Cognitive Evaluation for Memory Concerns
Although early dementia diagnosis can help reduce associated costs and extend a patient's time spent in the community, many older adults fail to receive a clinical cognitive evaluation from a medical provider.
More than 5 million Americans are living with Alzheimer's disease (AD), the most common type of dementia. Among Americans over the age of 65, AD affects one of every nine individuals and is the fifth leading cause of death.1 Many older adults with dementia, however, have never received a clinical cognitive evaluation from a medical provider.
Delayed or missed diagnoses of dementia are a major public health concern in the United States. Early recognition and evaluation of dementia can benefit affected individuals and their families in terms of long-term planning and timely access to relevant treatments—which may mean more time spent in the community and less time in a long term care facility. When started early, currently available pharmaceutical therapies may lessen the severity of symptoms and enhance quality of life in some individuals.
Early diagnosis can also help reduce some of the costs associated with the disease, such as hospitalizations, long-term institutional placement, and the significant costs of informal caregiving. There are also downsides to indiscriminately screening all older individuals for thinking and memory impairment. These include the potential harm inherent with false positive diagnoses, which are possible with all diagnostic work-ups but have significant psychological implications, given the paucity of available treatments for common neurodegenerative dementias.
The US Preventive Services Task Force (USPSTF) recently concluded that there was insufficient published medical evidence to support the idea of universal screening for dementia for all older adults over the age of 65. Targeted clinical cognitive evaluations in individuals with even mild symptoms of thinking or memory impairment, however, are likely to be far more impactful. The USPSTF verified that some screening tools might be especially useful in the clinical evaluation of individuals with cognitive impairment.2
There is no widely adopted method or clinical algorithm for detecting and evaluating patients who may have dementia, unlike many other diseases. While the Medicare Annual Wellness Visit (AWV) launched in 2011 under the Affordable Care Act includes a free assessment of cognitive function, there is as yet no standardized method for performing this evaluation. The Alzheimer's Association has developed recommendations to guide primary care physicians in operationalizing the cognitive assessment component of the AWV, but no data are currently available on what methods or tools are being used and how many individuals have been determined to have cognitive impairment.3
A recent study published in the journal Neurology involving the authors of this article sheds light on what factors influence the likelihood of receiving a clinical cognitive/memory evaluation in the United States.4
Evidence of Infrequent Clinical Cognitive Evaluations
More than one-half of the participants (55.2%) with dementia had not received a cognitive evaluation by a physician. Extrapolating these data to the US population, this suggests that around 1.8 million elderly Americans with dementia have not been evaluated for cognitive complaints. Interestingly, only 5% of study participants who were experiencing milder cognitive impairment but did not meet criteria for dementia had been evaluated by a physician, suggesting that most people with mild or moderate thinking or memory issues do not seek out an evaluation as well.
Only marital status and severity of dementia symptoms were found to be important factors influencing the likelihood of receiving a clinical cognitive evaluation. Participants who were married were more than twice as likely to receive a cognitive evaluation. Married couples may be more attuned to changes in a partner's memory and thinking and may provide support or assistance in making sure that the partner is seen by a physician. Spouses may also feel more comfortable than children in expressing concerns to a spouse or physician. Unmarried elderly individuals may worry more that disclosing concerns and undergoing a cognitive evaluation could result in a loss of autonomy. Participants with more severe dementia were also more likely to receive a cognitive evaluation, suggesting that many people may not recognize their symptoms as a health concern or may delay talking to their physicians until the disease has progressed to a later, more severe stage.
This study provides valuable insight into factors that have an effect on whether individuals receive a clinical cognitive evaluation. It does not, however, significantly explore the specific reasons affected individuals were not evaluated. There are numerous potential explanations for the aggregate findings of delayed or missed diagnoses of dementia. These include lack of ascertainment by physicians and limited ability to recognize the symptoms by individuals themselves or their families. There are many physician-reported barriers to dementia diagnosis, such as time constraints during office visits, difficulty in accessing and communicating with specialists, ambivalence about the value and utility of making an early diagnosis of dementia, and worry about causing harm to patients.5,6
Many older adults actively experiencing memory difficulties do not seek help or consult the primary care provider. Social stigma associated with dementia, the tendency to regard substantive cognitive changes as a normal part of "getting older," limited access to care, and cost-related concerns may cause patients to delay or avoid talking to their physicians about a cognitive evaluation. Future research in this area may further explore the relationship between these factors and cognitive evaluation by a medical provider, as well as the perceived utility of cognitive evaluations among patients, families, and physicians.
