Memory Assessment During Routine Medical Exams

Contributed by: Dennis Fortier, President, Medical Care Corporation
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As we have noted in this space before, the Health Care Reform Act will mandate "detection of cognitive impairment" during routine Medicare Exams beginning in 2011. However, the approach by which physicians will comply with this new requirement remains an open question.

How should cognitive impairment be detected in a primary care setting?

The merit of any particular solution must be judged on several factors. For example, with all other factors held equal, a brief test would be superior to a short test as would a non-invasive test be superior to an invasive one. Cost matters as well; surely a less expensive test is preferable to a costly one. Similarly, a test that is highly sensitive to even subtle declines in cognition would be a better solution than one that only detects more severe symptoms.

While I have described attributes for comparing "tests", it may be that a test need not be part of the ideal solution. Perhaps physicians need only be proactive in soliciting memory concerns (or other cognitive complaints) from their patients.

Under such a scenario, those who express a concern could advance to a more sophisticated evaluation and the others would be questioned again at their next annual wellness exam. That's not a perfect solution for detecting problems in patients who are not already concerned, but many experts in this space would argue that such an approach would be a major leap forward. In fact, it might be the only approach that blends enough pragmatism and cost-efficacy to actually work in a busy primary care setting.

I recently listened to a webimar about a brief instrument called the "AD8", an informant-based questionnaire that could be useful in helping physicians identify patients who need a more thorough evaluation of their cognition. Various participants from the audience, many with ties to competing instruments, raised concerns about the whether or not it was a viable solution. An expert panel then discussed various pros and cons of the AD8 during the ensuing dialogue. The point of this post is not to evaluate the AD8 but to highlight the value of a new focus on cognitive health.

From my perspective, the facts that (1) Health Care reform is mandating more attention to cognitive health and (2) national discussions are unfolding to explore competing approaches, are both extremely positive developments. Memory concerns must be identified and addressed as early as possible to ensure timely intervention against progressive illnesses. This is our best bet to avoid future insolvency of our public health care system.

Efforts to initiate discussions about brain health between patients and their physicians are exactly what we need. We are on the right track.
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