Cognition is a Critical Vital Sign for Older Adults: The Need for Early Detection of Cognitive Impairment is Now

Educate the public about usual cognitive functioning of older adults and the benefits of early detection of cognitive impairment

Too often we hear from patients and their family members—and sometimes from healthcare professionals—that cognitive impairment is inevitable with aging. This is simply not true; the majority of adults aged 65 and older do not develop MCI/ADRD and many remain cognitively healthy well into their 90s and 100s (Beker et al., 2020; Qiu & Fratiglioni, 2018). Studies of the “oldest old” demonstrate this reality and point to important health and lifestyle factors that may have an impact on the onset and trajectory of cognitive impairment (Duarte et al., 2017; Krivanek et al., 2021; Zeng et al., 2017). Moreover, the majority of older adults report feeling happy and satisfied with life as they age (Jeste et al., 2013; Van Damme-Ostapowicz et al., 2021). Thus, public health campaigns highlighting these facts about cognitive health and positive aspects of aging may help debunk the myth that cognitive impairment is a “normal” part of growing old. If presented in tandem with information about warning signs and symptoms of cognitive impairment, such as those promulgated by the Centers for Disease Control and Prevention (https://www.cdc.gov/aging/healthybrain/ten-warning-signs.html) and the Alzheimer's Association (https://www.alz.org/alzheimers-dementia/10_signs), and the benefits of early detection, the likelihood of seeking help when concerns about cognitive impairment arise may be increased. Furthermore, creating targeted education strategies based on background variables such as socioeconomic status, race, and ethnicity, as well as highlighting stress and resilience factors, such as education and literacy engagement, may help in reaching diverse segments of society (Nkwata et al., 2021; Stine-Morrow et al., 2015).

Address gaps in the healthcare workforce for older adults with cognitive impairment

As the US healthcare system faces the challenge of attempting to care for an aging population with high rates of MCI/ADRD and other chronic illnesses, national policy needs to develop to address gaps in the dementia care workforce (Alzheimer’s Association, 2022; National Institutes of Health/National Institute on Aging, 2019). National organizations and leaders in the dementia field have recommended addressing these gaps and/or workforce shortages by developing plans to improve education and training initiatives across disciplines and settings. For example, the American Psychological Association (APA, 2020) identified the need to encourage the inclusion of aging content and life span developmental focus in curricula across levels of psychology training. APA emphasized the importance of including education on the contribution of older adults to society, providing a balanced view of aging, and finding ways to reduce and counteract ageist beliefs. The National Academies of Sciences, Engineering, and Medicine's Committee on Population (CPOP) and the National Institutes of Health/ National Institute on Aging (NIH/NIA) formed multidisciplinary work groups that convened to address ways to meet the health and long-term care needs of this growing population (NIH/NIA, 2019). Emphasis was also placed on addressing the needs of at-risk populations, including people in rural areas, low-income families, and non-English speaking individuals.

Critical workforce gaps (Weiss et al., 2020) include, first, recruitment and retention of a dementia-capable workforce; this requires collaboration between organizations to meet education and training needs to address health professional and direct care workforce shortages. To this point, 55% of surveyed primary care physicians caring for patients with AD reported too few dementia care specialists in their communities to meet current demands (Alzheimer’s Association, 2022). High costs associated with dementia healthcare services and supports suggest the emerging education and training needs of the dementia care workforce must be cost-effective. However, low wages and insurance reimbursement rates perpetuate the gap in the workforce; without financial incentive to care for people with dementia, staffing shortages and high turnover rates will continue.

A third gap, effective communication and collaboration between healthcare professionals, direct care providers, and family caregivers, can help minimize stress, decrease duplication of services, reduce costs, and improve quality of care (Aguirre et al., 2022; Amjad et al., 2016; Boustani et al., 2011; Callahan et al., 2006; Galvin et al., 2014; Reuben et al., 2019). Changes in reimbursement for dementia care are necessary to support collaborative care models; no dementia clinic is sustainable using the current fee-for-service Medicare payment program (but see Borson et al., 2017).

Train primary care providers in early detection of cognitive impairment and educate them about available resources

In spite of the benefits of early detection, a significant percentage of individuals with cognitive impairment are undiagnosed. It is estimated that 50–67% of individuals aged 65 and older with dementia are not recognized or diagnosed by their primary care provider (PCP) (Bradford et al., 2009; Connolly et al., 2011; Iliffe et al., 2009; Valcour et al., 2000). PCPs are the first line of medical care; they are often the first healthcare professional who patients or their families notify when there are concerns about cognitive decline. They are also the healthcare professional who sees the patient most often and may have the longest relationship with patients (Alzheimer’s Association, 2019). Moreover, PCPs comprise a large portion of the outpatient healthcare workforce (Petterson et al., 2018). Thus, PCPs represent a critical piece of the solution for earlier detection of cognitive decline.