Advice for Patients and Families
Remind patients that there are a number of modifiable conditions that can cause chronic progressive cognitive impairment, including side effects from common medications, undertreated sleep problems such as obstructive sleep apnea, or mood problems such as depression and anxiety, that can each affect concentration and short-term memory. Systemic conditions including electrolyte imbalances, hormone-related conditions, and nutritional deficiencies are also common causes of cognitive impairment and can be modified with appropriate medical therapy.
Benzodiazepines, which are widely used to treat anxiety, insomnia, and other conditions seen with advancing age, can cause problems with memory and cognition. Findings from one recent large case-control study of elderly individuals, published in The British Medical Journal, also suggest that there is a strong link between benzodiazepine use and AD.7 The study showed that people who use benzodiazepines can increase their risk of developing AD by more than 50%. While brief use (up to three months) of these drugs did not lead to a significant increase in risk, long-term exposure was associated with a 32% increased risk of AD when the drugs were used for three to six months, and an 84% increased risk for more than six months of use. This association was stronger for long-acting benzodiazepines, which are often prescribed for anxiety but was also seen with short-acting versions, which may be prescribed for insomnia. Patients who are currently taking benzodiazepines should consult their physicians if they are experiencing significant changes in memory and thinking. It may be prudent to discuss with patients the risks and benefits of taking these drugs, and whether current use is warranted.
Medical management can be useful for patients with confirmed diagnoses of dementing illnesses. In the case of AD, beginning symptomatic treatments early, including cholinesterase inhibitors and memantine, may help reduce certain cognitive symptoms and can improve quality of life. Vascular dementia, which is caused by a series of strokes or inadequate blood flow that damages brain tissue, can be managed by monitoring and controlling cardiovascular risk factors including high blood pressure, cholesterol, and blood sugar, and by exercising, eating healthy, and not smoking. Other neurodegenerative conditions such as Parkinson's disease have their own specific treatments that are also associated with improved clinical symptoms.
A timely diagnosis of dementia can allow patients and families more time to address living arrangements and changes necessary to home safety, financial and legal affairs, and other forms of long-term planning. This can involve challenging but important conversations about power of attorney, driving safety, living wills, and the utility of assisted living or nursing home residential care. Initiating these conversations earlier can strengthen the bonds of friendship with others who might sometimes feel marginalized by an individual's quiet struggles with regular conversations or social activities. It can also help affected individuals exercise autonomy over challenging decisions that will affect their care and their families going forward. The Alzheimer's Association has compiled many helpful documents and resources for families to aid in health care, financial, legal, and end-of-life planning after a diagnosis with AD or other dementia: www.alz.org/i-have-alz/plan-for-your-future.asp.
One of the major difficulties for most people is distinguishing between mild cognitive changes that occur as part of normal aging and early signs of dementia. Physicians often use the term "dementia" to refer to cognitive impairment that comes on gradually and also affects a patient's activities of daily living and independence. Nevertheless, it can be challenging to tease apart which early cognitive features are alarming and which are within a normal range. Some symptoms that might prompt patients and family members to seek medical care more quickly include getting lost in a familiar place, forgetting the names or identities of familiar people, and neglecting one's personal safety, hygiene, and nutrition.8
The term mild cognitive impairment (MCI) has been used to refer to a disorder that causes slight cognitive changes that can be noticed by the individuals experiencing them but are not severe enough to interfere with the individual's daily life. Although some individuals with MCI have an increased risk for developing dementia, many do not experience clinical progression over time.8 As with the dementias, an experienced clinician should be able to explore the possible causes of MCI in a given individual and initiate appropriate diagnostic testing or treatments.
One rule of thumb is that if, because of a memory or thinking problem, a person increasingly needs help with tasks he or she was once able to manage, it would be useful to schedule an appointment to discuss these changes with a physician. Close relatives may be comfortable enough to voice concerns to a spouse or family member, but it should be done privately and gently, emphasizing the importance and value of having the concerns checked out early. Family members also could bring it up in regular conversation by recommending that the individual take advantage of Medicare's free annual wellness exams. It requires only scheduling an appointment with the primary care physician; the cognitive evaluation is a component of the AWV.
What Can Physicians Do?
To guide health care providers in assessing cognitive impairment during the AWV, the Alzheimer's Association has published a recommended algorithm and a list of suggested cognitive screening tools.3 The algorithm for assessment of cognition is a stepwise process intended to detect patients who are at an increased risk for having dementia. Each annual assessment allows physicians to more easily determine whether a patient is experiencing gradual cognitive decline over time.
