Minneapolis – A routine primary-care visit typically includes weighing-in, blood-pressure monitoring and a body-temperature check. In some cases, the physician may also listen to patients’ heart and breathing rhythms, look down their throats or check their ears.
What’s between the ears is another matter, however. Routine screening for mental function or cognitive impairment is rarely done in the VA or the private sector, according to J. Riley McCarten, MD, medical director of the Geriatric Research Education and Clinical Center (GRECC) at the Minneapolis VA Health Care System.
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“The brain is an important enough organ that standard routine testing should be done in everybody,” McCarten said, pointing out that, “unless the patient is obviously disoriented,” primary-care physicians usually do no cognitive screenings. Even when a screening is performed, he said, it is “very rudimentary.”
The problem is that the kind of warning signs that would signal dementia and prompt screening, such as inappropriate dress or trouble answering questions during an interview, often only occur in a later stage of illness, McCarten noted. By that point, the patient is likely to have suffered an array of preventable issues.
McCarten said he has a “simple rationale,” for his practice: “If someone has trouble learning or remembering new information, it is irresponsible to write them a prescription or give them advice.”
The problems go far beyond following medical advice, however.
“Unrecognized dementia puts people at risk for all sorts of outcomes – not just medical,” he said. “There is financial mismanagement. People will mismanage their social lives. They can’t keep up with social contacts. They are isolated, bored, agitated, mentally and physically inactive. When someone sits at home alone, staring out the window, that is a Petri dish to develop bad outcomes.”
McCarten, the lead author of an important new study on the effect of screening on diagnosing cognitive impairment in patients who were seen in VA primary-care clinics, is seeking to make evaluation for mental function a routine practice in physician offices.
Diagnosing Older Veterans
That study, published in a recent issue of the Journal of the American Geriatrics Society, involved veterans, age 70 or older with no indication of memory loss. It found that brief cognitive screenings, combined with offering further evaluation, increased new diagnoses of cognitive impairment in older veterans two- to three-fold.1
Of the 8,342 veterans offered screening, 8,063 (97%) accepted, 2,081 (26%) failed the screen, and 580 (28%) agreed to further evaluation. Among those accepting further evaluation, 93% were documented to have cognitive impairment, including 75% with dementia. Comprehensive evaluation was performed by advanced practice registered nurse trained in dementia care and integrated into the primary-care clinic.
Additionally, 118 patients who passed the initial screen still requested further evaluation, and 87% were found to have cognitive impairment, including 70% with dementia.
Interestingly, the initial screening, the Mini-Cog assessment, takes only two minutes but can be a powerful indicator, McCarten said.
“This is a basic test,” he emphasized. “You give them three words to remember, have them draw a clock and then ask them to remember the three words. In the most common form of dementia, Alzheimer’s disease, recent memory is what’s most prominently affected and affected early. Delayed recall is a pretty good indicator.
“The clock draw itself is particularly useful if someone has to follow verbal instructions and demonstrate visual/spatial kills. Executive function taps into other major cognitive domains.”
Most current practice guidelines do not call for routine cognitive impairment/dementia screening, even on older patients. The American College of Physicians, U.S. Preventive Health Task Force, and Alzheimer’s Association recommend screening only when a patient, family member or friend approaches a provider with some type of complaint that could be due to dementia.
Therefore, McCarten suggested, screening only occurs “if a physician is suspicious of problem or patients or family report a problem. This is an insensitive way to identify people who are impaired. Often patients are unaccompanied. They may not have recognition of the problem. Dementia is an occult disease; people don’t recognize they have it.”
Cognitive impairment also is not just a problem of the elderly, especially at the VA where growing number of younger patients suffer from issues such as TBI or PTSD.
“Cognitive function is the most important biological function, and it deserves attention in every single person. High school athletes get baseline extensive cognitive screening if they are involved in any contact sport. [Military servicemembers] get pretty extensive baseline screening,” McCarten said.
While the study looked at older veterans, he said, “Anybody could have cognitive problem caused by drug abuse, HIV, multiple sclerosis or TBI. A lot of things cause impairment.”
McCarten said his efforts to widen dementia screening began when current VA Undersecretary for Health Robert A. Petzel, MD, was director of VISN 23 and pushed disease-management initiatives in areas such as diabetes, depression, congestive heart failure and COPD.
“We were approached as members of the geriatric and extended-care service line and asked, ‘What chronic disease are you dealing with, and how are you going to fix it?’” The result was an emphasis on dementia prevention, screening and treatment, which is now a national concern for VA, McCarten said.
Efforts to expand screening appear to be well-received by patients at VAMCs nationally.
A study published last year by researchers from the Durham, NC, VA Medical Center involved a cross-sectional study of consecutive patients who presented for primary-care appointments and were evaluated face-to-face using the Dementia Screening and Perceived Harms (SAPH) questionnaire. The study, published in the April 2011 issue of the International Journal of Geriatric Psychiatry, reported that 81% of primary-care patients indicated that they desired dementia screening.2
Impetus for more cognitive screening will not come only from inside healthcare but also from the broader population, especially aging baby-boomers, McCarten suggested. “There is recognition more broadly that this is important. You see pop-ups on your computer, ‘Take this quiz.’ Cognitive quizzes are available as part of the electronic culture we live in. Patients take them and show them to their doctor and say, ‘What should I do?’”
1. McCarten JR, Anderson P, Kuskowski MA, McPherson SE, Borson S, Dysken MW. Finding dementia in primary care: the results of a clinical demonstration project. J Am Geriatr Soc. 2012 Feb;60(2):210-7. doi:
10.1111/j.1532-5415.2011.03841.x. PubMed PMID: 22332672.
2. Holsinger T, Boustani M, Abbot D, Williams JW. Acceptability of dementia
screening in primary care patients. Int J Geriatr Psychiatry. 2011
Apr;26(4):373-9. doi: 10.1002/gps.2536. Epub 2010 Sep 15. PubMed PMID: 20845398.
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