Today, I review, link to, and excerpt from “Alzheimer’s Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting”. [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Alzheimers Dement. 2013 Mar;9(2):141-50. doi: 10.1016/j.jalz.2012.09.011. Epub 2012 Dec 20.
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- Abstract
- Keywords
- 1. Introduction
- 2. Guiding principles for recommendations
- 3. Review of available brief tools for use during the AWV
- 4. Recommended algorithm for detection of cognitive impairment during the AWV
- 5. Full dementia evaluation
- 6. Discussion
- 7. Author Disclosures
- Supplementary data
- References
Abstract
The Patient Protection and Affordable Care Act added a new Medicare benefit, the Annual Wellness Visit (AWV), effective January 1, 2011. The AWV requires an assessment to detect cognitive impairment. The Centers for Medicare and Medicaid Services (CMS) elected not to recommend a specific assessment tool because there is no single, universally accepted screen that satisfies all needs in the detection of cognitive impairment. To provide primary care physicians with guidance on cognitive assessment during the AWV, and when referral or further testing is needed, the Alzheimer’s Association convened a group of experts to develop recommendations. The resulting Alzheimer’s Association Medicare Annual Wellness Visit Algorithm for Assessment of Cognition includes review of patient Health Risk Assessment (HRA) information, patient observation, unstructured queries during the AWV, and use of structured cognitive assessment tools for both patients and informants. Widespread implementation of this algorithm could be the first step in reducing the prevalence of missed or delayed dementia diagnosis, thus allowing for better healthcare management and more favorable outcomes for affected patients and their families and caregivers.Keywords
Annual Wellness Visit; AWV; Cognitive impairment; Assessment; Screen; Dementia; Alzheimer’s disease; Medicare; Algorithm; Patient Protection and Affordable Care Actfig28 when server ready1. Introduction
The Patient Protection and Affordable Care Act of 2010 added a new Medicare benefit, the Annual Wellness Visit (AWV), effective January 1, 2011. The AWV includes routine measurements such as height, weight, and blood pressure; a review of medical and family history; an assessment to detect cognitive impairment; and establishment of a list of current medical providers, medications, and schedule for future preventive services. In addition, during the first AWV only, beneficiaries are to be screened for depression (if not completed under a separate Medicare benefit) and for functional difficulties using nationally recognized appropriate screening questions or standardized questionnaires. Although the U.S. Preventive Services Task Force (USPSTF) in 2003 concluded that there was insufficient published evidence of better clinical outcomes as a result of routine screening for cognitive impairment in older adults, the Task Force recognized that the use of cognitive assessment tools can increase the detection of cognitive impairment [1]. As per the Centers for Medicare and Medicaid Services (CMS) regulation, the AWV requires detection of cognitive impairment by “… assessment of an individual’s cognitive function by direct observation, with due consideration of information obtained by way of patient report, concerns raised by family members, friends, caretakers, or others” [2]. During the public comment period, several organizations, including the Alzheimer’s Association, noted that the use of a standardized tool for assessment of cognitive function should be part of the AWV.The use of a brief, structured cognitive assessment tool correctly classifies patients with dementia or mild cognitive impairment (MCI) more often than spontaneous detection by the patients’ own primary care physicians (83% vs 59%, respectively) [8].3. Review of available brief tools for use during the AWV3.2. Workgroup review resultsOf the five publications that focused specifically on
identifying brief cognitive assessments most suitable or
most used in primary care settings [11–15], all selected
the Memory Impairment Screen (MIS), and four of these
publications [11,12,14,15] also selected the General
Practitioner Assessment of Cognition (GPCOG) and the
Mini-Cog (Table 2).The following attributes of the GPCOG, Mini-Cog, and
the MIS contributed to their selection as most suited for routine use in primary care:
- Requires 5 minutes or less to administer.
- Is validated in a primary care or community setting.
- Is easily administered by medical staff members who
are not physicians.- Has good to excellent psychometric properties.
- Is relatively free from educational, language, and/or
culture bias.- Can be used by clinicians in a clinical setting without
payment for copyrights.- Charging a fee for clinical use of brief cognitive assessment tool has become an issue because of increased enforcement of the MMSE copyright.
