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 Sandra, a fit 65-year-old woman, believes in the benefits of proactive health care. She exercises regularly and never misses an annual physical. So when she sees a flier for a free memory screening event at her local Kmart, she thinks it's a great opportunity to check on her brain health too.
Sandra's reasoning may seem intuitive. We check the circulatory, lymphatic and respiratory systems. Why shouldn't we check the organ responsible for their executive function?
This question lies at the heart of a brewing debate fueled by disagreement among Alzheimer's disease (AD) experts, including the nation's leading nonprofit advocacy groups. The debate centers on "memory screening," which uses standardized tests to determine whether a person has normal cognition for his age. Such tests ask people to answer questions and complete simple tasks, such as remembering words and drawing a clock. These screenings, which can take up to 10 minutes, are administered face-to-face at a health fair or a doctor's office.
The controversy about this particular method arises from an urgent need to better manage AD, the fatal neurological disease that robs people of their ability to reason, function and participate in life.
"We have to find better ways of treating and taking care of people with AD or we're simply going to be overrun by the epidemic that's already started. That's going to be a disaster, not only for people with AD, but for everyone else, because it's going to wreck our health care system," says William Thies, PhD, vice president of medical and scientific relations for the Alzheimer's Association.
To prepare for the looming epidemic, advocacy groups, researchers and the government have reviewed the role of memory screening. The AFA supports the tool as a way to identify potential patients, who could benefit from early treatment. The Alzheimer's Association does not believe that memory screening leads to earlier detection or treatment intervention.
Both sides agree that people who exhibit cognitive problems should undergo immediate evaluation by a physician. The benefit of screening seemingly asymptomatic individuals is the point of contention.
Benefits of Early Diagnosis
Advocates say that all older adults benefit from memory screening because it detects cognitive problems before memory loss is noticeable.
The AFA began holding an annual national memory screening day five years ago as a way to offer free, confidential memory screenings. More than 2,000 sites, such as community centers and Kmart pharmacies, provide free memory screenings and educational information about AD.
Eric J. Hall, chief executive officer of the AFA, says the foundation is simply trying to promote "awareness, knowledge and empowerment" so people can get the care they need. The AFA stresses that screening is not a diagnosis.
Critics agree that memory screening would be beneficial if it culminated in early diagnosis. But they say it's incorrect to assume that memory screening actually leads to earlier diagnosis and treatment. Inaccurate tests and lack of follow-up foil the process, they say.
Studies show that factors such as age, ethnicity and education can decrease the accuracy of commonly used screening tests. Mass screenings, such as those administered at national memory screening days, produce more inaccurate results because the environment can be distracting, critics say.
In recent years, physicians have successfully diagnosed AD patients by performing a battery of tests. However, John Trojanowski, MD, PhD, director of the Alzheimer's Disease Center at the University of Pennsylvania, says this process may take multiple visits over the course of two to three years.
One in 10 diagnoses is still incorrect, Dr. Trojanowski estimates, even after physicians conduct these extensive physical, neurological, psychological and mental exams. He dismisses 10-minute memory screening exams as useless.
Advocates say that memory screenings are valuable, even if they sometimes produce inaccurate results. Paul Solomon, PhD, is a neuroscience expert at Williams College and a member of the Alzheimer's Disease Screening Discussion Group, which recommends routine screening. He compares memory screening to other screening techniques, such as mammograms for breast cancer.
Dr. Solomon says many mammograms show false positives. Although an abnormal mammogram calls for a full diagnostic evaluation, it doesn't mean a woman has breast cancer. But if she does, the subsequent evaluation can lead to early diagnosis, which provides the best opportunity for effective treatment.
However, unlike mammograms, many patients who receive poor scores at mass screenings do not follow up with their physicians. Patients who do find little infrastructure to handle positive memory screening results.
"If you screen people and they take the report to their physician, what is he going to do with that?" asks Charles Smith, MD, a neurologist at the University of Kentucky Sanders-Brown Center on Aging and leader of a study on a new AD screening device, Cognision. "The assumption is that there's this huge system in place to do something with the information that people have obtained at Kmart." The medical community simply is not equipped to process the results of mass memory screenings, he says.
Even when a memory screening is conducted in a doctor's office, a positive result for memory problems does not necessarily lead to treatment. An article in the Wall Street Journal cites a study in the Journal of General Internal Medicine by Soo Borson, professor and dementia specialist at the University of Washington. Of 524 adults screened in a doctor's office, only one in five who exhibited memory problems was referred to a specialist or received a diagnosis or prescription for medication, the study found. Lack of time may be one reason for so little physician follow-up, Borson suggests.
John Wesson Ashford Jr., MD, PhD, agrees. "The typical story is that the doctors are busy and overworked," says the senior research scientist at the Stanford/VA Agig Clinical Research Center and chair of the memory screening advisory board for the AFA. "[Doctors] ask their patients if they have any problems, and the first thing people forget is that they have a memory problem. That might seem funny, but unfortunately, it's reality. Doctors mostly don't have time to deal with the issue."
