Is Memory Screening a Good Idea?

Contributed by: Dennis Fortier, President, Medical Care Corporation
________________________________________________

Is Memory Screening a Good Idea?

Yesterday was National Memory Screening Day and, as usual, there were many editorials in print and online discussing the pros and cons of memory screening. As is often the case, the answer to the question that headlines this article varies greatly depending on whom you ask. When discussed in the press, I rarely see a balanced view of pros and cons but rather a biased presentation of the "facts" aimed at supporting the author's opinion. Here's a summary of what I consider to be the most important considerations.

First, the term "screening" is open to interpretation and is generally used inconsistently from author to author depending on their respective attitudes toward screening.

For those who tend to be against memory screening, they usually adopt the traditional definition of screening which suggests that programs are perpetrated on large populations of symptom free subjects, perhaps even against the will of the subjects. I would agree that a comprehensive, population-based approach is probably not a good idea for many pragmatic reasons related to educating and further evaluating the multitudes of people whose screening results would warrant further attention.

Those who support memory screening tend to adopt a definition consistent with "case finding". This essentially means performing a memory assessment on those with concerns about their memory or evidence that it is declining. With this definition, I would support the general argument that, for people who have a memory concern, some type of evaluation (a screening if you will) should be available to them. This makes sense and would greatly improve our ability to intervene against problems in their earliest stages.

It strikes me that if we could all adopt a common understanding of what is meant by "memory screening", most of the controversy and debate would likely vanish. Having said that, there are three other prominent themes in the argument against memory screening that are not related to the definition of “screening”. Here are my comments on those themes.

Type I Errors – False Positives

This pertains to the possibility of inflicting unnecessary angst in healthy people who could be improperly assessed and mistakenly told that their memory is impaired. Those against memory screening speculate that this could lead to undue anxiety, depression, and even suicide. While that may be plausible, there is really no supporting evidence and it is probably off base. The few studies that have been conducted on attitudes toward screening have shown that people seeking memory assessment are often anxious from the outset and learning the result of an assessment, be it positive or negative, tends to reduce their anxiety.

Type II Errors – False Negatives

This pertains to the possibility that unsophisticated screening instruments or untrained screeners could miss signs of impairment and mistakenly tell symptomatic subjects that they are healthy. This of course might reduce the likelihood of that person seeing a physician and getting good care. That’s a reasonable argument and is likely to be true because we know that patients may seek second opinions when they get “bad medical news” but they are far less likely to do so after receiving “good medical news”. I think it is reasonable to insist that a beneficial memory assessment program would require both the use of a well-validated assessment instrument and well trained administrators.

The Importance of Medical Expertise

This argument suggests that, regardless of mistakes in either direction, people learning that they have a memory problem may fear Alzheimer’s disease as the underlying cause and these people should be counseled and educated immediately to assuage their anxiety. If the structure of a screening program is “high volume” and “public” in nature, then it may be conducted in an environment lacking the medical expertise that some patients will require. I would agree that there may be some real costs associated with screening programs that are not conducted within a framework capable of providing proper follow-up attention to subjects who learn of memory impairments. These costs must be considered in the evaluation of any program's merit.

A Commonly Neglected Perspective

In general, the discussions I see in the media tend to consistently neglect one important aspect of the anxiety consideration. A high percentage of the people that seek to participate in self-selecting memory assessment programs (that is, programs for which one may voluntarily seek to have their memory assessed), are already somewhat anxious about a perceived decline in their memory. We know that such anxiety is often unfounded and that many worries are merely a slowing of name recall or diminished concentration associated with normal aging. As such, voluntary memory screening programs may reassure and relieve anxiety in a high number of normally aging individuals who have been needlessly worrying about their cognitive health. This is a real benefit that should be weighed against other costs when evaluating the value of a given program.

To summarize, we may not be ready for widespread memory screening but we are certainly ready for programs that provide accurate assessment and expert follow-up for those individuals who perceive a decline in their memory. Doing so is one of the best approaches available for promoting early intervention and effective treatment for many aging people with medical conditions that impair cognitive function.