Although PCPs are aware of a mandate or need for cognitive screening as a routine part of patient care, challenges such as limited time, lack of training, and uncertainty about what to do with a positive screen have hindered implementation. In fact, even though cognitive assessment is required for Medicare patients as part of their Annual Wellness Visit, less than one-third of Medicare patients reported actually receiving cognitive screening as part of their visit (Alzheimer’s Association, 2022). The average primary care visit is 15–17 min (Tai-Seale et al., 2007), which leaves little room for cognitive screening. Involvement of advanced practice providers, nurses, social workers, and medical assistants in cognitive screening akin to taking blood pressure and other vital signs is likely needed to maximize the provider's time with the patient.

Lack of training in cognitive assessment techniques that can be conducted quickly in the primary care setting is a major barrier to implementation. PCPs have reported a lack of familiarity with brief cognitive assessments and low use of resources developed by specialty groups designed to assist PCPs in conducting these assessments (Alzheimer’s Association, 2019). Lack of time and training in administration, scoring, and interpretation of brief cognitive assessment results in incorrect scoring or reporting in 25–33% of cases (Cannon & Larner, 2016; Wojtowicz & Larner, 2015).

Surveyed PCPs also indicated differentiating MCI from normal aging as challenging and concern about high false positive and false negative rates of brief cognitive assessments (Alzheimer’s Association, 2019, 2022), which underscores the importance of using techniques that are evidence-based (Logie et al., 2015). However, brief cognitive assessments are not meant to diagnose MCI but to identify people who may benefit from a more thorough evaluation. Moreover, given the diversity of our society and that certain underrepresented groups are disproportionately vulnerable to developing MCI/ADRD (Alzheimer’s Association, 2019), it is important that providers use culturally appropriate assessments. Thus, taking into account factors such as age, education, socioeconomic status, and language in the interpretation or selection of assessment techniques needs to be part of the training process. It may also benefit PCPs to know there are cognitive, among other, benefits associated with standardized testing itself (Benjamin & Pashler, 2015).

The care pathway for individuals who screen positive for cognitive impairment may vary depending on how comfortable the provider is diagnosing and managing patients with MCI/ADRD and access to referral resources. As indicated above, not everyone with cognitive impairment has dementia and some have treatable causes of their cognitive impairment (e.g., medication side effects, metabolic abnormalities, psychological disorders like depression or anxiety). Thus, identification of cognitive impairment can trigger the need to explore reversible causes for cognitive symptoms, some of which can be addressed in the primary care setting or will fine-tune subsequent referrals (e.g., sleep specialist for sleep apnea). Unfamiliarity with treatment approaches for MCI may contribute to hesitancy in screening for cognitive impairment. The American Academy of Neurology published updated practice guidelines for diagnosis and treatment of MCI (Petersen et al., 2018) that outline pharmacological and nonpharmacological treatment options to be considered and reviewed with patients.

Although the majority of dementia diagnoses are made by PCPs, many feel uncomfortable making the diagnosis or believe they are ill-prepared to care for individuals with dementia (Alzheimer's Association, 2020). Centers for Medicare and Medicaid Services require that a care plan for patients with dementia address neuropsychiatric symptoms, cognitive symptoms, functional limitations, and referral to community resources. Knowing when to refer to specialists is a critical part of the training needed for PCPs and may include cases of atypical presentation, presence of behavioral/psychiatric symptoms, or need for a second opinion. ³

For PCPs to take advantage of the many resources available to diagnosis and manage individuals with cognitive impairment, concentrated efforts are needed to provide education and training about these resources. Providing training and resources to PCPs may enhance their confidence in being able to identify and treat individuals with cognitive impairment or know where to send patients to get the care they need, ultimately forming a partnership with other members of the care team. Training of PCPs is particularly critical in light of the aforementioned shortage of specialty providers to manage all patients with dementia.

