Gap of interest: Identification of Dementia in Primary Care
During Medicare enrollees’ Annual Wellness Visit, primary care physicians are asked by CMS to “detect cognitive impairment…by direct observation, with due consideration of information obtained via beneficiary reports and concerns raised by family members, friends, caretakers, or others.”1 However dementia, one of the more severe forms of cognitive impairment, remains undiagnosed in a large percentage of primary care samples.2 Screening tests (i.e., structured assessments), can assist detection of dementia, especially when informants are not available for questioning. While it is generally agreed that there is no gold standard for screening, physician reliance on routine history and physical examination is often not sufficient to properly diagnose dementia.2 The U.S. Preventative Services Task Force and the Alzheimer’s Association recommend the use of evaluation of signs/symptoms and the use of a structured assessment, in a step-wise-fashion.2-3 While we do not yet have strong interventions for dementia, early detection can lead to: (1) evaluation for reversible causes of memory loss, (2) allow time for patients and families prepare for future care (i.e., living arrangements, financial considerations, advanced directives, etc.).
It is not clear from current research exactly what the prevalence of structured assessment in primary care is, however, there are only a small number of cognitive screening tests that have been validated in primary care.3 Therefore, even if they are being used, it is likely that the most appropriate assessment may not be utilized. Ideally, screening for dementia would include an assessment of signs/symptoms of cognitive impairment followed by a structured assessment which as been validated in both primary care, and the specific demographic population that best represents the patient (i.e., age, race/ethnicity, language, education level). While there is no gold standard, there are a number of cognitive screening assessments (i.e., direct patient assessments and informant questionnaires) that can be adequately utilized in the primary care setting. Consequences of inadequate or improper assessment can lead to poor care outcomes for both the patient and practitioner (e.g., patient without capacity and no appointed DPOA for healthcare or finances).
1https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/AWV_chart_ICN905706.pdf (accessed 4/10/18)
2Boustani, M. et al., (2003) Screening for dementia in primary care: A summary of the evidence for the U.S. preventative services task force. Ann Intern Med, 138:927-937
3Cordell, C.B. et al (2013) Alzheimer’s Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting. Alzheimer’s & Dementia, 9:141-150