Cognitive Assessments in Primary Care: Preparation and Tools May Mitigate Diagnosis Risks

Recent reimbursement changes by the Centers for Medicare and Medicaid Services (CMS) allow primary care providers to meet their patients’ mental health needs and help build their practices by performing cognitive assessments.

This opportunity is timely: More than 5 million adults are already affected by dementia—a number that is only expected to rise. Thus far, primary care providers able to perform cognitive assessments and patients needing cognitive assessments have often missed each other: Physicians may be unaware of cognitive impairment in more than 40 percent of their cognitively impaired patients, and one study found that more than half of patients with dementia had not received a clinical cognitive evaluation. Plus, the isolation that the pandemic temporarily enforced for many may have accelerated or temporarily exacerbated cognitive impairments. 

In recognition of the scale on which assessments are needed due to the aging population of the United States, CMS has increased payment for primary care providers who perform cognitive assessments. As practices take advantage of CMS’s new billing rules, successfully integrating cognitive evaluations into a practice’s workflow without magnifying liability risks takes some preparation.

To mitigate risks of misdiagnosis, primary care providers should become proficient with cognitive assessment tools. To further prevent harm, providers may wish to familiarize themselves with community resources to help families cover gaps in care. Both measures will help providers improve patient safety while mitigating their risk of claims.

Diagnostic Cautions

Patients who have recently experienced cognitive changes are often seen first by their primary care providers. While spouses or family members sometimes assume these changes are caused by dementia, they could be caused by a medication issue, or by multiple sclerosis, a brain tumor, or any other number of other organic causes which, if suspected by the primary care provider, would necessitate a referral to neurology. Providers should remain mindful of the need to avoid cognitive biases like anchoring or premature closure. while distinguishing between dementia and the many other possible causes of cognitive changes. Therefore, to avoid claims related to delayed diagnosis of other conditions, primary care providers may wish to review the symptoms that could indicate an organic problem, as well as those that could indicate an issue in the psychiatric domain prior to offering cognitive assessments.

Malpractice risks also include failure to diagnose dementia, and failure to recognize that the dementia has progressed in a way that puts the patient in harm’s way. This raises questions regarding when and how assessments are best performed.

Timing of Dementia Screening

Medical professional societies have offered conflicting recommendations regarding when or under what circumstances older adults should be screened for dementia.

In September 2019, the American Academy of Neurology recommended annual screening guidelines for older adults. In the interests of potential early intervention, they recommended screenings even in the absence of any reported cognitive symptoms. However, both the U.S. Preventive Services Task Force and the American Academy of Family Physicians have expressed reservations about this practice, citing the stress and the self-doubt that could be inspired by the screening itself as a potential patient harm.  

When some symptoms are present, observed perhaps by a spouse or family member, all agree that performing an assessment early on can convey some benefits. Even in the absence of any available medical intervention that could resolve the issue, providers can advise many measures to help protect the patient from harm.

Risk Reduction for Patients With Dementia

At the other end of the spectrum from the patient with few symptoms present is the patient who arrives for the cognitive evaluation in the advanced stages of dementia. In such cases, the provider should evaluate whether the patient is at risk of harm in their current living situation. It may be possible to extend their time in the home by removing any obvious tripping hazards, such as rugs, protecting from fires by shutting off the stove and using a microwave as a substitute, or by utilizing a caregiver or adult daycare. Another measure might be to close off areas of the home, like an upstairs or basement area. If family members are living with the patient, the use of alarming devices, especially on doors, can assist with protections.

This is where knowing community resources proves valuable. Even though they may be familiar with a few major programs, providers should become familiar with all programs that their community offers, such as local religious organizations that provide adult daycare or other support to help protect the patient when the family members are not at home. Especially when family members are just becoming aware of the extent of the patient’s needs, and just beginning to intervene, such community resources can provide stopgap measures that impact patient safety.

Researching community resources is part of preparing the practice’s toolkit for cognitive assessments. Ideally, this toolkit should prepare the provider and practice to perform the assessment and arrive at the correct diagnosis (if any) or referral, and to take steps toward the plan of care. Preventing or at least mitigating immediate safety risks for the patient both increases patient safety and mitigates provider liability.

Assessment Tools

A dementia-screening visit typically lasts about 50 minutes, and includes the patient as well as the person CMS describes as an “independent historian,” typically a spouse or family member. CMS does allow dementia assessments to be performed via telehealth, and says it will do so permanently.

A number of tools are available for physicians and advanced practice providers who plan to perform cognitive assessments. They include:

• Clock Drawing Test (CDT): This dementia assessment is familiar to many primary care providers. Patients are handed a pre-drawn clock face, and asked to add numbers and arms to the clock so that it shows a particular time. Because this test demands simultaneous deployment of cognitive, motor, and perceptual functions, the patient’s degree of ability to complete this task offers a quick sketch of their overall current cognitive functioning.
• Mini–Mental Status Examination (MMSE): This assessment asks questions that test the patient’s orientation, memory, attention, language, and visual-spatial skills. It stratifies its scoring based on the patient’s education level.
• Time and Change (T&C): This assessment combines aspects of the CDT with a task in which the patient is asked to count a dollar out of change. This mini-assessment can indicate whether a full dementia screening is called for.
• Memory Impairment Screen (MIS): This test involves activities like reading a short list of words, performing another task for a few minutes, then trying to remember the words. Crucially, the MIS test comes in an MIS-T version suitable for telephone encounters.