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Guideline recommends not screening asymptomatic adults (≥65 years of age) for cognitive impairment
OTTAWA, ON, November 30, 2015 – The Canadian Task Force on Preventive Health Care (CTFPHC) has released its recommendations to Canadian clinicians and policymakers on screening for cognitive impairment in adults aged 65 years and older. These recommendations were published today in the Canadian Medical Association Journal (CMAJ).
Cognitive impairment occurs along a continuum from mild cognitive impairment (MCI), characterized by memory complaints occurring as part of the normal aging process, to more severe memory and cognitive deficits occurring as a result of dementia, which impede daily functioning.
The guideline, developed by the CTFPHC, an independent body of specialists with expertise in primary care and prevention, recommends against screening asymptomatic adults (≥65 years of age) for cognitive impairment, citing a lack of research in support of screening; the ineffectiveness of treatments; and a high rate of false positives1 as its rationale. This new guideline, available at: www.canadiantaskforce.ca updates prior guidelines developed by CTFPHC in 2001. A physician FAQ document is also available on the CTFPHC website.
“While clinicians should remain alert to patients with symptoms of cognitive impairment who may require diagnostic inquiry, we strongly recommend against screening all asymptomatic, community dwelling adults aged 65 years and older,” said Dr. Kevin Pottie, chair of the CTFPHC guideline working group.
Since 2001, CTFPHC has recommended against screening for cognitive impairment in adults aged 65 years and older (where cognitive impairment has not been identified as a specific concern). This recommendation is re-affirmed with the current guidelines, which in turn are consistent with other Canadian, and international guidelines such as the BC Ministry of Health 2014 Guidelines, the National Institute for Health and Care Excellence (NICE) 2011 Guidelines and the U.S. Preventive Services Task Force (USPSTF) 2014 Guidelines.
CTFPHC found no trials evaluating the benefits or harms of screening for cognitive impairment. According to available research however, the screening tools used to diagnose mild cognitive impairment often incorrectly classify individuals as cognitively impaired. Approximately one in eight to ten people using the Mini Mental State Examination [MMSE] and one in four people using the Montreal Cognitive Assessment tool [MoCA] are falsely labeled – an error that has been shown to lead to psychosocial harms such as a lack of independence, stress, and depression.
According to the CTFPHC’s findings, even when individuals are accurately diagnosed with mild cognitive impairment, available evidence suggests that pharmacological treatment is not effective, and non-pharmacological treatment (i.e., exercise, cognitive training, and rehabilitation) produce small, clinically insignificant benefits.
CTFPHC Findings:
Screening
A review of available evidence highlights that no randomized trials have evaluated the benefits and harms of screening for cognitive impairment.
Pharmacological treatments
- The CTFPHC systematic review found that cholinesterase inhibitors failed to improve behaviour or function in the context of mild cognitive impairment.
- A review of the evidence by the U.S. Preventive Services Task Force (USPSTF) found a small and likely clinically insignificant short-term benefit of cholinesterase inhibitors [Donepezil (Aricept), Rivastigmine (Exelon), and Galantamine (Reminyl)] on cognitive and global function in those with MCI or mild to moderate dementia.
Non-pharmacological treatments
- Available data suggests that non-pharmacological treatments such as exercise, cognitive training, and comprehensive rehabilitation may produce small benefits, but if present they do not appear to be large enough to be clinically significant.
Dietary supplements or vitamins
- A systematic review concluded that dietary supplements or vitamins did not improve cognition.
Harms
- The findings of the evidence review highlight a lack of quality trials evaluating the benefits and harms of screening for cognitive impairment and the lack of effective treatment for mild cognitive impairment.
“The CTFPHC’s findings have identified multiple opportunities for research,” said Dr. Kevin Pottie, chair of the CTFPHC guideline working group. “It is clear that we need more precise screening tools and treatments, including preventive approaches that improve clinically relevant outcomes for cognitive impairment.”
For the complete report and details on the CTFPHC’s findings and recommendations and accompanying clinician KT tools, please visit: www.canadiantaskforce.ca
About the Canadian Task Force on Preventive Health Care
The Canadian Task Force on Preventive Health Care has been established to develop clinical practice guidelines that support primary care providers in delivering preventive health care. The mandate of CTFPHC is to develop and disseminate clinical practice guidelines for primary and preventive care, based on systematic analysis of scientific evidence.
1False positive: A result that indicates that a given condition is present when it is not.