DIAGNOSIS: Many seniors feel their brainpower may not be what it used to be. They also know Medicare offers free cognitive tests. Yet half of these seniors won’t take one. Find out who won’t, why not and why they ought to.
Despite clear signs that their memory and thinking abilities have gone downhill, more than half of seniors with these symptoms haven’t seen a doctor about them, a research study finds.
Two thirds of individuals 65 and older who screened positive for cognitive impairment refused subsequent evaluation according to the first study of its kind to examine older adults’ willingness to undergo diagnostic assessment. The Indiana University Center for Aging Research, Regenstrief Institute and Eskenazi Health study of approximately 500 older adults found that individuals living alone were the least likely to agree to diagnostic assessment following a positive screening test for dementia.
Screening is designed to detect if a problem exists. Diagnostic assessment provides a diagnosis based on the best available tests.
“Traits of Patients Who Screen Positive for Dementia and Refuse Diagnostic Assessment“ is published in the June issue of Alzheimer’s & Dementia: Diagnosis, Assessment & Disease Monitoring, an open access, peer-reviewed journal from the Alzheimer’s Association.
In addition to living alone, an individual’s negative preconceptions of the stigma surrounding dementia were associated with refusal to undergo diagnostic assessment; although, surprisingly, not with unwillingness to undergo initial screening.
Those who agreed to continue from positive screening to diagnostic assessment were also more likely to agree with positive statements about other types of screening, such as colonoscopy.
Age, sex and race appeared to have no impact on an older adult’s decision to follow or not follow a positive cognitive impairment screening result with diagnostic assessment.
“The findings from our study are important given the low rates of detection of dementia and the high percentage of older adults with dementia who never receive a cognitive evaluation,” said Nicole Fowler, Ph.D., the IU Center for Aging Research and Regenstrief Institute investigator who led the new study. “Early intervention and education of patients and their caregivers on dementia and dementia screening could increase the number of patients seeking diagnostic assessment and inform efforts that address the perceived stigmas associated with dementia screening.
“While screening and evaluation can’t delay or alter dementia progression, definitive diagnosis based on a cognitive assessment can alert physicians to treatable symptoms and allow the older adult and family members to prepare for future cognitive decline,” Dr. Fowler said.
Study participants did not have a previous diagnosis of dementia. They received primary care at Eskenazi Health, one of the largest safety net health systems in the United States.
“Understanding patients’ attitudes about the risks and benefits of early identification of dementia and how those attitudes translate to behaviors toward screening is vital to assess the value of population-based dementia screening,” Dr. Fowler, who is also an assistant professor of medicine at IU School of Medicine, said.
How Many of Us are Affected?
In a related study, University of Michigan researchers and their colleagues say their findings suggest that as many as 1.8 million Americans over the age of 70 with dementia are not evaluated for cognitive symptoms by a medical provider, which in some patients can lead to a failure to uncover modifiable causes of thinking or memory impairment.
The study, published online in Neurology , the medical journal of the American Academy of Neurology, documents a clear lack of clinical testing for seniors with signs of cognitive problems.
Those who were married, and those with the worst levels of dementia symptoms, were more likely to have had their memory and thinking ability evaluated by a primary care doctor, neurologist or psychiatrist. The study included people with mild cognitive impairment through severe dementia, from all causes.
“Early evaluation and identification of people with dementia may help them receive care earlier,” says study author Vikas Kotagal, M.D., M.S., who sees patients at the University of Michigan Health System and is an assistant professor in the U-M Medical School’s Department of Neurology . “It can help families make plans for care, help with day-to-day tasks including observed medication administration, and watch for future problems that can occur. In some instances, these interventions could substantially improve the person’s quality of life.”
Free Dementia Testing Now from Medicare
The data in the study come from before the start of Medicare’s free annual wellness exams for seniors, which began in 2011 under the Affordable Care Act and are required to include a cognitive evaluation.
