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Level III – Dementia Routine Screening (Cognitive Impairment)

Level III Services: Preventive services that clinicians and care systems could provide to patients, but only after careful consideration of the costs and benefits. Providing these services is left to the judgment of individual care systems, clinicians and their patients.

The USPSTF recommendations are fully endorsed by the ICSI Preventive Services work group.
Grade of Recommendation and Level of Certainty as Evaluated by USPSTF
  1. “The current evidence is insufficient to assess the balance of benefits and harms of screening for cognitive impairment.”
(USPSTF Last Revised 2014)
Grade of Recommendation:
  1. I Statement

Level of Certainty:

  1. Insufficient
“Benefits:
The prevalence of dementia in the United States is 5% in persons ages 71 to 79 years, increasing to 24% in those ages 80 to 89 years and 37% in those older than age 90 years. The prevalence of older adults with MCI is difficult to estimate because of differences in the definition of MCI and methods used in studies; estimates range widely, from 3 to 42% in adults age 65 years and older. Approximately 40 to 50% of older adults report subjective memory symptoms. The rate of progression of MCI to dementia is uncertain.
Although the evidence on routine screening is insufficient, there may be important reasons to identify early cognitive impairment. In addition to its potential to help patients make diagnostic and treatment decisions, including treatment of reversible causes of dementia and management of comorbid conditions, early recognition of cognitive impairment allows clinicians to anticipate problems patients may have in understanding and adhering to recommended therapy. This information may also be useful to patients and their caregivers and family members in anticipating and planning for future problems that may develop as a result of progression of cognitive impairment. Although the overall evidence on routine screening is insufficient, clinicians should remain alert to early signs or symptoms of cognitive impairment (for example, problems with memory or language) and evaluate as appropriate. The National Institute on Aging has information on the detection and management of cognitive impairment for patients and clinicians, including a database of tools to detect cognitive impairment (available at www.nia.nih.gov).
Harms:
Information about the harms of screening, including labeling and the effect of false-positive results, is limited. Acetylcholinesterase inhibitors are associated with adverse effects, some of which are serious, including central nervous system disturbances and bradycardia. Gastrointestinal symptoms are also common. Information about the harms of non-pharmacologic interventions is limited, but these harms are assumed to be small. Exercise interventions are not associated with serious adverse effects.
Benefits-Harms Assessment:
Increasing age is the strongest known risk factor for cognitive impairment. The ε4 allele of the apolipoprotein E gene is a reported risk factor for Alzheimer disease. Other reported risk factors for cognitive impairment include cardiovascular risk factors (such as diabetes, tobacco use, hypercholesterolemia, hypertension and the metabolic syndrome), head trauma, learning disabilities (such as Down syndrome), depression, alcohol abuse, physical frailty, low education level, low social support and having never been married.
Several dietary and lifestyle factors have been associated with decreased risk for dementia; these factors have weaker supporting evidence than those previously mentioned. Adequate folic acid intake, low saturated fat intake, longer-chain ω-3 fatty acids, high fruit and vegetable intake, Mediterranean diet, moderate alcohol intake, educational attainment, cognitive engagement, and participation in physical activity are all associated with decreased risk for dementia.”
Relevant Resources:
http://www.uspreventiveservicestaskforce.org/uspstf/uspsdeme.htm
Implementation Tools and Strategies:
Screening for Cognitive Impairment in Older Adults