Accuracy, Assessment Time, Test Administration, Tracking and Training are the top categories to help customers choose.
Background: Identifying cognitive impairment at its earliest stages. It's possible now more than ever before to slow or even reverse memory decline.
Across the spectrum of healthcare, the concept of timely intervention has been well demonstrated by the many preventive care or routine screenings for conditions such as heart disease, metabolic disorders, and breast and prostate cancer.
All of these medical conditions, if not identified and treated early, will lead to less sub-optimal outcomes and increased healthcare expenditures.
As the global population ages, promoting and facilitating brain health has become increasingly imperative to maintaining quality of life and to reducing the socioeconomic burden caused by a rising prevalence of cognitive impairment due to Alzheimer’s disease (AD) and other related disorders [1].
Since 2011, CMS has required identification of cognitive impairment during Medicare Annual Wellness Visits (AWV) [2].
Guidelines from CMS state that, “You can also detect cognitive impairment as part of a routine visit through direct observation or by considering information from the patient, family, friends, caregivers, and others. You may also use a brief cognitive test and evaluate health disparities, chronic conditions, and other factors that contribute to increased risk of cognitive impairment.
CMS guidelines go on to state: “If you detect cognitive impairment at an AWV or other routine visit, you may perform a more detailed cognitive assessment and develop a care plan during a separate visit. This additional evaluation may be helpful to diagnose a person with dementia, such as Alzheimer’s disease, and to identify treatable causes or co-occurring conditions such as depression or anxiety [3].”
However, despite such CMS requirements and heightened public awareness about the importance of cognitive health, a survey led by the National Alzheimer’s Association has revealed that only 16% of seniors (65 years and older) receive regular cognitive assessments during routine health check-ups from their primary care physicians (PCPs) (Figure 1) [4].
The same survey by the National Alzheimer’s Association [4] shows that less than a half of PCPs assess cognition in their practice. In addition, among the very few who administer an objective cognitive evaluation, nine of 10 administers an assessment which does not reliably detect mild cognitive impairment (MCI) and is only appropriate for identifying patients in the dementia stages. Examples include the Mini-Mental State Examination (MMSE), Clock Drawing Test (CDT), Montreal Cognitive Assessment (MoCA), and the Mini-Cog.
Currently, there is no clear guidance on what instruments are best suited for such early stage assessments for an aging population.
The vast majority of promoted instruments target dementia stages (Figure 2) where patients have lost independence and require assistance from others [5,6]. At even the mild dementia stage, the window of optimal treatment efficacy has been lost and the opportunity for successful therapeutic intervention has been compromised.
As AD disease modifying therapies and potential prevention of the disease progression becomes more available, identifying cognitive impairment at its earliest stages becomes critical in clinical care settings [6, 7].
This also goes beyond AD and related disorders as cognitive impairment are frequently caused by more treatable conditions. These include, but are not limited to, heart diseases, metabolic disorders, diabetes, depression, menopause, certain medications, and lifestyle choices, and all of which greatly benefit from early detection and treatment [7].Key Criteria for Cognitive Assessment at Home or in Clinical Care Settings
7 key criteria to evaluate when implementing cognitive assessments.
1. Accuracy and Test Validation
When considering accuracy of the assessment tools, it is important to consider both sensitivity (ability to identify impairment) and specificity (ability to identify normal). Additionally, it is important to understand its accuracy in different stages of cognitive impairment (e.g., mild cognitive impairment, mild dementia, moderate dementia).
Many commonly used assessment tools show high accuracy in dementia stages but not in earlier stages (e.g., mild cognitive impairment). Some tools with high accuracy may lack in specificity leading to high false positives. Therefore, it is important to give a careful consideration on the test validation criteria including sample size, disease stages, clinical setting, and diagnostic criteria used to determine disease stages.
2. Assessment Time
While comprehensive neuro-psychologic assessments are useful especially for differential diagnosis, they require trained neuropsychologists and typically take 1.5 to 2 hours. Therefore, pragmatic tools should fit in busy practices taking minimum time to qualified for its reimbursement. Additionally, a time to score the test must be taken into considered as it varies test-to-test.