Incentivize early detection efforts of PCPs and other healthcare providers

The personal and societal benefits of identifying cognitive impairment early are not ambiguous. Likewise, the costs of failing to detect cognitive impairment are clear and substantial. Procedures should not only allow clinicians the time to conduct screenings but adequately incentivize them to do so. Medicare understood these necessities when they authorized reimbursement to clinicians for conducting cognitive assessments and providing a care plan at a separate clinical visit. In fact, Medicare invested significant resources aimed at raising awareness of the eligibility and coverage requirements of this service, including extensive local and national outreach and collaboration with multiple stakeholder groups. Such actions are commendable but without similarly incentivizing clinicians to conduct cognitive screenings when concerns present, and as part of their required duty to assess cognition during the Annual Wellness Visit, patients with cognitive impairment will continue to be missed at unacceptable rates and will not receive the necessary care they require and deserve.

It is notable that Medicare policy specifies that during the Annual Wellness Visit, clinicians must utilize an appropriate screening instrument to assess for depression or other mood disorders. Thus, despite the increasing prevalence of cognitive impairment facing our aging society, comparatively higher standards and expectations for detecting depression have been set forth. The importance of assessing mental health in primary care settings is not a matter of debate; rather, it sets an example for how to elevate the assessment of cognitive impairment via the use of standardized screening measures that have similarly been recognized by national professional medical and psychological organizations. A similar strategic approach to cognitive impairment needs to be standardized and recognized by national medical professional organizations. The likelihood of clinicians utilizing cognitive screening measures would increase if Medicare were to mandate a short list of well-validated standardized measures that were amenable to use in primary care settings. Given the push toward value-based healthcare, such utilization could be supported further if the use of cognitive screening measures were included as a Merit-Based Incentive Payment System (MIPS) quality measure. MIPS is the program Medicare uses to determine whether eligible clinicians receive a payment bonus, penalty, or no payment adjustment based on a composite performance score. Incentivizing via MIPS the use of an accepted brief cognitive assessment tool during the Annual Wellness Visit would be a welcome step toward early detection of cognitive impairment.

Leverage technology to improve early detection of cognitive impairment

Technology can facilitate the early identification of cognitive impairment in the growing aging population. Telehealth administration of cognitive screening measures for older adults has shown promise in detecting cognitive deficits (Brearly et al., 2017; Marra et al., 2020). Telehealth administration of these measures within Primary Care, Psychiatry, and Neurology may allow for automated, standardized, and serial assessment of cognitive status that can be easily tracked within the electronic health record.

Atypical findings on cognitive screening measures may identify potential cognitive impairment, but a comprehensive neuropsychological evaluation will confirm and aid in the differential diagnosis of mild cognitive difficulties (Roebuck-Spencer et al., 2017). Comprehensive neuropsychological evaluations have traditionally involved face-to-face testing, but teleneuropsychology (TNP), or the use of telehealth for neuropsychological assessment, is an area of rapid growth, fueled by the prolonged need for social distancing during the COVID-19 pandemic. TNP involves standardized measures and their interpretation within a clinical context and knowledge of the measures’ psychometric properties. Older adults with cognitive difficulties have been reliably identified using TNP (Brearly et al., 2017; Marra et al., 2020; Wadsworth et al., 2018), which may allow for increased access to brain health services, especially if used in conjunction with telehealth screening measures. Telephone-based cognitive screening has been used in dementia research to help identify eligible candidates for clinical trials and other studies, with a number of measures for use in aging populations (Carlew et al., 2020). Telephone cognitive screening may be particularly useful to address barriers to access to technology needed for TNP—more common in aging and low-income populations. Notably, TNP is not self-administered computerized cognitive assessment batteries, many of which have limited sensitivity, reliability, and normative data (Wild et al., 2008; Zygouris & Tsolaki, 2015). In this way, computerized cognitive assessment batteries are like screening tests; atypical findings may raise concern about MCI/ADRD that requires further investigation to arrive at a diagnosis (Bauer et al., 2012; Zygouris & Tsolaki, 2015).

Potential barriers to the widespread implementation of TNP include issues around insurance reimbursement and access to technology. It remains unclear whether TNP services will be covered beyond the COVID-19 pandemic. Some insurance companies do not cover neuropsychological evaluation at all, and many have an annual benefit for neuropsychological services, which makes it challenging to bill for different tiers of cognitive assessment within the same calendar year (i.e., reimbursement of a screening evaluation and then a full evaluation if needed). The challenges of in-home neuropsychological assessment include privacy, access to stable internet and appropriate technological devices, and accurately capturing data from hands-on tasks (Bilder et al., 2020; Hewitt et al., 2020). For these reasons, integration of TNP screening within clinical settings (e.g., primary care) may be more feasible.