Screening for Dementia -- Is It a No Brainer?
Screening for Dementia -- Is It a No Brainer?
As people are living longer, dementia is becoming a significant issue for society. Dementia is now recognised as a major concern in society, and the numbers of people estimated to have dementia in the UK population appear to have stabilised at around 700,000. Globally, 35.6 million people are estimated to meet criteria for dementia, a number predicted to double every 20 years. Given the absence of treatments that significantly alter the natural history of the clinical syndrome of dementia, there has been increased emphasis on early diagnosis, with research exploring assessment tools and biomarkers that might predict with certainty a particular clinical outcome. At the same time, there has been pressure to focus on biomedical profiles, which assume a very close link between the pathobiology and the manifest clinical syndrome.
Estimates of dementia prevalence have long been used by policy makers to consider what services might be necessary for populations. However, in the last few years, these estimates have come to be used rather differently, as the baseline against which the gap in known cases is measured. The implications for health and social services have become increasingly articulated, most recently in the UK Prime Minister's Challenge and policies that appear to introduce implicit screening into acute and primary care settings. There is, however, a disconnection between the rhetoric on the benefits of an early diagnosis of dementia and the strength of the evidence required to introduce such measures on a national scale. Despite this lack of evidence, public surveys suggest the population thinks that dementia is modifiable, and that screening is self-evidently therefore a 'good thing'.
Cognitive impairment has been reported to be unrecognised in significant numbers (up to 80%) of affected patients in primary care. There is a significant gap in expected vs. observed prevalence. The reasons are multifactorial. There is a general improvement in general practitioners, attitudes and confidence in diagnosis but there are many factors that lead to under recognition. Reasons highlighted include the complexity of cognitive decline and impairment as part of continua in the ageing population, influenced by many cultural, social and clinical factors; poor awareness of how common it is or, indeed, the opposite, awareness of just how common it is; poor confidence of GPs in their clinical skills; therapeutic nihilism – the perception (and possibly knowledge) that current treatments are often ineffective; the belief that the patient would rather not know; perceived lack of time and other resources; and also the belief that diagnosis is not within the realm of general practice. Symptoms may often be seen as part of the normal ageing process by carers, patients and professionals which, from a population perspective, is true. This, from a population perspective, is true as only a proportion of those people with low cognitive performance will meet specific criteria for a diagnosis of dementia. There will be a range of explanations including terminal decline, lifelong poor cognition, comorbidity, effects of medication and impairment associated with specific disorders such as cancer, vascular disorders and ageing itself.
Abstract and Introduction
Abstract
As people are living longer, dementia is becoming a significant issue for society. Dementia is now recognised as a major concern in society, and the numbers of people estimated to have dementia in the UK population appear to have stabilised at around 700,000. Globally, 35.6 million people are estimated to meet criteria for dementia, a number predicted to double every 20 years. Given the absence of treatments that significantly alter the natural history of the clinical syndrome of dementia, there has been increased emphasis on early diagnosis, with research exploring assessment tools and biomarkers that might predict with certainty a particular clinical outcome. At the same time, there has been pressure to focus on biomedical profiles, which assume a very close link between the pathobiology and the manifest clinical syndrome.
Introduction
Estimates of dementia prevalence have long been used by policy makers to consider what services might be necessary for populations. However, in the last few years, these estimates have come to be used rather differently, as the baseline against which the gap in known cases is measured. The implications for health and social services have become increasingly articulated, most recently in the UK Prime Minister's Challenge and policies that appear to introduce implicit screening into acute and primary care settings. There is, however, a disconnection between the rhetoric on the benefits of an early diagnosis of dementia and the strength of the evidence required to introduce such measures on a national scale. Despite this lack of evidence, public surveys suggest the population thinks that dementia is modifiable, and that screening is self-evidently therefore a 'good thing'.
Cognitive impairment has been reported to be unrecognised in significant numbers (up to 80%) of affected patients in primary care. There is a significant gap in expected vs. observed prevalence. The reasons are multifactorial. There is a general improvement in general practitioners, attitudes and confidence in diagnosis but there are many factors that lead to under recognition. Reasons highlighted include the complexity of cognitive decline and impairment as part of continua in the ageing population, influenced by many cultural, social and clinical factors; poor awareness of how common it is or, indeed, the opposite, awareness of just how common it is; poor confidence of GPs in their clinical skills; therapeutic nihilism – the perception (and possibly knowledge) that current treatments are often ineffective; the belief that the patient would rather not know; perceived lack of time and other resources; and also the belief that diagnosis is not within the realm of general practice. Symptoms may often be seen as part of the normal ageing process by carers, patients and professionals which, from a population perspective, is true. This, from a population perspective, is true as only a proportion of those people with low cognitive performance will meet specific criteria for a diagnosis of dementia. There will be a range of explanations including terminal decline, lifelong poor cognition, comorbidity, effects of medication and impairment associated with specific disorders such as cancer, vascular disorders and ageing itself.
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