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Abstract
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Dementia is a devastating neurologic condition now accounting for more than 100 000 deaths annually in the US. Symptoms typically begin as mild difficulties with memory that progress to incapacitation over years. Medications have modest average benefits (although amyloid-targeting antibodies show promise in some early trials), and early screening has not proven to improve prognosis.1 Priorities for medical care include controlling comorbidities (eg, depression), reducing risk factors (eg, alcohol use), avoiding complications (eg, constipation), optimizing supports (eg, hearing aids), maintaining lifestyle (eg, exercise), and continuing social connections. Medical care requires substantial judgment due to the tension between safety and freedom for adults with a diagnosis of dementia as a progressive illness.
Jun et al2 conduct a cross-sectional ecological analysis assessing how policies of mandatory reporting of dementia might be associated with a patient’s willingness to disclose symptoms or a clinician’s willingness to diagnose dementia (presumably from the fear of losing a driver’s license). The analysis focuses on 4 states with mandatory fitness-to-drive reporting of dementia to vehicle licensing agencies (eg, California) and the apparent rate of physicians underdiagnosing dementia, defined by a statistical model contrasting observed to expected Medicare claims. The results suggest that mandatory reporting is associated with an increase in the number of physicians underdiagnosing dementia, from 7.8% in states with driver self-reporting and 7.7% in states with no mandates to 12.4% in states with mandatory reporting (P < .001). The implication is that mandatory reporting is aversive to patients and clinicians and is thereby associated with widespread underdiagnosis.
Correlation does not prove causation in an ecological analysis because each region differs in weather, wealth, weaknesses, and countless other factors. One interpretation of an observed correlation is direct causality; for example, mandatory reporting might prevent vehicle crashes, lead to fewer cases of brain injury, and ultimately avert cognitive declines in later life. A different interpretation is reverse causality; for example, some adults with early cognitive decline might leave California due to the high cost of living, prevailing traffic congestion, or other pressures. A third interpretation is confounding; for example, adults in California might be more likely to exercise regularly and become less prone to dementia and to driving. A final interpretation is measurement artifact; for example, an apparent decrease in dementia might reflect biased self-report.
All 4 potential interpretations of the correlation between mandatory reporting and decreased dementia can be argued, although Jun et al2 emphasize measurement artifact. For example, the lower rate of dementia in California might be too good to be true and could, instead, reflect the silencing effect of governmental regulation. Furthermore, the dementia rate is also relatively low in Delaware (another state with mandatory reporting), yet not relatively low in Oregon or Pennsylvania (the other 2 states with mandatory reporting). This pattern leads Jun et al2 to caution that mandates may sometimes have unintended consequences that hinder clinicians from diagnosing dementia. More generally, the tension between patient privacy and community safety has no easy solution for individuals in the US who may not fully trust their state governments. ...
Language: en |