The Executive Suite: How to discuss cognitive screenings with your Medicare patients

Thursday, June 27, 2019

How to discuss cognitive screenings with your Medicare patients

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.