Introducing Annual Screenings for Cognitive Impairment

More than half of elderly Americans with dementia have never had a clinical cognitive evaluation, reported a 2015 Neurology study. That’s a startling statistic, considering older adults with cognitive impairment, including Alzheimer’s disease (AD), are more likely to have self-care deficits, which can lead to disease complications and increased healthcare costs.

Early detection of cognitive impairment is critical to better long-term outcomes. Earlier treatment of AD and other types of dementia potentially can help patients achieve more symptom relief and maintain more independence longer. Numerous studies are exploring possible treatments to slow, stop or prevent brain damage and mental decline.

With AD and other dementias becoming epidemic in the U.S., medical providers should be proactive at identifying and addressing the needs of the growing patient population. However, cognitive impairment often goes unrecognized in primary care.

Cleveland Clinic is taking steps to change that. A new effort is underway that will ensure Cleveland Clinic primary care patients will be screened annually for cognitive impairment. It will be a giant step forward in identifying patients with potential dementia, ultimately leading to earlier diagnosis and earlier treatment.

“There are no clear guidelines about how to do this, so Cleveland Clinic is coming up with its own,” says geriatrician Saket Saxena, MD. “We are using testing that is easy to do and can be incorporated in a primary care setting.”

Pilot finds more impairment than realized

A group within Cleveland Clinic’s Center for Geriatrics first explored the concept in 2014 with an 8-week pilot test. Medical assistants (MAs) and nurses in a Cleveland Clinic internal medicine clinic screened patients age 65 and older for cognitive impairment using Mini-Cog™ and another validated screening tool. Mini-Cog evaluates patients based on word recall and a clock-drawing test. MAs and nurses also screened for depression using an established patient health questionnaire.

About 17 percent of patients (36 of 206) screened positive for cognitive impairment. About 10 percent (16 of 153 patients) screened positive for depression. Primary care providers referred patients with abnormal screenings to geriatrics, psychiatry or social work. MAs and nurses reported preference for the Mini-Cog tool when conducting cognitive screening, perceiving it as more relevant and easy to use than the other tool.

“The pilot showed that there was more impairment than we realized and that these patients potentially needed more intervention, education and assistance,” says geriatrician Amanda Lathia, MD. “It was clear that there was value in coordinating primary care and geriatrics.”

Formalizing the screening process

In late 2016, Cleveland Clinic’s Medicine Institute introduced a formal Behavioral Health and Social Needs initiative to improve screenings and access to resources for various populations, including elderly patients with cognitive impairment. Teams of caregivers, including geriatricians, have formed four work groups:

1. Workflow
2. Skills and abilities
3. Research
4. Community resources

Dr. Lathia has participated in the workflow group to determine logistics for cognitive screenings. As in the 2014 test, patients age 65 and older will be screened with Mini-Cog during a primary care appointment. MAs and nurses will conduct the test annually as part of a pre-visit assessment during the rooming process.

“They’ll enter the Mini-Cog score in the electronic medical record,” says Dr. Lathia. “Practitioners then can view an order set, which could involve referring to geriatrics or another specialty and/or recommending lifestyle modifications. Patient education materials will be available for those who have abnormal screenings.”

Dr. Saxena is participating in the skills and abilities group to prepare clinic support staff to administer and score screenings, and help practitioners determine what to do when cognitive impairment is suspected.

“Our first step was identifying training materials, including videos, handouts and one-on-one coaching,” says Dr. Saxena. “An initial group of medical assistants provided feedback on the training to help us refine it. Soon we’ll be going out to all our family health centers to train everyone who will be involved with the screenings.”

Screening rollout is anticipated to begin later this year.

Tracking patients over time will improve care

The screening is not foolproof, says Dr. Lathia. Some patients potentially could score well on Mini-Cog yet still have impaired executive function, which could affect how they follow treatment instructions, manage medications and keep appointments, for example. But it’s still a good place to start, she says.

Dr. Saxena predicts more abnormal screenings will be reported.

“More patients may not necessarily have dementia, but we’ll be able to track them over time and see how their care needs change,” he says.

Being aware of cognitive changes will assist providers in altering care paths sooner, which could improve long-term outcomes, potentially decreasing hospitalizations and readmissions. Cleveland Clinic and community resources can be brought in earlier, not just when cognitive disability becomes severe.

“When practitioners are more aware of cognitive impairment, they can spend more time on patient education, address polypharmacy, and encourage patient caregivers to help with medicines and health management,” says Dr. Lathia. “Earlier treatment may help avert or at least delay some unwanted effects of dementia.”