However, Dr. Ashford says physicians would be more likely to recommend further evaluation if patients presented their abnormal memory screen results from events such as the National Memory Screening Day. He believes the day educates patients and empowers them to begin a dialogue with their physicians.
Treatment Options
Both sides agree that patient education is important because many people don't realize treatment is available.
Some FDA-approved drugs treat the symptoms of AD. And advocates say it's important to screen people before they exhibit symptoms because AD medicines are most effective when taken early in the disease. However, some critics say it's not helpful to identify people before they exhibit noticeable memory problems because medication is useful only in those with clear symptoms.
Disagreement also exists about the benefits of AD medications because they cannot change the disease's outcome. "If there was treatment for AD, I'd recommend screening, but there is no disease-modifying therapy," says Dr. Trojanowski.
The AFA says treatment does not have to improve the condition to be helpful. There is no "silver bullet," says Hall. Instead, medications slow the progression of symptoms.
However, some debate the drugs' ability to meaningfully improve quality of life for a substantial length of time, including the United States Preventive Services Task Force (USPSTF), a federally funded, independent panel of experts. The USPSTF, which doesn't support or reject memory screening, believes medication offers limited benefits. The drugs do not help people remain independent, the USPSTF states.
However, Dr. Ashford believes medications can have a significant impact on patients and their families by improving their quality of life for six months to two years. "That's worth a lot," he says. "Before these medications were available, I saw so many patients who were just impossible to manage and whose families were suffering. If you can get them on medication, all of a sudden, everyone's doing a lot better," he says.
Both sides agree that a healthy lifestyle can help prevent the onset of AD. Dr. Trojanowski "passionately recommends" exercise, cognitive stimulation, social networking, maintaining a low BMI and blood pressure, and diet and exercise for everyone, whether or not they perform well on a memory test.
The concept of memory screening as a motivator extends to other important issues as well. Many families must make important decisions for their loved ones who have succumbed to the disease. Advocates of memory screening say an abnormal result leading to early diagnosis gives patients time to plan for their care, decide on future living arrangements and set their financial affairs in order while they're still lucid. An early diagnosis also can help families prepare emotionally and alert them to monitor patients' medications and driving.
True Value of Screenings
It's difficult to objectively evaluate the overall medical, financial and social effects of memory screening because no large-scale, long-term studies on the practice exist.
Dr. Trojanowski says resources from the already-underfunded field should not be allotted for memory screening without hard data showing that it ultimately improves an AD patient's experience.
Dr. Ashford believes that sufficient information supports the "cost-worthiness" of memory screening, citing 200 tests for dementia. He has analyzed the evidence of the disease, the benefits of a true positive, the harms of a false negative and the cost of the assessment. He concluded that annual memory screening is beneficial for everyone over 75, and for people over 65 with a family history or other risk factors.
Looking Toward the Future
A report by the Alzheimer's Association predicts that 10 million baby boomers will develop AD in their lifetimes. Dr. Solomon expresses the pressing need for stronger action against the disease's onslaught.
"What we're doing now is not working. Half of the people with this disease are not diagnosed, and three quarters of them are not treated. This problem is going to magnify when the number of people with this disease increases three-, four- or five-fold over the next 50 or 60 years. I'm not sure we have the luxury to wait," he says.
You can take immediate action by speaking with your doctor about AD if you have any concerns. Advocates and critics of memory screening agree this communication is crucial, but disagree over the best means to achieve it.
The AFA encourages routine memory screening in primary care, in addition to National Memory Screening Day. The Foundation supports a proposal to add a memory screening test to the "Welcome to Medicare" physical, the initial exam for Medicare Part B, to record a baseline score for everyone enrolled.
Rather than a mandated, standardized exam, the Alzheimer's Association promotes "cognitive surveillance" by patients and physicians. Thies says the structure of conversations between physicians and patients can be "highly variable and adjusted to the needs of particular practices and patients."
Ideally, the debate over memory screening will become irrelevant when disease-modifying drugs and vaccines are developed. Dr. Smith is optimistic about drug research. But a medical breakthrough may not come in time to save the current health care system.
George J. Isham, MD, MS, a member of the USPSTF, recognizes the need to address this "devastating" and "compelling" situation, but says that passion for the cause should not preclude systematic evaluation. "People are very concerned about this condition and want to do everything possible for it, regardless of effectiveness."
Until memory screenings are proven effective, the decision to use them rests with patients and physicians. However, a conversation with your physician can prove invaluable.
Nicole Woods is a former assistant editor at ADVANCE, the parent company that produces this Web site. This article originally appeared in Healthy Aging in 2008, and was re-tooled for a consumer audience to help consumer understand the debate about memory screening.
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