Removing barriers to screening for cognitive impairment in primary care settings

Primary care practitioners (PCPs) are often the first health care professionals to encounter cognitive concerns in patients, and therefore play a crucial role in recognizing cognitive impairment. However, most cases of Alzheimer’s disease (AD) and mild cognitive impairment (MCI) are not diagnosed by their PCPs, meaning that these individuals do not receive interventions that could slow or prevent further decline or address other health risks related to cognitive impairment. AD and related dementias (ADRD) are a major cause of morbidity and mortality, in addition to being one of the costlier conditions to society.

Thus far, two risk assessment tools have been developed, although neither have been validated in primary care settings. A third tool, which uses electronic health record (EHR) data, is currently being tested. There are several cognitive screening tests currently available, but further research is required to determine their accuracy, particularly in cases of MCI in primary care settings.

A research article, published in the Annals of Family Medicine and based on findings from a 2022 Interdisciplinary Geriatrics Summit, hosted by the National Academy of Neuropsychology, analyzed and presented key points and knowledge gaps regarding methods for detecting cognitive impairment in primary care settings. Summit participants propose a novel workflow to facilitate improved detection of cognitive impairment during routine primary care visits, focused on the annual wellness visit, which is available to Medicare beneficiaries, in addition to further opportunities for clinical practice and research.

The global population is getting older, thus the prevalence of cognitive impairment impacting overall health and independence is also rising dramatically. According to a study published in Alzheimer’s & Dementia: The Journal of The Alzheimer’s Association, the number of people living with AD is projected to double to as many as 14 million people by 2060 in the United States alone. Despite increased prevalence of cognitive impairment, it remains under-recognized and under-treated, with as many as 61.7% of dementia cases going undetected by PCPs. For patients who are Black or Hispanic, have early-onset dementia or mild MCI, detection rates are even lower.

Currently, the most frequently used cognitive screening test in primary care is the Mini-Mental State Examination (MMSE), which, according to the article, is outperformed by other tests and is recommended to be replaced. The Montreal Cognitive Assessment (MoCA) is the most well validated cognitive screening test in population-based cohorts, yet its validity is limited in heterogenous groups of older adults.

The U.S. Census Bureau projects there to be nearly 95 million people aged older than 65 by 2060. Despite this, there are only approximately 500,000 PCPs. Therefore, screening the entire population of people aged older than 65, annually, is neither feasible nor supported by any evidence available in the research. Participants of the 2022 summit instead recommend using a tool to identify a higher-prevalence and at-risk pool of the population to be screened.

No one screening approach will meet the needs of the entire population, and more research is required to tailor screenings to the settings in which they are used. That said, the ideal cognitive screening test would be automated—to save PCPs time and avoid human error in scoring and interpretation—and include each of the following criteria:

• Less than 10 minutes to administer.
• Minimal training required to administer, score and interpret.
• Minimally affected by external factors unrelated to cognitive impairment.
• Acceptable to population of older adults.
• Sensitivity and specificity 80% or greater.
• Sensitive to mild stages of cognitive impairment.
• Assesses both memory and executive function, the domains frequently affected in the most common causes of dementia.

With the above considerations in mind, summit participants recommend implementing the following workflow for early detection of cognitive impairment in primary care settings:

1. Through use of a risk stratification tool, asking a small number of questions and/or using an alert in the EHR based on information readily available in the record, identify individuals at high risk for cognitive impairment.
2. If a patient has a concern or is deemed to be at high risk for cognitive impairment, use a flag to trigger administration of a short cognitive screening measure (5 minutes or less) by clinic staff and/or administration of a patient/informant questionnaire prior to the visit. Alternatively, a brief cognitive screening tool validated for remote administration could be administered through the EHR.
3. If the screening result is positive, initiate a 3- or 4- visit assessment pathway.
   1. Participants recommend a longer cognitive screening measure—the MoCA, for example—be administered during the inaugural visit, in order to confirm a positive screen and better understand any difficulties the patient may be dealing with. The first visit can also be used to rule out possible modifiable conditions—sleep disorders or severe mental health problems—based on a brief first examination, assessing physical signs and reviewing medications.
   2. The second visit should focus on an assessment of any changes since the first visit, serving as time to make referrals for additional tests.
   3. The third visit could be spent reviewing test results and deciding whether the patient should be referred to a dementia specialist.
4. Use practical and evidence-based guidance to make and effectively communicate a diagnosis of a neurocognitive disorder and beginning treatment.

Summit participants also emphasize the importance of activating key stakeholder groups, including health care systems, health care teams and patients and their families. To activate health care systems, they should be alerted to the costs and consequences of dementia. Also, dementia specialists can partner with professional organizations focused on primary care to develop and refine materials to increase knowledge of health care team, thereby activating them. For patients and their families, it’s important to identify dementia as a manageable chronic condition and explain that there are reversible causes of cognitive impairment.

“We expect that the reporting of this Summit’s key points and recommendations will be a catalyst for developing partnerships between PCPs and dementia specialists and for creating concrete plans to facilitate early detection of cognitive impairment among older adults in primary care clinics and to implement procedures for following up on positive screens,” the authors of the research article concluded. “Harnessing the collective wisdom of PCPs and dementia specialists, in collaboration with patients, families, payers, health care administrators and funders is imperative to move the needle toward reducing negative consequences of ADRD.”