New Guidelines on Screening for Cognitive Impairment

Susan Jeffrey

December 21, 2012

The Alzheimer's Association has released new recommendations to help clinicians detect cognitive impairment during Medicare Annual Wellness Visits.

Based on the findings of an expert workgroup convened by the association, the recommendations aim to provide comprehensive guidance on how to assess for cognitive impairment in the primary care setting. "While physicians are required to include detection of cognitive impairment as part of the Medicare Annual Wellness Visit, until today there has been no comprehensive guidance to physicians on how to accomplish that," notes a release from the Alzheimer's Association.

"We understand that by assessing and documenting cognitive status on an annual basis during the Annual Wellness Visit, clinicians can more easily monitor gradual cognitive decline in a patient over time," said Bill Thies, PhD, Alzheimer's Association chief medical scientific officer, in the statement. "Through this workgroup process, we now have a comprehensive recommendation for a brief, step-by-step process to detect cognitive impairment that includes tools for patients and family members as well as an emphasis on vital patient history, self-reported concerns and clinician observations."

The recommendations are published online December 20 in Alzheimer's & Dementia: Journal of the Alzheimer's Association as a free-access paper. Besides the publication, a process algorithm for clinicians lists the brief tools for use with patients and family members.

No Single Test

In January 2011, the Patient Protection and Affordable Care Act added a new Medicare benefit, the Annual Wellness Visit, that requires an assessment to detect cognitive impairment. The panel, with lead author Cyndy B. Cordell, from the Alzheimer's Association in Chicago, writes, "The Centers for Medicare and Medicaid Services (CMS) elected not to recommend a specific assessment tool because there is no single, universally accepted screen that satisfies all needs in the detection of cognitive impairment."

To provide primary care physicians with guidance on cognitive assessment during the annual wellness visit, as well as when to refer for further testing, the association convened a group of experts to establish an algorithm for cognition assessment that includes unstructured queries and observation of the patient, as well as structured assessment tools used with both patients and their caregivers.

The tools recommended include the Mini-Cog, the Memory Impairment Screen (MIS), and the General Practitioner Assessment of Cognition (GPCOG) because they are relatively free of education, race, or cultural bias and take only 5 minutes or less to administer. Tools for use with the patient's spouse, family, or friends included the AD8, the Short Informant Questionnaire on Cognitive Decline in the Elderly (short IQCODE), and the Informant GPCOG.

The use of these tools allows clinicians to get an objective score that indicates a passed or failed assessment indicating the need for referral. One study found that these types of structured tools detected more than 80% of patients who later converted to mild cognitive impairment or dementia during follow-up, compared with only 59% detection by physician observation alone, the Alzheimer's Association statement notes.

"As a leader in the Alzheimer's community, the Alzheimer's Association believes that part of its role is to fuel the advancement of early detection and diagnosis. The Workgroup recommendations empower and equip physicians with a pathway that allows them to make informed choices about which structured assessment tools work best for them and the patients they serve," said Dr. Thies. "Whether the tools the Workgroup identified are used or other detection instruments, informal observation is not enough."

"We urge all primary care physicians to use the recommended step-by-step cognitive assessment process to take full advantage of the opportunity the Medicare Annual Wellness Visit provides — earlier detection of dementia, potentially earlier treatments, better healthcare management for patients and more favorable outcomes for affected families," Dr. Thies concludes.

According to the Alzheimer's Association's "2012 Alzheimer's Disease Facts and Figures" report, among the more than 5 million Americans with Alzheimer's disease, as many as half have not been given a diagnosis. With earlier detection, patients can access currently available treatments and patient services, as well as make any necessary financial and care plans, the association statement adds.

Alzheimer's & Dementia. Published online December 20, 2012. Full text

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