3.3. Patient structured cognitive assessment tools
recommended for AWVIn alignment with the workgroup’s guiding principles
Table 1 Review articles of brief cognitive assessment tools—select inclusion and comparison criteria and supported by data in the six selected SERs/reviews, the GPCOG, Mini-Cog, and MIS are brief structured tools that are suitable for assessment of cognitive function during the AWV. Each tool has unique benefits. The GPCOG has patient and informant components
that can be used alone or together to increase specificity
and sensitivity [18]. The Mini-Cog has been validated in
population-based studies and in community-dwelling
older adults heterogeneous with respect to language, culture, and education [19–22]. The MIS is a verbally
administered word-recall task that tests encoding as
well as retrieval [23], and is an option for patients who
have motor impairments that prevent use of paper and
pencil.3.4. Structured cognitive assessment tools for use with
informantsCognitive assessment combined with informantreported data improves the accuracy of assessment
[24–27]. If an informant is present during the AWV,
use of a structured informant tool is recommended.
Similar to cognitive assessment tools for use with
patients, there is no single “gold standard” informant
tool; however, relatively few brief informant tools
have been validated in community and/or primary care
settings. Brief tools appropriately validated include the
Short IQCODE [25], the AD8 [28], which can be administered in-person or by telephone, and the aforementioned GPCOG [18], which has both patient and informant components.4. Recommended algorithm for detection of cognitive
impairment during the AWV4.1. Incorporating assessment of cognition during the
AWVThe Alzheimer’s Association Medicare Annual Wellness
Visit Algorithm for Assessment of Cognition for consistency
(Figure 1) illustrates a stepwise process. The process is intended to detect patients with a high likelihood of having dementia. The AWV algorithm includes both structured assessments discussed previously and other less structured patient- and informant-based evaluations. By assessing and documenting cognitive status on an annual basis during the AWV, clinicians can more easily determine gradual cognitive decline over time in an individual patient—a key criterion for diagnosing dementia due to Alzheimer’s disease and other progressive conditions affecting cognition.For patients with a previous diagnosis of MCI or dementia, this should be documented and included in their AWV
list of health risk factors. Annual unstructured and structured
cognitive assessments could be used to monitor significant
changes in cognition and potentially lead to a new diagnosis
of dementia for those with MCI or new care recommendations for those with dementia.
4.2. Detection of cognitive impairment during the AWV—
initial HRA review, conversations, and observationsThe first step in detection of cognitive impairment during
the AWV (Fig. 1, Step A), involves a conversation between a clinician and the patient and, if present, any family member
or other person who can provide collateral information. This
introduces the purpose and content of the AWV, which includes: a review of the HRA; observations by clinicians
(medical and associated staff); acknowledgment of any selfreported or informant-reported concerns; and conversational queries about cognition directed toward the patient and others present. If any concerns are noted, or if an informant is not present to provide confirmatory information, further evaluation of cognition with a structured tool should be performed.Patient completion of an HRA is a required element of the
AWV and can be accomplished with the help of a family member or other knowledgeable informants, including a professional caregiver. Published CMS guidance offers healthcare
professionals flexibility as to the specific format, questions,
and delivery methods that can be used for an AWV HRA
[29]. The following questions may be suitable for the AWV
HRA and have been tested and evaluated in the general population through the Behavioral Risk Factor Surveillance System or presented as HRA example questions:1. During the past 12 months, have you experienced confusion or memory loss that is happening more often or
is getting worse [30]?
2. During the past 7 days, did you need help with others
to perform everyday activities such as eating, getting
dressed, grooming, bathing, walking, or using the toilet [29]?
