“At Liberty” (cognitive screening)

A Scottish citizen, over the age of 65 years, recently wrote to a Parliamentarian with concerns about mandatory cognitive screening in Scotland’s acute hospitals.

Following this a helpful letter was received from the former Cabinet Minister for Health and Wellbeing, Alex Neil. The letter is three pages long and goes on to describe how Scotland has done “rather well” in every area. Here is an extract about “delirium screening”:


This letter from Alex Neil confirms that “patients are perfectly at liberty to decline participation”. Here reference is made to the 4AT test which is a “brief screening tool” that is registered to screen for delirium and “cognitive impairment”.

It would have perhaps been even more helpful if our Cabinet Minister for Health & Wellbeing had confirmed if this “liberty” might also apply to other cognitive “screening tools” used in Scottish hospitals.

I have given my thoughts regarding consent to screening tests in my reply to the new Draft Care Standards.

Healthcare Improvement Scotland, based on Inspections to all our acute hospital have made cognitive screening of all our “elderly” admitted to hospital a key recommendation. As part of the inspection process “compliance” with the use of screening has been measured. My experience is that individual NHS Boards will wish to follow the recommendations of Healthcare Improvement Scotland as fully as possible.

Areas for improvement 2014

Those who have read my writings on cognitive screening will know that I share fully every understanding of just how serious delirium, dementia or cognitive impairment can be. I may have been misunderstood, but I share the determination to improve assessment, care and treatment.

My concern is specifically with screening as a starting point, using brief and reductionist “tools”. I worry about the potential consequences of departing from time-honoured professional nursing and medical assessment. Here I use cognitive rating scales as an important additional aspect to most assessments.  I explain to every patient the limitations of such tests, with advice on the benefits and the potential harms. I do not call tests “tools” even if this is how they have been so named.

Screening in other areas of medicine has raised considerable debate e.g. breast screening, PSA screening to name but a few. I see no reason why screening of our cognition should be free from such critical appraisal. As thinking beings, we can all agree that our cognition (how we think and feel) is most complex and not solely “shaped” by our brain.

I am not apologetic for raising concerns about reductionist approaches. I fully appreciate that such approaches are well-intentioned. I also refute the charge, made by a very senior professional in NHS Scotland , that I am “scaremongering”.

I have recently seen older patients discharged from hospital with wrongful diagnoses. The consequences have been significant for those concerned and upsetting to witness.

Here are some of the potential consequences of screening:

(1) false-negative diagnosis of delirium/dementia

(2) false-positive diagnosis of delirium/dementia

(3) over-simplification of complex and serious conditions

(4) heightening of fear in our elders

(5) increased reliance on pathways started with said “screening tool”

(6) medical confusion: that the ‘parabolic distribution of cognition with age’ risks being turned completely into disease

(7) risk of even greater prescribing of anti-psychotics (by following said pathways)

(8)  loss of autonomy:  a reductionist basis to “capacity”


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