Even so, says Kotagal, “The results of this study have implications in both primary care and specialty care settings. Recognizing cognitive impairment in older individuals is important, and physicians should explore reasons why dementia has occurred and communicate these findings clearly with patients and family members so that they can take this information with them when they leave the office.”
More about the study population
Adapted from the National Institute on Aging
The study was part of a larger, nationally representative, community-based study called the Health and Retirement Study, based at the U-M Institute for Social Research . From that study, 856 people age 70 and older were evaluated for dementia, including a video interview and standard testing. For each participant, a spouse, child or other person who knew the person well was asked whether the participant had ever seen a doctor for any concerns about memory or thinking.
A total of 297 of the participants met the criteria for dementia. Of those, 45 percent had seen a doctor about their memory problems – and the more severe their issues, the more likely they had had that evaluation. By comparison, 5 percent of those with memory and thinking problems that did not meet the criteria for dementia had been tested by a doctor for those issues, and 1 percent of those with normal memory and thinking skills had undergone testing.
People who were married were more than twice as likely to undergo cognitive evaluations as people who were not married. Why? “It’s possible that spouses feel more comfortable than children raising concerns with their spouse or a health care provider,” said Kotagal. “Another possibility could be that unmarried elderly people may be more reluctant to share their concerns with their doctor if they are worried about the impact it could have on their independence.”
Other demographic factors did not have an effect on whether or not people had cognitive evaluations, including race, socioeconomic status, the number of children and whether children lived close to the parents. “Our results show that the number and proximity of children is no substitute for having a spouse as a caregiver when it comes to seeking medical care for memory problems for a loved one,” Kotagal said.
Next stop: Finding out why
While the study doesn’t answer the question of why people with signs of dementia don’t get tested, Kotagal suggests that many factors may be involved – – some driven by the patient, some by physicians, and others by the nature of our health system.
Many patients and physicians, he says, may perceive that clinical cognitive exams don’t have enough value. But experts have shown that they can improve medical outcomes and help reduce societal costs.
For instance, knowing that a stroke or vascular issues in the brain caused dementia means patients can work to control risk factors like blood pressure that might otherwise cause it to keep worsening.
The next steps in research on this topic are to find out why patients don’t get tested, and what parts of the diagnostic process are most valuable to patients and caregivers.
Indiana University Study
- In addition to Dr. Fowler, authors of the study are Amie Frame, MPH, and Anthony J. Perkins, M.S., of the IU Center for Aging Research and Regenstrief Institute; Sujuan Gao, Ph.D., and Patrick Monahan, Ph.D., of IU School of Medicine; Dennis P. Watson, Ph.D., of the Richard M. Fairbanks School of Public Health and Malaz A. Boustani, M.D., MPH, of the IU Center for Aging Research, Regenstrief Institute and IU School of Medicine.
- This was were supported by grants from the National Institute on Aging (R01AG029884 and 5R01AG040220) and NIH’s National Center for Advancing Translational Sciences (KL2TR000146 and KL2TR001106).
University of Michigan Health System Study
- In addition to Kotagal, the study’s authors include Kenneth Langa, M.D., Ph.D., who holds professorships in both the U-M Medical School and Institute for Social Research; U-M neurologist Roger Albin, M.D., U-M neuropsychologist Bruno Giordani, Ph.D. and U-M researcher Mohamed Kabeto, M.S. Authors from other institutions are Brenda Plassman, Ph.D. of Duke University, who directs the ADAMS study from which the data on dementia patients was obtained; and James Burke, M.D., Ph.D., Gwenith G. Fisher, PhD, Robert B. Wallace, MD, MS, David C. Steffens, MD, MH and Norman L. Foster, MD. Langa is a member of the U-M Institute for Healthcare Policy and Innovation.
- The study was supported by the University of Michigan, the National Institute on Aging (AG027010, AG009740, and AG007137), and University of Utah. Reference: Neurology,doi/10.1212/WNL.0000000000001096
- Indiana University
- University of Michigan Health System