Debate continues over early cognition screening: 'we know it's a good thing for people to talk to their physicians about any memory concerns they have.'.

WASHINGTON -- Some Alzheimer's disease-related groups--but not all--are stepping up calls for earlier and more frequent cognition screening, citing an aging population increasingly at risk for dementia.

The disease affects 1 in 10 people older than age 65 years, and almost half of those older than age 85 years, according to the Alzheimer's Foundation of America. It is the seventh leading cause of death in the United States.

A cognition screen can establish a baseline, and be used to prompt referrals to clinicians who can pinpoint the cause of memory loss or loss of executive functioning, Eric J. Hall, CEO of the New York-based AFA, said in an interview. Some of those causes may be treatable, Mr. Hall said.

An Alzheimer's diagnosis is important; knowing it early in the disease progression helps patients and families prepare, and early intervention can improve quality of life, he said.

The AFA has been seeking coverage of cognition screening as part of the "Welcome to Medicare" exam. The exam is offered during the first 6 months of Medicare Part B coverage; beneficiaries pay 20% of the cost if they've met the deductible. If they have not met the deductible, they may be liable for the exam's entire cost. The exam covers a medical and social history; a review of risk factors for depression; a review of functional ability and level of safety; an assessment of height, weight, blood pressure management, and visual acuity; an ECG and interpretation of the diagnostic test; and education, counseling, and referral.

To add cognition screening would require an act of Congress, according to a spokesperson at the Centers for Medicare and Medicaid Services.

The AFA's call for early screening and coverage was echoed by a group of experts convened by Pfizer Inc. and Eisai Inc., who issued a consensus statement in November. Pfizer and Eisai manufacture Aricept (donepezil), an Alzheimer's drug.

In the consensus document, the Alzheimer's Disease Screening Discussion Group urged all adults aged 65 years and older to seek cognition screening during a physical exam. Screening should be conducted on those with a strong family history of the disease or those who are concerned about memory problems, as well as on anyone admitted to an assisted-living or long-term care facility, said the seven-member panel.

Two of the panelists are paid speakers for Pfizer: Paul Solomon, Ph.D., clinical director of the memory clinic at Williams College, Williamstown, Mass., and Dr. Barry W. Rovner, director of clinical Alzheimer's disease research at Jefferson Medical College, Philadelphia.

At a briefing on the consensus document, Dr. Solomon said there are a number of validated cognition screening tools that can be used by practitioners, including the Mini-Mental State Examination, verbal fluency test, and clock-drawing test. "A delay in diagnosis can undermine Alzheimer's patients and their families in [their] ability to plan financially, socially, emotionally, and medically for the future," he said.

Dr. Rovner called for more training during medical school and residency on the importance of cognition screening, and for more education programs to target primary care physicians and the public.

Patients aren't talking with physicians about memory loss, according to an AFA survey of 1,902 people who participated in the organization's National Memory Screening Day in 2006. Of the survey respondents, 97% had never been given a memory test.

Of those surveyed, 80% said they had visited a primary care physician within the last 6 months, but fewer than 10% of those with self-identified memory problems had talked about them with their doctor.

The 2007 National Memory Screening Day was held in mid-November at 2,000 sites in 46 states, including 1,100 Kmart pharmacies. The AFA is supported by drug company grants and private donations. Memory Screening Day participants are given access to a special Web site that contains education materials and three cognition tests recommended by the AFA's Memory Screening Advisory Board.

The Chicago-based Alzheimer's Association does not see the wisdom of such health fair-type screening events, William Thies, Ph.D., vice president of medical and scientific relations, said in an interview. Patients may not get enough encouragement to talk with their physicians, and the tests used for screening are often not sensitive or specific enough, thus potentially leading to false-negative or false-positive results, he said.

"But we know it's a good thing for people to talk to their physicians about any memory concerns they have," Dr. Thies said, adding that the Alzheimer's Association encourages physicians to conduct more "cognitive surveillance."

Once a dialog has started, physicians can determine whether the patient is just worried or if diagnostics are necessary, Dr. Thies said.

There had once been a similar debate over the utility of screening for cholesterol, he said. Now there is a consensus on how and when to measure lipids, the definition of normal cholesterol levels, and the benefits and risks of treatment.

"I have no doubt that we will get there with Alzheimer's disease at some point; we're simply not there yet," Dr. Thies said.

BY ALICIA AULT

Associate Editor, Practice Trends