How PCPs can anticipate cognitive decline in their patients
Early detection using modern tools is necessary to improve the quality of life of your patients
In less than 15 years, the population of people aged 65 and older in the United States is expected to reach 80 million, up from less than 55 million in 2019, according to US Census projections. Unfortunately, years of life gained are often associated with health-related disability. As part of the United Nations Decade of Healthy Aging (2021-2030), there is global momentum to foster healthy aging and add life to years.
Neurological disorders, such as stroke, Parkinson’s disease and dementia, are the leading cause of disability worldwide. The WHO predicts that brain-related disabilities will account for half of the global economic impact of disability by 2030. Dementia is the disability American adults fear most and Alzheimer’s disease is the most feared type of dementia. more frequent. Currently, more than 10 percent of people age 65 and older and about a third of people age 80 and older have Alzheimer’s disease, according to the Alzheimer’s Association. Promoting brain health is key to adding life in years.
Unfortunately, the current state of brain care delivers too little too late, failing to promote brain health and prevent or minimize the impact of brain-related disabilities. To improve care and manage growing needs, the following challenges must be addressed:
The current approach to brain health is largely reactive with minimal attention paid to preventing cognitive decline and promoting cognitive resilience. Brain care usually only becomes a priority if a patient or family member raises a concern, which delays diagnosis and shortens the window of opportunity for intervention, especially given patients’ reluctance to do share their concerns (e.g., because of stigma). The approach to heart health or cancer screening illustrates the power and promise of a different and more proactive approach to brain health.
Primary care providers (PCPs) face practical barriers to performing more systematic screening.A recent survey by the Alzheimer’s Association found that almost all PCPs (96%) think it’s important to assess patients aged 60 and over for cognitive impairment, but they currently perform assessments for half (48%). Among the top barriers, 72% of PCPs said they have trouble differentiating pathological cognitive impairment from normal aging and 47% say they lack the expertise to perform cognitive assessments. PCPs also report a lack of access to cognitive tests and the resources and time to administer them. Taken together, PCPs are not well equipped to screen and monitor patients with cognitive impairment at present.
Limited access to specialized resources for a specific diagnosis leads to delays in initiating care plans. Unfortunately, there is a significant shortage of specialists, which often leads to wait times of three to nine months to see one. Many patients might not need specialist referral if PCPs were better equipped to provide diagnostic and management services, especially to patients with uncomplicated cases of dementia and other diseases of the brain. brain.
Early detection of cognitive impairments and specific diagnoses, such as mild cognitive impairment (MCI), offers several opportunities to benefit individuals and their families:
Impact the cognitive trajectory through lifestyle and health interventions. Research shows that preserving brain function and building cognitive resilience is a lifelong endeavor. A growing body of evidence also suggests that interventions addressing modifiable risk factors, such as obesity, hearing and/or visual impairment, nicotine use, high blood pressure, high cholesterol, impaired mood, medication side effects, poor diet, sleep disturbances, lack of exercise and/or loneliness may help mitigate the risk of cognitive impairment and progression to dementia (see Lancet Commission 2020, FINGER study 2015). Encouragingly, in a 2022 Lifebrain survey, 70% of people said that memory issues would be a key motivation for them to improve their lifestyle (under the guidance of their healthcare team). These results underscore the need for a greater emphasis on prevention and the implementation of personalized interventions as early as possible.
Plan what matters most. Early diagnosis allows patients and their families to define their future goals and plan for them (i.e. live the life they choose based on what matters most to them specifically). A survey by the Alzheimer’s Association found that 85% of older adults in the United States want to know early if they have Alzheimer’s disease, citing their top two reasons as the ability to plan with their family and get a earlier treatment (both 70%).
Get timely care and access to clinical trials. Clear and early diagnosis helps ensure that therapies can be implemented much earlier, during the windows of opportunity where the greatest improvements are possible. It also gives patients time to consider enrolling in clinical studies, allowing researchers to follow them longitudinally and develop objective measures of target engagement for new treatments.
PCPs are well positioned to partner with individuals and their families to promote brain health, identify cognitive impairment early, and ensure interventions are aligned with what matters most to each patient. To do this, PCPs need new tools. Fortunately, the landscape of cognitive assessments is changing rapidly as technology advances, technology adoption among older adults increases, and external events – as exemplified by the COVID-19 pandemic – drive innovation.
There are several limitations to traditional cognitive screening tools. Paper-based assessments require manual workflows, involve subjective scoring and interpretation, and offer only limited information about a person’s cognitive abilities, making them neither efficient nor scalable. Additionally, larger neuropsychological batteries are required for confirmatory diagnosis and the process of performing these tests and obtaining the results can be time-consuming and labor-intensive and, therefore, can introduce unnecessary delays in the clinical decision-making process.
Digital cognitive assessments are creating a new space for proactive screening and intervention in primary care. AI-based assessments that measure performance on a range of tasks and analyze a wide range of metrics offer the potential for early detection and specific diagnosis, detecting subtle signs of cognitive impairment in sub -preclinical types of AD and MCI. These tools are also much more efficient, can integrate easily into primary care workflows, and may not require physician administration. Automated scoring and immediate interpretation frees up more time for PCPs to focus on next steps for the patient, which some digital solutions also help with integrated clinical decision support.
More widespread use of digital cognitive assessments can benefit patients, providers, and the entire healthcare system. Digital solutions deliver value to PCPs by improving both cognitive assessment rates and practice workflows, while providing new revenue opportunities. They can be effectively integrated into annual well visits, establishing reliable practice for cognitive screening, and they can help PCPs take advantage of new Medicare reimbursement codes for cognitive assessment and care planning, which have been underutilized to date. Additionally, in a value-based world of health care delivery, simplified assessments offer the potential to help prevent complications requiring urgent or acute care by quickly identifying those most at risk. By enabling broader and more effective screening, digital assessments can help facilitate earlier and more impactful interventions, more efficient triage to specialists, and opportunities for patients to participate in clinical trials.
It’s never too early, but it’s also never too late, to impact individual cognitive trajectories and reduce the risk of brain disability and dementia for patients. Gaining a deeper understanding of new approaches to digital brain health assessments can empower PCPs to help their patients stay ahead of cognitive decline and transform human health.
Alvaro Pascual-Leone, MD, PhD is Chief Medical Officer of Linus Health, Professor of Neurology at Harvard Medical School, Principal Investigator at the Hinda and Arthur Marcus Institute for Aging Research, and Medical Director of the Deanna and Sidney Wolk Center for Memory Health at Hebrew SeniorLife.
Ankur Bharija, MD is vice president of geriatrics at Linus Health and assistant professor and practicing geriatrician, primary care and population health, at Stanford University School of Medicine.
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