Mandatory Cognitive Assessments Set to Become Part of Annual Wellness Visits

Deborah Brauser

December 07, 2010

December 7, 2010 — The Alzheimer's Association is establishing a new workgroup of field experts to provide primary care physicians with guidance on cognitive assessments, which are due to become a mandatory part of annual wellness visits by Medicare patients starting January 2011.

Part of the Patient Protection and Affordable Care Act, these assessments are part of final regulations for implementing the new wellness visits, which were announced November 3 by the Centers for Medicare and Medicaid Services (CMS).

"We have maintained for quite some time that the key to early diagnosis for Alzheimer's disease is cognitive surveillance in a medical care system that has the capacity to move people into a more intensive evaluation of their cognitive problems as they begin to show difficulties with simple tasks," William H. Thies, PhD, chief medical and scientific officer for the national office of the Alzheimer's Association in Chicago, Illinois, told Medscape Medical News.

Dr. William H. Thies

"We look at the Medicare action really as confirmation that we're on the right track and that they saw the wisdom of our advice," added Dr. Thies.

He noted that "this is an area that is often given short attention" in the absence of both adequate reimbursement and definitive medications that will stop the progression of Alzheimer's disease.

"Previous research has shown that you don't need either of those things to get benefit for the patient. And we think the new rules from Medicare will encourage people to look at how they're going to go about fulfilling this cognitive surveillance request."

Building Consensus

According to the Alzheimer's Association, the purpose of the workgroup is to build consensus around appropriate methods and processes that can be used in the primary care setting to detect possible cognitive impairment during the wellness visits.

If further assessment of cognition is indicated during the visit, the workgroup will also provide guidance for practitioners as to the follow-up process to determine a definitive diagnosis.

The group will also help determine approaches and conversation starters with patients about possible concerns or how to address patients who do not follow up.

"By convening stakeholders, thought leaders, and experts in the Alzheimer's arena to collaborate on cross-cutting solutions, the Association believes the valuable insights these leading experts will provide will help reduce undiagnosed cognitive impairment," they write.

Simple Process Needed

Dr. Thies said that he predicts that the group, which will begin meeting in January, will immediately start on developing a "very simple, fairly wide-open" cognitive surveillance process.

"It may be something as simple as a 2- or 3-word recall, where you give a patient 3 words to remember at the start of their visit and then at the end you ask them to tell what those words are," he said.

"Obviously you can't do a cognitive diagnosis with that. But if you see people over a period of years and they do really well on that test and then all of a sudden they're not, then that's the signal to move to a more intense evaluation."

He noted that he thinks the new assessment system will be either a series of tests or some sort of criteria for tests that the clinician can select, plus suggestions for a follow-up system to put into place.

"Identifying that someone is beginning to have cognitive difficulties will be just the beginning. Ideally they would then go on to further evaluation that would either confirm or not confirm the diagnosis of dementia and be as specific as possible for Alzheimer's or not Alzheimer's. And then that diagnosis would be taken into consideration as the rest of the care of that patient is considered," said Dr. Thies.

After the workgroup comes to a consensus, Dr. Thies said that the fate of their decisions is open to a number of possibilities. "It could go as far as becoming official rules for CMS, if they so choose, or it may simply become advice for physicians who are trying to implement this type of yearly visit and the cognitive evaluation that’s part of it."

Trying to build these kinds of systems as efficiently as we can and as early as we can is going to be really important if we're going to have any hope at all of managing this epidemic.

It may take some time for the workgroup to reach process recommendations, yet January's mandatory implementation is right around the corner. In the interim, Dr. Thies recommends that for now clinicians can best prepare by doing an overall situation assessment.

Dr. Thies said he hopes the workgroup's recommendations lead to a definitive cognitive surveillance process being put into place for most patients older than 65 years.

"Only about half of the 5.3 million Americans that have Alzheimer's today have a diagnosis. So trying to build these kinds of systems as efficiently as we can and as early as we can, is going to be really important if we're going to have any hope at all of managing this epidemic," he said.

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