A new report from The Gerontological Society provides guidance to physicians when they perform annual wellness visits (AWV) on Medicare beneficiaries.
A significant benefit of the 2010 Affordable Care Act has been the elimination of copays and deductibles when Medicare beneficiaries receive an annual wellness assessment with their primary care provider.
Although the detection of cognitive impairment is among items to be assessed during the annual wellness exam, a dedicated tool for this purpose is not mandated.
The new report outlines a plan for addressing this shortcoming and shows how increased detection leads to earlier and optimal diagnostic evaluation and referral to post-diagnosis support and educational services in the community.
Experts believe the interventions will ultimately lead to improved health-related outcomes and well-being for Medicare beneficiaries with diagnosed dementia and their families.
“The Medicare AWV offers a universal opportunity for primary care providers to start a conversation with older adults and their families about cognitive changes that might be worthy of further investigation,” said Richard Fortinsky, Ph.D., chair of the workgroup that created the report.
“Our workgroup’s report provides guidance for providers so they can start this conversation and, as appropriate, employ evidence-based assessment tools to detect cognitive impairment.”
“Increased detection of cognitive impairment is essential for earlier diagnosis of Alzheimer’s disease and related dementia — and also earlier diagnosis leads to more timely linkage of older adults and their families with community-based services and supports,” said workgroup member Katie Maslow, M.S.W.
In the report, the workgroup outlines a recommended for four-step process achieving its goals.
Step one is to begin the cognition conversation. To increase detection of cognitive impairment and promote earlier diagnosis of dementia in the Medicare population, the workgroup endorses that primary care provider’s use the AWV.
This annual visit between the physician and patient visit is an opportunity to kickstart — that is, to initiate and continue — a conversation with beneficiaries and their families about memory-related signs and symptoms that might develop in older adulthood.
Step two is to assess the patient if he or she is symptomatic.
The workgroup endorses use of a cognitive impairment detection tool from a menu of tools having the following properties:
- it can be administered in five minutes or less;
- it is widely available free of charge; it is designed to assess age-related cognitive impairment;
- it assesses at least memory and one other cognitive domain;
- it is validated in primary care or community-based samples in the U.S.;
- it is easily administered by medical staff members who are not physicians;
- and it is relatively free from educational, language, and/or cultural bias.
Step three is to evaluate with full diagnostic workup if cognitive impairment is detected. The workgroup recommends that all Medicare beneficiaries who exceed threshold scores for cognitive impairment based on the cognitive assessment tools used in step two undergo a full diagnostic evaluation.
Numerous published clinical practice guidelines are available to primary care providers and specialists to help them arrive at a differential diagnosis.
Step four involves referral to community resources and clinical trials, depending on the diagnosis. The workgroup recommends that all Medicare beneficiaries who are determined to have a diagnosis of Alzheimer’s disease or related dementia be referred to all appropriate and available community services to learn more about the disease process and how to prepare for the future with a dementia diagnosis.
“The workgroup views this suggested four-step process as a framework for communicating with a wide variety of stakeholders about the critical importance of incorporating cognitive impairment detection into everyday clinical practice with older adults,” Fortinsky said.
“We look forward to building on this report by helping to plan additional activities intended to disseminate and implement the report’s recommendations in communities throughout the country.”