How PCPs can prevent cognitive decline in their patients

Early detection using modern tools is necessary to increase the quality of life of your patients

In less than 15 years, the population of people 65 and older in the U.S. is expected to grow to 80 million, up from under 55 million in 2019, according to U.S. Census projections. Unfortunately, however, the years of life gained are often associated with health impairment. As part of the UN Decade for Healthy Aging (2021-2030), there is a global push to promote healthy aging and add life to the years.

Neurological diseases such as stroke, Parkinson’s disease and dementia are the leading cause of disability worldwide. WHO predicts that brain-related disabilities will account for half of the global economic impact of disability by 2030. Dementia is the most feared disability among US adults, and Alzheimer’s disease is the most common type of dementia. Currently, more than 10 percent of people 65 and older and about one-third of people 80 and older have Alzheimer’s, according to the Alzheimer’s Association. Promoting brain health is critical to supplementation life to years.

Unfortunately, the current state of brain care offers 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 given 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 raise concerns (eg, due to stigma). The approach to screening for heart health or cancer illustrates the power and promise of a different, more proactive approach to brain health.

Primary care providers (PCPs) face practical barriers to conducting more routine screening.A recent Alzheimer’s Association survey found that nearly all PCPs (96%) believe it is important to evaluate patients age 60 and older for cognitive impairment, but they currently perform evaluations for half (48%). Among the key barriers, 72% of PCPs said they had difficulty distinguishing pathological cognitive impairment from normal aging, and 47% said they lacked expertise in performing cognitive assessments. PCPs also reported a lack of access to cognitive tests, as well as the resources and time to administer them. Taken together, PCPs are currently ill-equipped to screen and monitor patients for cognitive impairment.

Limited access to specialty resources for specific diagnoses results in delays in initiating care plans. Unfortunately, there is a significant shortage of specialists, often resulting in waiting times of three to nine months to see one. Many patients may not need specialist referrals if PCPs were better equipped to provide diagnostic and management services, particularly to patients with uncomplicated cases of dementia and other brain diseases.

Early detection of cognitive impairment and a specific diagnosis, such as mild cognitive impairment (MCI), offers several opportunities to benefit individuals and their families:

Impact on cognitive trajectory through lifestyle and health-related interventions. Research shows that preserving brain function and building cognitive resilience is a lifelong effort. Growing evidence also suggests that interventions targeting modifiable risk factors such as obesity, hearing and/or visual impairment, nicotine use, elevated blood pressure, high cholesterol, mood disorders, medication side effects, poor diet, disturbed sleep, lack of exercise and/or loneliness may help reduce the risk of cognitive impairment and progression to dementia (see Lancet Commission 2020, FINGER study 2015). Encouragingly, in a 2022 Lifebrain survey, 70% of respondents said memory problems would be a key motivator for them to improve their lifestyle (under the guidance of their care team). These results highlight the need for greater emphasis on prevention and the implementation of tailored interventions as early as possible.

Plan the essentials. Early diagnosis enables patients and their families to define their future goals and plan for them (ie, live the life they choose based on what is most important to them specifically). An Alzheimer’s Association survey found that 85% of older adults in the US would like to know early if they have AD, citing the top two reasons as being able to plan with their families and getting treatment earlier (both 70%) .

Get timely care and access to clinical trials. Clear and early diagnosis helps ensure that therapies can be applied much earlier, during windows of opportunity when the greatest improvements are possible. It also gives patients time to consider enrolling in clinical trials, 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 that interventions are tailored to what is most important to each patient. To do this, PCPs need new tools. Fortunately, the landscape of cognitive assessments is evolving rapidly as technology advances, increasing adoption of technology by older adults, 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 insight into a person’s cognitive abilities, making them neither effective nor scalable. In addition, larger neuropsychological batteries are required for confirmatory diagnosis, and the process of administering these tests and obtaining results can be time- and labor-intensive and thus can introduce unnecessary delays into the clinical decision-making process.

Digital cognitive assessments are building a new space for proactive screening and intervention in primary care. AI-enabled assessments that measure performance on a series 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 preclinical AD and MCI subtypes. These tools are also much more efficient, can be easily integrated into primary care workflows, and may not require physician administration. Automated scoring and immediate interpretation further frees up PCP time to focus on next steps for the patient, which some digital solutions also support through integrated clinical decision support.

Greater use of digitally enabled cognitive assessments can benefit patients, providers, and the larger healthcare system. Digital solutions offer value to PCPs by improving both cognitive assessment levels and practice workflows while providing new revenue opportunities. They can be incorporated effectively into annual well visits, establishing a reliable practice for cognitive screening, and can help PCPs take advantage of new Medicare reimbursement codes for cognitive assessment and care planning that have not previously been used. In addition, in a world of value-based health care delivery, streamlined assessments offer the potential to help prevent complications requiring urgent or acute care by early identification of those at highest risk. By enabling broader and more effective screening, digital assessments can help facilitate earlier and more impactful interventions, more efficient specialist triage, and opportunities for patients to participate in clinical trials.

It is never too early, but also never too late, to influence individual cognitive trajectories and reduce the risk of brain-related impairment and dementia for patients. Gaining a deeper understanding of new approaches to digital assessments of brain health may empower PCPs to help their patients prevent 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, Senior Scientist at the Hinda and Arthur Marcus Institute for the Study of Aging, and Medical Director of the Deanna and Sidney Wolk Center for Memory Health at Hebrew SeniorLife.

Dr. Ankur Bharia 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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