3. During the past 7 days, did you need help from others
to take care of things such as laundry and housekeeping, banking, shopping, using the telephone, food preparation, transportation, or taking your own medications [29]?A noted deficit in activities of daily living (ADLs) (e.g.,
eating and dressing) or instrumental activities of daily living
(IADLs) (e.g., shopping and cooking) that cannot be attributed to physical limitations should prompt concern, as there is a strong correlation between decline in function and decline in cognitive status across the full spectrum of dementia [31]. In addition to clinically observed concerns, any patient- or informant-reported concerns should trigger further
evaluation [13]. Positive responses to conversational
queries, such as “Have you noticed any change in your memory or ability to complete routine tasks, such as paying bills
or preparing a meal?” should be followed up with a structured assessment of cognition.Upon realizing the time constraints of a typical primary
care visit, if no cognitive concerns surface during the initial
evaluation and this information is corroborated by an informant, the clinician may elect not to perform a structured cognitive assessment and assume that the patient is not currently demented. This approach is supported by studies in populations with low rates of dementia that suggest the absence of memory difficulties reported by informants and patients reduces the likelihood that dementia is present [32,33].4.3. Structured cognitive assessment tools for use with
patients and informants during the AWVThe second step in detection of cognitive impairment during the AWV (Figure 1, Step B) requires cognitive assessment using a structured tool. Based on synthesis of data from the six review articles previously discussed, patient tools suitable for the initial structured assessment are the GPCOG, Mini-Cog, and MIS.
Recognizing that there is no single optimal tool to detect
cognitive impairment for all patient populations and settings, clinicians may select other brief tools to use in their
clinical practice, such as those listed in Table 3. The 15 brief
tools listed were evaluated in multiple review articles
(passed through at least two review search criteria for tools
possibly suited for primary care) or are used in the VA. Tools
listed in Table 3 are subject to the inclusion/exclusion criteria of each review and do not represent the entire listing of
the .100 brief cognitive assessment tools that may be suitable for primary care practices.If an informant is present, defined as someone who can
attest to a patient’s change in memory, language, or function
over time, it is suitable to use the AD8, the informant component of the GPCOG, or the Short IQCODE, during the AWV.4.4. Primary care workflow considerations
According to the algorithm, any patient who does not
have an informant present should be assessed with a structured tool. For such patients (and for practices that implement structured assessments during all AWVs), completion
of this structured assessment can be administered by trained
medical staff as the first step for cognitive impairment detection. This could improve office efficiency. To increase acceptance of a structured assessment, the reason provided to the patient can be normalized with a statement such as,
“This is something I do for all of my older patients as part
of their annual visit.” When the initial assessment prompts
further evaluation, explanation of results should be deferred
until a more comprehensive evaluation has been completed.
“There are many reasons for not getting every answer correct. More evaluation will help us determine that,” is an example statement that may encourage patients to pursue
further testing.5. Full dementia evaluation
Patients with assessments that indicate cognitive impairment during the AWV should be further evaluated to
determine appropriate diagnosis (e.g., MCI, Alzheimer’s
disease) or to identify other causes. As reflected in the algorithm (Figure 1, Step C), initiation of a full dementia evaluation is outside the scope of the AWV, but can occur in
a separate visit either on the same day, during a newly scheduled visit, or through referral to a specialist. Specialists who have expertise in diagnosing dementia include geriatricians, geriatric psychiatrists, neurologists, and neuropsychologists. The two-visit approach has been cited as a time-effective process to evaluate suspected dementia in primary care [34] and is consistent with the two-step approach widely used in epidemiologic research on dementia. Regardless of the timing and setting, clinicians are encouraged to counsel
patients to include an informant in the diagnostic process.Components of a full dementia evaluation can vary depending on the presentation and include tests to rule in or out the various causes of cognitive impairment and establish its severity. Diagnostic evaluations include a complete medical history; assessment of multiple cognitive domains, including episodic memory, executive function, attention,language, and visuospatial skills; neurologic exam (gait, motor function, reflexes); ADL and IADL functioning; assessment for depression; and review for medications that may adversely affect cognition. Standard laboratory tests include
thyroid-stimulating hormone (TSH), complete blood count
(CBC), serum B12, folate, complete metabolic panel, and,
if the patient is at risk, testing for sexually transmitted diseases (human immunodeficiency virus, syphilis). Structural
brain imaging, including magnetic resonance imaging
(MRI) or computed tomography (CT), is a supplemental
aid in the differential diagnosis of dementia, especially if
neurologic physical exam findings are noted. An MRI or
CT can be especially informative in the following cases: dementia that is of recent onset and is rapidly progressing;
younger onset dementia (,65 years of age); history of
head trauma; or neurologic symptoms suggesting focal
disease.
