Last time you went to the doctor for a routine check-up you were probably screened for depression, diabetes, or cancer.
But you most likely weren’t screened for one of the most debilitating and costly conditions facing our country: neurodegenerative disease – most notably, Alzheimer’s. It’s time for this to change.
About 90% of Americans with mild cognitive impairment, the earliest symptomatic stage of Alzheimer’s disease, are undiagnosed for the same reason doctors once resisted delivering cancer diagnoses that were seen as purely bad news. But as treatment options for cancer improved, patients understood that a stage one cancer diagnosis is very different from a stage four diagnosis. Early diagnosis means hope for treatment.
Alzheimer’s is at the same inflection point.
We now have better diagnostics and interventions for cognitive decline. If doctors can find cognitive impairment, we can prevent or slow the decline into dementia. But if screening doesn’t become standard, we will continue to miss the window when intervention can help.
I first saw the cost of missed cognitive decline in my own family. My grandfather covered for my grandmother’s dementia, smoothing mistakes to the point that the rest of our family missed it entirely, even though I’m a primary care physician and my mother was a geriatric care nurse. Within two weeks of my grandfather passing away unexpectedly, we realized my grandmother had dementia so severe she had to be placed in a locked dementia unit. If her own family of medical professionals missed her cognitive decline, how can we expect busy primary care doctors to catch it in a 15-minute visit?
We should be screening for cognitive decline the way we screen for cancer and depression — with validated tools that are proven effective to detect changes early, when they are most treatable.
As it stands, Medicare’s Annual Wellness Visit requires assessment of an individual’s cognitive function but leaves the method to the provider’s discretion. Doctors often satisfy the requirement by asking a screening question: “Are you worried about your thinking or memory?” If the patient says no, the provider moves on. This assessment method was clinically sufficient when the Annual Wellness Visit was created in 2011, because few diagnostic options existed. But today – with advances like digital cognitive assessments and blood-based biomarker testing – relying on a single question is like looking for a fracture without ordering an X-ray.
The policy changes needed to address this gap are straightforward. The Centers for Medicare & Medicaid Services (CMS) already requires cognitive assessment during the Medicare Annual Wellness Visit. It could dramatically reduce the number of missed cases by mandating the use of standardized, validated cognitive assessment tools, just as it requires standardized tools to screen for depression. It could also require providers to administer a validated test at the patient’s initial “Welcome to Medicare” visit to establish a cognitive baseline so that any future decline can be differentiated from normal aging.
CMS can also ensure these assessments are feasible in real-world primary care by updating billing codes. Administering validated cognitive tests takes time and coordination from entire care teams, but CMS’s billing codes haven’t kept pace with that reality. Updating Medicare payment to account for a provider’s time and effort would remove a major barrier to adoption and allow clinicians to practice according to today’s science. And it can be done administratively, without new legislation or lengthy rulemaking.
CMS could also use billing code changes to enable the adoption of digital cognitive assessments, from companies like Cognivue, Cogstate, or Linus Health, my employer and the assessment I use in my clinic. These tools can accurately detect cognitive impairment and some only require three minutes of a medical assistant’s time to administer. Yet current billing codes require at least 16 minutes of a clinician’s time to get paid for a cognitive assessment. CMS could remove these time restrictions if a validated DCA is used, which would enable more patients to be assessed in less time without increasing reimbursement, allowing physicians to focus their efforts on people who show cognitive decline and need follow-up attention.
Some people say earlier diagnosis for Alzheimer’s disease is not meaningful because there isn’t much to do about it. But research shows that 45% of dementia cases could be prevented or delayed through early intervention and lifestyle changes, such as walking 7,000 steps a day. Today, I’m guiding my own mother through lifestyle changes to address mild cognitive impairment. So far, she has lost 75 pounds and is learning to play piano. Early detection was the starting line for these life-changing improvements.
The science to fight Alzheimer’s disease has advanced dramatically. The question is whether we will use today’s breakthroughs to fight back and give families healthier, longer, happier lives.
Dr. John Showalter MD is a practicing primary care physician and the COO of Linus Health.
