Memory Assessment During Routine Medical Exams

Contributed by: Dennis Fortier, President, Medical Care Corporation
________________________________________________

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.
--------------------------------------------------------------------------------
A better understanding and more awareness of Alzheimer's related issues can impact personal health decisions and generate significant impact across a population of aging individuals. Please use the share buttons below to spread this educational message as widely as possible.

How to Best Detect Early Alzheimer's Disease

Contributed by: Dennis Fortier, President, Medical Care Corporation
________________________________________________

Sometimes, a lot of press coverage is devoted to an interesting misinterpretation of a fact that, once correctly understood, is not nearly as interesting. This is one of those times.

Over the past week, I have seen intense coverage of a story about how friends and family are better at spotting early signs of Alzheimer's dementia compared to traditional tests that a doctor might use. This sounds great until you unpack the headline and understand the facts.

Even Mild Dementia is a Severe State of Health
The problem, as we point out often in this space, is the definition of "dementia". Even mild dementia, which sounds like a subtle condition, is actually a severely impaired state of mental health. To meet the definition of dementia, even mild dementia, a patient must be so impaired that their loss of function interferes with their occupational or social life. Demented people, even mildly demented people, cannot completely care for themselves.

Detecting Dementia does not Require a Test
With this is mind, many experts make the case (and I agree with them), that a test for dementia is not necessary. Dementia is a readily apparent condition that a friend or family member should easily recognize. The fact that doctors still use tests that cannot accurately distinguish between a demented person and a non-demented person is indicative of ineffective clinical practices.

For the record, there are newer, more accurate tests, such as the MCI Screen, that detect dementia with almost perfect accuracy. More importantly, they also identify much earlier and subtler stages of decline known as mild cognitive impairment. However, this current finding from Washington University and published in Brain, compared the ability of friends and family at spotting spot Alzheimer's dementia with the accuracy of "traditional" tests. This is a clear and damming comment about the poor accuracy and minimal utility of the "traditional" test they used for comparison, the Mini-Mental State Exam (MMSE).

In this study, input was collected with an instrument called the AD8, an eight item questionnaire that is completed, on behalf of the patient, by an informant (friend of family member). It was shown to be better at identifying demented patients than the MMSE. That is great news and the AD8 is a non-invasive tool that would be a pragmatic improvement over the MMSE in a primary care setting.

The Bottom Line
I think the most important message, buried in this recent spate of press, is that the traditional tests are not as good as the AD8 at detecting dementia, but detecting dementia doesn't really require a test. To intervene early against Alzheimer's disease, and to reassure healthy patients that their perceived memory decline is not caused by underlying disease, physicians need instruments that accurately detect mild cognitive impairment.

Advances in detecting dementia are not interesting stories, regardless of how much press they get.

Follow Brain Today on Twitter

--------------------------------------------------------------------------------
A better understanding and more awareness of Alzheimer's related issues can impact personal health decisions and generate significant impact across a population of aging individuals. Please use the share button below to spread this educational message as widely as possible.