Several physician concerns and financial barriers have been identified in implementing cognitive assessment in clinical care settings [4, 8]. These include but are not limited to:
High rates of false positive or negatives of the assessment tools
Lack of training or confidence in performing such assessments
Lack of time during patient visits
Lack of financial reimbursement for time spent discussing results
Lack of financial reimbursement for performing an assessment
3. Test Administration and Scoring
There are three primary modes of test administration: pen-and-paper, computer guided, and computerized. Each mode requires a different setting, training, and up-front financial investment. It is also important to note that some tests do not have or may not have readily available normative data to adjust the score for age, gender, race, and education. Additionally, whether or not any given assessment lends itself to telehealth delivery is an important consideration as the trend for remote care delivery is increasing sharply.
Pen-and-Paper Tests are the most traditional approach to a brief assessment. It requires a clinician to administer the test and also requires a manual scoring. Due to the lack of standardization and/or lack of guided administration, these tests require training and expertise for valid and reliable delivery.
Computer Guided Tests are designed to guide a proctor through a standard test administration. Some of these require specialized equipment while others can be accessed over an online platform without any additional devices in the office. Scoring of computer guided tests is done automatically for reporting purposes.
Computerized Tests are self-administered by patients using a device or an online platform, and generally requires an upfront financial investment. Although these tests are self-administered, physician or staff time to oversee and navigate patients is required.
Some of the most commonly used Pen-and-Paper Tests are copyrighted. Careful consideration should be made prior to the use in order to obtain permission from the copyright holders.
4. Longitudinal Tracking
For both disease management (e.g., treatment outcome) and preventive care purposes (e.g., Medical Annual Wellness visit), it is important to monitor patients’ cognition longitudinally.
Pen-and-Paper Tests do not lend itself to easy long-term storage, integration into electronic health records (EHRs), or longitudinal data tracking. Additionally, due to the lack of guided administration, the test results may vary across different test administrators.
Computer Guided Tests may provide electronic storage and longitudinal tracking of the test results.
Computerized Tests may provide electronic storage and longitudinal tracking of the test results.
It is important to adjust the result scores for patient demographics during longitudinal monitoring. However, some assessments may lack normative data for score adjustment.
5. Training
Each mode of assessment requires different types of training
Pen-and-Paper Tests require training for test administration and scoring.
Computer Guided Tests require minimum training as the platform will guide a proctor for its administration with automatic scoring.
Computerized Tests do not require test administrator training. However, they require patient training by physician or staff, as well as time to navigate patients or trouble-shoot problems during the assessment.
6. Reimbursement
To qualify for reimbursement, the test administration time and the cognitive domains evaluated must be considered. Reimbursement varies based on who administers the test (physician vs. staff) and its interpretation as well as on the mode of test administration. Computerize tests are reimbursed at lower rate than proctor administered tests. It is important to note that MMSE, one of the most commonly used pen-and-paper tests, is not reimbursed under any code by CMS.
7. Cost of Implementation and Assessment
Depending on assessments, there may be usage/access fee, upfront device purchase cost, copyright permission fee, test forms purchasing cost, and other administrative cost (e.g., account maintenance). It is important to evaluate these costs against available reimbursement as well as staff and physicians time required to operationalize such assessments.
References
1. Alzheimer’s Association. 2024 Alzheimer’s Disease Facts and Figures. Alzheimer’s Dement 2024;20(5).
2. A Billing and Coding: Cognitive Assessment and Care Plan Service (CMS website: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=59036&ver=13&)
3. Cognitive Assessment & Care Plan Services (CMS website: https://www.cms.gov/medicare/payment/fee-schedules/physician/cognitive-assessment)
4. Alzheimer’s Association. 2019 Alzheimer’s Disease Facts and Figures. Alzheimer’s Dement 2019;15(3):321-87.
5. Cordell CB, Borson S, Boustani M, et al. Medicare Detection of Cognitive Impairment Workgroup. Alzheimer's Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting. Alzheimers Dement. 2013 Mar;9(2):141-50.
6. Athilingam P, Visovsky C, Elliott AF, Rogal PJ. Cognitive screening in persons with chronic diseases in primary care: challenges and recommendations for practice. Am J Alzheimers Dis Other Demen. 2015 Sep;30(6):547-58.
7. Liss JL, Seleri Assunção S, Cummings J, et al. Practical recommendations for timely, accurate diagnosis of symptomatic Alzheimer's disease (MCI and dementia) in primary care: a review and synthesis. J Intern Med. 2021 Aug;290(2):310-334.
8. de Levante Raphael D. The Knowledge and Attitudes of Primary Care and the Barriers to Early Detection and Diagnosis of Alzheimer's Disease. Medicina (Kaunas). 2022 Jul 7;58(7):906.
