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

According to the Alzheimer’s Association, an estimated 6.9 million Americans ages 65 and older are afflicted with Alzheimer’s Disease, the most common type of dementia. Estimates from the Population Reference Bureau suggest that by 2040, 12 million Americans will suffer from dementia. In addition, the isolation experienced by many during the pandemic may have accelerated or temporarily exacerbated cognitive impairment.

Primary care practitioners may be unaware of cognitive impairment in their cognitively impaired patients, or they may fail to offer cognitive evaluations. In recognition of the scale on which assessments are needed due to the aging population of the United States, CMS increased payment for primary care practitioners who perform cognitive assessments. As practices care for the increase in older patients and take advantage of the CMS billing rules, successfully integrating cognitive evaluations into a practice’s workflow without magnifying liability risks takes some preparation.

Diagnostic Cautions

Often, a patient who has recently experienced cognitive changes is seen first by a primary care practitioner. While the spouse or family members sometimes assume that changes are caused by dementia, they could also be caused by medications or other diseases (such as multiple sclerosis or a brain tumor), necessitating a referral to neurology. Cognitive biases like anchoring or premature closure may interfere with distinguishing between dementia and the many other possible causes of cognitive changes. To avoid claims related to delayed diagnosis of other conditions, review the symptoms that could indicate an organic or psychiatric issue 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

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

In 2019, the American Academy of Neurology (AAN) recommended annual screening guidelines for older adults as a quality metric. In the interests of potential early intervention, AAN recommends screenings even in the absence of any reported cognitive symptoms. However, reservations about this practice include the stress and self-doubt that could be inspired by the screening itself as a potential patient harm.  

When some symptoms are present, however, all agree that performing an early assessment can convey some benefits. Even in the absence of any available medical intervention that could resolve the issue, practitioners can advise on measures to help protect the patient from harm.

Risk Reduction for Patients With Dementia

Some patients may arrive for a cognitive evaluation in the advanced stages of dementia. In such cases, the practitioner should evaluate whether the patient is at risk of harm in their current living situation. It may be possible to extend the patient’s time at home by removing any obvious tripping hazards (rugs, for example), protecting the patient 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 alarm devices, especially on doors, can assist with protection.

Practitioners 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 family members are not at home. When family members are discovering the extent of the patient’s needs and just beginning to intervene, community resources can help with patient safety by covering gaps in care.

Researching community resources is part of preparing the practice’s toolkit for cognitive assessments. Ideally, the toolkit should prepare the practitioner and practice to perform the assessment, arrive at a diagnosis or make a referral, and formulate the plan of care. Preventing or mitigating immediate safety risks for the patient increases patient safety and reduces practitioner liability.

Assessment Tools

A dementia-screening visit typically lasts about 50 minutes and includes the patient as well as the person that CMS describes as an “independent historian,” typically a spouse or family member. CMS allows dementia assessments to be performed via telehealth.

A number of tools are available for practitioners who plan to perform cognitive assessments. They include the following tools:

• Clock Drawing Test (CDT): 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 the task offers a quick sketch of 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.

• 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.

• General Practitioner Assessment of Cognition (GPCOG): Part 1 is a screening tool for use in primary care and is available in multiple languages. If the patient scores less than 8 on Part 1 of the test, additional information is needed, and Part 2 of the test should be completed with an informant.

• Digital Cognitive Testing Tools: The FDA has cleared several digital cognitive assessment tools including the Automated Neuropsychological Assessment Metrics (ANAM), Cambridge Neuropsychological Test Automated Battery (CANTAB Mobile®), CognICA, Cognigram, and Cognivue. (See also: The National Institute on Aging. Cognitive assessment considerations: Understanding the evidence. December 8, 2023. https://www.nia.nih.gov/health/cognitive-assessment-considerations-understanding-evidence)

Patient Safety Strategies

• Become proficient with cognitive assessment tools to assist with diagnosis.
• Take advantage of Medicare reimbursement to provide early testing.
• Educate families and patients on the advantages of early detection for possible treatment with existing and new drugs to slow disease progression.
• Assist families in making early and ongoing arrangements to protect dementia patients in their homes and as the disease progresses.
• Use community resources to help patients and families cover gaps in care.

For guidance and assistance in addressing any patient safety or risk management concerns, contact Patient Safety and Risk Management at (800) 421-2368 or by email.