Promoting widespread use of brief assessment tools in primary care for early detection of cognitive impairment

Mild cognitive impairment, which occurs in about one in six individuals in the U.S., age 65 and older, remains substantially underdiagnosed, especially in disadvantaged populations.

Convened by the non-profit UsAgainstAlzheimer's, The Brief Cognitive Assessment Work Group, is composed of 15 clinicians, researchers and health systems administrators from across the U.S. The group advocates for early detection of cognitive impairment to benefit both patients and caregivers by providing time to plan for future care, allowing preventive steps to potentially delay some symptoms as well as recognizing cognitive impairment due to a currently treatable condition.

The expert panel's recommendations for policymakers and payers on strategies to promote widespread and equitable use of brief cognitive assessment tools in primary care are published in Alzheimer's & Dementia, a peer-reviewed journal of the Alzheimer's Association.

"Over the past 15 years, we and other researchers have been studying the risks and benefits of early detection of cognitive impairment and shown it can be beneficial and causes no harm, as measured by patient distress," said work group member Nicole Fowler, PhD, MHSA, who is also a Regenstrief Institute research scientist and an Indiana University School of Medicine faculty member. "There have been policy changes to spur and increase detection in primary care, such as including screening for cognitive impairment in the Medicare Annual Wellness visit, but there has been little specificity – directions on how to accomplish this -- given to providers."

The routine use of brief cognitive assessment tools, which are not diagnostic, is a promising approach to improving cognitive impairment detection according to the work group. These tools are intended to help identify patients in need of full cognitive examination. The expert panel notes that brief cognitive assessments can address barriers that more in-depth cognitive assessments encounter, such as the limited time available during medical appointments and insufficient clinician training.

The role of this paper was to be as specific as possible about what we actually need as a system to do this. For example, what kind of tools already exist to conduct cognitive impairment detection in primary care that are facile to use, that are easily integrated into the workflow? How can clinicians and healthcare systems potentially get reimbursed for screening for mild cognitive impairment?"

Dr. Nicole Fowler, PhD, MHSA, Regenstrief Institute research scientist

To address these and other challenges, the expert panel recommends:

• incorporating brief cognitive assessments into the regular workflow of primary care practices through the use of support team members.
• calling on professional societies, healthcare systems and other stakeholders to develop and broadly disseminate guidance on clinician communication of cognitive discussions with patients; and
• health systems configure electronic health records to incorporate brief cognitive assessments.

An estimated 15 percent of individuals with mild cognitive impairment will develop dementia within two years. By 2030 nearly 40 percent of Americans living with Alzheimer's will be Black or Latino. By 2050 the number of Americans living with Alzheimer's disease is projected to grow to 12.7 million.

"Expanding the use of brief cognitive assessments to detect suspected early-stage cognitive impairment in primary care" concludes, "…the long-standing neglect of detection of cognitive impairment has resulted in a hidden epidemic. As our under-standing of the biology of neurodegenerative diseases improves and better treatments emerge, concerted efforts from many stakeholders are necessary to identify patients who can benefit from those innovations, and do so in a timely and equitable manner."

UsAgainstAlzheimer's provided funding to facilitate the consensus-building process of the expert panel and support the drafting of the perspective paper.