Re: There is no evidence base for proposed dementia screening
We are relieved that Koekkoek and colleagues (1) share our fears about the plan to screen in primary care all patients over the age of 75 for dementia.
We would like to respond to Koekkoek and colleagues’ additional comments, of which the second was particularly interesting.
Firstly, whether this case finding programme is screening or not, we would still maintain that the benefits have yet to be proven and the possibility of harm seems not even to have been considered.
Secondly, Koekkoek et al. suggest that diagnosing dementia as early as possible might assist management of co-existing conditions such as type 2 diabetes mellitus. They cite an observational (cross-sectional) study demonstrating an association between high levels of social support and glycaemic control in people with type 2 diabetes mellitus and cognitive impairment (defined by HRS-cog scores in the lowest quartile) (2). Unfortunately, there is no evidence of benefit of any intervention in this group of people with diabetes or of any of the other groups for whom case finding for dementia is proposed. If any individual has social or care needs, these should be met on the basis of need, not diagnosis.
Koekkoek et al. fail to disprove our contention that the benefits of early diagnosis of dementia do not outweigh the harms. Not only has the benefit they postulate not been established but, crucially, the risk of harm has not been assessed (3).
We would absolutely agree that “we should take cognitive functioning into account in patients with complex diseases, such as diabetes, and adjust treatment and monitoring to the preserved capacity of individual patients to assure safe self-management and prevent adverse events, especially in elderly with long-standing or more complicated disease.” The medical management of any patient must be tailored to them in every way, not just their cognitive functioning.
We also agree that there should be neither taboo nor stigma associated with diagnosing dementia. One of the most effective antidotes to stigma is effective treatment. Identifying and providing interventions known to have clinically significant benefits should therefore be prioritised (4).
We infer from Koekkoek at al.’s last sentence that they agree with us that there is indeed a significant risk of harm (“doom and gloom”) associated with a case finding programme for dementia, which is not evidence-based.
1 Koekkoek PS, Janssen J, Kappelle LJ, et al. Early detection of dementia: not only doom and gloom. BMJ Rapid Responses. 2013. http://www.bmj.com/content/345/bmj.e8588/rr/629558 (accessed 11 Feb2013).
2 Okura T, Heisler M, Langa KM. Association between cognitive function and social support with glycemic control in adults with diabetes mellitus. Journal of the American Geriatrics Society 2009;57:1816–24.
3 Brunet MD, McCartney M, Heath I, et al. There is no evidence base for proposed dementia screening. BMJ 2012;345:e8588–e8588.
4 Brunet MD, McCartney M, Heath I, et al. Re: Open Letter to The Prime Minister and the Chief Medical Officer Regarding Proposals to Introduce Screening for Dementia. British Medical Journal (Rapid Response). 2012. http://www.bmj.com/content/344/bmj.e2347/rr/621214 (accessed 7 Jan2013).
Competing interests:
No competing interests
13 February 2013
Martin D Brunet
general practitioner
Margaret McCartney, general practitioner, Fulton St Medical Practice, Glasgow, Iona Heath, retired general practitioner and former president, Royal College of General Practitioners , Jonathan Tomlinson, general practitioner, Lawson Practice, Hackney, London, Peter Gordon, consultant psychiatrist for older adults, NHS Forth Valley, John Cosgrove, general practitioner, High St Surgery, Birmingham, Peter Deveson, general practitioner, Derby Medical Centre, Epsom, Sian Gordon, general practitioner, Graeme Medical Centre, Falkirk, Sally-Ann Marciano, registered general nurse and dementia campaigner, Deborah Colvin, general practitioner and local medical committee chair, Lawson Practice, Hackney, London, Melissa Sayer, general practitioner, Statham Grove Surgery, Stoke Newington, London, Ruth Silverman, general practitioner, Statham Grove Surgery, Stoke Newington, London, Naureen Bhattia, general practitioner, Limehouse Surgery, London
Rapid Response:
Re: There is no evidence base for proposed dementia screening
We are relieved that Koekkoek and colleagues (1) share our fears about the plan to screen in primary care all patients over the age of 75 for dementia.
We would like to respond to Koekkoek and colleagues’ additional comments, of which the second was particularly interesting.
Firstly, whether this case finding programme is screening or not, we would still maintain that the benefits have yet to be proven and the possibility of harm seems not even to have been considered.
Secondly, Koekkoek et al. suggest that diagnosing dementia as early as possible might assist management of co-existing conditions such as type 2 diabetes mellitus. They cite an observational (cross-sectional) study demonstrating an association between high levels of social support and glycaemic control in people with type 2 diabetes mellitus and cognitive impairment (defined by HRS-cog scores in the lowest quartile) (2). Unfortunately, there is no evidence of benefit of any intervention in this group of people with diabetes or of any of the other groups for whom case finding for dementia is proposed. If any individual has social or care needs, these should be met on the basis of need, not diagnosis.
Koekkoek et al. fail to disprove our contention that the benefits of early diagnosis of dementia do not outweigh the harms. Not only has the benefit they postulate not been established but, crucially, the risk of harm has not been assessed (3).
We would absolutely agree that “we should take cognitive functioning into account in patients with complex diseases, such as diabetes, and adjust treatment and monitoring to the preserved capacity of individual patients to assure safe self-management and prevent adverse events, especially in elderly with long-standing or more complicated disease.” The medical management of any patient must be tailored to them in every way, not just their cognitive functioning.
We also agree that there should be neither taboo nor stigma associated with diagnosing dementia. One of the most effective antidotes to stigma is effective treatment. Identifying and providing interventions known to have clinically significant benefits should therefore be prioritised (4).
We infer from Koekkoek at al.’s last sentence that they agree with us that there is indeed a significant risk of harm (“doom and gloom”) associated with a case finding programme for dementia, which is not evidence-based.
1 Koekkoek PS, Janssen J, Kappelle LJ, et al. Early detection of dementia: not only doom and gloom. BMJ Rapid Responses. 2013. http://www.bmj.com/content/345/bmj.e8588/rr/629558 (accessed 11 Feb2013).
2 Okura T, Heisler M, Langa KM. Association between cognitive function and social support with glycemic control in adults with diabetes mellitus. Journal of the American Geriatrics Society 2009;57:1816–24.
3 Brunet MD, McCartney M, Heath I, et al. There is no evidence base for proposed dementia screening. BMJ 2012;345:e8588–e8588.
4 Brunet MD, McCartney M, Heath I, et al. Re: Open Letter to The Prime Minister and the Chief Medical Officer Regarding Proposals to Introduce Screening for Dementia. British Medical Journal (Rapid Response). 2012. http://www.bmj.com/content/344/bmj.e2347/rr/621214 (accessed 7 Jan2013).
Competing interests: No competing interests