Mind-robbing Alzheimer’s disease, the leading cause of dementia in the United States, usually starts quietly and largely hidden from view. Its manifestations range from mild symptoms such as forgetting important dates and events to requiring round-the-clock care and help with daily living activities such as walking, eating, and bathing.
By the time Alzheimer’s is diagnosed, it’s generally too late to do much to halt it. One goal of the Medicare annual wellness visit is to improve the detection of early stages of cognitive impairment, an Alzheimer’s precursor. Yet a study we recently conducted suggests that the wellness visit has fallen short of doing this. We believe the visit would work better if physicians were given more specific guidance on how to detect cognitive impairment, and what steps to take for follow-up diagnostic assessment and care.
Earlier and more accurate identification of individuals with cognitive impairment could improve patient-centered medical care and advance planning. Physicians, for example, could avoid prescribing certain medications that might further worsen memory and thinking skills, or at least adjust their dosing. Early awareness of cognitive impairment can also help better manage other conditions, such as diabetes or heart disease, through heightened attention to patients’ growing difficulty to care for themselves.
Earlier identification of cognitive impairment may also provide greater opportunities for people to participate in clinical trials for disease-modifying treatments that may benefit only those in early stages of the disease. The bipartisan HOPE for Alzheimer’s Act, supported by the Alzheimer’s Association, would increase access to information on care and support for newly diagnosed individuals and their families and ensure that an Alzheimer’s or dementia diagnosis is documented in the patient’s medical record.
The annual wellness visit was formally launched in January 2011. It includes an assessment of cognitive function — which is not otherwise part of routine clinical practice — along with various elements of preventive care. The uptake of this new benefit has been slow, with approximately 20 percent of eligible Medicare fee-for-service beneficiaries receiving it in 2016.
We sought to determine whether the annual wellness visit has had any effect on the detection of cognitive impairment or on patient management, including whether it led to additional cognitive testing, the initiation of treatment, or more careful management of medications with potentially harmful effects on cognition. To do this, we examined medical and pharmacy claims data for a large random sample of Medicare fee-for-service beneficiaries between 2010 and 2014. We followed patients for one year after their first annual wellness visit and evaluated their management compared with similar Medicare beneficiaries who did not participate in such a visit.
As we wrote in the Journal of the American Geriatrics Society, the annual wellness visit, at least as implemented through 2014, has not substantially moved the needle for detecting and managing cognitive impairment. Although we observed some evidence of increased lab testing for reversible causes of cognitive impairment, we saw no meaningful differences in diagnoses of cognitive impairment, initiation of anti-dementia treatment, or changes in the management of potentially harmful medications between those who had a wellness visit and those who did not.
Observational studies like ours that rely on administrative data have obvious limitations, including the time horizon considered and the lack of detailed clinical information underlying the medical encounters. That said, this question emerges from our research: Why doesn’t the annual wellness visit improve the identification and management of cognitive impairment?
Although our study can’t answer it directly, we believe that a key issue is how the visit is implemented in clinical practice.
When the wellness visit was introduced, the Centers for Medicare and Medicaid Services provided physicians with general guidance for evaluating patients’ cognitive and functional capabilities but did not recommend a specific tool for doing that. Nor did it provide a course of action when cognitive impairment was detected during the visit. We aren’t blaming CMS — it couldn’t do that because no widely accepted screening measure exists that adequately and comprehensively addresses all the criteria for identifying cognitive impairment.
To provide some guidance to the physicians administering the annual wellness visits, a group of experts, including Dr. Malaz Boustani, one of the study co-authors, worked with the Alzheimer’s Association to develop a road map for assessing cognitive function during the annual wellness visit. It includes a series of recommendations for primary care physicians, including patient observation, unstructured questions to ask during the visit, and implementation of structured assessment tools for both patients and caregivers. Other guidelines regarding follow-up evaluation and management if cognitive impairment is suspected are also available. However, the degree to which such algorithms have been implemented in practice is largely unknown.
Requiring cognitive screening through the annual wellness visit without giving physicians the resources to use the information derived from it in patient care is unlikely to meaningfully improve early detection and management of individuals with cognitive impairment. As the number of Americans living with Alzheimer’s diseases rises from 5.7 million today to nearly 14 million by 2050, we need more research into how the visit is conducted and what type of additional steps physicians should take afterward to determine how it can deliver on its promise of earlier detection of cognitive impairment and improved management of older adults in the United States.
Noam Kirson, Ph.D., is a vice president at Analysis Group Inc., where Urvi Desai, Ph.D., is a manager. Nicole Fowler, Ph.D., is an assistant professor of medicine at the Indiana University School of Medicine. The Journal of the American Geriatrics Society study was funded by Eli Lilly and Co.