Evidence Lacking for Cognitive Screening in Older Adults, USPSTF Says

Alireza Atri, MD, PhD

The United States Preventive Services Task Force (USPSTF) has concluded that there is insufficient evidence to evaluate the benefits and harms of screening for cognitive impairment in older, community-dwelling adults.

The recommendation—or lack thereof—comes at a time when the neurology community continues to push for early and consistent cognitive screening, especially in those at risk for Alzheimer disease or dementia, as clinical research and drug development focuses on early intervention.

Notably, the USPSTF’s recommendation, which is unchanged since its last iteration in 2014, applies to adults age 65 and older who do not have recognized signs or symptoms of cognitive impairment, which it defines as significant decline in 1 or more cognitive domains that interfere with a person’s independence and daily activities.

Given the lack of high-quality evidence supporting or against cognitive screening in this population, the USPSTF encourages health care providers to be watchful for early signs and symptoms and to screen when appropriate.

“The USPSTF recognizes that clinical decisions involve more considerations than evidence alone,” the Task Force wrote. “Clinicians should understand the evidence but individualize decision-making to the specific patient or situation.”

READ MORE: Alireza Atri, MD, PhD, on the Importance of Cognitive Screening and Early Detection

Based on their evaluation, the Task Force found that while there is adequate evidence supporting the high sensitivity and specificity of some screening tools, positive predictive values vary based on prevalence in certain populations and are generally lower for detection of mild cognitive impairment than for dementia.

In terms of benefits, the USPSTF found that while some pharmaceutical interventions, including treatment with memantine and acetylcholinesterase inhibitors (AChEIs), may have a small effect on short-term cognitive function, whether these effects are clinically meaningful or sustained over the long-term is still uncertain. In addition, the Task Force found that there is inadequate direct evidence to support a benefit for cognitive screening in this population, as well as lacking evidence to support the benefits of other interventions, including those meant to support caregivers and improve decision-making.

Despite their recommendation, the USPSTF recognizes that there may be benefits to early detection.

“Burdens of cognitive impairment include direct effects on the patient (eg, loss of function and relationships, financial misjudgments, and nonadherence with recommended therapies), direct effects on caregivers (eg, burden and depression), and effects on society (eg, costs of care),” they wrote. “Early detection of cognitive impairment can allow for identification and treatment of reversible causes, may help clinicians anticipate problems patients may have in understanding and adhering to medical treatment plans, and may also be useful by providing a basis for advance planning on the part of patients and families.”

Notably, the recommendations don’t necessarily align with recent quality measurement initiatives by the American Academy of Neurology, who, in September 2019, announced a new quality metric that requires neurologists to screen all adults 65 and older for thinking and memory problems.²

In an interview with NeurologyLive, Alireza Atri, MD, PhD, medical director of the Banner Sun Health Research Institute, spoke about the importance of open-ended cognitive screening and the value that early detection and intervention can bring to the table.

“The US Preventative Services Task Force for years has said well, there's no level 1 data to advocate or not advocate for this. Well, the fact is that there's no level 1, randomized, double-blind, placebo-controlled trial data that says that you shouldn't smoke or that you should use a parachute if you're going to jump out of a plane. I mean, it goes against so much clinical sense and common sense--just because those studies haven't been funded doesn't mean that there's no value in doing it. And that goes for screening in the general public,” Atri said. “If you have patients who are coming to a neurologist for a problem related to the brain, the AAN is recognizing that that in itself is a risk factor for cognitive impairment and dementia. So there's the element of screening, which is doing it in people without risk or you can have detection or stratified screening, or you can go about it based upon concerns. The Alzheimer's Association clinical practice guidelines really defines the screening pathway as starting with a concern for a change about anything from anybody--patient, informant, or clinician, that's a good place to start.”

REFERENCES

1. Owens DK, Davidson KW, Krist AH, et al; for the US Preventive Services Task Force. Screening for cognitive impairment in older adults: US Preventive Services Task Force recommendation statement. JAMA. 2020;323(8):757-763. doi:10.1001/jama.2020.0435.

2. Foster NL, Bondi MW, Das R, et al. Quality improvement in neurology: mild cognitive impairment quality measurement set. Neurology. 2019;93:1-9. doi10.1212/WNL.0000000000008259.