The first step of the assessment involves a conversation among the physician, patient, and a family member or other informant who may be present, to identify any self-reported concerns, to make conversational inquiries about cognitive symptoms, to note any observations reported by others including medical providers, and to help the patient complete the Health Risk Assessment questions. The second step involves the use of a structured tool to assess cognition in patients with noted cognitive concerns or in those who do not have an informant present. The last step is a full dementia evaluation of patients whose assessments indicate cognitive impairment. This evaluation can occur during a follow-up visit in primary care or through referral to a specialist. A diagram of this stepwise process, included as part of the Alzheimer's Association published recommendations, is available (see Figure 1).
The Alzheimer's Association recommends that a cognitive assessment be performed on all Medicare patients exhibiting signs or symptoms of cognitive impairment. These can include patient-reported concerns, functional deficits in a patient's ability to manage day-to-day activities, or other observations by medical providers themselves. For patients who have no such concerns, the recommendations suggest corroborating this with a family member or informant and, if no one is available, conducting a brief structured cognitive assessment such as the General Practitioner Assessment of Cognition, the Memory Impairment Screen or the Mini-Cog test. Each of these screening evaluations is intended to take less than five minutes to complete, making them ideal for an AWV. The Alzheimer's Association has published a review of these tests and other similar brief provider-assessed cognitive screening tests.3
In order to avoid the potential for false positives inherent in this testing algorithm, it may be useful to use other overlapping screening methods that can also be completed quickly in the context of an office visit. This has led to the development and validation of a brief Dementia Screening Indicator for use in primary care settings.9 This simple tool can help physicians identify a subgroup of patients at increased risk for dementia by stratifying older adults into high- and low-risk groups for more targeted screening. The Dementia Screening Indicator can be accessed at http://campuslifeservices.ucsf.edu/clsforms/documentsmedia/dementiarisk/. As this tool is integrated into clinical settings, the Dementia Screening Indicator may help to maximize the benefits of cognitive screening, while avoiding harms of overdiagnosis including unnecessary and expensive follow-up testing and avoidable worry among patients and their families.
Overcoming patient/family, physician, societal, and system-related barriers to cognitive evaluation is necessary for facilitating early diagnosis. Findings from the authors' recent study offer insight into factors that are associated with receiving clinical cognitive evaluations. The Medicare AWV provides an opportunity for health care providers to educate patients and families about the signs and symptoms of dementia and the value of early recognition and management. The Alzheimer's Association recommendations and tools such as the Dementia Screening Indicator may help to ease physician-reported barriers to diagnosis. Each of these is another step forward in reducing the occurrence of delayed and missed diagnoses of dementia and improving care and outcomes for patients and families.
— Jenny E. Ostergren, MPH, is a PhD candidate in health behavior and health education at the University of Michigan School of Public Health. Her research interests are in the areas of mental health and aging, risk communication and decision making, psychological and behavioral implications of genetic testing, and public health ethics, with current research focusing on understanding factors influencing dementia help-seeking behavior among older adults.
— Vikas Kotagal, MD, MS, is a neurologist at the University of Michigan Medical Center. His clinical focus is on the care of patients with neurodegenerative conditions including dementias, gait disorders, tremor disorders, and parkinsonian conditions. He conducts clinical research on the role of modifiable risk factors in neurodegenerative conditions including dementias and Parkinson's disease.
2. Moyer VA, U S Preventive Services Task Force. Screening for cognitive impairment in older adults: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(11):791-797.
3. Cordell CB, Borson S, Boustani M, et al. Alzheimer's Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting. Alzheimers Dement. 2013;9(2):141-150.
4. Kotagal V, Langa KM, Plassman BL, et al. Factors associated with cognitive evaluations in the United States. Neurology. 2015;84(1):64-71.
5. Hinton L, Franz CE, Reddy G, Flores Y, Kravitz RL, Barker JC. Practice constraints, behavioral problems, and dementia care: primary care physicians' perspectives. J Gen Intern Med. 2007;22(11):1487-1492.
6. Boise L, Camicioli R, Morgan DL, Rose JH, Congleton L. Diagnosing dementia: perspectives of primary care physicians. Gerontologist. 1999;39(4):457-464.
7. Billioti de Gage S, Moride Y, Ducruet T, et al. Benzodiazepine use and risk of Alzheimer's disease: case-control study. BMJ. 2014;349:g5205.
8. Forgetfulness: knowing when to ask for help. National Institute on Aging website. http://www.nia.nih.gov/health/publication/forgetfulness. Updated Match 30, 2015. Accessed January 25, 2015.
9. Barnes DE, Beiser AS, Lee A, et al. Development and validation of a brief dementia screening indicator for primary care. Alzheimers Dement. 2014;10(6):656-665.e1.