Ask the experts: should we screen for Alzheimer’s disease?

Part 2: This week’s ‘Ask the experts’ column at Neurology Central with Maria Carrillo (Alzheimer’s Association), Linda Nazarko (London North West Healthcare NHS Trust, UK), Gabriel Vargas (Amgen, CA, USA) & Henrik Zetterberg (University of Gothenburg, Sweden) focuses on the often controversial topic of screening for Alzheimer’s disease. Introduced in our last post, we will now drill down deeper into the pros and cons of screening.

Why is there such a strong debate as to whether we should screen individuals for Alzheimer’s?

Carrillo: The U.S Preventive Services Task Force’s 2014 comprehensive review found that there is not enough available evidence about the benefit or harm of cognitive screening in older adults without cognitive symptoms to make a recommendation for or against it. The Alzheimer’s Association says that lack of recommendation points to the need for more, well-designed, long-term research to generate credible, high-quality evidence.

Much of the debate centers on whether there is enough evidence to support universal screening as beneficial. With early screening there is the potential for patient harm due to misdiagnosis, unnecessary tests and treatments, and the associated avoidable costs. On the other hand, there is the potential for positive outcome with early detection. The earlier one tries to diagnose an individual with Alzheimer’s, the more difficult it becomes to separate normal cognitive aging vs. changes due to Alzheimer’s.

Do you think we should take on a population screening approach for AD?

Zetterberg: No, not until we have effective, safe and affordable treatments.

Vargas: I think absolutely, once we have disease modifying medications. I don’t see much purpose if we can’t treat the disorder. I think once medications that have a real disease-modifying effect are available individuals should be screened using either PET or CSF for amyloid load much in the same way we now perform colonoscopies on subjects when they turn 50.

Nazarko: Yes, but I also think we need to promote health and wellbeing. We can reduce the risk of people developing dementia by encouraging people to maintain a healthy weight, a normal blood pressure and a healthy cholesterol. If we can reduce cardiovascular and metabolic risk factors we’ll have a healthier population. As people are living longer we need to enable them to live well and health promotion should begin in early adulthood.

How will patients benefit from an Alzheimer’s diagnosis?

Nazarko: It enables the person who is in the early stages to plan for the future, to work with their families and others to develop an advanced care plan and to have a voice in ongoing treatment and care. It can be empowering.

Do people really want to know if they have Alzheimer’s?

Carrillo: Fear of causing emotional or psychological distress is one of the most common reasons healthcare providers and family members give for not sharing a dementia diagnosis with the affected individual. However, studies that have explored this issue have found that few patients become depressed or have other long-term emotional problems because of being informed of their diagnosis. In a study of individuals and their caregivers before and after a dementia diagnosis, no clinically significant changes in depressive symptoms were noted and anxiety either remained unchanged or decreased. Anecdotally, the Alzheimer’s Association has found that, for many individuals, receiving a clear reason for their changes in behavior and memory abilities actually provides some relief.

Nazarko: No one wants to know that they have a disease that cannot readily be treated, however I believe that clinicians have a duty to enable people to understand that their problems are as a result of a disease process and to enable that person to access support to manage the consequences, for example difficulty with managing day to day activities.

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You would also enjoy: Ask the experts Part 1 and Part 3.

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