It sounds like a good idea. Have primary care doctors learn about older patients’ cognitive health by putting all of them, during routine office check-ups, through a few minutes of tests in which they are asked to recall lists of words, draw a clock face, describe the day and date of their appointment, talk about current events, and take on other simple tasks.
Such screenings, some advocates for the aged say, can be an important way to diagnose early and try to provide for help for patients with dementia and its most common affliction, Alzheimer’s disease. But a blue-ribbon panel of experts that advises the nation on medical testing and procedures isn’t buying the argument: The U.S. Preventive Services Task Force (USPSTF) has given such screenings the group’s letter-grade rating of I, meaning the evidence is incomplete that a test or procedure is harmful or beneficial.
“More research is needed on the effect of screening and early detection of cognitive impairment … on important patient, caregiver, and societal outcomes, including decision-making, advance planning, and caregiver outcomes. The body of evidence on screening and interventions for cognitive impairment would benefit from more consistent definitions and reporting of outcomes to allow comparisons across trials, especially from trials with longer-term follow-up …Research is needed on treatments that clearly affect the long-term clinical course of cognitive impairment. It is also important that studies on screening and interventions for cognitive impairment report harms and reasons for attrition of trial participants.”
Judith Graham, a columnist covering aging issues for the independent Kaiser Health News Service, reported that the USPSTF decision isn’t going down well with seniors and their advocates:
“The task force’s stance is controversial, given how poorly the health care system serves seniors with memory and thinking problems. Physicians routinely overlook cognitive impairment and dementia in older patients, failing to recognize these conditions at least 50% of the time, according to several studies. When the Alzheimer’s Association surveyed 1,954 seniors in December 2018, 82% said they thought it was important to have their thinking or memory checked. But only 16% said physicians regularly checked their cognition. What’s more, Medicare policies appear to affirm the value of screening. Since 2011, Medicare has required that physicians assess a patient’s cognition during an annual wellness visit. But only 19% of seniors took advantage of this voluntary benefit in 2016, the most recent year for which data is available.”
But critics — while conceding the soundness of available cognitive screenings such as the Mini-Cog, the Memory Impairment Screen, the General Practitioner Assessment of Cognition and the Mini-Mental Status Examination — question whether enough primary care physicians have the training or capacity to follow-up with results they get after testing seniors. Patients and doctors alike have expressed deep disappointment, for example, with available prescription medications for cognitive decline, and efforts to develop safe and effective heavier-duty meds, say, for Alzheimer’s, have hit a wall in clinical trials.
If the screenings raise concerns, this also can lead to a cascade of other tests or procedures that, ultimately, put patients on that uncertain treatment path. If they are found, down the road, to be clear of cognitive challenges, they by then may have been stigmatized and they may spend their remaining time fretting about their mental wellbeing, critics say.
In my practice, I see not only the harms that patients suffer while seeking medical services, but also the problems they can encounter due to over testing, over diagnosing, and over treating of patients, particularly the elderly. Too many screenings turn out to be unnecessary, costly, invasive, and even painful, and older patients bear a terrible brunt of doctors attempts to be over cautious with those in their care or of their medical standing (needless fears of medical malpractice claims). It also can be that a few unscrupulous doctors see tests as a way to increase revenue.
The more fundamental issue that, frankly, cursory cognitive exams may fail to address is this: Just how much time are doctors spending with patients and how well do they know them? Studies find that doctors spend 18 minutes or so with patients in office visits. That’s too little time to take care of patient needs, much less to build great and important relationships. Doctors know this and it upsets them, too.
The crushing pace at which medical factories set treatment goals is a growing problem for practices owned by big hospitals or even hedge funds and run by MBA-credentialed bean counters. The problems of the time crunch grow in exponential ways when it comes to older patients, many of whom may have chronic and multiple conditions for caregivers to consider. Doctors and patients already struggle in seasoned patients with challenges like polypharmacy, where, perhaps without knowing, individuals are prescribed too many medications, too many of which may interact in harmful fashion.
In brief, doctors need to spend more time — and quality moments — with older patients, and, for those that they know well, dispensing with cognitive screenings in favor of hearty, insightful conversation may be more revealing about the state of seniors minds and bodies.