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Screening for Memory Loss, Alzheimer’s Disease, and Dementia
Primary care physicians and other healthcare practitioners routinely screen for many diseases, including hypercholesterolemia, hypertension, and prostate and breast cancer, to mention a few. Yet Alzheimer’s disease, one of the most common disorders in older adults, is rarely screened for ( ). Interestingly, not only do most patients readily agree to memory screening, but also many are enthusiastic about having their memory treated as seriously as other functions of the body. In a study that we conducted several years ago ( ), all patients over the age of 60 years visiting a primary care practice over an eight-week period were asked if they were willing to undergo a brief (<10 minutes) screen of their memory. Although both our group and the primary care physician who collaborated on the study had some initial concern regarding the patients’ reaction to being approached about the memory screen, we were all relieved when the typical response of patients was being pleased that their physician was concerned about their memory. Of the 145 patients aged over 60 years who visited the practice during this period, 139 agreed to be screened. The few who did not agree to being screened at that time typically did so because of time constraints, and most indicated that they would be willing to be screened at a later time. The results of the study indicated that, of the 139 screened, 13 screened positive (requiring follow-up regarding their memory function); this result was about what we would expect given an incidence of dementia of approximately 10% in individuals over the age of 60. Ten of these patients were later diagnosed with Alzheimer’s disease, two with a mixed dementia, and one had mild cognitive impairment. This study showed both that screening in primary care can identify patients with Alzheimer’s disease and that patients are overwhelmingly in favor of having their memory screened.
To Screen or Not to Screen?
To an increasing number of clinicians, the argument that we screen our patients for memory disorders seems obvious. But screening for cognitive function is not without its critics. The criticisms come from both practical and theoretical concerns ( Box B1 ).
Box B1
Barriers to Early Detection of Alzheimer’s Disease
From Solomon, P. R., & Murphy, C. A. (2005). Should we screen for Alzheimer’s disease? A review of the evidence for and against screening Alzheimer’s disease in primary care practice. Geriatrics, 60(11), 26–31.
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Patient may be unaware; denies or minimizes symptoms
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Evaluation may be time-consuming and not compensated financially
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Belief that memory loss may be part of normal aging
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Belief that Alzheimer’s disease is not treatable by some healthcare professionals and the general public
To Screen
There are a number of reasons to screen our patients in the context of day-to-day clinical practice. Below we discuss a number of the more important reasons to screen patients for memory loss.
Underdiagnosis of Alzheimer ’ s Disease
One of our colleagues who has a very busy primary care practice tells a story about a 72-year-old woman who came in for a check-up for her type 2 diabetes. For reasons our colleague did not understand, her medications did not seem to be controlling her insulin levels. She reported taking the medications as prescribed, monitoring her diet, and even exercising daily. He was puzzled. At the end of the visit she talked to him about a trip she had taken with her sister last month. She conveyed the details of the trip without difficulty. They then walked out of the examination room to the waiting room together, where they met the patient’s sister. Our colleague mentioned the trip the two sisters had recently taken only to be confronted with a blank look. It turns out that the two sisters had taken the trip, but it was six years earlier. This interaction led to a memory screen for the patient and the eventual diagnosis of Alzheimer’s disease. It also explained the patient’s poor control of her diabetes: it seems she was not reliably taking her medication nor was she reliably controlling her diet or exercising.
Perhaps because the symptoms of early-stage Alzheimer’s disease are subtle and not readily detectable and because patients with early Alzheimer’s disease may appear entirely appropriate in the context of a brief office visit ( ), cases of Alzheimer’s disease in the early stages often go undetected during a primary care visit. By some estimates, up to 95% of cases of mild dementia are not detected by clinicians ( ). In one small study, 78.6% of patients with mild dementia, 71.4% with moderate dementia, and 20% with severe dementia had no indication of cognitive deficits in their medical records ( ). Other studies in primary care practices have found rates of dementia between 50% and 66% ( ). In brief, many cases of early-stage Alzheimer’s disease are missed, and, as the example of our diabetic patient reveals, these patients’ memory problems can have potentially dangerous consequences.
Benefits of Medication
As discussed in detail in Chapter 19, Chapter 20 , there are currently four approved medications for the treatment of Alzheimer’s disease: donepezil (generic and Aricept), rivastigmine (Exelon), galantamine (now generic, formerly under the names Razadyne and Reminyl), and memantine (generic and Namenda). Each of these medications provides “symptomatic benefit” (i.e., facilitates function of remaining neurons/synapses), but does not protect against subsequent neuronal loss (i.e., no “disease-modifying” properties). The cholinesterase inhibitors are approved for all stages of Alzheimer’s disease (mild, moderate, and severe) and data suggest that they are most beneficial when administered early in the course of disease ( ). Memantine is approved for moderate to severe Alzheimer’s disease. The emergence of disease-modifying treatments further emphasizes the need for early detection and diagnosis. There are currently drugs in clinical trials that are being evaluated for their ability to alter amyloid production or aggregation, and others that may clear brain amyloid (see Chapter 23 ). Early detection and treatment will be the key to the eventual success of disease-modifying drugs.
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