Most doctors don’t screen for dementia, but that may change in Massachusetts
Nine out of 10 older people get their blood pressure checked when they visit their primary care doctors, and 73 percent are screened for hearing or vision loss. But what about problems with memory or thinking? Only 16 percent are asked about that.
Those are among the findings in a pair of surveys conducted by the Alzheimer’s Association and released last week. The results show that although Alzheimer’s disease and other types of dementia are common afflictions of old age, when it comes to detecting early symptoms, many doctors just don’t want to go there.
“Some people feel like there’s not much we can do for dementia,” said Dr. Erin E. Stevens, a geriatrician at Massachusetts General Hospital. Doctors hesitate to give a devastating diagnosis when they have no treatment to offer, she said.
In Massachusetts, that may start to change. Massachusetts General Hospital is developing a program to collaborate with primary care doctors in managing the illness. And a first-in-the-nation law passed last year requires all doctors, nurses, and physician assistants to get training in Alzheimer’s diagnosis and care.
The law is intended, in part, to address a shocking statistic from an earlier survey of Medicare beneficiaries: Half of Americans with Alzheimer’s disease have not been diagnosed, and half of those with a diagnosis have not been told about it. In addition to the training, the Massachusetts law requires physicians to disclose an Alzheimer’s diagnosis to the patient or family member.
These provisions reflect a growing recognition that even though Alzheimer’s is fatal, people can live with it for a decade or more — and much can be done to improve the quality of those years, especially if you start early.
Alzheimer’s disease is the most common form of dementia, a condition involving loss of memory and other mental abilities to the point of interfering with daily life. Alzheimer’s probably results from a combination of genetic, lifestyle, and environmental factors that interact to different degrees in each patient.
The Alzheimer’s Association estimates that 1 in 10 Americans age 65 and older has Alzheimer’s dementia.
The association surveyed 1,000 primary care physicians around the country and a representative sampling of 1,954 consumers age 65 or older. Nearly all primary care physicians — 94 percent — said they consider it important to assess all elderly patients for cognitive impairment, but only 47 percent say it’s their standard protocol.
Patients come in with a host of medical issues, and if they don’t exhibit cognitive problems or raise questions about their memory, the other health problems are likely to take up the whole visit, explained Dr. Blair Wardenburg Fosburgh, a Boston internist.
Additionally there’s no reliable easy-to-use screening tool for dementia, she said. Medicare pays for an hourlong annual wellness visit that is supposed to include a cognitive assessment, but requirements for assessments are vague, Fosburgh said.
And even if a cognitive problem in recognized, she said, “Sometimes you feel powerless to really do much.”
The few medications for Alzheimer’s merely slow the disease’s progression, but the effects are modest and they don’t work for everyone.
In the absence of treatment or cure, what patients and their families most need is help managing the illness day by day. But doctors don’t have those resources at their fingertips, nor the time or expertise to organize them.
Fosburgh is optimistic that will change soon for her practice, which is based at Massachusetts General Hospital.
The hospital plans to pilot a program in which a dementia-care team will be embedded in primary care practices at the hospital. When a doctor suspects dementia, he or she will turn to specialists in the office who can confirm the diagnosis and to social workers who can help patients and their families find and arrange the services they need.
Among the other findings in the survey:
■ Nine out of 10 elderly patients say they trust their doctor to recommend testing for thinking or memory problems but, on average, the doctors assess just half of their senior patients.
■ The most common reasons physicians gave for not assessing patients was the absence of symptoms or lack of time.
■ A majority also said patients resist the idea.
People don’t like to hear bad news, said Jim Wessler, CEO of the Alzheimer’s Association, Massachusetts/New Hampshire chapter. But physicians also aren’t trained in diagnosing dementia and often don’t understand the value of doing so.
Wessler told of a physician frustrated that none of the medications he prescribed were reducing a patient’s high blood pressure. Not until he performed a cognitive screening did he realize his patient was forgetting to take the pills, and forgetting that he hadn’t taken them.
Dr. Brent P. Forester, chief of geriatric psychiatry at McLean Hospital, said that it’s important to screen for memory problems because they could be symptoms of illnesses that have nothing to do with dementia but should be treated, such as depression, vitamin deficiency, thyroid problems, or an infection.
Even if tests rule out other causes and the patient appears to have Alzheimer’s or another form of dementia, Forester said, knowing about it as soon as possible gives people an opportunity to make the most of their remaining faculties — perhaps traveling while they can still enjoy it — and to plan for how to manage what lies ahead.
But Dr. Malaz A. Boustani, professor of aging research at the Indiana University School of Medicine, said his research has found no benefit from cognitive assessments the way medicine is generally practiced. “Unfortunately the system is not ready for cognitive assessments at this time,” he said.
Conducting widespread cognitive screening would be like offering mammograms in a system with no ability to perform biopsies or administer chemotherapy, he said.
“I feel their pain. The primary care doctors, they don’t have the resources and they don’t have the time,” Boustani said.
Boustani works with a central Indiana health system that does have the resources. Eskenazi Health, which encompasses inpatient and outpatient settings, started a collaborative dementia-care program more than decade ago. Patients meet with a team to develop a care plan, which is continually adjusted over time.
The system trains and employs “community health workers,” who need only a high school degree. These workers meet with families, help them address any difficulties, constantly measure how well the family functions, and work to reduce stress on the family member responsible for caregiving.
The program, he said, results in better health and a higher quality of life — and saves money.