Intended for healthcare professionals

Rapid response to:

Analysis Too Much Medicine

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

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5125 (Published 09 September 2013) Cite this as: BMJ 2013;347:f5125

Rapid Response:

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

This provocative and thoughtful article has stimulated a variety of responses. These include the necessary distinction between awareness campaigns and proactive screening for cognitive decline, and the investigation of those who sense or whose relatives notice some progressive change in cognitive ability. The thorough assessment of the latter would still seem an appropriate role for ‘memory services’, however constituted. Increased public awareness has already influenced referral to memory clinics however.

Some objective support for this comes from a retrospective review of patients attending our working age neurology-led memory clinic. The percentage of people with an organic dementia decreased from 65% in 2004 & 2006 to 45% in 2012. Since then we have also reviewed all new clinic referrals clinic over a 10 month period and the pattern was maintained, with only 45% of patients fulfilling criteria for an organic memory problem. A similar change in referral profile has been seen elsewhere in the UK 1. As Le Couteur et al. claim, people with memory complaints can all too easily be diagnosed with a prodrome of dementia such as subjective memory decline. We agree that this type of label is not likely to be useful but argue that patients with non progressive memory complaints are distressed and their symptoms are often chronic. There is some evidence of chronicity from a study of people with Functional Memory Disorder (defined as 1. Acquired memory impairment that significantly affects their professional and/or private life. 2. Neuropsychological tests are within 1.5 standard deviations of age-corrected normative data. 3. Absence of a recognizable organic cause of cognitive impairment or major psychiatric disease. 4. Aged >70) which reported remission in only a handful of cases 2. Depression and anxiety are very common in our clinic and a multidisciplinary approach and staff establishment in the memory clinic would be the ideal way of meeting these patients’ needs.

The other salient change in the memory clinic referral profile is the presentation of many more patients with early stage Alzheimer’s disease. These present the greatest difficulty in accurate diagnosis and management and highlight the need for more accurate and better assessment instruments which should be validated for this population. Desirable changes in primary and secondary care are improved pathways for the assessment and management of these patients with early cognitive decline as well as the patients with ‘benign’ and non-progressive but disabling ‘non-organic’ memory complaints.

1. Menon R, Larner AJ. Use of cognitive screening instruments in primary care: the impact of national dementia directives (NICE/SCIE, National Dementia Strategy). Fam Pract 2011;28(3):272-6.
2. Schmidtke K, Pohlmann S, Metternich B. The syndrome of functional memory disorder: definition, etiology, and natural course. Am J Geriatr Psychiatry 2008;16(12):981-8.

Competing interests: No competing interests

27 September 2013
Daniel J Blackburn
Consultant Neurologist
Michael F Shanks, Kirsty A Harkness, Markus Reuber, Annalena Venneri
Sheffield Teaching Hospitals NHS FOundation Trust and Sheffield Institute for Translational Neuroscience, University of Sheffield.
Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, 385A Glossop Road, SHEFFIELD, S10 2HQ, UK