A number of well known bodies, including the Alzheimer's Association and the American Academy of Neurology (AAN), feel there should be screening for Alzheimer's disease. Early detection assists financial and service planning as well as provision on a governmental and personal level. Screening is generally thought of as a good thing but it is actually offset by a variety of issues that also need to be addressed. In this Sharepost I consider the benefits as well as the possible costs of screening.
Alzheimer's disease certainly meets the criteria of a disease that merits screening. First, it is a disease common within the population. We know the incidence of Alzheimer's is increasing in many countries as people live longer. It is estimated that over five million Americans are living with the disease. If scientists can't find a way to cure or prevent Alzheimer's then the number could range between 11-16 million by the year 2050.
One major problem of screening is that insurance companies do not currently cover cognitive testing. Many policies exclude reimbursement for conditions classified as a "nervous or mental disorder".
Secondly, the criteria for early screening states that the symptoms of Alzheimer's should not be obvious. Many people have mild cognitive impairment that neither they nor their families are aware of. Research shows that many primary healthcare doctors also miss symptoms of mild Alzheimer's disease, let alone mild cognitive impairment (MCI). It is known that people with MCI are at a high risk of progressing to dementia, one of which is dementia of the Alzheimer's type.
Thirdly, treatments should be available for screening to be merited. There is increasing evidence that treatment interventions for Alzheimer's are beneficial earlier rather than later. However, there are issues with the effectiveness of treatments. Food and Drug Administration (FDA) approved treatments such as Aricept, Exelon, Reminyl and Namenda, can help some people for periods of time. There is currently no cure for Alzheimer's disease. A few alternative treatments such as vitamins, herbs, hormones, and healthy lifestyles (exercise, diet, brain exercise) have also been shown to have benefits. Behavioral treatments, neuroleptic and anti epilepsy medications, can help, as can occupational and social support service networks. But while a cure eludes us the problem of psychological distress and in severe cases, mental illness that can follow diagnosis from early screening, remains a significant ethical issue.
One of the basic rules of screening is non-maleficence (do no harm). Screening for Alzheimer's is non-invasive and requires nothing in the way of drugs, injections, x-rays or similar techniques. In this respect the rule is adhered to. However, like all screening there are dangers with false negatives (saying nothing is wrong when actually there is) or false positives (saying something is wrong when actually there isn't). All tests are fallible and false positive tests can have the effect of preventing proper diagnosis and early treatment.
Is early screening/diagnosis always a good thing when no cure exists? Might it exacerbate the existing stigma of particular diseases like Alzheimer's? Does the benefit of early knowledge outweigh the costs to the individual in terms of their psychological wellbeing?
Screening debates often revolve around an assumption that the patient has the right to know about their health status. However, some people argue that screening may also undermine an individual's autonomy and that the process increasingly puts power and control in the hands of others. This may sound a little dramatic, but screening increasingly embraces the healthy, because we are all ‘at risk' of something.
Where do I stand with this? Let me say first of all that I've only touched on some of the questions and issues relating to the ethics of screening. I believe it is useful for everyone to decide for themselves and this decision will inevitably be informed by personal circumstances, spirituality, personal beliefs and values.
Published On: September 19, 2008