The Alzheimer’s Association, world’s leading voluntary health organisation in Alzheimer’s care, support and research has released new recommendations to help health care providers in detecting cognitive impairment as part of the Medicare Annual Wellness Visit. In developing recommendations, the Association convened a group of experts to survey the current literature and build consensus around an effective, practical and easy process that could be used in the primary care setting.

The recommendations are released by the Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association.

While physicians are required to include detection of cognitive impairment as part of the Medicare Annual Wellness Visit, as there have been no comprehensive guidance to physicians on how to accomplish that. Detecting possible cognitive impairment is the first step in determining whether or not further evaluation is needed.

“We understand that by assessing and documenting cognitive status on an annual basis during the Annual Wellness Visit, clinicians can more easily monitor gradual cognitive decline in a patient over time,” said Bill Thies, Ph.D., Alzheimer’s Association chief medical scientific officer. “Through this workgroup process, we now have a comprehensive recommendation for a brief, step-by-step process to detect cognitive impairment that includes tools for patients and family members as well as an emphasis on vital patient history, self-reported concerns and clinician observations.”

According to the Alzheimer’s Association’s 2012 Alzheimer’s disease facts and figures report, more than 5 million Americans with Alzheimer’s disease, as many as half have not been diagnosed. Without initial detection, these individuals would not be diagnosed which would deprive them of available treatments and services as well as the opportunity to make financial and care plans.

“Widespread use of the steps identified by the Alzheimer’s Association Medicare Detection of Cognitive Impairment Workgroup could make significant inroads in reducing the prevalence of missed or delayed dementia diagnosis by either establishing a baseline for cognitive surveillance or a trigger for further diagnostic evaluation,” Thies added

Starting with an examination of published systematic evidence review studies, the Workgroup then explored whether or not there was consensus in the literature concerning validated tools and commonly used rule-out assessments most suited for primary care practitioners. In addition to the range of tools identified, the recommendations offer suggested questions to include in the required Health Risk Assessments that patients must provide for the visit. The recommendations include tools that are available in multiple languages and are unaffected by levels of education or different cultural backgrounds.

While the workgroup emphasizes in its recommendations “no one tool is recognized as the best brief assessment to determine if a full dementia evaluation is needed,” several tools were found most suited for assessing cognitive impairment at no cost to the health care provider during the visit. These include the Mini-Cog, the Memory Impairment Screen (MIS), and the General Practitioner Assessment of Cognition (GPCOG). Positive attributes of these tests are that they were relatively free of education, race or cultural bias and take five minutes or less to administer – a very favourable aspect given the often limited time primary care physicians have per patient. Recognized tools suited for those close to the patient such as spouses, family members or friends were the AD8, the Short Informant Questionnaire on Cognitive Decline in the Elderly (short IQCODE), and the Informant GPCOG.

Use of a tool allows clinicians to obtain an objective score that indicates either a passed or failed cognitive assessment and can improve detection of impairment that should be further evaluated. One study found that structured tools detected more than 80 per cent of patients who during follow-up were diagnosed with mild cognitive impairment or dementia compared to the detection of only 59 per cent whose detection relied on physician observation alone.

“As a leader in the Alzheimer’s community, the Alzheimer’s Association believes that part of its role is to fuel the advancement of early detection and diagnosis. The Workgroup recommendations empower and equip physicians with a pathway that allows them to make informed choices about which structured assessment tools work best for them and the patients they serve,” said Thies. “Whether the tools the Workgroup identified are used or other detection instruments, informal observation is not enough.”

“We urge all primary care physicians to use the recommended step-by-step cognitive assessment process to take full advantage of the opportunity the Medicare Annual Wellness Visit provides – earlier detection of dementia, potentially earlier treatments, better healthcare management for patients and more favorable outcomes for affected families,” concluded Thies.

The Association is looking forward to work with physician organisations and government agencies as it works to disseminate these recommendations.