Neurologists and other physicians providing neurological care should screen patients age 65 and older yearly for cognitive impairment, according to new metrics for quality improvement issued by the American Academy of Neurology (AAN) today.
As part of a new measurement set for treating mild cognitive impairment, the AAN recommends physicians measure how frequently they complete yearly cognitive screenings of older adults receiving neurologic care. This metric and others were prepared by the American Academy of Neurology Institute (AANI) and published in Neurology. This is the first time the AAN has proposed annual assessment of cognitive health status as a metric of quality improvement.
Quality neurological care for older patients should include knowing whether they have cognitive problems, said lead author Norman Foster, MD, of the University of Utah in Salt Lake City. “The measure is based upon evidence of a gap between quality care and frequent practice,” he told MedPage Today.
“Providers often fail to suspect a cognitive problem in those with impairment,” Foster added. “As a result, clinically significant memory and thinking problems may not be recognized and lead to mismanagement, including failure to recognize and treat contributing conditions or use of medications that worsen memory.”
The AAN initiative may appear to diverge from a draft U.S. Preventive Services Task Force (USPSTF) recommendation issued last week, which concluded that “current evidence is insufficient to assess the balance of benefits and harms of screening for cognitive impairment in older adults” based on a systematic review of cognitive impairment screening in primary care.
“While we identified several brief screening instruments that can help clinicians identify older adults with dementia, there is no published evidence that such screening improves patient or caregiver outcomes, nor on the harms that might be related to screening,” said Carrie Patnode, PhD, MPH, of the Kaiser Permanente Center for Health Research in Portland, Oregon, who led the USPSTF review.
“Additionally, while hundreds of studies exist that evaluate the effectiveness of treating early-stage dementia with medications and non-pharmacologic interventions, the benefits to patients and caregivers are quite small and of uncertain clinical significance,” Patnode told MedPage Today.
But the USPSTF draft addressed routine screening in primary care, Foster noted, while the AAN quality measures apply to those who are receiving neurological care from a medical provider — a somewhat different population.
“The AAN already has recognized the importance of periodic cognitive assessments in patients with some of the most serious neurological disorders,” Foster said.
“The current quality measure applies to all patients receiving neurological care including very common disorders such as headaches, sleep problems, dizziness, weakness, and numbness that primary care and other providers see most often,” he continued. “They are relevant to all patients neurologists see.”
Yet Foster also said the measures were developed by “a multidisciplinary stakeholder work group … recognizing that the findings would be relevant not only to neurologists but also to primary care or other physicians providing neurological care,” he said.
Besides yearly cognitive assessments, the metrics track:
- Cognitive and functional assessments for patients with mild cognitive impairment or memory loss
- Disclosure of mild cognitive impairment diagnosis and counseling about treatment options
- Assessment and treatment of factors contributing to mild cognitive impairment, including hearing or vision loss, illness, depression, sleep disturbance, or medication side effects
- Avoidance of anticholinergic medications for patients with mild cognitive impairment
- Education for care partners of patients with mild cognitive impairment
Physicians can use one of several validated tools to assess cognition, including the Montreal Cognitive Assessment (MoCA), Mini-Mental State Examination (MMSE), Memory Impairment Screen (MIS), St. Louis University Mental Status examination (SLUMS), Mini-Cog, Clinical Dementia Rating (CDR), Self-Administered Gerocognitive Examination (SAGE), or neuropsychological evaluation.
These screening tools are not equal or interchangeable, and clinician judgment is needed in selecting and interpreting which one is best, the AAN noted. Some tools require 2 minutes or less, others 12 to 15 minutes.
Last Updated September 18, 2019
The AAN paper had no targeted funding.
Authors reported relationships with the NIH, the June Morris Trust, the Rodney and Carolyn Brady Fund, GE Health, AbbVie, Biogen, Suven, Lilly Pharmaceuticals, Proactive Memory Services, Eisai, Novartis, Roche, Neurotech EEG, the FDA, the Alzheimer’s Association, Takeda, Avanir, Piramal, the Florida Department of Health Ed and Ethel Moore Alzheimer’s Disease Research Program, and the American Academy of Neurology.
Primary Source
Neurology
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