There is not a lot of evidence that anyone needs to be seen annually for something like this – this is really a political approach to health care that is quite a bit different from anything the USPSTF policy has recommended. But even though we're not exactly sure how it will all play out, it's going to be up to the practices to get it done.”
None of the panel members expressed any financial conflicts related to the screening tool.