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Most clinical screening tests are designed to give providers a heads up on the potential development of a disease. While most patients readily agree to screening tests, the idea of screening for any possible cognitive decline often is a scary topic for patients - and creates a complex decision-making situation for providers.

The Medicare Annual Wellness Visit, launched in 2011, includes coverage of cognitive screening services for Medicare beneficiaries every 12 months. The parameters of the program allow physicians to “assess the beneficiary’s cognitive function by direct observation while considering information from beneficiary reports and concerns raised by family members, friends, caregivers and others. If appropriate, use a brief validated structured cognitive assessment tool.” (CMS Medical Learning Network)

The wellness visit is the perfect opportunity to foster healthy conversations with patients about cognitive function and to explain that not all cognitive decline is caused by Alzheimer’s disease, says Keith Fargo, director of scientific programs and outreach at the Alzheimer’s Association. “A lot of cognitive decline is caused by things that are treatable, including sleep apnea, depression and other medical conditions.”

And primary care physicians (PCPs), who serve as the quarterback for coordinated care, see their patients frequently throughout the year and develop relationships over years, have the distinct advantage of knowing their patients. They may be able to detect changes that go overlooked or ignored by friends and family. Plus, the physician-patient relationship may be the only one where the topic of cognitive screenings won’t be met with a strong emotional response.

Cognitive screening recommendations

The medical community’s acceptance of cognitive screenings is still a mixed bag, partly because of inadequate research indicators amid an incredibly complex neurological field. The U.S. Preventive Services Task Force (USPSTF), an independent body that develops recommendations for clinical preventive services, issued a decision of insufficient evidence of the benefits in 2014 but revisited the topic in 2017 through a detailed review of cognitive conditions and possible interventions.

The taskforce chose not to change its original view of insufficient evidence of benefits, but it recognized that mild cognitive impairment (MCI) is a unique condition among other cognitive diseases that merits more research on the benefits of screening and intervention.

While the USPSTF’s position remains one of caution, it does open the doors for more research on MCI and the development of better screening for early cognitive decline, writes the AAFP: “The diagnosis of dementia currently is initiated mostly on the basis of a clinician's suspicion regarding patient symptoms or caregiver concerns, and although the evidence for routine screening is insufficient, there may be important reasons to identify early cognitive impairment.”

However, the indicators for prompting a cognitive assessment can be a gray area for physicians: It’s a detective hunt of medical and mental hints that includes a close analysis of the health risk assessment, physicians’ own observations and patients’ responses to in situ questions. The need for a cognitive assessment also relies greatly on self-reported symptoms, so it’s crucial that physicians engage patients and their families in healthy, proactive conversations about cognition as a normalized topic during wellness exams.

So, which cognitive screening tests are recommended for use in a Medicare Annual Wellness Visit, and under what circumstances is further testing indicated?

The Alzheimer’s Association has developed a physician flowchart designed and approved for use during the Medicare Annual Wellness Visit. It outlines a suggested clinical decision-making process and recommends specific screening tests based on physician observations and the patient’s own responses. The screening tests can be administered in less than 10 minutes apiece and may reveal important data indicating the need for further testing.

graphic courtesy of the Alzheimer's Association

 Patients who readily confirm an awareness of their own symptoms or who have scores that indicate a possible problem on an initial screening test should be given more detailed assessments and/or be referred for a full dementia evaluation, the Alzheimer’s Association suggests.

The Alzheimer’s Association recommends that patients who are unable to confirm their own symptoms or who deny symptoms observed by clinicians or reported by family members should still be given a brief structured assessment, such as the Mini-Cog, GPCOG or MIS. Other tests such as the Short IQCODE or AD8 can be administered concurrently to gather more insights.

The American Association of Family Physicians (AAFP) website provides a FAQ page on how to implement the Annual Wellness Visit program, including the rules for billing under Medicare Part B, the specific billing codes used and an explanation of how the Medicare Annual Wellness Visit differs from an initial preventive physical exam.

Engage patients in the cognitive screening conversation

Physicians may see the topic of cognitive decline as a medical health discussion that endeavors to track a change of condition, but patients often view it as a frightening talk about a disease that has no cure.

Alzheimer’s disease specifically and dementia in general have become terms that terrify many patients to the point of inhibiting their willingness to disclose symptomatic information to their physician. That makes it even more important about how PCPs approach the conversation of a cognitive screening test, Fargo says.

“It’s crucial that PCPs broach the cognitive screening subject by focusing on its importance as a baseline,” he says. “Treat cognitive screenings like a blood test. You may find something that indicates a possibility of a problem and then that might lead to another test.” This approach gives patients the understanding that the baseline test should be updated at least yearly, he adds.

When patients’ screening test scores warrant further exploration, taking a proactive stance in the exam room can make all the difference. It’s vital for providers to explain to patients that a cognitive screening test is an assessment, not a diagnosis. While screening tests may indicate a problem with brain function, further testing will be required to determine what is causing it.

Fargo says part of a PCP’s job is to engage patients in learning about and embracing their medical conditions and their ongoing wellness, including pointing them to specialists and reliable online resources to help them learn more.

Why early detection matters

Current research is gradually revealing that early detection can help extend longevity and enhance quality of life for those who are eventually diagnosed with a cognitive disease.

“Diagnosis often doesn’t occur until symptoms are advanced, but it would be much better if a diagnosis could occur during the mild cognitive impairment (MCI) stage,” Fargo says. “Unmanaged dementia is much more expensive than managed dementia, and an early diagnosis gives patients the opportunity to get into clinical trials.”

Progressive cognitive decline has no cure, but some medications and treatment plans can make a big difference in daily functioning and disease development. “Positive lifestyle changes matter, and the earlier you start them, the better,” Fargo adds. “Even people with a current diagnosis of dementia can maintain function longer under a program of proactive interventions.”

Among the most enticing research efforts are those on MCI, a condition that is still fuzzy on definitions and yet full of possibilities for interventional progress. The interest in unearthing the early roots of cognitive decline is so high that the Alzheimer’s Association has ramped up the outreach for its TrialMatch program to help connect patients with more than 250 clinical trial programs.  

“Most PCPs are aware that medication can assist with certain symptoms,” Fargo says. “But clinical trials can match patients with studies concerning their exact condition and allow them to participate in research that could be disease-modifying.”

A cognitive screening test is a tool, not silver bullet. But screening tools serve a crucial role in the documentation of early signs of cognitive impairment, allowing providers to spot patterns in brain function decline before they’ve progressed into dementia. The next step is tracking down the cause of cognitive decline and playing an active role in care coordination, especially if medication, exercise and/or lifestyle changes could slow the disease progression.

Engaging patients in conversations about how overall health supports brain function, especially for those with indicators of vascular dementia or stroke, can turn a scary subject into an opportunity for patient empowerment and better disease management.

Pamela Tabar, CADDCT, CDP, is a certified Alzheimer’s disease and dementia care trainer based in Medina, Ohio.

Resources for your practice

• The Medicare Annual Wellness Visit booklet (PDF, Centers for Medicare & Medicaid Services)

• The Medicare Annual Wellness Visit fact sheet (Alzheimer’s Association)

• Interventions for preventing cognitive decline, mild cognitive impairment and Alzheimer’s disease (AHRQ clinical research)

• 5 things to know about complementary health practices for cognitive function, dementia, and Alzheimer’s disease (designed for patients, from the National Institute on Aging)