Analysis Too Much Medicine

Political drive to screen for pre-dementia: not evidence based and ignores the harms of diagnosis

BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f5125 (Published 09 September 2013) Cite this as: BMJ 2013;347:f5125
  1. David G Le Couteur, professor of geriatric medicine 1,
  2. Jenny Doust, professor of clinical epidemiology 2,
  3. Helen Creasey, dementia specialist 3,
  4. Carol Brayne, professor of public health 4
  1. 1Centre for Education and Research on Ageing, ANZAC Medical Research Institute and the Charles Perkins Centre, University of Sydney and Sydney Research, Concord, 2139, Australia
  2. 2Centre for Research in Evidence Based Practice, Bond University, Robina, Australia
  3. 3Centre for Education and Research on Ageing, Concord RG Hospital
  4. 4Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
  1. Correspondence to: D Le Couteur david.lecouteur{at}sydney.edu.au

Summary box

  • Clinical context—Dementia is age related and with an ageing global population is predicted to become an overwhelming and costly problem

  • Diagnostic change—Introduction of broader diagnostic criteria for mild cognitive impairment and pre-dementia based on new cognitive screening tests coupled with cerebrospinal fluid biomarkers and neuroimaging

  • Rationale for change—Past neglect of services and research in dementia has fuelled international calls for action and earlier treatment

  • Leap of faith—People with mild symptoms will eventually develop dementia and interventions are more likely to be effective at an early stage

  • Impact on prevalence—The current prevalence of dementia is thought to be 10-30% in people over the age of 80, but the adoption of new diagnostic criteria will result in up to 65% of this age group having Alzheimer’s disease diagnosed and up to 23% of non-demented older people being diagnosed with dementia

  • Evidence of overdiagnosis—Screening for cognitive impairment and measurement of biomarkers and neuroimaging are increasing the diagnosis of mild cognitive impairment, which in many people will improve spontaneously

  • Harms from overdiagnosis—Unnecessary investigation and treatments with side effects; adverse psychological and social outcomes; and distraction of resources and support from those with manifest dementia in whom need is greatest

  • Limitations—Current case identification and screening policy relies mostly on anecdotal and observational data from potentially biased sources, including those with vested commercial interests, rather than evidence from clinical trials. There is a lack of research focused on older people, in whom dementia is most prevalent

  • Conclusions—Current policy is rolling out untested and uncontrolled experiments in the frailest people in society without a rigorous evaluation of its benefits and harms to individuals, families, service settings, and professionals

Current policy in many countries is aimed at increasing the rates of diagnosis of dementia and cognitive impairment.1 2 …

Sign in

Free trial

Register for a free trial to thebmj.com to receive unlimited access to all content on thebmj.com for 14 days.
Sign up for a free trial

Subscribe