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Clinician Article

Screening for cognitive impairment in older adults: A systematic review for the U.S. Preventive Services Task Force.



  • Lin JS
  • O'Connor E
  • Rossom RC
  • Perdue LA
  • Eckstrom E
Ann Intern Med. 2013 Nov 5;159(9):601-12. doi: 10.7326/0003-4819-159-9-201311050-00730. (Review)
PMID: 24145578
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Disciplines
  • Public Health
    Relevance - 7/7
    Newsworthiness - 6/7
  • Geriatrics
    Relevance - 7/7
    Newsworthiness - 5/7
  • Family Medicine (FM)/General Practice (GP)
    Relevance - 6/7
    Newsworthiness - 5/7
  • FM/GP/Mental Health
    Relevance - 6/7
    Newsworthiness - 5/7
  • General Internal Medicine-Primary Care(US)
    Relevance - 6/7
    Newsworthiness - 5/7
  • Psychiatry
    Relevance - 6/7
    Newsworthiness - 4/7

Abstract

BACKGROUND: Earlier identification of cognitive impairment may reduce patient and caregiver morbidity.

PURPOSE: To systematically review the diagnostic accuracy of brief cognitive screening instruments and the benefits and harms of pharmacologic and nonpharmacologic interventions for early cognitive impairment.

DATA SOURCES: MEDLINE, PsycINFO, and the Cochrane Central Register of Controlled Trials through December 2012; systematic reviews; clinical trial registries; and experts.

STUDY SELECTION: English-language studies of fair to good quality, primary care–feasible screening instruments, and treatments aimed at persons with mild cognitive impairment or mild to moderate dementia.

DATA EXTRACTION: Dual quality assessment and abstraction of relevant study details.

DATA SYNTHESIS: The Mini-Mental State Examination (k = 25) is the most thoroughly studied instrument but is not available for use without cost. Publicly available instruments with adequate test performance to detect dementia include the Clock Drawing Test (k = 7), Mini-Cog (k = 4), Memory Impairment Screen (k = 5), Abbreviated Mental Test (k = 4), Short Portable Mental Status Questionnaire (k = 4), Free and Cued Selective Reminding Test (k = 2), 7-Minute Screen (k = 2), and Informant Questionnaire on Cognitive Decline in the Elderly (k = 5). Medications approved by the U.S. Food and Drug Administration for Alzheimer disease (k = 58) and caregiver interventions (k = 59) show a small benefit of uncertain clinical importance for patients and their caregivers. Small benefits are also limited by common adverse effects of acetylcholinesterase inhibitors and limited availability of complex caregiver interventions. Although promising, cognitive stimulation (k = 6) and exercise (k = 10) have limited evidence to support their use in persons with mild to moderate dementia or mild cognitive impairment.

LIMITATION: Limited studies in persons with dementia other than Alzheimer disease and sparse reporting of important health outcomes.

CONCLUSION: Brief instruments to screen for cognitive impairment can adequately detect dementia, but there is no empirical evidence that screening improves decision making. Whether interventions for patients or their caregivers have a clinically significant effect in persons with earlier detected cognitive impairment is still unclear.

PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.


Clinical Comments

Family Medicine (FM)/General Practice (GP)

Screening for things we cannot treat or for which we cannot positively and meaningfully impact patient-oriented outcomes is antithetical to the tenets of screening. Glad to see this common sense, "keeping it real" piece from USPSTF. Screening for dementia is full of potential patient-harming outcomes.

Geriatrics

Two key findings. First, it is possible to accurately detect cognitive impairment with various instruments. Second, treatment interventions (pharmacological or non-pharmacological) for cognitive impairment either have clinically insignificant effects, or have not been adequately studied (especially their long-term effects).

Psychiatry

This is a well done review. Although interventions have low effect sizes currently, research for more effective treatments are underway, and we now have two FDA approved ligands for PET scanning.

Public Health

As a geriatrician and program manager, this article helps to determine whether or not to pursue a general screening strategy in our elderly population vs a case-finding strategy that is based on clinical warning signs of dementia.

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