- Dr Simon Moore MD CCFP
New Guidelines: Cognitive Impairment
As we prepare The Review Course we are keeping a close eye on new guidelines that came out last year, as these are all fair game for the exam and important to know. As well you'll need to know all about screening tests (scroll down to the end to read about a common screening mistake).
The Canadian Task Force on Preventive Health Care has just published a new guideline for screening for cognitive impairment. What do you need to know about it? In a word, DON'T.
That's right - don't screen for cognitive impairment.
WHO DOES THIS APPLY TO?
The recommendation is for patients > 65 yrs old living in the community.
The CTFPHC researchers found no evidence that screening is beneficial. In fact, when they looked for studies that they could base their recommendations on, they found none.
Not only is there little research, but we know there can be harm if everyone who comes in your door is given a MMSE or MOCA test. Both of these checklists have false positives (MMSE: 1 in 10, MOCA: 1 in 4).
Finally, medication is not helpful in mild cognitive impairment, and exercise and cognitive training have little benefit. So even if we did identify cognitive impairment early, there's usually not much that can be done about it.
The CTFPHC has created a helpful one-page summary of the guideline.The entire publication is available on the CMAJ website.
SCREENING: DON'T MAKE THIS COMMON MISTAKE
Just like every screening test, this guideline ONLY applies to patients with NO symptoms. In other words, if a patient presents with symptoms of declining memory, they DO need to be investigated.
This may seem obvious, but you will often see experienced clinicians incorrectly use the terms"screening bloodwork" or "a screening colonoscopy" when referring to symptomatic patients.If you are doing labs to find out why a patient is fatigued, then the lab test is a diagnostic evaluation - not a screening test (because fatigue is a symptom and therefore the patient is symptomatic).
In the same way, a colonoscopy for a patient with rectal bleeding or other symptoms is a diagnostic test - not a screening test. (To make it more confusing, a colonoscopy CAN be done to look for colon cancer in a patient without symptoms - and then it IS correctly referred to as a "screening colonoscopy."
Don't make this common error, especially on your exam! The term "screening" only applies if the patient has no symptoms and the test was being done to look for a disease when the patient felt well.
Attendees at The Review Course (now SOLD OUT in Toronto - thank you!) will learn about other screening tests you need to know, and the other new guidelines published this year - some of which recommend major changes to the way we have typically done things.